    [Senate Hearing 115-335]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-335

      EXAMINING THE VETERANS CHOICE PROGRAM AND THE FUTURE OF CARE IN THE
                                   COMMUNITY

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  JUNE 7, 2017

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

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             Available via the World Wide Web: http://www.fdsys.gov

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                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman

    Jerry Moran, Kansas                  Jon Tester, Montana, Ranking
    John Boozman, Arkansas                   Member
    Dean Heller, Nevada                  Patty Murray, Washington
    Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
    Mike Rounds, South Dakota            Sherrod Brown, Ohio
    Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
    Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                         Joe Manchin III, West Virginia

                      Thomas G. Bowman, Staff Director \1\
                      Robert J. Henke, Staff Director \2\
                    Tony McClain, Democratic Staff Director

                          Majority Professional Staff
                                Amanda Meredith
                                 Gretchan Blum
                                Leslie Campbell
                                Maureen O'Neill
                                   Adam Reece
                                 David Shearman
                                Jillian Workman

                          Minority Professional Staff
                                Dahlia Melendrez
                                Cassandra Byerly
                                    Jon Coen
                                  Steve Colley
                                   Simon Coon
                               Michelle Dominguez
                                 Eric Gardener
                                   Carla Lott
                                  Jorge Rueda

    \1\ Thomas G. Bowman served as Committee majority Staff Director
    through September 5, 2017, after being confirmed as Deputy Secretary of
    Veterans Affairs on August 3, 2017.
    \2\ Robert J. Henke became the Committee majority Staff Director on
    September 6, 2017.
                                C O N T E N T S

                                  ----------

                                  June 7, 2017
                                    SENATORS

                                                                       Page
    Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
    Murray, Hon. Patty, U.S. Senator from Washington.................    10
    Moran, Hon. Jerry, U.S. Senator from Kansas......................    13
    Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    17
    Sanders, Hon. Bernard, U.S. Senator from Vermont.................    19
    Rounds, Hon. Mike, U.S. Senator from South Dakota................    21
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    25
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    28

                                   WITNESSES

    Shulkin, Hon, David J., M.D., Secretary, U.S. Department of
      Veterans Affairs; accompanied by Baligh R. Yehia, M.D., Deputy
      Under Secretary for Health for Community Care, Veterans Health
      Administration.................................................     5
        Prepared statement...........................................     7
        Response to posthearing questions submitted by:
          Hon. Johnny Isakson........................................    63
          Hon. Dan Sullivan..........................................    64
          Hon. Bernie Sanders........................................    64
          Hon. Mazie K. Hirono.......................................    68
          Hon. Joe Manchin III.......................................    69
    Steele, Jeff, Assistant Director, National Legislative Division,
      The American Legion............................................    31
        Prepared statement...........................................    33
        Response to posthearing questions submitted by Hon. Mazie K.
          Hirono.....................................................    69
    Atizado, Adrian, Deputy National Legislative Director, Disabled
      American Veterans..............................................    37
        Prepared statement...........................................    38
        Response to posthearing questions submitted by Hon. Mazie K.
          Hirono.....................................................    70
    Fuentes, Carlos, Director, National Legislative Service, Veterans
      of Foreign Wars of the United States...........................    44
        Prepared statement...........................................    45
        Response to posthearing questions submitted by Hon. Mazie K.
          Hirono.....................................................    71
    Stultz, Gabriel, Legislative Counsel, Paralyzed Veterans of
      America........................................................    48
        Prepared statement...........................................    50
        Response to posthearing questions submitted by Hon. Mazie K.
          Hirono.....................................................    72

                                    APPENDIX

    Association of American Medical Colleges; prepared statement.....    75
    Stacy, David, Government Affairs Director, Human Rights Campaign;
      prepared statement.............................................    82

      EXAMINING THE VETERANS CHOICE PROGRAM AND THE FUTURE OF CARE IN THE
                                   COMMUNITY

                                  ----------

                            WEDNESDAY, JUNE 7, 2017

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:36 p.m., in
    room 418, Russell Senate Office Building, Hon. Johnny Isakson,
    Chairman of the Committee, presiding.
        Present: Senators Isakson, Moran, Boozman, Heller, Rounds,
    Tillis, Sullivan, Tester, Murray, Sanders, Brown, and
    Blumenthal.

          OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN,
                       U.S. SENATOR FROM GEORGIA

        Chairman Isakson. Let me call this meeting of the Veterans'
    Affairs Committee of the U.S. Senate to order. I thank
    everybody for their attendance today, particularly, Secretary
    Shulkin. Thank you for being here today, and thank you, Dr.
    Yehia, for being here today. Thanks to all our VSOs who are
    here, who will be on the second panel. I know sometimes waiting
    through the first panel for the second panel, it takes a long
    time, and sometimes there are not as many Members of the
    Committee here. When you get to testify is when the big guy
    gets to testify, but believe me, we pay close attention to
    every bit of testimony that comes in. We appreciate your
    participation because we consider ourselves a team from the
    standpoint of the Veterans Administration.
        In my opening remarks, I want to focus on that for just a
    second. I do not think there is any question that the fact that
    David Shulkin was confirmed 100 to nothing; the first
    Presidential appointee that was voted in unanimously.
    Yesterday, we had a voice vote passage of a bill we could not
    move in the U.S. Senate a year ago, which is a unanimous vote
    as far as I am concerned. We did so because we found common
    ground where we needed to. We plowed new ground where we had
    to, but most importantly, we kept the veterans foremost in our
    minds, not ourselves as politicians or the press or somebody
    who wanted to play games.
        What we are going to talk about today is probably the most
    challenging subject we will deal with in this term of Congress
    as far as the Veterans Administration is concerned.
    Accountability had its pitfalls and had its potholes, but it
    was doable, and we proved it was doable. I want to thank the
    Ranking Member, Jon Tester, for his leadership in helping us
    get that through, and not the least, Jerry Moran who also was a
    tremendous help on our side, and Marco Rubio is not on the
    Committee but was a very active member who promoted
    accountability from the beginning. And we finally got it done.
        Today, we are going to be talking about the Veterans Choice
    issue. I was here in August 2004 when we started the great
    Veterans Choice debate. It was on the conference committee when
    we did the final bill that we passed, and finally, the decision
    to pass what we finally passed, we capitated in terms of
    available funding to some point it would die unless we fixed
    it. Well, we are at the point where if we do not fix it
    permanently, we are going to have a program that is either
    going to be out of money, out of gas, or out of both.
        We also have learned a lot in the last 27 months about how
    the Choice Program has worked the way we designed it, and we
    know there are some things we need to change. We know we have
    to look at the 40-mile rule and the 30-day rule and make them
    better rules for the veteran and for the Veterans
    Administration and making something that works for Choice
    rather than an incumbent to Choice.
        We need to see to it that VA, for all intents and purposes,
    is unleashed to provide the highest-quality service it can and
    make the decisions it makes on the ground at the time they need
    to make them. We need to give them the funding and the
    commitment and the resources to be able to do that.
        But, on the same token, I think we have to be as open
    minded on making Choice work in the future as we have been on
    finally getting accountability done yesterday. There are going
    to be some things that some people are going to find hard to
    take or hard to talk about. There are going to be people
    thinking change is bad. Change is not bad. Change is good. What
    we are going to have to do on Choice is change some. We have to
    change some ideas, change some direction, and change some
    results.
        In the end, we remember our goal is to see to it that
    veterans have the choice to get the services they need, whether
    it is care in the community or in the VA hospital or clinic in
    a timely basis. That way the VA can run its health care system
    the way it sees fit to meet the demands of those veterans and
    deliver them the highest-quality service possible.
        Dr. Shulkin yesterday demonstrated that he had the acumen,
    the intellect, and the intestinal fortitude to make the kind of
    decision you have to make to really bring a system into the
    21st century. Yesterday's decision in terms of Cerner and
    bringing in the medical records was huge.
        I have been personally very pleased at the response of the
    President, of elected officials, of Members of Congress, and of
    many people in the industry, because that is a giant leap
    forward, where our software will be interoperable between the
    DOD and the Veterans Administration, where veterans will not
    fall through a hole once they leave active duty to go on to the
    Veterans Administration and be lost for a year before we
    finally find them.
        I think we will ultimately realize savings, innovation, and
    advancement, and we are going to be sure that we hold Cerner
    accountable and the Veterans Administration accountable for
    those to be the results of this decision.
        I want to publicly commend Secretary Shulkin on having the
    fortitude to do that, pulling that trigger, so to speak, and
    pledge my support to help in every way possible to see the
    transition is smooth and works.
        With that said, I welcome Dr. Shulkin here today. Dr.
    Yehia, I welcome you here today, because I know you are the
    real brains behind a lot of these recommendations. I am not
    going to take the heat off of Dr. Shulkin. I am going to put
    some of it on your back as well.
        I want to thank the Ranking Member for being such a good
    partner in this effort and turn to him for his opening
    statement.

                 OPENING STATEMENT OF HON. JON TESTER,
               RANKING MEMBER, U.S. SENATOR FROM MONTANA

        Senator Tester. Well, thanks, Mr. Chairman. I want to,
    before I get in my prepared remarks, echo the Chairman's
    comments about what happened with the DOD electronic medical
    records. I think the challenge is also what he just said, and
    that is making sure it is done efficiently, effectively, and
    timely. We look forward to not only holding Cerner, but your
    feet to the fire on that as we move forward.
        Thank you, Mr. Chairman, for having this hearing today. I
    am looking forward to this hearing because Choice has been such
    a train wreck.
        I held listening sessions in Missoula and Billings last
    week, two of the biggest communities in Montana. Veterans have
    told me that the Choice Program has not improved access. In
    fact, it has made it worse. In the process, it has caused a lot
    of veterans and community providers to lose faith in the VA.
    Even though it is contracted out, we get the blame.
        When we passed Choice, 3 years ago, the fact of the matter
    is we passed it to increase the availability of health care in
    a more timely manner, and quite frankly, I cannot speak for all
    the States here, but Montana has done just the opposite.
        So, we have got a lot of work to do to win some folks back,
    and that should be really the focus of our conversation today,
    as it should be every day, and that is the veterans.
        Earlier this year, I was pleased that we could come
    together in a bipartisan manner to make some much-needed
    changes to Choice. It was one of the first bills that President
    Trump signed. As those changes are fully implemented, I know
    more veterans will hopefully have more timely access to care in
    their own communities when the care cannot be provided by the
    VA.
        However, it is no silver bullet. We need a dramatic revamp
    of the VA's Community Care Program, but we need to be
    thoughtful in that approach. Rather than just giving a veteran
    a card to seek health care, which I know would be easy to do,
    as we talked yesterday, the path forward should be an
    integrated program with the VA being the backstop and the
    community providers filling in the gaps. Why? Because in the
    end, we owe it to our veterans to make sure they have the best
    health care possible, and if there is a screw-up, ultimately,
    you and I both know, Mr. Secretary, it is going to end up on
    your desk. So, we have got to do it right.
        The VA should continue to serve as a coordinator and
    primary provider of care while the private sector fills in the
    gaps, and it is clear that the VA provides critical and
    necessary services to millions of veterans who benefit from
    specialized care, specialized care that in some cases is far
    better in the VA than it is in the private sector. These
    services are far, far, far too important to risk to outsource
    them because our veterans are depending on them.
        That is especially in the case of places like Montana,
    where local providers are often unable to absorb those veterans
    or to provide the specialized care that those veterans require.
        Now, do not get me wrong. There is an important role for
    community care in the delivery of health care to veterans, and
    we need to utilize that. But I will tell you, I reject any
    proposals to divert critical resources to community care that
    would hollow out the VA and impair its ability to provide care
    to millions of veterans who rely upon VA services that you guys
    provide, and I might say in almost every case you provide it
    very, very well.
        Mr. Secretary, over the past few weeks, we have had a
    number of discussions about the Department's proposals for the
    future of VA health care, and I know this is not a hearing to
    dissect the budget. But I really want to reiterate my concern
    from yesterday about the large increase for community care
    seemingly being made at the expense of in-house VA care.
        I want to talk about how you arrived at those numbers, and
    I expect, as always, you will give it to me straight, because I
    am not going to be the guy up here who allows the
    Administration to chip away at VA health care. I will tell you
    why: because if I do, the next panel we hear from, the VSOs,
    will be all over me, and they should be. We should not reduce
    access to the VA because Washington is not staffing hospitals
    or clinics or because resources are not being appropriately
    allocated. Sending veterans to the private sector does not
    absolve the VA of the responsibility or the benefits. The VA is
    just as responsible when a veteran has a bad experience in the
    private sector as they are if they had a bad experience in a VA
    hospital. So, we cannot let the VA lose oversight of the
    quality of care that our veterans have earned, regardless of
    where it is.
        Sending the veterans into already underserved communities
    based on poorly designed or questionable metrics really does
    smack of setting the VA up for privatization. We have had these
    conversations before. Make no mistake about it. Under any of
    these conditions, veterans will unnecessarily suffer, and I do
    not think either one of us want that.
        So, I am encouraged to take what we hear today into
    account, and we will take your suggestions and move forward in
    the next Choice Program, Choice 2.0, whatever you want to call
    it, to make sure it works better, make sure it works as
    Congress intended when they passed it 3 years ago.
        With that, I just want to say thank you, guys, for being
    here. I appreciate your work, and quite frankly--and I am going
    to say so far, but I anticipate it is going to continue--I
    appreciate your forthrightness about what is going on within
    the VA. Admitting to problems is the first step toward solving
    them, and I think you guys have taken the first step in a lot
    of cases. I commend you on that.
        You did--and you were confirmed by 100 to nothing, as you
    pointed out to the Chairman earlier today.
        Chairman Isakson. Thank you, Senator Tester, and thank you
    for your support. I echo all the--I endorse all the statements
    that you made and the challenge we had to meet to make these
    changes.
        Our first panel and our first testimony will be from Dr.
    David Shulkin, the Secretary of the VA, who will be accompanied
    and assisted, I am sure, by Baligh--let me make sure. Is Baligh
    right as the first name, and Yehia is the second name? I am
    always afraid I am going to mess that up. We welcome you for
    being here and enjoyed our meeting yesterday.
        Let me say to both of you, normally, we give you 5 minutes,
    and then we will submit your testimony for the record. I am
    going to be very liberal on how much time. You take the amount
    of time you think that you need to lay out your presentation on
    Choice, and after that, we will do a question-and-answer from
    the Members of the Committee. We will call the second panel
    forward and do a Q&A with them.
        It is a pleasure to introduce Dr. Shulkin, the Secretary of
    Veterans Affairs of the United States of America.

       STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S.
    DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY BALIGH R. YEHIA,
      M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR COMMUNITY CARE,
                     VETERANS HEALTH ADMINISTRATION

        Secretary Shulkin. Great, great. Thank you, Chairman
    Isakson, Ranking Member Tester.
        I thought both of your opening statements were excellent,
    so hopefully, we are going to have a good hearing ahead of us.
        I am going to take less than 5 minutes because I really
    want to be able to make sure that we address all of your
    questions, and so thank you again for the opportunity to be
    here to talk about the Community Care Program that the
    Department has and included in that, of course, the Choice
    Program.
        I did want to say that I thought that yesterday afternoon,
    VA really took a big step closer to getting the type of
    accountability legislation that we need, so I want to thank all
    of you for doing that. Really, on behalf of the veterans in
    this country, I want to give a deep thanks to Senator Rubio,
    who sponsored the accountability bill, and to you, Chairman,
    and to the Ranking Member for your support and leadership and
    all the Members on the Committee.
        I think the Senate sent a pretty clear message to veterans
    that veterans are your priority, and that the VA has to be
    there to serve them.
        I also wanted to say thank you for helping us enact the
    Veterans Choice Program Improvement Act, and my thanks as well
    to the Ranking Member for sponsoring the bill and to other
    Members on the Committee who were cosponsors, and in particular
    to Senator McCain for his help.
        As more veterans than ever before picked Choice, we are
    seeing increased demand. Just in the first quarter of fiscal
    year 2017, we saw 35 percent more authorizations for Choice
    than we did in the first quarter of 2016. So far, in fiscal
    year 2017, we have approximately 18,000 more Choice-authorized
    appointments per day than we did in fiscal year 2016, but we
    still have a lot more work to do.
        That is why we are seeking support for the Veterans
    Coordinated Access and Rewarding Experiences Program, the
    Veterans CARE program. Let me just go over that again because
    you need a good acronym in Washington. The Veterans Coordinated
    Access--that is the C and the A--Rewarding Experiences program,
    the CARE program.
        I have testified before, and I will report again today,
    that our overarching concern remains veterans' access to high-
    quality care when and where they need it. That is regardless of
    whether the care is in VA or in the community.
        Our goal is to modernize and consolidate community care. We
    owe veterans a program that is easy to understand, simple to
    administer, and that meets their needs. That is the CARE
    program, and now it is time to get this right for veterans, so
    we need your help.
        Today, the criteria and processes for veteran access to
    community care are too often arbitrary, administrative, and
    unnecessarily cumbersome, but it does not have to be that way.
        Here is how veterans could experience VA health care with
    your help. The veteran talks with their VA provider. That is a
    conversation over the phone, virtually, or in person. The
    outcome is a clinical assessment. The clinical assessment may
    indicate that the VA specialist is best for the veteran, or it
    may indicate that community care is best to meet the veteran's
    needs. If community care is the answer, then the veteran
    chooses a provider from a high- performing network. That is the
    veteran choosing a provider from the high-performing network.
    Assessment tools help veterans evaluate community providers and
    make the best choices themselves.
        We may help veterans schedule appointments in the
    community, or in some circumstances, veterans can schedule the
    appointments themselves. We make sure community providers have
    all the information they need to treat the veteran. We get the
    veteran's record back. We pay the veteran's bill. This is all
    about individualized, convenient, well-coordinated, modern
    health care and a positive experience for the veteran. If the
    VA does not offer the necessary service, then the veteran goes
    to the community. If the VA cannot provide timely services, the
    veteran goes to the community. If there are unusual burdens in
    receiving care, the veteran goes to the community. If a service
    at a VA clinic is not meeting quality metrics for specific
    services, veterans needing that service go to the community,
    while we work to support that clinic to improve its
    performance. Veterans who need care right away will have access
    to a network of walk-in clinics. In its simplest term, if the
    VA does not offer the service, if the VA cannot provide the
    service in a timely manner, or we are failing to meet community
    standards, veterans will have the opportunity to receive
    community care.
        So, the Veterans CARE Program will ensure veterans get the
    right care at the right time with the right provider. With
    Veterans CARE, veterans drive their experience. They have more
    choice, and they have more say in their care. Because care is
    coordinated around the individual clinical needs of veterans,
    the CARE Program is tailored to veterans. Because veterans will
    know who to call to get care, the CARE Program is easier for
    veterans. Because veterans will have more flexibility to get
    the right care in the right place, the CARE Program is more
    convenient for veterans. And since eligibility is based on
    clinical needs, not administrative criteria like 40 miles or 30
    days, the CARE Program is veteran-centric and patient-centric.
        The whole process requires only a VA team, a network of
    community providers, and the veteran, all while decreasing the
    number of handoffs involved.
        But, we cannot do this without your help and without
    legislation, so thank you. We look forward to any questions you
    may have today.
        [The prepared statement of Secretary Shulkin follows:]
         Prepared Statement of Hon. David J. Shulkin, M.D., Secretary,
                      U.S. Department of Veterans Affairs
        Good afternoon, Chairman Isakson, Ranking Member Tester, and
    distinguished Members of the Committee. Thank you for the opportunity
    to discuss the Department of Veterans Affairs (VA) Community Care
    Program, including the Veterans Choice Program, which allows for
    Veterans to access the care they need and deserve. I am accompanied
    today by Dr. Baligh Yehia, Deputy Under Secretary for Health for
    Community Care in the Veterans Health Administration (VHA).
                       veterans choice program extension
        We are extremely grateful for the recent efforts of Congress that
    resulted in the enactment of the ``Veterans Choice Program Improvement
    Act,'' which removed the expiration date for the Veterans Choice
    Program and allows the Department to use the full $10 billion
    originally allocated to care for Veterans in the community. It also
    made VA the primary coordinator of benefits and allowed for better
    health information exchange between VA and community providers. These
    changes will lead to more Veterans getting community care and will
    reduce the administrative burdens of using the program for Veterans,
    community providers and Federal partners, and VA staff. While progress
    has been made, there is still more work to be done to serve our
    Nation's Veterans.
                          future of va community care
        VA needs a different approach to ensure we can fully care for
    Veterans. We need your help in modernizing and consolidating community
    care. Veterans deserve better, and now is the time to get this right.
    We believe that a redesigned community care program will not only
    improve access and provider greater convenience for Veterans, but will
    also transform how VA delivers care within our facilities.
        This redesigned program must have several key elements. First, we
    need to move from a system where eligibility for community care is
    based on wait times and geography to one focused on clinical need and
    quality of care. This will give Veterans real choice in getting the
    care they need and ensure it is of the highest quality. At a minimum,
    where VA does not offer a service, Veterans will have the choice to
    receive care in their communities. Second, we need to make it easier
    for Veterans to access urgent care when they need it. This will ensure
    that Veterans will always have a choice and pathway to get their urgent
    needs addressed. Third, the new program must maintain a high performing
    integrated network that includes VA, Federal partners, academic
    affiliates, and community providers. We need to ensure that VA is
    partnering with the best providers across the country to take care of
    our Nation's Veterans. Fourth, it must assist in coordination of care
    for Veterans served by multiple providers. Finally, we must apply
    industry standards for quality, patient satisfaction, payment models,
    health care outcomes, and exchange of health information. By doing so,
    Veterans can make informed decisions about their care and VA can have
    the tools to better compete within communities.
        We believe redesigning community care will result in a strong VA
    that can meet the special needs of our Veteran population. Where VA
    excels, we want to make sure that the tools exist to continue
    performing well in those areas. Veterans need the VA and for that
    reason, community care access must be guided by principles based on
    clinical need and quality. VA needs the support of Congress to level
    the playing field with industry by making it easier to modernize our
    infrastructure, leverage IT technologies, hire the best talent, and
    operate more like the private sector. A good example is management of
    our real property and infrastructure portfolio, where numerous barriers
    prevent VA from being agile in response to Veterans health care needs
    in different geographic areas. We want to work with Congress to discuss
    the best ways to bring common sense to this area.
        VA also needs tools to improve our recruitment, hiring and
    retention of the best professionals to serve our Veterans. These tools
    could include improvements to hiring and pay authorities to better
    address vacancies in our medical center and VISN director positions, to
    help at least in part address disparities with the private sector. As a
    final example, there is Federal law that requires VA facilities to have
    a smoking area. We all know the impact on health from smoking, and
    smoking cessation is the most immediate and dramatic step a Veteran, or
    anyone, can take to improve their health. VA strongly supports H.R.
    1662 which would repeal this requirement. Action in these areas will
    make VA more modern, and be an enabler for our dedicated workforce to
    be more effective in their service to Veterans.
        In order to improve care for our Veterans, we want to work with
    Congress to develop needed legislation for the future of VA community
    care. This legislation would have to be enacted by the end of the
    fiscal year to ensure that VA has sufficient time to proceed with
    regulations and other changes needed to implement the new vision. If we
    can accomplish this together, we would set VA on a bold new direction
    to not only increase access to community care but also transform the VA
    itself. We are committed to moving care into the community where it
    makes sense for the Veteran. Finally, I want to make sure that everyone
    understands that making better use of community care must be done in a
    fiscally responsible way. We cannot continue to grow our funding in the
    same way we have done over this past decade. And, I want to be clear
    that I am committed to strengthening the VA system and will not support
    efforts to privatize this much needed and essential system. The
    ultimate judge of our success will be our Veterans. With your help, we
    can continue to improve Veteran's care, in both VA and the community.
        Thank you and we look forward to your questions.

        Chairman Isakson. Thank you very much, Secretary Shulkin,
    for a concise statement yet a very thorough statement regarding
    the proposal on the CARE Program.
        Let me begin by talking about the quality metrics that you
    talked about in terms of health care facilities in communities.
    You will be relying on a lot of community information in terms
    of quality of health care, in terms of making your decision as
    to who in the private sector would deliver care to a veteran if
    the veteran could not get the care from the VA; is that
    correct?
        Secretary Shulkin. Yes.
        Chairman Isakson. Are the quality metrics available today
    in a seamless standard format?
        Secretary Shulkin. Here is what we have available today. As
    you know, we have recently published the wait times of our
    veterans that are on the website right now. The VA is ahead of
    the private sector on that. We hope the private sector will
    follow our lead and begin to start publishing wait-time data.
    So, we have VA data but not public data.
        What we do have for both the VA and the private sector are
    patient satisfaction scores, called CAP scores, that are the
    same surveys in the VA and outside in the private sector.
        We do have quality metrics. We have quality metrics for
    inpatient care, where there are more metrics in the private
    sector then the VA, but what we are really doing now is
    developing those metrics--and so is the private sector--for
    ambulatory care. So, between all of those measures, there is
    enough to make the types of comparisons we are talking about,
    and it is only going to get better over time.
        Chairman Isakson. An eligible veteran comes to the VA for
    health care, and the VA clinic that he goes to that is near him
    or the hospital that serves him as a veteran does not offer
    that service, whatever it might be. That automatically gives
    him the opportunity to go, he or she to go to the private
    sector in community care; is that correct?
        Secretary Shulkin. It does, yes.
        Chairman Isakson. Second, if the community quality rating
    is not good, does that automatically give them a chance to
    choose community service, community care, rather than go to the
    VA?
        Secretary Shulkin. What we are doing in this program, we
    are designing it to be that way. We want to make sure that if
    the service is low performing, if it is below what the veteran
    could get in the community, that they have the opportunity.
    They do not have to leave the VA. They are given a choice so
    that they are able to get care in the community or stay at the
    VA, because if a veteran has a good experience and they have
    trust in their provider, they are going to want to stay where
    they are. But, that is the purpose.
        The whole idea here is to improve the VA, not to get more
    care in the community, and the very best way that I know how to
    improve health care is to give the patient--in this case, the
    veteran--choice and to make those choices transparent, to let
    everybody see, because then if you are not performing as high a
    quality service, you are going to want to provide a higher-
    quality service, because you want to be proud of what you are
    working on. And I want the VA to be improving over time. I
    think this will help us do that.
        Chairman Isakson. You tell me, Dr. Yehia, if this is a
    correct statement or not. Under the old statement, we set in an
    arbitrary qualification to use the community care to be the
    number of days you had to wait for an appointment or the number
    of miles it took a canary to fly from where you lived to where
    the clinic was available. Is that not correct?
        Dr. Yehia. That is right.
        Chairman Isakson. Now we are talking about a judgment call
    made as to whether or not a veteran who is eligible for VA
    health care can go to the community care servant or go to the
    VA. Is that correct?
        Dr. Yehia. That is right. We are empowering the veteran and
    their care team to make those decisions rather than having
    arbitrary administrative roles.
        Chairman Isakson. But, there is going--somebody at the VA
    is going to be a part of that decision. It is not going to be
    just the veteran making that decision. They are not going to go
    to the community care alone. Who is that person in the VA that
    makes that decision?
        Dr. Yehia. Their doctor and the care team that supports
    them.
        Chairman Isakson. So, this doctor, his doctor at the VA is
    the person that will ratify his decision to go to the private
    sector based on--or go to community care based on the fact of
    either the quality metrics in the community or based on the
    fact they cannot offer the service that the veteran needs. Is
    that correct?
        Dr. Yehia. That is right.
        Chairman Isakson. Do you consider that as a--I am going to
    take a little bit more in my time. This is important. Do you
    consider that a threat to you, Doctor?
        Dr. Yehia. No.
        Chairman Isakson. You are a doctor, and, David, you are
    too?
        Dr. Yehia. Well, I think, patients come to doctors to get a
    clinical assessment and to get their advice. That is how we are
    trained as we go through medical school, so it is our
    responsibility to have those conversations, figure out what
    makes sense for them. So, the advantage of the CARE Program
    compared to the current Choice Program is it helps us decide
    the right place, the right doctor, the right location, and the
    right time for that patient to get their care. So, I actually
    think it is going to empower doctors in the system and patients
    in the system to make decisions that make sense for them.
        Chairman Isakson. I want you to listen to this.
        I would assume veterans who are otherwise eligible for VA
    health care but are not using it, because they got private
    health insurance or something else, it would be more attractive
    to come to the VA for their services because you have got that
    choice, and it is made in the way it is made?
        Dr. Yehia. Yes. In some circumstances, we have been seeing,
    you know, ``if you build it, they will come.'' More people are
    interested in receiving VA health care than before.
        Chairman Isakson. So, the concern that some might have,
    that this is a threat to VA and VA health care, it, in fact, in
    many ways is going to put an additional pressure on VA and VA
    health care to provide services to a greater number of
    veterans. Because I happen to agree with Senator Tester. None
    of us sitting at this table want to dissolve the VA, do away
    with VA health care, or close anything.
        On the other hand, we do not want to perpetuate a problem.
    We are trying to solve what has been a huge problem, which we
    could not solve 27 months ago when we kind of cut and run on
    it. Now we have got the chance to do it. So, we have no goal
    whatsoever to reduce the role of the VA health care system in
    the life of a veteran or take away or close a single clinic or
    a single facility. We want to make sure that we have the best
    service available to the veteran, and if we do that, if you
    build it that way, talking about the system, they will come.
    Then, the VA will be even more--have an even brighter future
    than it has got today as well, so I appreciate the response to
    that.
        Senator Tester.
        Senator Tester. I would want to kick it over to the good
    Senator from Washington.

            HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

        Senator Murray. Thank you very much, Mr. Chairman.
        Secretary Shulkin, in your draft veteran care plan, you
    outline a number of pilot projects that sound to me
    uncomfortably like proposals that are made by the so-called
    Strawman Document--it is from the Commission on Care--and by
    the extreme--and to me unacceptable--plan put forward by the
    Concerned Veterans of America, and those include creating a VA
    insurance plan and separating it from care delivery, dividing
    the governance of a VA insurance plan and the health system, an
    alternative care model that sends veterans directly to the
    private sector.
        The goal of those types of initiatives, as originally
    stated in the Strawman Document, is, quote, ``As VA facilities
    become obsolete and are underused, they would be closed when
    availability and accessibility of care in the community is
    assured.'' Those policies serve not only to dismantle the VA
    and start the health care system down a road to privatization,
    I just want you to know I will not support them, and I will
    fight them with everything I have.
        So, I want to ask you: why are you agreeing to pursue those
    unacceptable policy options?
        Secretary Shulkin. Well, first of all, I appreciate you
    sharing your thoughts and as clearly as you have.
        I share your goal. I am not in support of a program that
    would lead towards privatization or shutting down the VA
    programs.
        What I am in support of is using pilots to test various
    ideas about governance, about the way that the system should be
    organized, and the way that we should evolve, because I do not
    know, without testing different ideas, whether they are good
    ideas or not.
        We do not recommend--we did not take those principles and
    recommend that is how the VA should be organized. I do not
    believe that, but what we are open to, in the spirit of
    innovation and in the spirit of testing, different ideas and
    different pilot sites. But, I do not want the consequences that
    you talked about.
        One of the reasons why this is early on and we want to get
    feedback from all of you is to make sure that even the things
    that we are piloting are things that we want--we want to drive
    them toward desired outcomes.
        So, I would be glad to work with you on those, but I do
    want to make sure--since I do not think we are going to get
    everything in this piece of legislation that we are ultimately
    hoping to get to in terms of a desired result, I want to make
    sure that we give ourselves room to innovate and to test new
    ideas.
        Senator Murray. Well, Dr. Yehia, these types of proposals
    did not appear in your earlier drafts of the plan for a new
    non-VA care plan. Why the change?
        Dr. Yehia. Well, I think they are more like testing these
    different ideas. When you think of the Center for Medicare and
    Medicaid, their Innovation Center, this is a little bit of what
    these pilots are designed after. That body of CMS is really
    driving innovation in health care. They are testing value-based
    models. They are testing accountable care organizations, and
    they are figuring out what works. And those things that work,
    they are spreading across.
        So, I think in the spirit of innovation and testing our
    different ways to integrate with the community, it makes sense
    to see if it works or it does not work.
        Senator Murray. Well, here is what is missing from the
    conversation, is how you plan to actually build and strengthen
    the VA system for the long term. You have not put forward a
    comprehensive plan to do some of the things that the VA really
    needs to do--get more front-line providers, increase
    appointments, expand services, build and upgrade facilities,
    bring more veterans into the system. Those to me are the things
    that you do if you are trying to build and strengthen the VA
    system that we have, that veterans want.
        The proposals that you have lead me as singularly moving us
    in an opposite direction, and if you propose to only invest--
    invest in certain select types of care like TBI or PTSD or
    polytrauma or prosthetics, hospitals cannot be viable when you
    invest in only a handful of lines like that.
        So, let me ask you the question in reverse: how are you
    going to build a comprehensive VA system?
        Secretary Shulkin. Well, Senator, I think what you have
    just outlined is our agenda, to be able to build up and
    strengthen the system. We call it ``modernize the system,'' the
    way that you have.
        About 10 days ago, I gave a comprehensive report on 13
    areas of risk. They included exactly what you said, what we
    need to do to make this a stronger system that is going to be
    sustainable into the future. That is my goal. That is the only
    thing I am trying to do.
        I do believe, though, that you make a stronger system by
    giving your patients, your customers, more choice. That is how
    I believe every company has improved their product and has
    differentiated successful----
        Senator Murray. If you only give your----
        Secretary Shulkin. Yes.
        Senator Murray [continuing]. Customers a choice to get out,
    you are going to rob the resources from the system that we need
    to make sure is working.
        Secretary Shulkin. I could not agree more, and in fact,
    that is why we are not recommending that this be an unfettered
    Choice Program in 2017.
        I hope that we will get to the point that I do believe that
    VA has the investment that it needs to become the modern system
    that it will be able to successfully get patients in and out.
        Senator Murray. I have one more area I want to cover. You
    know where I am coming from.
        Secretary Shulkin. Yes.
        Senator Murray. I want to also say that I am really
    concerned that the VA is continuing to propose billing
    veterans' private health insurance for care for service-
    connected conditions. In your draft veteran care plan, you
    propose charging veterans $50 for walk-in clinic care. Your
    requested bill language puts on cap on how high you can make
    those copayments and would allow you to charge veterans for
    service-connected care.
        So, I am deeply concerned about that, and I just want to
    ask you: Do you think it is appropriate to break the Nation's
    longstanding commitment to provide care for injuries received
    in military service and ask veterans to foot the bill?
        Secretary Shulkin. Well, let us make sure that we have the
    same understanding. My understanding is we did not ask to bill
    other health insurance for service-connected disabilities, so
    that is not what we are proposing. I do not know why there is
    confusion over that.
        Senator Murray. But, you do propose charging veterans $50
    for walk-in health care.
        Secretary Shulkin. OK. So, a walk-in, a walk-in benefit is
    a brand-new benefit. We do not offer that today. What we are
    talking about in this is expanding the benefit to provide
    veterans the ability to get convenient care in their
    neighborhoods.
        The way that we are proposing it is there would be no
    change in the copay or benefit structure for the first two
    visits of a brand-new benefit. Following that, then after two
    visits--because there is a cost. We are adding a benefit, but
    we cannot add an unlimited new benefit. So, after two visits,
    we would propose that there be a copay cost, but this is no
    takeaway. This is an added benefit, because we believe it is
    the right thing to do.
        Senator Murray. I think it is a break in the tradition----
        Secretary Shulkin. Yes.
        Senator Murray [continuing]. I have deep concerns about
    that.
        And I am way over my time.
        Chairman Isakson. Senator Moran.

               HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

        Senator Moran. Chairman, thank you very much.
        Dr. Shulkin, Dr. Yehia, thank you very much for joining us
    today. I want to thank you for appearing before our
    Appropriations Subcommittee, now about a month ago, and
    particularly thank you for the conversations that we had in my
    office prior to that hearing. I indicated then and would
    indicate now publicly, that is the best set of conversations I
    have had with VA officials in the 7 years I have been a member
    of the U.S. Senate. So, I find your leadership refreshing from
    what my experience has been.
        I hope that--I guess I would ask that question: what is the
    attitude like at the VA today, different than it was in the
    past, in the short time that you have been there? You were
    there before being Secretary. You are now there as a Secretary.
    What is the VA like today in comparison to what it was last
    year or the year before or the year before that?
        Secretary Shulkin. I think people have not come to the
    exact same conclusion that you have. I think that there are a
    lot of people still watching, and there may be some people that
    are hopeful and some people that are concerned about changes.
    So, whenever you are going through change and you are trying to
    make decisions quicker and create decisions that have been
    years in the making and have not been made, you are going to
    have some people that are anxious. I think people are sitting
    and saying, ``I hope that this is the right direction,'' but
    there are a lot of people that are more cautious than you.
        Senator Moran. Thank you for that honest answer.
        Let me suggest to you, Mr. Secretary, that one way that I
    think that all of us on this Committee and Members of Congress
    can be helpful to you is to continue the dialog with us, to be
    responsive to our inquiries. Again, I think that has not been a
    practice in the past, and often, circumstances that I have been
    in, the requests that we make for information end up with a
    standard form letter reply that tells us next to nothing, where
    at best, you can say you responded because you sent me a
    letter. But, it did not tell me anything about what I was
    asking about.
        Secretary Shulkin. If you get those letters, send them back
    because I agree. It is just a waste of the postage stamp.
        Senator Moran. I appreciate that. Again, I would say when
    it comes to the Choice Program, which I think will be perhaps
    the most important piece of legislation this Committee
    considers in the foreseeable future, with the greatest level of
    consequences to veterans in Kansas and across the country, that
    I would ask for your commitment that this is going to be a
    joint effort with VSOs.
        I asked you when we first met, before your confirmation,
    that you quickly meet with veterans service organizations and
    solicit their input and have honest dialog with them. I would
    ask you to do the same thing with us as we try to figure out
    what makes sense.
        This Committee represents a set of different geography and
    different set of circumstances that I think we can bring to the
    table in trying to solve problems from our largest cities to
    our smallest towns.
        Secretary Shulkin. Yes. We are starting where Senator
    Tester started us, which is that the Choice Program----
        Senator Moran. Now I am nervous.
        Secretary Shulkin. No, no, no, no. [Laughter.]
        No, he is right. The Choice Program was not working for
    veterans the way that it should, and you were instrumental,
    Senator Moran, in pointing that out to us all along.
        So, this is now a journey, and I have to tell you, we have
    been engaging the VSOs. We have been in listening sessions. We
    have changed this plan a half dozen times because of their
    feedback, and I think even Senator Murray is going to find that
    we are going to be open and responsive to concerns. So, we are
    looking for that type of relationship with you.
        Senator Moran. I appreciate that. For example, I learn
    something about the Choice Program almost every day, certainly
    every week in conversations with veterans and conversations
    with health care providers.
        I completed another round of 127 visits, one to each
    hospital in the State of Kansas, where I learned things about
    the Choice Program that I probably should have known, but it
    never occurred to me, the way it was operating, at least from
    that provider's perspective. And, again, I think all of us here
    can provide information that can be helpful in getting a Choice
    Program that serves our veterans well.
        In response to Senator Murray's question, you said
    something that caught my attention: This will not be an
    unfettered Choice Program.
        Secretary Shulkin. Yep.
        Senator Moran. I wanted to give you the opportunity to
    explain to me and to the Committee what that means.
        Secretary Shulkin. Yes. There are some that have suggested
    that the very best approach is just give veterans a card, a
    voucher, and let them go whatever they want to go. And I think
    that there are some significant concerns about that, and you
    are going to see this proposal is not that.
        This proposal is to develop a system that is designed for
    veterans, that coordinates their care, and gives them the
    options when it is best for in the VA and when it is best in
    the community.
        Unfettered choice is appealing to some, but it would lead
    to essentially, I believe, the elimination of the VA system
    altogether. It would put veterans with very difficult problems
    out into the community with nobody to stand up for them and to
    coordinate their care, and the expense of that system is
    estimated to be, at the minimum, $20 billion more a year than
    we currently spend on VA health care. So, for all those
    reasons, I am not recommending that we have unfettered access.
        At some point in the future, if you design the system
    right, giving veterans complete choice, I believe, in
    principle, is the direction we should be headed in but not in
    2017.
        Senator Moran. Mr. Chairman, I would conclude by indicating
    to Secretary Shulkin and with my appropriator's hat on, we
    cannot afford to provide two different systems of service.
        Secretary Shulkin. That is right.
        Senator Moran. They cannot overlap with each other. They
    have got to find the place in which they have a purpose. We
    cannot afford to do both.
        Secretary Shulkin. Yes. I agree.
        Senator Moran. Mr. Chairman, thank you.
        Chairman Isakson. Thank you, Senator Moran.
        Senator Tester?
        Senator Tester. Yes. Thank you, Mr. Chairman, and I am
    almost inclined to have the Secretary say that Tester was right
    again for the record.
        Secretary Shulkin. I will not do that again.
        Senator Tester. OK. All right. I did not think you would.
    [Laughter.]
        Look, I have got a couple things. I know we said that--I
    did not want to make this a budget hearing, but there are a
    couple things in the budget, I really do have to touch on.
        Secretary Shulkin. Yes.
        Senator Tester. One of them was the President's Budget
    Request lays out a plan that would pay for expanded access to
    private-sector care by taking money from disabled vets or, even
    worse, elderly disabled vets. Is it the intent, do you think,
    the Administration is going to move forward with that, or are
    you going to be able to put any input into that to make sure
    that that does not happen?
        Secretary Shulkin. Well, we certainly noted the strong
    concerns not only of Members of Congress, but certainly from
    the VSOs. And I will tell you, we are going to take that
    concern very seriously. Nobody wants to be taking away
    unnecessary benefits from veterans and certainly not putting
    them into poverty, so that is a significant concern.
        We have tried to go back. Remember this is a budget that
    adds multiple billions of dollars more into veterans' benefits,
    into both health care and on the mandatory side. We have gone
    up from 2016 to 2018 on mandatory benefits over $12 billion, so
    remember this is more benefits going to veterans.
        We felt an obligation to go back and look at our current
    programs and say, ``Are they designed the right way? Is there a
    way to refine them?'' So, we need to continue to look to get
    that right.
        Senator Tester. Good.
        I want to go back to the Choice Program, community care
    versus VA care, and tell you where--we are probably all on the
    same page around this rostrum, but as we are all on the same
    page and the budget comes out and gives a 33 percent increase
    for private-sector care versus a 1.2 increase for care provided
    directly by the VA, it does not take very many budgets like
    that and pretty soon you are not going to have any vets going
    to the VA, because all the money is going to community care.
    And they will follow the money. I promise you, they will follow
    the money.
        I think that--I do not want to put words in the VSO's
    mouth. They will have a chance here in a bit. But, I think most
    of the veterans I talk to say build the VA's capacity.
        In Montana, we do not have enough docs. We do not have
    enough nurses. We do not have enough of anything. Quite
    frankly, that takes away from the experience and the quality of
    care. So, by putting 1.2 percent increase for care provided
    directly by the VA and 33 percent for private-sector care, we
    are privatizing the VA with that budget.
        Secretary Shulkin. Well, I told you I was not going to say
    that you were right again, but there is a lot--there is a lot
    that you said that I think we both agree with. The goal is not
    to privatize the VA.
        What we are asking for in this is something we do not have.
    We need additional flexibility between the money that goes into
    the community and the money that can be spent in the VA. Right
    now, we are restricted to a 1 percent ability to transfer money
    between.
        We are seeking that you give us more latitude there for
    exactly the reason you are talking about, Senator. We need our
    medical centers and our VISNs to be able to say that they need
    to build capacity in the VA where it is not available.
        The reason why we are letting people go into the community
    now is because if the VA does not have it, we have to get them
    that care.
        Senator Tester. I got it, but if we do not make the
    investment so they can get that health care, they will never
    get that health care within.
        Secretary Shulkin. Right.
        Senator Tester. OK.
        Secretary Shulkin. Yes.
        Senator Tester. Good. Now, I had a meeting with some vets
    up in Kalispell. They said that you bring on new docs; they are
    fuzzed up about the VA. They love it. They are in for about 2
    or 3 years, and they get burned out. One of the reasons they
    get burned out is an issue that you addressed earlier, and I
    want to go back to it. That is the doctor's ability to refer
    patients to the private sector without having to refer to
    somebody above them and maybe even go to Denver in our case and
    then back. I do not know where the puzzle goes to.
        But, I do know that doctors are not allowed, even for a
    simple x-ray in the private sector or an MRI, to be able to do
    that, and they get fed up with it. Doctor, Doctor, you would
    probably get fed up with it too if you were treating a patient.
        Are you saying that they are going to be allowed to be able
    to access the doc, in consultation with the veteran, and going
    to be able to clinically decide whether they need to go in
    there, and there is not going to be a bunch of red tape
    attached?
        Secretary Shulkin. Well, you know, both Dr. Yehia and I see
    patients in the VA, so we understand the frustration when
    people tell us how to practice medicine.
        This plan is to put the decisions back into the hands of
    the patient and the provider.
        Senator Tester. Good.
        Secretary Shulkin. But, we--but listen, you know, this is--
    we have to also make sure that the resources that we spend of
    the taxpayers are appropriate. So, we are going to give
    guidelines, but we are not going to be micromanaging.
        Senator Tester. That is fine.
        And just real quick, because my time has run out, do you
    need that to be a part of the Choice bill that we write up, or
    do you have that authority right now to do that?
        Secretary Shulkin. Well, right now, you have the TPA in the
    middle. Remember, we have this multiple-step process, so we
    need legislation.
        Senator Tester. So, you need legislation. Thank you.
        Secretary Shulkin. We do.
        Senator Tester. Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Tester.
        Senator Sullivan?

              HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA

        Senator Sullivan. Thank you, Mr. Chairman, and, gentlemen,
    thank you for your testimony.
        I want to start by echoing the Chairman's comments about
    the move that you took yesterday, Mr. Secretary. You know, I
    think, as you and I talked about before the hearing, people
    have been talking about integrating the DOD and armed
    services--or active duty systems on health care for, gosh,
    decades. So, you took the step. Thank you. I am sure it is not
    going to be without hiccups, but I think you have the support
    of this Committee behind you on that.
        Secretary Shulkin. Thank you.
        Senator Sullivan. A number of us actually serve on this
    Committee and the Armed Services Committee, so we can kind of
    keep an eye on it from both ends. So, thank you for that.
        I also wanted to thank you and Dr. Yehia. I know both of
    you put a lot of time in the issue of the Tribal Sharing
    Agreements in Alaska. You know how important it is to our
    State, not just the Alaska Native vets, who have a tremendous
    record of patriotic military service, but to non-Native vets. I
    know you are focused on that. I just want to thank you for
    providing that kind of top-level focus.
        I wanted to talk about a couple things, Mr. Secretary, that
    you and I saw when we took a trip out to Alaska together, some
    which were Alaska-specific, some of which were national issues.
        Let me begin by, if you remember, we ran into a number of
    vets. Really, I think the first time, you and I learned a lot
    out there on this issue of providers not being reimbursed quick
    enough by the VA, and then them turning to the young, you know,
    25-year-old soldier who just came back from Iraq, hitting him
    up with a big bill and a collection agency riding him. What are
    we doing to address that? That obviously was an issue we saw in
    Alaska, but I know it is a national issue. How are we trying to
    address that? There is nothing more stressful than a young guy
    who gets approved to go the VA--or woman--gets an appointment,
    gets a surgery, and the next thing you know, he has got an
    $80,000 bill that some collection agency is after him and
    ruining his credit score. How are we trying to address that
    nationally?
        Secretary Shulkin. Well, we did see that way too often,
    particularly early on with the Choice Program.
        With the extension, with the Choice Improvement Act, that
    is something that is actually now changed in law. That VA has
    taken over the responsibility of being the primary coordinator
    of benefits. That takes the veteran out of the middle.
        Part of what we have experienced with the Choice Program is
    a different set of rules for when veterans get care in the
    community and a different set of rules when they get care in
    the community. So, we confused veterans, we confused providers,
    we confused our own staff. We are moving toward a single set of
    rules for care in the community, and we are never going to put
    the veteran in the middle again like what we did.
        The one exception that I still am concerned about is
    emergency care, and as you know, there was a court case
    recently that required--it is called the Staab decision--that
    required VA to pay emergency medical care, and it is going to
    take us a year to write the regulations to do that. So, a
    veteran may find themselves in the position you are talking
    about that.
        Senator Sullivan. Yes.
        Secretary Shulkin. That worries us a lot, but we are
    probably about 9 months away from fixing that problem.
        Senator Sullivan. Good.
        You know, Senator Tester mentioned the issue of a lack of
    docs, particularly in big rural States like his and mine. We
    are close to introducing, I think with the support of the VA,
    the Serving Our Rural Veterans Act, which would establish pilot
    residency programs in big rural States. I should just call that
    the Shulkin bill because, to be honest, that was your idea when
    we were out in Alaska. We just want to get your commitment. I
    think you will see bipartisan support here, but we want to kind
    of finalize that with the VA to make sure you guys are good to
    go with that one.
        Secretary Shulkin. Well, one of the things we know, you do
    not have a medical school in Montana or one in Alaska. When you
    train physicians and they have a good experience where they
    train, particularly at VAs, they want to tend to stay there,
    and that is what we want. We want them to ultimately see a
    career in the Federal Government in this way, so we are very
    supportive of that.
        Senator Sullivan. Good. Great.
        Let me ask a final issue. You know--and you saw it when you
    were in Alaska. The Choice Program up there was an utter
    disaster, as it was in a lot of States, and you committed--and
    I think the VA has done a good job on it. We are not 100
    percent there yet, in Alaska, pilot program that was really
    focused on trying to fix some of these Choice issues. How often
    do you receive updates, now that you are the Secretary, on the
    performance of that pilot program, and how do you measure
    performance?
        And I will offer that up to both of you.
        Secretary Shulkin. Yes. Yeah, I would rather have Dr. Yehia
    answer that.
        Dr. Yehia. Yes. We stay in close contact with our
    colleagues in Alaska because, really, they are serving as a
    model of where we are going with care and also with our new RFP
    proposal. It is how you get care locally more in the hands of
    that patient, their care team, and the local community
    provider.
        I think they are having some issues with staffing they were
    continuing to work through because of the great number of
    volume that they do----
        Senator Sullivan. Yes.
        Dr. Yehia [continuing]. Of delivering care in the
    community, but for the most part, the experiences of the
    veterans has been excellent, and the timeliness of actually
    getting care into the community has improved from before. We
    are happy with the progress that is being made there.
        Senator Sullivan. But, you are continually monitoring it?
        Dr. Yehia. Absolutely.
        Senator Sullivan. OK. Thank you.
        Mr. Chairman, thank you. I have one final question I will
    submit for the record, but it actually relates to the vacant
    and underutilized list of buildings, where I think you had a VA
    building in Anchorage, AK, that is actually very utilized and
    very important, and it was on the list. So, we will submit that
    for the record, just to get clarity on that. It may have been a
    mistake on the VA's part.
        Secretary Shulkin. We could have made a mistake there. Yes.
        Senator Sullivan. OK. Thank you.
        Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Sullivan.
        Senator Sanders.

             HON. BERNIE SANDERS, U.S. SENATOR FROM VERMONT

        Senator Sanders. Thank you, Mr. Chairman.
        Good to see you, Dr. Shulkin.
        Secretary Shulkin. Good to see you.
        Senator Sanders. Let me tell you my starting assumptions
    when I look at these issues. I start off with the assumption
    that for those veterans who get into the VA system in a timely
    manner, generally speaking, they think--and having talked to
    all of the veterans' organizations about this, I think they
    confirm it--that, generally speaking, the quality of care is
    good, that the average veteran in this country, in fact, is
    very, very proud of the care that they get at the VA, despite a
    lot of attacks that we have seen over the years and despite the
    reality that there are problems within the VA, in any system as
    huge as the VA, not to mention there are many problems in our
    general health care system outside of the VA as well.
        All right. So, here is my concern. I want to see the VA be
    strengthened, provide the highest-quality care in a timely
    manner to all of our veterans, and I think what concerns me is,
    as I understand it--correct me if I am wrong--that today there
    are some 45,000 vacancies--doctors, nurses, other medical
    personnel.
        I know some years ago, we appropriated some $5 billion into
    bringing more medical personnel into the system. I believe of
    that fund, there are only $600 million remaining. Is that a
    rough----
        Secretary Shulkin. Yes. $595 million. Yes.
        Senator Sanders. 595. All right. Close enough.
        How much money are you going to need to fill those
    vacancies to make sure that our veterans get quality care in a
    timely manner?
        Secretary Shulkin. We need what the budget says that we
    have. That is enough money for us to fill those positions and
    be able to take care of the veterans in the way that you have
    said. I agree with everything that you said that we want to do.
        Senator Sanders. OK. How long do you think it will take? I
    know it is easier said than done, but how long do you think it
    will take to fill those vacancies?
        Secretary Shulkin. Well, we generally fill about 32,000 a
    year. So, this is going to be a little bit of an accelerated
    effort to be able to fill those critical positions, but I do
    not think it is an impossible effort. I think that with a focus
    on making sure that these positions are filled, we are going to
    get that done over the course of this next year.
        You will always have turnover, Senator, so you are
    constantly--you know, people leave. You are constantly
    refilling. So, you know, the usual is about 32,000 a year.
        Senator Sanders. OK. Let me move to another area, an area
    that Senator Murray has led the effort on, that I have been
    working with her. We have made, over the years, some progress
    in assisting caregivers, which I think is just a huge issue. I
    mean, you often have wives, sisters, family members who have
    devoted much of their life, Mr. Chairman, to taking care of
    heroes and heroines who were wounded in battle. I know that we
    passed legislation to take care of the post-9/11 generation.
        I think it becomes humane and cost effective to expand that
    program. Mr. Chairman, I would hope that we can work together
    to do that. I think right now, as we speak, you have folks who
    have devoted their entire lives. They are often exhausted. They
    have given up their own careers to take care of veterans from
    Vietnam or Korea, even World War II and more recent wars. I
    would hope that we could expand that program.
        Would you say a word, Dr. Shulkin----
        Secretary Shulkin. Yes.
        Senator Sanders [continuing]. On how you see where we might
    want to go with the Caregivers Program?
        Secretary Shulkin. Well, as you know, the Caregivers
    Program, as currently authorized by Congress, only is
    authorized for post-9/11 veterans. I believe if you are going
    to look for the greatest value--and I am totally supportive of
    caregivers for post-9/11, but the greatest value would actually
    be in our elderly veterans, because what you want to do is
    allow people to remain in their homes as long as they possibly
    can because that is where, frankly, most of us would rather be
    than move to an institution.
        Senator Sanders. Can I interrupt you to just ask you?
        Secretary Shulkin. Yes, yes.
        Senator Sanders. I think you are absolutely right, but even
    from a dollars and cents point of view, doesn't it make sense
    to give support to those people who care for veterans in their
    homes rather than putting them in nursing homes?
        Secretary Shulkin. I think it does. I think that would be
    very cost effective.
        What we have done--and I will tell you part of what I hope
    that you are seeing them doing--when we have problems in the VA
    and things are not working, I am calling them out. I called out
    the Caregivers Program for essentially not working. We were
    giving caregiver benefits and then withdrawing caregiver
    benefits 90 percent of the time in some cases. So, I suspended
    all of the revocations of caregiver benefits. Now no one is
    getting them revoked until we review the policies and we make
    sure that we have it right, first of all.
        Second, we are looking at every benefit that we have, and
    many of them, not surprisingly, are different parts of VA--some
    are in VBA--to help support elderly, people that need help in
    their home, with home aides and caregivers in the home. We do
    not call them ``caregivers,'' but we have benefits for them.
        So, what we are going to be introducing in the next several
    months--I would say 2 months--is a revised set of criteria to
    be able to help support more veterans, particularly the elderly
    veterans, and where we find gaps, we are going to come back to
    you--we know Senator Murray is very interested in this as
    well--and ask for your help to be able to do the right thing
    for our veterans.
        Senator Sanders. Thank you very much.
        Chairman Isakson. On a personal note, I have talked with
    the Secretary about this and talked with Senator Murray about
    this. With caregivers, it is a huge problem. When you can
    benefit not only the veterans, but benefit and lessen some of
    the burden on the VA, if we do it right. I would like to work
    with it as well and continue to do so on that.
        I want to recognize Senator Rounds for his 5 minutes of
    questions and ask you to yield to Senator Blumenthal when you
    finish in case--I have got to go return a phone call real
    quick, and I will be right back. I am sure Senator Tester will
    take my place. Yeoman's work. Right?
        Senator Rounds.

            HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

        Senator Rounds. Thank you, Mr. Chairman.
        Gentlemen, I just want to talk a little bit about the
    difference between the proposed CARE plan and Choice as it is
    today, and I am assuming that if CARE were to step in that
    Choice would go away.
        Secretary Shulkin. Mm-hmm.
        Senator Rounds. Right now, the way that I understand it
    with Choice, the veteran makes the choice if they have been
    more than 30 days or more than 40 miles away, which is a lot of
    South Dakota, in terms of they make the choice of choosing a
    provider.
        Under the new program that you have proposed, the VA, they
    would make a trip to a VA facility in order to see a physician
    to begin with, who would then make the decision as to whether
    or not they would be able to be treated in their home
    community. Am I wrong on that, or did I misunderstand?
        Secretary Shulkin. It would be an option for a veteran to
    come into a medical center to see somebody or to simply call on
    the phone or do a text message through their HealtheVet system
    or any other way. So, it is not meant to be a physical
    consultation. It is just talking to your care team.
        Senator Rounds. So, the VA would then receive a phone call
    from a veteran, and then the VA would decide, ``You come in, or
    we will allow you to go to the physician of your own choice.''
        Secretary Shulkin. It should be a joint decision, but yes.
    Essentially, you have got the right.
        Senator Rounds. It does not sound like it is a joint
    decision.
        Secretary Shulkin. Well, when I treat patients, I would
    listen to my patients, and I understand what their needs are.
    If they say to me, ``Listen, I do not have a car. I have
    decreased visual acuity. It is hard for me to get around,'' I
    say, ``Listen, I want you close to home. I do not want you
    driving 30 miles and looking for a parking spot.''
        I think what good doctors and good providers do is they
    recognize this is a joint decision.
        Senator Rounds. Well, because right now--and we have talked
    about this before, but I just want to bring it up again.
        Secretary Shulkin. Yes.
        Senator Rounds. In South Dakota, we have had veterans who
    have literally gone to an optometrist, received a prescription,
    and simply asked the VA to fill a set of glasses and been told,
    ``Drive 170 miles if you want your glasses.''
        Secretary Shulkin. That is ridiculous.
        Senator Rounds. It is, and yet what you are suggesting is
    that same alternative could once again become a reality in
    rural States if we do not provide some sort of evidence or some
    sort of assurance that a veteran outside of that area has some
    say other than simply requesting permission of the VA to use a
    local physician.
        Secretary Shulkin. Well, if we are making veterans do that,
    we are implementing this program wrong.
        Now, having said that, it is----
        Senator Rounds. Then, why not make it clear so that there
    is no misunderstanding?
        Secretary Shulkin. Yeah, yeah. We are going to be issuing
    guidance for sure, but we----
        Senator Rounds. How about putting it in the law?
        Secretary Shulkin. About----
        Senator Rounds. How about putting it in the rules?
        Secretary Shulkin. Well, yeah.
        Senator Rounds. Because--here is the reason why I am saying
    that. In 2009, we had the Emergency Care Fairness Act. It was
    signed by President Obama in 2010. That allowed for veterans to
    go to an emergency room, regardless of whether it was a VA
    facility or a non-VA facility, and that law made it pretty
    explicit that the VA would pay for that emergency room care
    just as if they went to a VA facility.
        2011 came. 2012 came. 2013 came. Those were denied time
    after time after time by a VA that said, ``Well, our rules do
    not say that. We do not interpret the law that way.''
        Furthermore, in 2014--I believe that is the Staab case. The
    Staab case has now been in court. It has been decided. It has
    been appealed. The VA lost. It has been appealed again, and the
    VA lost. What I believe I just heard you say was that it is
    going to be a year before we have the rules in place to pay for
    emergency room care for some of these veterans that have been
    waiting for years to get reimbursed?
        Secretary Shulkin. Yes. Let me be clear about that. Your
    history is accurate. From the day I became Secretary, I
    instructed the VA: there will be no more delays in moving
    forward to pay those cases. We lost in court. It was not even
    close. OK. Every----
        Senator Rounds. They refused to even listen to the final
    request----
        Secretary Shulkin. Right.
        Senator Rounds [continuing]. For an appeal.
        Secretary Shulkin. Yes. Our refusal to accept reality is
    only hurting veterans. So, we are moving forward with that, and
    nobody should do anything to delay that anymore, but----
        Senator Rounds. So, now, how much do we owe those veterans
    right now under that plan?
        Secretary Shulkin. About $2 billion.
        Senator Rounds. $2 billion. And you are suggesting that it
    will take a year to create the rules?
        Secretary Shulkin. To write the regulations.
        Senator Rounds. In the meantime, we have got veterans who
    have been waiting for 7 years now for reimbursement for
    emergency room care? Is not there some kind of an alternative
    here for an emergency determination as to a rule that the court
    has ordered it be paid?
        Secretary Shulkin. Well, this is still in court under
    appeal. We will hear sometime this summer, but----
        Senator Rounds. So, who makes the decision as to whether or
    not the VA should continue with an appeals process such as that
    after the courts have turned them down?
        Secretary Shulkin. Yes.
        Senator Rounds. You have got veterans--in one case, one who
    is 94 years old with a $10,000 bill, and they just decided they
    are not going to pass away until they get that bill paid.
        Secretary Shulkin. Yes.
        Senator Rounds. Now, maybe we ought to just delay that
    appeals a little bit longer, and the gentleman can live a
    little bit longer. But, it seems to me that we are barking up
    the wrong tree----
        Secretary Shulkin. Well----
        Senator Rounds [continuing]. If we are going to have
    another appeals process before we take care of these veterans.
        Secretary Shulkin. Well, once again, there is going to be
    no delay. We are doing everything we can to get those bills
    paid.
        Senator Rounds. Mr. Secretary, with all due respect----
        Secretary Shulkin. Yes.
        Senator Rounds [continuing]. You just told me it is going
    to be a year to write the rules.
        Secretary Shulkin. Well, that is the way that this works.
    We cannot pay unless we have the regulation that allows us to
    pay, and, you know, I wish we had started this earlier. But, we
    are doing this now.
        Senator Rounds. I think this--you know, I like what you are
    trying to do at the VA.
        Secretary Shulkin. Yep.
        Senator Rounds. We need the reforms.
        Secretary Shulkin. Yep.
        Senator Rounds. With all due respect, if that is the
    approach that we take when it comes to one in which we have
    already lost in court and we are talking $2 billion owed to
    veterans, but we want the veterans out there who right now
    might be seeing a Choice Program which is being improved and
    one that they can actually get in rural areas to the physician
    of their own choice, and now we want them to believe that in
    the future, the VA will, if it is only their authority--that
    they will make the appropriate decision to allow them to
    continue to go to a doctor outside of the VA based solely upon
    the VA's decisionmaking process?
        Secretary Shulkin. We are following your rules. We are
    instructed we are only allowed to pay, use taxpayers' money,
    when we have regulations that allow us to pay it.
        I am saying I am not willing to put the veterans in the
    middle, and everybody at VA now knows they are to write those
    rules and get this fixed as soon as possible.
        Senator Rounds. With all due respect, once again, Mr.
    Secretary----
        Secretary Shulkin. Yes.
        Senator Rounds [continuing]. The law was written in 2009.
    It was signed into law. It was signed by the President in 2010,
    and in 2011----
        Secretary Shulkin. OK.
        Senator Rounds [continuing]. You rewrote the rules at the
    VA to interpret it different than what the law says. Now you
    have got a court case, which has continued on, and you have
    lost in every single appeal. Now you are suggesting that we are
    going to continue the appeal, and then you are going to write
    the----
        Secretary Shulkin. OK. So----
        Senator Rounds. I am sorry, but there is something wrong
    with this process, sir.
        Secretary Shulkin. Well, you and I agree that this should
    not have happened to the veterans, and you and I agree that we
    have lost the case. That is why I am proceeding to pay these
    bills. You and I may not agree.
        Senator Rounds. I thought we said we were going to go
    through the appeals process.
        Secretary Shulkin. Yes, yes. I am going to explain to you
    why I believe it is the right thing to go through the appeals
    process, because we are agreeing to pay these bills on veterans
    who are not service-connected and who have other health
    insurance. That $2 billion that I have agreed that we are going
    to pay, I am going to take away from other parts of my budget
    that should be helping veterans that really need our help, that
    do not have other health insurance and are service-connected.
    So, from a policy point of view, I believe the court made the
    wrong decision, so I am going to fight that out in court.
        But, I am not going to keep putting the veterans in the
    middle. We are going to pay those bills, because we have lost
    this case up until time the court tells us otherwise, and I
    will not delay a day to keep these veterans out of the middle.
        Now, if I can use my authorities to avoid the type of
    veteran that you have talked about from being penalized, I will
    issue those types of waivers, because I think it is the right
    thing to do, and I want to work with you on it. But, I believe
    that the VA should not be using its money this way, but until I
    have a day that a court agrees with me, I am not going to put a
    veteran in the middle.
        Senator Rounds. Well, Mr. Chairman, my time has expired,
    but I just think this is one of those programs where----
        Secretary Shulkin. Yes.
        Senator Rounds [continuing]. A good example of where we may
    have to agree to disagree today, but this has got to be
    resolved, Mr. Chairman. Thank you.
        Thank you, Mr. Secretary.
        Chairman Isakson. Thank you for your attention to it,
    Senator Rounds. You have been a real leader on this particular
    issue.
        Senator Blumenthal.

                       HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Mr. Chairman. I want the
    record to reflect that Senator Rounds would not yield to me and
    that he took all my time. [Laughter.]
        I want to follow up on this case, but I do not want to take
    all of my time with it----
        Chairman Isakson. Sure.
        Senator Blumenthal [continuing]. Because as a Department of
    Justice lawyer as well as Attorney General, I would like to
    pursue the very important questions that Senator Rounds is
    asking you, particularly as to what authority you may have or--
    --
        Secretary Shulkin. Yes.
        Senator Blumenthal [continuing]. More likely the Department
    of Justice to just drop the appeal and decide that you are not
    going to subject the VA to the burden of doing these
    reimbursements in the face of the possibility--and I hate even
    to raise it--that a court could reverse the rulings below, and
    then you will have reimbursed a lot of people----
        Secretary Shulkin. Yes.
        Senator Blumenthal [continuing]. With potential liability
    to whomever.
        Secretary Shulkin. Yes. I would be glad to talk to you more
    about that, and listen, I understand. This is a situation that
    I inherited. I want to do the right thing. You both have a lot
    of experience in this. I would like to talk to you about it.
        Senator Blumenthal. But, perhaps on a bipartisan basis,
    Senator Rounds and I can explore this issue.
        Secretary Shulkin. Yes. Thank you.
        Senator Blumenthal. I know your heart is in the right
    place.
        Secretary Shulkin. Yes.
        Senator Blumenthal. That is the important thing, and let me
    just begin by saying I appreciate the very significant
    contribution that you have made already in your new position as
    well as throughout a career of dedication to improving American
    health care for veterans and for the American people in
    general.
        I want to express, first, my appreciation to your
    commitment to CBOCs in Connecticut and around the country,
    because I think they are a way of strengthening the VA health
    care system and enabling more health care to be available to
    veterans where they live, closer to their homes, and more
    timely. We have found that fact to be true in Connecticut, and
    as you may know also, Connecticut is seeking to enhance its
    CBOCs. I hope that you will commit to continuing that effort.
        Secretary Shulkin. Mm-hmm.
        Senator Blumenthal. The record should reflect that you are
    nodding and you are in agreement, so I think----
        Secretary Shulkin. I am always open to anything that will
    improve the care for our veterans.
        Senator Blumenthal. Second, on the issue of improving
    health care, raising what may seem to many to be a small issue,
    Internet connections in VA facilities, I appreciated the VA's
    commitment to providing Internet connections in the West Haven
    facility. It has not yet been completed. My understanding is
    that a contract has been signed, but the faster we can make
    those Internet connections available in Connecticut, West
    Haven, and throughout the country, my understanding is that
    there are a number of other facilities where inpatient veterans
    cannot communicate with the outside world through the Internet,
    which is unfortunately for their medical care, because as we
    all know, a patient who is isolated and alone and depressed and
    otherwise out of touch with the world is not likely to improve
    or recover as fast as somebody who feels support from the
    outside world.
        I was alerted to this issue by a veteran friend of mine who
    was undergoing cancer care, and I have been campaigning for it,
    so to speak. I appreciate your cooperation.
        Women veterans. I would like to ask for your commitment
    that you will continue to pursue any and every opportunity for
    expanding and enhancing health care for women veterans, whether
    it is under the Choice Program or any of the other programs. I
    am deeply impressed with the advocacy by women and by the VSOs
    on their behalf, and I want to thank them for their advocacy,
    not only the Iraq and Afghanistan veterans, the post-9/11
    veterans, but all veterans who have served. I think your heart
    is----
        Secretary Shulkin. Yes.
        Senator Blumenthal [continuing]. In the right place on that
    one too.
        Secretary Shulkin. Yes.
        Senator Blumenthal. And, finally, before my time expires, I
    would like to know on the new electronic health records system,
    what you can do to allay some of our--at least my skepticism
    founded on close to 7 years of experience of hearing ``It is
    all going to be OK'' from both sides, the Department of Defense
    and the VA.
        I know that Senator Tester has expressed very powerfully
    his feeling that implementation must be done efficiently,
    effectively, and timely. We are talking about a major
    commitment of resources with the best will in the world. It
    cannot happen without resources. Do you have a commitment from
    the President of the United States that those resources will be
    forthcoming this year or next year?
        Secretary Shulkin. The President is very excited about the
    possibility of putting finally this together as one system that
    is going to serve active military and veterans, and he is
    extremely supportive.
        We do not know what those resources and what that plan
    looks like exactly at this time. So, until I have a fully
    developed plan, I do not think it is fair to ask for either
    Congress' full support or the President's full support until I
    can say exactly what we need.
        But, I will not be putting forth a plan that I do not
    believe has a high likelihood of success.
        Senator Blumenthal. Well, for the President to be excited
    is good in this instance. For the President to be supportive is
    fine, but I have to tell you, show me the money. I hate to
    question your credibility, and I am not doing that, but I feel
    we really need to be very hardheaded and demanding here because
    changing the system and saying we are going to abandon the
    present system may have unintended consequences. I hope that
    there will be that kind of--because the veterans deserve it.
        Secretary Shulkin. Yeah, yeah.
        Senator Blumenthal. I know everybody in this room feels
    that we have betrayed a trust here. I do not mean to be too
    harsh on anyone. Again, with the best will in the world, the
    resources simply have not been forthcoming, and I trust you to
    devote your full energy to it.
        Secretary Shulkin. Yes. You know, I said earlier this week
    that I personally led the implementation at several
    institutions of EMR systems. I have never done anything on this
    scale. So, I am approaching this with an extreme deal of
    caution, knowing the false starts.
        I am comforted by the fact that the DOD is a couple years
    ahead of us and has really worked hard to plan this out in a
    well-designed way, but I have said that we need approximately 3
    to 6 months to come up with what this plan is, what the
    resources are needed. I will not proceed unless I feel that
    this is a plan that we can execute on.
        I do have the President's commitment to modernize this
    system. I think you are seeing it in the budget this year that
    he is willing to put the resources necessary to get this system
    back to where it needs to get.
        I am feeling optimistic about the path forward but cautious
    enough to share some of your concerns.
        Senator Blumenthal. We are talking about real money here
    because the Department of Defense has already spent $4.3
    billion. It is expected to spend $9 billion. Your commitment
    will have to be in roughly that same range. I deeply respect
    and I am grateful for the President's commitment in the budget
    to devoting more resources to the VA. But, we are talking about
    a different order of magnitude here.
        Secretary Shulkin. Yes.
        Senator Blumenthal. Thank you.
        Thank you, Mr. Chairman.
        Chairman Isakson. In the interest of bipartisan equity and
    at your request, Senator Blumenthal, let then record reflect
    that the addition 3 minutes and 37 seconds you took actually
    exceeded Senator Rounds' 5 seconds. [Laughter.]
        Senator Blumenthal. I offer my deep apologies.

           HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

        Senator Tillis. You helped me save my time by making that
    same point, but it was a very important discussion. I want to
    continue with electronic health records.
        Dr. Shulkin, how many electronic health record platforms do
    you have in the VA?
        Secretary Shulkin. We have one.
        Senator Tillis. You have one central system today?
        Secretary Shulkin. Yes. Well, there are 130 versions of one
    central system.
        Senator Tillis. That was really my point.
        Secretary Shulkin. Yeah, yeah, yeah.
        Senator Tillis. You have 130 individual instances of
    electronic health records----
        Secretary Shulkin. Yes.
        Senator Tillis [continuing]. Within your own enterprise
    that you have to rationalize and integrate to get an enterprise
    platform.
        Secretary Shulkin. Yes. That is a considerable problem for
    us.
        Senator Tillis. I am just trying to point to the
    implementation challenge here.
        Now, 30 to 40 percent of your community care or your care
    provided is through community care. To what extent does the
    electronic health record right now flow seamlessly between that
    30 to 40 percent of community care providers?
        Secretary Shulkin. Well, we have partial interoperability.
    We have it, of course, with the DOD, and we have it with about
    a thousand providers in the community.
        Senator Tillis. But, to a certain extent----
        Secretary Shulkin. Partial.
        Senator Tillis [continuing]. A part of the enterprise that
    you have control under, you have over a hundred instances
    within your enterprise. You have several hundred, maybe
    thousands of instances outside of your enterprise.
        Secretary Shulkin. Absolutely.
        Senator Tillis. Now you have the added instances that would
    be any of the providers through Choice.
        Secretary Shulkin. Yes.
        Senator Tillis. That is before you actually start
    integrating with the DOD----
        Secretary Shulkin. Right.
        Senator Tillis [continuing]. Which is why it is completely
    reasonable to think it is going to take you 3 to 6 months to
    rationalize the system. It is also why I think it is very
    important that we get people in permanent positions on your
    team----
        Secretary Shulkin. Absolutely.
        Senator Tillis [continuing]. To take responsibility and
    have accountability for execution. I think there are nine or so
    that we have not received nominations for. They need to be
    expedient with getting their paperwork done. We need to get
    them confirmed so that you can execute, because that 3-to-6-
    month window is probably going to slide more to the 6-month
    side if we do not have the permanent leaders in place.
        Over what period of time did it take to actually settle on
    the commercial off-the-shelf system, the same platform the DOD
    has? Was that just a unilateral decision, or did you go through
    a selection process?
        Secretary Shulkin. No. I took a look at about 17 years of
    commission reports, recommendations, hearings, external
    consultants, spoke to people, brought in experts from the
    outside, including CIOs and CEOs, and then I made the decision.
        Senator Tillis. Good. You made a great decision. I am glad
    to see that you did not confuse it with an RFP process that
    would have put you further away and added more cost.
        I am the Chair of the Personnel Subcommittee in Senate
    Armed Services. I would like to get feedback from you all on
    things that we may even want to put in, in terms of report
    language, to get the Department of Defense ready on a
    reasonable timeframe, on a reasonable basis, to know when you
    would connect to them. But, it is only after you have
    rationalized all these underlying systems that that would be
    relevant. I would like to get that information so we could
    potentially have it considered for the NDA.
        I want to go back to something that I think is critically
    important here when we talk about ``show the money.'' We have
    got to show you the money. If we add additional requirements
    and we do not provide money, then something else suffers. Just
    in the exchange that you had with Senator Rounds, that money is
    coming from somewhere. We need you to better communicate to
    this Committee. If they agree with the court decision and they
    want to see that decision move forward, then they need to
    understand where those resources are going to come from, or we
    are going to have a subsequent committee [hearing?] where we
    beat you over the head for slowing down something, which you
    are slowing it down simply because you do not have the resource
    stream that you originally thought you did before a new
    requirement came before you.
        So, in your capacity as Secretary, it is very important for
    you to speak assertively to us when our actions either for not
    new capabilities or actions outside of all of our control like
    court decisions are actually squeezing your resources. Do I
    have your commitment you are going to do that in a very up-
    front, sometimes even aggressive way?
        Secretary Shulkin. I think you saw the beginning of that
    right here.
        You know, regarding the $2 billion, it is not that I do not
    want to pay that for veterans. This is that I am going to need
    to take that $2 billion away from veterans that I fear need the
    help more.
        Senator Tillis. We need to know where that is coming from.
        Secretary Shulkin. That is right.
        Senator Tillis. You know, that is why--to the veterans
    services organizations--when I am sometimes seen as opposing a
    well-intentioned proposal by my colleagues, it is because we
    ask you to do something more with no more resources.
        Secretary Shulkin. Right.
        Senator Tillis. We cannot have it both ways. We cannot on
    the one hand ask you to make people feel good about another
    priority that we want when we have not sufficiently resourced
    the priorities that we have already set.
        So, I think it is very important for when people ask you to
    achieve other levels of service without the total resources to
    make it very clear that that is what they are doing, so that we
    can have more discipline to achieve fulfilling the promises
    that we currently have, and then we will get to other ones that
    we want to fulfill.
        I am going to go way under 3 minutes and 40 seconds, but
    maybe just a couple more, Mr. Chair.
        So, the three things that I would just like for you to
    report back--you do not have to talk now or respond now--but
    the underlying systems, there are basically three phases of
    underlying systems and processes that you need to get right.
    One is appointments, and we all know that. We need an
    appointments platform that is rationalized, consistent,
    executed well across all the VISNs.
        We need the health care record, which we have talked about,
    and I think it is pretty clear that you are on the right path,
    but you have got a lot of work to do.
        Then, we also need to focus--I think Senator Sullivan
    referred to the billing system. I have literally gone across my
    State and told medical providers to use us as caseworkers when
    they are not getting paid promptly. That will be disruptive to
    you all, but until we can get rid of the red tape, we will just
    use our scissors to cut through it, at least for providers in
    North Carolina. I hope my other colleagues have extended the
    same offer to their providers.
        And, I would like to have, I would like an update from you
    all when you can get to it, the 12 breakthrough priorities. I
    feel like the electronic health records are a part of what you
    were talking about doing for information technology, so that is
    a part of it. I would like to get an update so that I can
    figure out how much of that is leverage-able and what our
    current progress is.
        I would like to think that the good work that was done over
    the last 2 years is not being repurposed. You have assured me
    that it is not.
        Secretary Shulkin. Right.
        Senator Tillis. I think it would be helpful to frame our
    discussions, going forward in the context of those priorities,
    what legislation action you need and what slips when we add new
    priorities to you.
        Thank you.
        Secretary Shulkin. Thank you.
        Chairman Isakson. Thank you, Senator Tillis. Appreciate
    your participation and your patience in waiting till the very
    end. Thank you very much.
        Dr. Shulkin, thank you very much for your testimony----
        Secretary Shulkin. Sure.
        Chairman Isakson [continuing]. Your leadership, and we
    continue to stand behind you to help you in any way we can.
        Dr. Yehia, thank you for making all the big decisions at
    the VA and giving Dr. Shulkin all the credit. We appreciate it
    very much. [Laughter.]
        We will now take Panel No. 2, the VSOs. If you all will
    come forward. [Pause.]
        I would like to welcome our second panel for testimony
    today and appreciate your patience in listening through the
    first panel. Your opinions as the VSOs are very important to us
    and a critical way for us to make decisions for the future of
    the Veterans Administration. Each of you will be recognized for
    up to 5 minutes and then stay for Q&A, if you will.
        First is Mr. Jeff Steele, Assistant Director of National
    Legislative Division of The American Legion; Adrian Atizado,
    Deputy National Legislative Director of Disabled American
    Veterans; Carlos Fuentes, Director of the National Legislative
    Service, Veterans of Foreign Wars; and Gabriel Stultz,
    Legislative Counsel, Paralyzed American Veterans.
        We will start with you, Mr. Steele, with your testimony.
    You are recognized for 5 minutes.

        STATEMENT OF JEFF STEELE, ASSISTANT DIRECTOR, NATIONAL
               LEGISLATIVE DIVISION, THE AMERICAN LEGION

        Mr. Steele. Thank you, Chairman.
        Let me quickly echo and thank you for your leadership on
    the passage of the accountability bill yesterday.
        Chairman Isakson. Thank you. We will get the door closed,
    so we can all hear you. Thank you very much.
        Mr. Steele. Thank you for your leadership, Chairman
    Isakson----
        Chairman Isakson. Thank you.
        Mr. Steele [continuing]. Ranking Member Tester, Senator
    Rubio, on the accountability bill's passage yesterday.
        Some use the term ``choice'' to imply quality. Some use the
    term ``interchangeably'' to mean access, and some champion the
    term as a ``right'' or ``freedom.'' The bottom line is that
    veterans receive care at VA because they have earned it. The VA
    is, in fact, a public trust, and the President has vowed to
    keep it a public system, a vow we wholeheartedly support.
        Chairman Isakson, Ranking Member Tester, and distinguished
    Members of this Committee, on behalf of Charles Schmidt, the
    National Commander of The American Legion, it is my duty and
    honor to present The American Legion's position on the Veterans
    Choice Program and the future of care in the community.
        The Choice discussion has distracted many in Congress and
    the community from focusing on what is really at stake here,
    and that is the future of VA. Let me be perfectly clear. The
    American Legion is not interested in preserving VA for the sake
    of VA itself. We support and protect VA because of the
    institution it represents, and that is guaranteed medical care
    and benefits support for veterans who have earned it, period.
        In our written presentation, The American Legion outlines
    the needs for the consolidation and unification of community
    care contracting practices or recommendations for public-
    private partnerships, suggestions on ways to increase capacity
    and other innovations that will support VA sustainability to
    ensure that VA remains a world leader in education, science,
    and health care.
        As a supplement to our written testimony, I will take a
    moment to address provider agreements. The American Legion
    appreciates the challenges VA faces in rural communities and
    wants to ensure that VA has the ability to contract with the
    most qualified and available medical services. Federal
    procurement regulations are daunting and cumbersome, but they
    were implemented to ensure that the Federal Government
    maintains good stewardship of people's tax dollars while
    seeking the highest possible quality and value.
        The American Legion recognizes that the added burden these
    regulations place on small businesses interested in working
    with the government can, in some cases, discourage them from
    selling to the government, and this added burden exacerbates an
    already limited marketplace for some primary care and specialty
    services in many geographical areas.
        The American Legion is not in favor of granting VA
    unlimited exceptions to the protections set forth in the
    Federal Acquisition Regulations, or FAR, but we do support an
    easing of compliance in limited circumstances. Any waiver
    allowing VA to bypass FAR compliance exposes VA to risk of
    abuse and will need to include increased and intense oversight
    that maintains the intent of the FAR and the integrity of the
    program.
        So, it is with great caution that The American Legion
    supports allowing VA relief from under FAR Part 19 and other
    necessary parts of the regulations in order to help encourage
    greater participation among qualified community providers who
    seek to serve veterans through VA provider agreements.
        The American Legion calls on Congress to grant limited
    exceptions to the FAR while instituting rigorous oversight so
    as to discourage abuse and safeguard integrity in the
    procurement and service delivery process.
        The VA has a great and awesome responsibility and will
    always require vigorous and vigilant oversight. VA must answer
    to veterans, Congress, and the people of the United States by
    providing expert caring service with complete and total
    transparency.
        We are a democratic republic, and with that comes an
    obligation, the obligation to use that transparency
    responsibly. As Americans, we have the responsibility to
    question authority, self-educate, and stay informed. Relying
    only on social or even mainstream media as the sole source of
    information is lazy and irresponsible, which is why The
    American Legion personally visits and evaluates VA medical
    centers, regional offices, and VA central offices continuously
    throughout the year.
        We review structures, programs, policies, and meet with
    millions of patients, beneficiaries, VA staff, medical
    providers, leadership, and stakeholders through our network of
    departments, our VA volunteer services, our accredited
    representatives, and our System Worth Saving Program.
        Our research is well documented. It is available for public
    review on our website, and our recommendations represent the
    voices of the largest veterans service organization in the
    country. Based on that experience and research, The American
    Legion adamantly opposes the degradation of organic VA health
    care services and calls on this Congress and Administration to
    reinforce and strengthen the Department of Veterans Affairs so
    that it can do what we all agree its needs to do--support
    veterans because they have earned it.
        Moving forward and appreciating the sincere need for
    community care, The American Legion simply urges Congress to
    fund the Community Care Program at appropriate levels, which
    should be no less than what is currently being allocated,
    without cannibalizing other areas of the VA budget.
        Thank you, and I look forward to your questions.
        [The prepared statement of Mr. Steele follows:]
        Prepared Statement of Jeff Steele, Assistant Director, National
                   Legislative Division, The American Legion
        The American Legion believes in a strong, robust veterans'
    healthcare system that is designed to treat the unique needs of those
    men and women who have served their country. However, even in the best
    of circumstances, there are situations where the system cannot keep up
    with the health care needs of the growing veteran population requiring
    VA services, and the veteran must seek care in the community. Rather
    than treating this situation as an afterthought, or an add-on to the
    existing system, The American Legion has called for the Veterans Health
    Administration (VHA) to ``develop a well-defined and consistent non-VA
    care coordination program, policy and procedure that includes a
    patient-centered care strategy which takes veterans' unique medical
    injuries and illnesses as well as their travel and distance into
    account.'' \1\
    ---------------------------------------------------------------------------
        \1\ Resolution No. 46 (2012): Department of Veterans Affairs (VA)
    Non-VA Care Programs
    ---------------------------------------------------------------------------
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee; On behalf of National Commander Charles E. Schmidt and the
    over two million members of The American Legion, we welcome this
    opportunity to comment on the veterans choice program and the future of
    care in the community.
        Make no mistake about The American Legion's position--we insist on
    a robust program that will support the sustainability of the VHA model
    of coordinated care, and we do not support degrading VHA's organic
    services. In fact, American Legion resolution number 372, passed at our
    National Convention in Ohio last year sums it up nicely:

            ``now, therefore, be it
              RESOLVED, By The American Legion in National Convention
            assembled in Cincinnati, Ohio, August 30, 31, September 1,
            2016, That The American Legion opposes any legislation or
            effort to close or privatize the Department of Veterans Affairs
            (VA) health-care system; and, be it further
              RESOLVED, That Congress enact legislation that provides the
            VA the authority to consolidate its multiple non-VA community
            care programs; and, be it further
              RESOLVED, That Congress enact legislation that would allow
            veterans to use their Medicare health care coverage, or private
            health care coverage, when receiving medical care or services
            in a VHA health-care facility, and Medicare be authorized to
            reimburse VA for such medical care and services; and, be it
            finally
              RESOLVED, That The American Legion remain open to further
            discussion on the possibility of expanding and improving VA's
            health-care
            services.'' \2\
    ---------------------------------------------------------------------------
        \2\ Resolution No. 372 (2016): Oppose Closing or Privatization of
    Department of Veterans Affairs
    ---------------------------------------------------------------------------
                               health care system
        This is the voice of more than 3 million voters who comprise The
    American Legion family.
        As Congress is now discovering and as The American Legion has
    previously testified, costs are skyrocketing beyond all budget
    predictions as the quest to provide ``choice'' has overtaken common
    sense governing. False narratives instigated by political interests
    trashed the department in 2015 and 2016 and continued to feed the
    media's insatiable appetite for scandal by spotlighting as many
    isolated incidents of malfeasance as they could find. Transparency is
    important and exposing criminal behavior is essential to good
    governance, but taken out of context this biased coverage fails to tell
    the more accurate story of an agency that serves millions of veterans
    every day with expert care. Hundreds of thousands of caring, well
    trained, and highly competitive professionals stream through the doors
    of VA medical centers throughout this Nation day in and day out for one
    purpose, and one purpose only--to care for those who have borne the
    battle--and overall, they do an excellent job.
        According to an initial report published in the Journal of the
    American Medical Association published online April 17, 2017:

            Initial Public Reporting of Quality at Veterans Affairs vs.
            Non-Veterans Affairs Hospitals
              Recently, the Centers for Medicare and Medicaid (CMS)
            announced the inclusion of Veterans Affairs (VA) hospital
            performance data on its Hospital Compare website. Prior to this
            release, comparisons of quality at VA vs non-VA hospitals were
            inconclusive and had methodological limitations. Given
            longstanding concerns about care at VA hospitals, our objective
            was to compare available outcome, patient experience, and
            behavioral health measures between VA and non-VA hospitals.
              Results--Veterans Affairs hospitals had better outcomes than
            non-VA hospitals for 6 of 9 PSIs. There were no significant
            differences for the other 3 PSIs. In addition, VA hospitals had
            better outcomes for all the mortality and readmissions metrics.
            However, on the patient experience measures, non-VA hospitals
            scored better overall than VA hospitals for nursing and
            physician communication, responsiveness, quietness, pain
            management, and on whether the patient would recommend the
            hospital to others. For behavioral health measures, non-VA
            hospitals did better on 4 of 9 measures, while VA hospitals did
            better on 1 of 9 measures.

        Following the Phoenix scandal, Congress appropriated $10 billion to
    help VA address any and all veterans who ended up on off-the-books
    waitlists \3\ that schedulers had developed, in an attempt to juggle
    the overwhelming requests they were receiving for VA care. This
    behavior was inexcusable and resulted in managers being improperly
    enriched with bonuses and incentives for a standard they had little
    control over meeting. The waitlist debacle began because schedulers
    were forbidden from using the official VA scheduling system once wait
    times started to exceed 14 days. Medical center executives' performance
    ratings were being directly tied to ensuring veterans were being seen
    within the, then Secretary of Veterans Affairs (SECVA) Eric Shinseki's
    directive of 14 days. This unrealistic goal soon became an example of
    the antithesis of performance management \4\ which led to the next
    SECVA focusing heavily on customer satisfaction and organizational
    management.
    ---------------------------------------------------------------------------
        \3\ April 2010 Schoenhard memo addressing gaming the system
        \4\ Performance Mismanagement: How an Unrealistic Goal Fueled VA
    Scandal
    ---------------------------------------------------------------------------
        Secretary McDonald instituted veteran-centric principles and
    programs while attempting to reprogram staff and midlevel leadership
    with his iconic I CARE \5\ core values; Integrity, Care, Advocacy,
    Respect, and Excellence. At the same time, Secretary McDonald was
    struggling to integrate the Choice directives into the VA's community
    care model despite the spending restrictions imposed by Congress on how
    the money was to be spent. The Choice program is a textbook example of
    how well intended overregulating can turn into troublesome unintended
    consequences.
    ---------------------------------------------------------------------------
        \5\ https://www.va.gov/icare/
    ---------------------------------------------------------------------------
        By committing $10 billion to this new procurement vehicle, Congress
    ignored all of the established contracting control measures used in
    VA's other community care programs. Choice instituted third party
    administrators, additional eligibility criteria, higher and
    inconsistent reimbursement rates, and a disconnected billing authority.
    In addition, the Choice Act mandated VA to issue paper Choice cards to
    every enrolled veteran that were essentially worthless, wasting
    millions and millions of dollars on designing, procuring, and mailing
    millions of these cards in 90 days or less.
        As part of the Choice legislation, Congress called for
    comprehensive studies into the VA's wait time issues. The VA found that
    the widespread assumption that these problems are worse in the VA than
    elsewhere is simply untrue. Based on a study by the independent RAND
    Corporation at the end of 2015, they found that ``wait times at the VA
    for new patient primary and specialty care are shorter than wait times
    reported in focused studies of the private sector.'' Overall, the
    report concluded that VA wait times ``do not seem to be substantially
    worse than non-VA waits.'' \6\
    ---------------------------------------------------------------------------
        \6\ A Product of the CMS Alliance to Modernize Healthcare federally
    Funded Research and Development Center Centers for Medicare & Medicaid
    Services (CMS) At the Request of: Veterans Access, Choice, and
    Accountability Act of 2014 Section 201
    ---------------------------------------------------------------------------
        The one thing the Choice Act effectively did was expose VA's
    practice of managing to budget as opposed to managing to need. While
    the Choice Act set a restrictive access boundary of 30 days of wait
    time, and 40 driving distance miles by presenting it as increasing
    access, the truth is, VA already had the authority to contract patients
    out to community care. They just rarely used the authority because
    their budget could serve twice as many veterans if redirected toward
    organic campus care or already negotiated and established community
    care contracts.
        Every year VA would send their budget request to the Office of
    Management and Budget (OMB) as calculated by the number of veterans
    they projected would require medical care from VA in the upcoming
    fiscal year, and every year OMB would recommend less money than VA had
    requested for the president's annual budget request. To Congress'
    credit, each year Congress would fund VA at an amount greater than what
    the president would request, but still lower than what VA had predicted
    their needs being. This budgetary tug-of-war continued for years while
    returning injured veterans became new patients of the VA, aging Vietnam
    and Korean War veterans consumed more medical services, and Congress
    opened free access to all returning combat vets regardless of whether
    or not they had a service-connected disability. Additionally, the
    Affordable Healthcare Act pushed veterans into VA who were eligible for
    VA care but never used the VA because they had access to private care,
    but who's private care didn't qualify for Obamacare. It was this
    combination of events in tandem with the national shortage of primary
    care doctors that was the foundation of the backlog of patients that
    finally erupted in 2014.
        Over the years, VA has implemented a number of non-VA care programs
    to manage veterans' health care when such care is not available at a VA
    facility, could not be provided promptly, or is more cost effective
    through contracting vehicles. Programs such as Fee-Basis, Project
    Access Received Closer to Home (ARCH), Patient-Centered Community Care
    (PC3), and the Veterans Choice Program (VCP) were enacted by Congress
    to ensure eligible veterans could be referred outside the VA for
    needed, and timely, health care services.
        On October 30, 2015, VA delivered to Congress the department's Plan
    to Consolidate Community Care Programs, its vision for the future
    outlining improvements for how VA will deliver health care to veterans.
    The plan sought to consolidate and streamline existing community care
    programs into an integrated care delivery system and enhance the way VA
    partners with other Federal health care providers, academic affiliates,
    and community providers. It promised to simplify community care and
    gives more veterans access to the best care anywhere through a high
    performing network that keeps veterans at the center of care. That
    legislation was never enacted.
        The American Legion commends this Committee for recognizing the
    need to fix the Choice program. The American Legion supported passage
    of the Veterans Access, Choice, and Accountability Act of 2014 as a
    temporary fix to help veterans get the health care they need,
    regardless of distance from VA facilities or appointment scheduling
    pressure. As Congress now recognizes a long-term solution requires
    consolidating all of VA's authorities for outside care, including
    Choice, PC3, Project ARCH and others, under one authority to help
    veterans only when and where VA cannot meet demand. The American Legion
    supports a strong VA that relies on outside care as little as possible
    and only when medically necessary, rather than a move toward vouchers
    and privatization.
        While many veterans initially clamored for ``more Choice'' as a
    solution to scheduling problems within the VA healthcare system, once
    this program was implemented, most have not found it to be a solution.
    Instead, they have found it to create as many problems as it solves.
    The American Legion operates our System Worth Saving program, which
    travels the Nation annually examining the delivery of healthcare to
    veterans. What we have found over the past decade, directly interacting
    with veterans, is that many of the problems veterans encountered with
    scheduling appointments in VA are mirrored in the civilian community
    outside VA. The solutions in many areas may not be out in the private
    sector, and opening unfettered access to that civilian health care
    system may create more problems than it solves. National Public Radio
    recently noted, ``Thousands of veterans referred to the Choice program
    are returning to VA for care--sometimes because the program couldn't
    find a doctor for them'' or ``because the private doctor they were told
    to see was too far away.'' \7\
    ---------------------------------------------------------------------------
        \7\ NPR-May 17, 2016
    ---------------------------------------------------------------------------
        As predicted by The American Legion, sending patients off VA
    campuses to community providers absent of well-crafted contracts, such
    as those used for Project ARCH and PC3, has led to inadequate
    compliance by local physicians. Their inability to return treatment
    records to VA following care provided by Choice led to uncoordinated
    care and putting veterans at serious risk for medical complications.
    When the Choice legislation was being developed, The American Legion
    insisted that any doctor treating a referred veteran have access to the
    veteran's medical records so that doctors would have a complete history
    of the veteran's medical history and be able to provide a diagnosis
    based on a holistic understanding of the patient's medical profile.
    This is important for a litany of reasons, not the least of which
    includes the risk of harmful drug interaction, possible overmedication,
    and a better understanding of the patient's previous military history--
    all important factors in wellness.
        Also, The American Legion was adamant that any treating physician
    contracted through Choice have a responsibility to return treatment
    records promptly to be included in the patients' VA medical file so
    that VA could maintain a complete and up-to-date medical record on
    their patients. We believed then, as we do now, that safeguarding of
    the veterans' medical records was so important, that we helped craft a
    provision that was included in the language that prevented VA from
    paying physicians until they turned over the treatment records to VA.
    Sadly The American Legion was forced to acquiesce our position in favor
    of paying doctors whether they turned over the medical records or not,
    because doctors weren't sending the records--it just wasn't that
    important to them--and when VA refused to pay based on the failure of
    docs to turn their medical records over to VA, the doctors blamed VA
    for not paying them in a timely manner, ultimately billing the veterans
    directly, and refusing to see any more VA-referred patients until they
    got paid. Since it was more important that veterans had access to
    sufficient medical care and not have their credit damaged, The American
    Legion supported repealing that provision.
        This, among other reasons including unsustainable cost, is why
    Choice is not the answer. The equation is simple; a dramatic increase
    in cost is guaranteed to result in an increased financial burden to
    veterans using VA care that will include higher co-pays, premiums,
    deductions, and other out-of-pocket expenses currently suffered by non-
    VA health care programs.
        The American Legion has worked with this Committee to ensure
    veterans receive the care and benefits they have earned, and we look
    forward to our continued work with this Congress and administration to
    better this program for veterans as well as taxpayers. We can start by:

        1. Open VA to more patients--volume decreases costs per patient and
    increases access.
        2. Make VA more competitive and allow them to accept ALL forms of
    insurance including Medicare, Medicaid, and etcetera.
        3. Make VA a destination employer by offering physicians rotations
    in research, emergency preparedness, and education areas.
        4. Call on VA to stand up a medical school. It fits within their
    statutory mission, they have the real estate, they have the expertise,
    they have the reputation, and they have resources. Think Service
    Academies.
        5. Insist VA engage in public-private partnerships with community
    hospitals across the country by renting wings of existing hospitals.

        That said--the first thing that needs to happen is that VA needs to
    start being treated equitably by congressional leaders and the media.
    The American Legion calls on Congress and the American people to treat
    VA with fair and balanced criticism as well as praise. Stop taking
    cheap shots at our healthcare system. It's hurting veterans, it's
    hurting morale, and its killing VA's recruiting efforts. If anyone
    thinks that killing VA will save taxpayer dollars, they are either
    woefully misinformed, delusional, or lying. Cost shifting to veterans
    has already begun, and proposals that will require veterans to pay for
    care to treat service-connected disabilities are already being
    discussed. This is immoral and unacceptable.
        VA can be more competitive if allowed to be, and the only outcry
    you will hear will be coming from the private hospitals in the country
    who will accuse the government of unfair competition. Medical care
    provided organically at VA is the best investment and greatest
    assurance the United States of America has to give our veteran
    community guaranteed healthcare sustainability, continuity of care, and
    ensure that our veterans continue to receive, the best care anywhere.

        The American Legion thanks this Committee for the opportunity to
    explain the position of the more than 2 million veteran members of this
    organization. For additional information regarding this testimony,
    please contact Mr. Jeff Steele at The American Legion's Legislative
    Division at (202) 861-2700 or jsteele@legion.org.

        Chairman Isakson. Thank you, Mr. Steele.
        Mr. Atizado?

       STATEMENT OF ADRIAN ATIZADO, DEPUTY NATIONAL LEGISLATIVE
                  DIRECTOR, DISABLED AMERICAN VETERANS

        Mr. Atizado. Thank you, Chairman Isakson, Ranking Member
    Tester, Senator Sanders, and distinguished Members of the
    Committee. First, I want to thank you for inviting DAV to
    testify at this critical hearing about Veterans Choice Program
    and the future of community care for veterans.
        Today's hearing is critically important to the 1.3 million
    members of the Disabled American Veterans. Our members, sir,
    rely quite heavily on the VA.
        In response to the 2014 access crisis, DAV supported the
    intent of the temporary Choice Program, but it has never really
    quite fully met congressional intent nor veterans' expectation.
        While referrals of veterans to Choice providers continue to
    increase, we continue to receive complaints from veterans in
    Choice providers, and I see Members on this Committee as well
    have heard those complaints. The underlying law has been
    amended twice, the original contract modified over 70 times,
    and over 20 letters of corrections have been issued.
        It is clear to DAV, the temporary Choice Program is not the
    long-term strategic solution. It fails to address the
    disconnect and the alignment of demand, resources, and
    authorities that the VA has pointed out and the Care
    Commission--Commission on Care. Even the Commission on Care,
    charged by Congress to evaluate and make recommendations to
    reform VA, found that the design and execution of the Choice
    Program are flawed.
        Now, in 2015, DAV and our independent budget partners
    developed a proposal called the Framework for Veterans Health
    Care Reform, based around four main pillars, and it is to serve
    as a guide, sir, a guide in developing the future of VA
    community care for veterans. That future requires a long-term
    solution, a comprehensive plan, if you will, to build an
    integrated high-performing network around a modernized VA
    health care system.
        Now, because even the Choice Program in place and the
    plethora of authorities, albeit cumbersome as has been alluded
    to, that VA is using to purchase care in the community, the
    vast majority of veterans still choose to rely on VA, a system
    created to meet their unique needs, and this Committee,
    Congress, and the Administration must honor this clear and
    overwhelming preference.
        To pay respect to the millions of veterans who choose VA
    year over year, our written testimony outlines some of the
    necessary improvements that Congress and VA must address to
    ensure the VA health care system itself becomes a high-
    performing integrated network. A central piece of a high-
    performing health system is its ability to empower its
    patients, to make important decisions to protect their health
    and their quality-of-life. DAV calls on Congress and the VA to
    focus on that goal of ensuring a veteran and their doctor, not
    some bean counter or some bureaucrat, chooses when a veteran
    should receive care in the community. That VA clinician, that
    clinician must help veterans identify, not dictate, their most
    appropriate and effective care.
        To this end, we are supportive of VA's approach of moving
    away from using arbitrary wait times and geographic distances
    toward shared decisionmaking. This leverages the relationship
    between a veteran and their doctor. It uses business
    intelligence about clinical performance and quality of care. We
    believe this new focus is more likely to be sustainable, cost
    effective, and garner higher patient satisfaction.
        In light of the high-performing network, community and
    Federal health care providers as partners must also meet
    certain standards to ensure veterans will have the best
    experience possible through timely, high-quality, and veteran-
    centric care.
        As we move forward, it is critical that every legislative
    action to increase access to care must simultaneously include a
    commensurate increase in resources. As evidenced in the Choice
    Program, we are all witnessing today that increased care in the
    community also increases demand for care in the VA. DAV
    disagrees with the proposed budgetary approach to use both
    discretionary and mandatory funds to provide medical care to
    veterans, and we vehemently oppose any budgetary approach to
    cut veterans' earned compensation as a means to fund the Choice
    Program or any community care program. This cost must be borne
    by the Federal Government, not by disabled veterans who have
    already paid more than their fair share.
        Mr. Chairman, building an integrated, high-performing
    network is a fundamental change culturally and operationally in
    how VA treats veterans today. It will take time and patience.
    The Commission on Care made clear that this is a significant
    undertaking that will take a decade or more to accomplish. You
    have DAV's commitment to work with this Committee and Congress,
    as we are doing with VA, on the next evolution for VA health
    care.
        This concludes my statement. I would be happy to answer any
    questions you may have.
        [The prepared statement of Mr. Atizado follows:]
       Prepared Statement of Adrian Atizado, Deputy National Legislative
                      Director, Disabled American Veterans
        Chairman Isakson, Ranking Member Tester, Distinguished Members of
    the Committee: Thank you for inviting DAV (Disabled American Veterans)
    to testify at this hearing to examine the Department of Veterans
    Affairs (VA) Veterans Choice program and the future of care in the
    community.
        As you know, DAV is a non-profit veterans service organization
    comprised of 1.3 million wartime service-disabled veterans that is
    dedicated to a single purpose: empowering veterans to lead high-quality
    lives with respect and dignity. Today's hearing is critically important
    to DAV as most of our members choose and rely heavily or entirely on VA
    health care.
        In the VA health care system, too many veterans are experiencing
    uneven and delayed access to quality veteran-centered care because of a
    ``disconnect in the alignment of demand, resources and authorities''
    for VA health care. \1\ Even before the Veterans Choice program was
    established as authorized by the Veterans Access, Choice, and
    Accountability Act of 2014 (Public Law 113-146), VA facilities had
    limitations on the services it could offer due to a variety of factors,
    including changing veteran demographics, aging facilities and the types
    of providers that could be recruited and retained at different regions
    of the country. VA's legacy purchased care programs, such as fee basis,
    were generally used to address a VA facility's limited availability of
    clinical services, the distance that veterans would have to travel to
    receive care at a VA facility, and the amount of time veterans had to
    wait for an appointment.
    ---------------------------------------------------------------------------
        \1\ Centers for Medicare & Medicaid Services Alliance to Modernize
    Healthcare (operated by MITRE Corporation). ``Independent Assessment of
    the Health Care Delivery Systems and Management Processes of the
    Department of Veterans Affairs, Volume I: Integrated Report.'' https://
    www.va.gov/opa/choiceact/documents/assessments/integrated_report.pdf
    ---------------------------------------------------------------------------
        Additionally, the manner in which VA historically referred veterans
    to community care was fragmented. VA did not track how long it took for
    veterans to be seen when referred to a community provider, the quality
    of care they received in the community, how it impacted veterans'
    health outcomes, or veterans' satisfaction. We frequently heard
    complaints that due to limited resources, VA providers were not allowed
    to send veterans to the community resulting in delayed access to needed
    care.
        Yet these issues persisted. Born out of the waiting list scandals
    and access crisis that culminated in the spring of 2014, the Choice
    program was authorized and implemented but has never fully met
    Congress' or veterans' expectations.
        Despite a difficult and complex national rollout mandated in just
    90 days, VA quadrupled the number of Choice authorizations from fiscal
    year (FY) 2015 to FY 2016. Veterans received more than 2.5 million
    Choice program appointments, and VA is poised to provide even more care
    in the community in FY 2017.
        We applaud Congress' work with VA to enact Public Law 115-26, which
    extended the Choice program until all of the remaining choice funds
    have been spent and to ensure continuity for veterans who access care
    through this program. As this Committee is aware, DAV supported this
    law as a short-term and temporary measure to ensure that veterans using
    the Choice program do not fall through the cracks while waiting for
    realistic and meaningful reforms to be enacted and implemented.
        DAV believes the current Choice program should continue to be used
    as a short-term solution, but only for as long as necessary to enact
    and implement a long-term solution based on a comprehensive plan to
    build an integrated, high performing network with a modernized VA
    health care system seamlessly working with other Federal and community
    providers.
        As this Committee is aware, problems remain in the Choice program
    and we continue to receive complaints from veterans and community
    providers. The Commission on Care also found, ``[t]he design and
    execution of the Choice Program are flawed.'' \2\ As such, DAV does not
    believe the Choice program should be expanded to new categories of
    veterans. Absent a high-performing integrated network, putting more
    veterans into the Choice program could result in less coordination of
    care, increased fragmentation of services, lower quality and ultimately
    worse health outcomes for more veterans. In addition, even a limited
    expansion of the current eligibility for the Choice program would add
    significant fiscal costs at a time when demand for VA health care is
    already rising faster than resources provided by Congress.
    ---------------------------------------------------------------------------
        \2\ Commission on Care. ``Final Report'' June 30, 2016. https://
    commissiononcare.sites.usa.gov/
    ---------------------------------------------------------------------------
        While the Choice program relieves some of the demand for VA medical
    care, it does not have the necessary elements to serve as a solid
    foundation for the future of community care. The underlying law has
    been fundamentally amended twice, the original contract has been
    modified over 70 times, 23 letters of correction have been issued to
    the contractors, and there are a number of pending and draft bills to
    amend the Choice program--yet necessary improvements to the overall VA
    health care system remain largely unaddressed.
        Thus, if the Choice program ends without an effective,
    comprehensive replacement, there would be tremendous dislocation and
    hardship for hundreds of thousands of veterans who would find
    themselves unable to access timely care in an already overburdened VA
    health care system.
                           beyond the choice program
        Over the past year, DAV, along with our partners in the Independent
    Budget (IB) (Paralyzed Veterans of America and Veterans of Foreign
    Wars), other major veterans service organizations (VSOs), VA Secretary
    Shulkin, the Commission on Care and many Members of the House and
    Senate, have discussed, debated and ultimately coalesced around a
    common long-term vision for reforming the veterans health care system.
    All support the concept of developing an integrated network that
    combines the strength of the VA health care system with the best of
    community care to offer seamless access for enrolled veterans.
        Yet there is a continued push by some for unfettered and unlimited
    choice. In our opinion, such pursuit of this unrealistic and narrow
    goal to expand access to care without a plan for containing costs and
    ensuring quality is unwise and unsustainable. Access to care without a
    focus on quality should not be the objective, nor should reducing cost
    at the expense of quality be acceptable. The pyrrhic goal of unfettered
    and unlimited choice also carries with it the potential to delay and
    distort realistic plans to move forward with implementing the shared
    vision of the veterans community and most active users of the VA health
    care system. We must not let this generational opportunity to reform VA
    health care to be encumbered by lack of a clear strategy toward an
    overarching goal to build an integrated, high performing network with a
    modernized VA health care system seamlessly working with other Federal
    and community providers.
        Veterans should not have to wait any longer to move forward with
    true and meaningful reform that keeps VA as the coordinator and primary
    provider of care. Even with the additional options of the Choice
    program, veterans in general overwhelmingly prefer to use VA.\3\ DAV
    strongly urges this Committee, Congress, and the Administration to
    honor the clear preference of the vast majority of veterans who choose
    to use the VA health care system--a system created to meet their unique
    needs.
    ---------------------------------------------------------------------------
        \3\ Of the over 1.2 million veterans who have received some
    community care in the Choice program, only about 5,000 veterans used
    the Choice program as their sole health care provider. United States.
    Cong. House. Committee on Veterans' Affairs. Hearings, Mar. 7, 2017.
    115th Cong. 1st sess. Washington: GPO, 2017.
    ---------------------------------------------------------------------------
        In 2015, DAV and our IB partners developed our proposed Framework
    for Veterans Health Care Reform based around four main pillars. First,
    we proposed restructuring the veterans health care delivery system by
    creating local integrated veteran-centric networks to ensure that all
    enrollees have timely access to high quality medical care. VA would
    remain the coordinator and primary provider for most veterans. We also
    called for establishing a veteran-managed community care program to
    ensure that veterans living in rural and remote areas have a realistic
    option to receive veteran-centric, coordinated care wherever they may
    live. This would require local communities to work with VA's Office of
    Rural Care to develop relationships with local providers, as well as
    increased flexibility in reimbursement rates to attract and retain
    community partners.
        Our second pillar for reform called for redesigning the systems and
    procedures that facilitate access to health care by creating a new
    urgent care benefit and taking other actions to expand access to care,
    such as extended hours in evenings and on weekends, as well as
    increased use of telehealth. We recommended that as the new integrated
    networks are fully phased in, decisions about providing veterans access
    to community network providers should be based on clinical
    determinations and veteran preferences, rather than arbitrary time or
    distance standards that exist in the current Choice program.
        Third, we proposed realigning the provision and allocation of VA's
    resources to better reflect its mission by making structural changes to
    the way Federal funds are appropriated, distributed and audited. Our
    plan calls for strengthening VA's budget and strategic planning process
    by establishing a Quadrennial Veterans Review, similar to the
    Quadrennial Defense Review currently used by the Department of Defense.
        The fourth and final pillar of our framework called for reforming
    VA's culture with transparency and accountability. In this regard, we
    strongly support the MyVA initiative, which has already resulted in
    good progress in making system-wide changes putting veterans in the
    center of VA's planning and operations, so that their needs and
    preferences are paramount.
                      a high performing health care system
        To address salient questions about how expanding access to and
    options for veterans health care will affect overall costs, it must be
    considered in terms of being cost effective while achieving the best
    outcomes and quality of life for veterans. Private sector providers and
    regional health organizations have been working more rapidly in recent
    years from volume and profitability of services toward providing
    holistic, patient-centered and coordinated care--the kind of care that
    VA strives to provide to all veteran patients. DAV believes that to
    provide holistic, veteran-centric and coordinated care while increasing
    access in a cost-effective manner, VA must remain the coordinator and
    primary provider of care in a high performing network, with Federal and
    community partners providing additional expertise and access whenever
    and wherever necessary.
        Coordination of care between VA and community providers is critical
    because studies have continually shown that lack of coordination
    increases the risk of unfavorable health outcomes for veterans. For
    example, a lack of care coordination may lead to unnecessary
    duplication of services, which is not only costly, but may also pose
    health risks to veterans who may receive and pay for care that is not
    needed. Moreover, the quality of care may be adversely affected if
    important clinical information is not promptly and clearly communicated
    between VA, Federal and community providers.
        In order to serve veterans effectively in a seamless integrated
    network as the coordinator and primary provider of care, VA itself must
    first be modernized and strengthened to address known gaps and
    deficiencies. Congress must therefore act to resolve a number of known
    legislative, policy and budgetary matters, including:

         Consolidating the plethora of statutory authorities and at
    least nine distinct programs with different administrative and clinical
    processes to purchase community care for veterans; \4\
    ---------------------------------------------------------------------------
        \4\ 38 U.S.C. Sec. Sec. 1701 note (Veterans Choice Program), 1703
    (Contract Care in the Community), 1703 note (Project Access Received
    Closer to Home), 1720 (Community Nursing Home Care), 1720C (Home and
    Community Based Care), 1725 (Emergency Care for Nonservice-connected
    Conditions), 1728 (Emergency Care for Certain Veterans with Service-
    Connected Conditions), 1741 (State Nursing Home Care), 1745 (State
    Nursing Home Medication) 8111 (Health Resource Sharing of VA and
    Department of Defense), 8153 (Enhanced Sharing Authority, Patient-
    Centered Community Care), and 25 U.S.C. Sec. 1645 (Indian Health
    Service/Tribal Health Program)
    ---------------------------------------------------------------------------
         The widening salary gap between private sector and VA to
    allow the Department to hire and pay the best and brightest;
         Improving VA's infrastructure to align with veterans'
    needs--beginning with VA leases, which have not been authorized since
    2012;
         Gaps in VA's medical care benefits package such as access
    to urgent care in the community, and differing eligibility for dental
    care and vision care; \5\
    ---------------------------------------------------------------------------
        \5\ VA provides audiology and eye care services (including
    preventive services and routine vision testing) for all enrolled
    veterans, but eyeglasses and hearing aids are provided only to veterans
    meeting certain criteria (See 38 U.S.C. Sec. 1707). Eligibility for VA
    dental care is limited by law and differs significantly from
    eligibility for medical care (See 38 U.S.C. Sec. 1712).
    ---------------------------------------------------------------------------
         The inadequate clinical grievance and appeals process
    available to veterans when there is a difference of opinion between the
    patient and provider;
         A permanent Provider Agreement authority for VA to
    purchase such things as in-home and community care for the most
    severely ill and injured veterans;
         Authority that would allow veterans greater access to
    telemedicine;
         Modernize its IT system--beginning with a new less
    cumbersome scheduling system, which allows veterans to self-schedule,
    allows meaningful health information sharing, simpler authorization and
    referral, and improved community provider payment systems.

        A central piece of a high-performing health system is its ability
    to empower its patients to make important decisions to protect their
    health and quality of life. One of the most common sources of patient
    dissatisfaction is not feeling properly informed about, and involved
    in, their treatment or in the developing their treatment plan. Shared
    decisionmaking--where patients are involved as active partners with the
    clinician in treatment decisions, to clarify acceptable medical options
    and choose appropriate treatments. While not all patients want to play
    an active role in choosing a treatment, most want clinicians to inform
    them and take their preferences into account.
        DAV calls on Congress and the VA to focus on the goal of ensuring a
    veteran and their doctor--not government bureaucrats--choose when a
    veteran should receive care in the community. VA must use evidence-
    based patient decision aids and improve the communications skills of
    all their health care providers to assist veterans in making informed
    decisions about their care, improve their knowledge and understanding
    of different treatment options, and give veterans a more accurate
    perception of risk, to help veterans identify--not dictate--the most
    appropriate treatments.
        We are supportive of VA's approach of moving away from using
    arbitrary wait times and geographic distances in determining when
    veterans should be given the option to receive care in the community.
    Through shared decisionmaking leveraging the relationship between a
    veteran and their doctor, and using business intelligence about
    clinical performance and quality of care, this new focus will strike a
    better balance in using community care to fill gaps in service than
    unfettered choice. This approach is more likely to be sustainable, a
    hallmark of good governance and garner higher patient satisfaction.
        However, this new approach, much like building an integrated, high
    performing network with community providers, is a fundamental change
    culturally and operationally in how VA provides care to our Nation's
    veterans. It will take time and patience and will require collaborative
    work between Congress, VA, and VSOs.
                               community partners
        VA continues to be challenged in fostering its relationship with
    community providers. Previous studies by the Government Accountability
    Office--including its most recent June 2015 report--demonstrate that
    its claims processing remains largely reliant on staff rather than
    leveraging IT solutions, resulting in frequent inappropriate actions
    such as non-payment, delayed payment or incorrect payment amounts. VA
    must act now to become a trusted and collaborative partner with
    community providers in order to rebuild lost or damaged relationships,
    enhance good relationships, and foster new ones.
        The Commission on Care also pointed out that community partners
    must undergo a thorough credentialing process to ensure that all
    providers have, `` . . . appropriate education, training, and
    experience, provide veteran access that meets [Veterans Health
    Administration (VHA)] standards, demonstrate high-quality clinical and
    utilization outcomes, demonstrate military cultural competency, and
    have capability for interoperable data exchange.'' That is why the
    Commission on Care recommended that ``[n]etworks be built out in a
    well-planned, phased approach . . . ''
        DAV calls on Congress and the new Administration to begin taking
    actions necessary for the next evolution of veterans health care to
    begin. VA health care must become an integrated, high-performing system
    first before it can serve as the foundation for a larger integrated
    network with other Federal and community providers, one in which all
    enrolled veterans will have the best experience possible through timely
    access to comprehensive, high-quality and veteran-focused care.
                                   resources
        As Congress and VA move forward, it is critical that every
    legislative action to increase access to care must simultaneous include
    a commensurate increase in resources. As evidenced in the Choice
    program, VA saw both increased access to care in the community and
    increased demand for care in VA, putting a strain on VA's budget.
        Last year, then-VA Secretary McDonald indicated the cost
    implication of increasing demand on VA stating, ``[J]ust a one percent
    increase in Veteran reliance on VA health care will increase costs by
    $1.4 billion.'' \6\ This year's budget request for VA notes the impact
    of the Choice Act with an increase of 1.89 percent in reliance on VA
    versus their other health care options,\7\ a roughly a $2.65 billion
    increase in needed resources.
    ---------------------------------------------------------------------------
        \6\ United States. Cong. House. Committee on Veterans' Affairs.
    Hearings, Feb. 10, 2017. 115th Cong. 1st sess. Washington: GPO, 2017.
        \7\ Department of Veterans Affairs Volume II Medical Programs and
    Information Technology Programs Congressional Submission FY 2018
    Funding and FY 2019 Advance Appropriations, pagesVHA-364, 366
    ---------------------------------------------------------------------------
        Moreover, DAV disagrees with the proposed budgetary approach to use
    both discretionary and mandatory funds to provide medical care to
    veterans. VA's community care program must be allowed to compete with
    other VA medical care programs such as long-term care, mental health
    and gender-specific care for the same finite resources. Moreover, we
    vehemently oppose the reduction of veterans compensation as a means to
    fund the Choice program. Increases in veterans' health care should be
    paid for by the Federal Government, not by disabled veterans.
        DAV and out IB partners have consistently testified about VA's
    inadequate resources to purchase community care, cumbersome and
    confusing purchase care authorities, inadequate IT systems for
    scheduling, financial and business processing, as well as insufficient
    resources and ineffective tools to address constrained and aging
    infrastructure that all hindered VA's ability to meet veterans health
    care needs on a timely basis. Of these concerns, none has a more direct
    impact on a veteran's ability to receive care in the community than
    limited funds provided to local VA facilities, which too often forced
    them to choose between meeting internal clinical needs or expanding
    access to community care.
        When Congress authorized the creation of the Choice program, they
    also authorized an ``independent assessment'' of VA health care to
    study the causes of and offer solutions for the access problems,
    resulting in a report by the MITRE Corporation, the Rand Corporation,
    and others in September 2015. As previously noted, the independent
    assessment's first finding was that there was a ``disconnect in the
    alignment of demand, resources and authorities'' for VA health care.
    Its first recommendation was that VA must ``address the misalignment of
    demand with available resources both overall and locally.'' In terms of
    access to care, it found that ``increases in both resources and the
    productivity of resources will be necessary to meet increases in demand
    for health care over the next five years.''
        The findings of this assessment confirmed what IB veterans service
    organizations (IBVSOs) have reported for more than a decade: the
    resources provided to VA health care have been inadequate to meet its
    comprehensive mission of care for veterans. While there are many
    factors that contributed to the access crisis, when there are not
    enough doctors, nurses, and other clinical professionals or enough
    usable treatment space to meet the rising demand for care by enrolled
    veterans, the result will inevitably be rationing of care, waiting
    lists and access problems. Further proof that demand was greater than
    VA capacity can be seen in the fact that even as care in the community
    increased dramatically over the last two years, care inside VA health
    care facilities still continued to increase, and according to VA 16
    percent of its primary care clinics are over capacity today.
        If it is not already evident in this testimony, DAV and our IB
    partners have not suggested that simply increasing funding by itself--
    without making significant reforms in VA--will lead to better health
    outcomes for veterans over the next 20 years. However, history shows
    that no VA reform plan has any chance of success unless sufficient
    resources are consistently provided to meet the true demand for
    services. With more and more veterans seeking VA care as it improves
    access, Congress will have to continue investing resources to allow VA
    to keep up with rising demand, or make difficult decisions to restrict
    enrollment or propose increased fees or copayments for veterans' care.
                                  mind the gap
        We are cognizant Choice funds are projected to run out by the end
    of this year or early next year, and that any legislation enacted by
    Congress--even if enacted before the end of this fiscal year--will
    require more than 90 days to implement as clearly evidenced by the
    recent experience with the Choice program roll-out. Moreover, existing
    VA community care authorities and programs are not sufficient to serve
    as a seamless bridge toward a long-term solution of a high performing
    integrated network combining VA with other Federal and community
    providers. To provide a short-term bridge, we believe VA needs to move
    forward expeditiously with its Request for Proposal (RFP) that was
    drafted and issued late last year. The RFP developed by VA in
    consultation and collaboration with a number of stakeholders, including
    DAV, would be a natural progression toward the future high performing
    integrated health care system we all envision.
        While continuing to appropriately fulfill its oversight
    responsibilities, DAV urges Congress to support the Department's
    efforts to move the RFP process forward so VA can enter into contracts
    with appropriate national providers before the end of this year to
    ensure veterans continuity of care so that no one falls through the
    gap.
                             realistic expectations
        Finally, we urge Congress to work with VA to set realistic
    expectations for the implementation of these much needed long-term
    reforms. Many of the supporting systems and technologies necessary to
    promote a truly seamless integrated network capable of delivering
    consistently high-quality, veteran-centric and timely care will need to
    be developed, optimized and customized for VA before full
    implementation of the new system. Also, while we support the goal of
    eliminating all access limitations on community care, including the
    current 40-mile and 30-day choice standards, these limitations can only
    be phased out as the integrated network becomes fully operational to
    avoid unintended negative fiscal and clinical outcomes.
        The Commission on Care was charged to develop plans to strengthen
    the VA health care system over the next 20 years. In its report, the
    Commission makes clear that this is a significant undertaking that will
    likely take a decade or more to accomplish. The report states: ``[t]he
    fruits of the transformation . . .  will not be realized over the
    course of a single Congress or a single 4-year administration.''
    Considering the magnitude and importance of this transformation, it is
    not only imperative that Congress and VA have the patience and vision
    for the long haul, but that they begin moving forward now.
        Mr. Chairman, after more than three years of spirited and
    passionate debate in Congress over the future of veterans health care,
    there is now remarkable consensus on how best to strengthen, reform and
    sustain the VA health care system. Veterans and their representative
    organizations, independent experts, VA leaders and many Members of
    Congress agree that the best veterans health care system would consist
    of integrated networks that combine the strength of VA with the best of
    community care to offer veterans real choices for quality and timely
    care. However, in order to build a truly high-performing network, VA
    must first modernize its own infrastructure, IT and operations before
    it can begin to integrate with qualified and credentialed community
    partners.
        We look forward to working with you to help fill in the details of
    such a plan for the next evolution of VA health care and we urge you
    and your colleagues in the 115th Congress to start implementing this
    shared vision so that ill and injured veterans can get the care they
    have earned and deserve, whenever and wherever they need it.

        That concludes my testimony and I would be pleased to answer any
    questions that the Committee may have.

        Chairman Isakson. Thank you for your testimony.
        Mr. Fuentes.

      STATEMENT OF CARLOS FUENTES, DIRECTOR, NATIONAL LEGISLATIVE
         SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES

        Mr. Fuentes. Chairman Isakson, Ranking Member Tester,
    Members of the Committee, on behalf of the men and women of the
    VFW, I would like to thank you for the opportunity to present
    our views on VA community care.
        In the past 3 years, the VFW has assisted more than 2,000
    veterans who needed help obtaining VA health care and has heard
    directly from more than 20,000 veterans on their VA health care
    experiences. Through this work, the VFW has identified a number
    of issues, has proposed more than 15 common-sense
    recommendations to improve the Veterans Choice Program.
        The VFW would like to thank this Committee for your
    leadership in addressing many of the issues that we have
    identified, such as making VA the primary payer for Choice
    Program care, removing restrictions when VA is able to share
    medical records, making clinical necessity an eligibility
    criteria, and recalculating how mileage is measured to account
    for how humans drive, not how birds fly.
        The Choice Program has come a long way since it was first
    created, but it continues to face several challenges that must
    be addressed. The biggest concern that the VFW continues to
    hear from veterans is regarding the breakdown of communication
    between VA, the third-party administrators, doctors and
    veterans. This breakdown has a significant impact on the care
    veterans receive, and it often leads to veterans having to put
    the pieces together in order to receive the care they need.
        For example, a veteran from Missoula, Montana, told us it
    took him 3 months, numerous phone calls, faxes, and emails to
    finally get the treatment he required. This issue has even led
    to veterans being sent to the wrong doctors because VA, the
    contractors, cannot figure out how to get them to the
    specialist who can provide the care they need.
        VA has taken a number of steps to address this breakdown
    and a number of other issues the VFW has identified. It has
    worked with TriWest and Health Net to have contractors
    collocated with VA Community Care staff to address issues in
    person instead of requiring VA staff to spend hours on the
    Choice hotline to have their questions answered.
        The VFW has received positive feedback from VA employees
    and veterans at collocated facilities. We urge VA to expand
    this best practice and incorporate it in any future Community
    Care Program.
        As the VFW has highlighted in our numerous Choice Program
    reports, which can be found at vfw.org/VAwatch, the eligibility
    criteria for the Choice Program must be reformed.
        While the VFW agrees that using clinical need to determine
    when veterans must be referred to community care is the right
    approach, we do not believe Congress or VA should dictate how
    long veterans must wait before being referred to community care
    providers. Arbitrary thresholds such as 30 days or 40 miles do
    not reflect the health care landscape of our country.
        When and where veterans must be seen is a clinical decision
    between a veteran and his or her doctor. Overall, Congress and
    VA must take the lessons learned and create a single,
    sustainable program.
        The VFW also urges Congress to swiftly pass provider
    agreement legislation authorizing VA to enter into non-FAR-
    based agreements with private-sector doctors which would ensure
    veterans can quickly receive care that cannot be provided at VA
    or through its community care programs.
        The VA health care system delivers high-quality care and
    has consistently outperformed the private sector in independent
    assessments. The VFW six health care surveys have also
    validated the veterans who use VA health care are satisfied
    with the care they receive.
        Veterans deserve reduced wait times and shorter commutes to
    their medical appointments. This means turning to the private
    sector when needed, but community care is only part of the
    solution. Congress must make certain VA has the resources and
    authorities to quickly recruit and adequately compensate a
    high-performing workforce, properly train its employees, hold
    wrongdoers accountable--and thank you for your leadership in
    taking steps to accomplish that goal yesterday--update its
    aging infrastructure, which includes VA being able to quickly
    lease facilities without requiring an Act of Congress.
        I would also like to mention that the VFW largely supports
    the proposal that VA has sent to Congress yesterday; however,
    we are concerned that it includes certain pilots, as Senator
    Murray identified earlier, that we are very concerned with and
    we oppose, and we would really, truly like the opportunity to
    discuss those. We oppose turning VA into an insurance pilot--an
    insurance program or turning VA into Amtrak, and we would
    really like to discuss those proposals moving forward.
        This concludes my testimony, and thank you for the
    opportunity.
        [The prepared statement of Mr. Fuentes follows:]
     Prepared Statement of Carlos Fuentes, Director, National Legislative
             Service, Veterans of Foreign Wars of the United States
        Chairman Isakson, Ranking Member Tester and members of the Senate
    Committee on Veterans' Affairs, On behalf of the men and women of the
    Veterans of Foreign Wars of the United States (VFW) and its Auxiliary,
    thank you for the opportunity to provide our views on the Choice
    Program and how to consolidate and improve the Department of Veterans
    Affairs' (VA) community care.
        In the past three years, the VFW has assisted hundreds of veterans
    who have faced delays receiving care through the Choice Program, and
    has surveyed more than 8,000 veterans specifically on their experiences
    using VA community care. Through this work, the VFW has identified a
    number of issues and has proposed more than 15 common sense
    recommendations on how to improve this important program. The VFW would
    like to thank the Committee for its leadership in addressing many of
    the issues the VFW has identified, such as making VA the primary payer
    for Choice Program care, removing restrictions on when VA is able to
    share medical records with Choice providers, making clinical necessity
    the trigger for community care, and recalculating how mileage is
    measured to account for how humans drive, not how birds fly.
        The VFW must also commend VA and the third party administers for
    their willingness to work with us to address issues veterans encounter
    when obtaining care through the Choice Program. VA has made more than
    70 modifications to the Choice Program's contract to address many of
    the pitfalls that have plagued the program, such as allowing the
    contractors to conduct outbound calls when they have the proper
    authorization to begin the scheduling process.
        However, the Choice Program continues to face several challenges
    that must be addressed. That is why the VFW is very concerned that the
    Administration has requested to make the Choice Program a permanent
    mandatory program. The VFW believes this program must be improved and
    consolidated with other VA community care programs, but we oppose
    making it a continuing it as a mandatory program. VA's medical care
    accounts are under discretionary spending and subject to sequestration
    budget caps. Having the Choice Program as the only VA health care
    program not subject to spending caps could lead to a gradual erosion of
    the VA health care system.
        The biggest issue that the VFW hears from veterans who use the
    program is the breakdown of communication between VA, the third party
    administrators, Choice providers and veterans. This breakdown has a
    significant impact on the care veterans receive. The VFW has heard from
    too many veterans that they were sent to the wrong doctor because VA
    and the contractor could not figure out how to make certain the veteran
    sees the specialist that can provide the care the veteran needs. For
    example, veterans who need to receive the recently developed cure for
    Hepatitis C have been sent to hepatologists who cannot provide them the
    lifesaving medications they need.
        The VFW has also heard from veterans that the breakdown in
    communication between VA, contractors and Choice providers often delays
    their care because their Choice doctors do not receive authorization to
    provide needed treatments. What is concerning is that veterans are left
    to piece together the entire story or else they do not receive the care
    they need; or they are left to pay for the care out of pocket because
    their Choice doctors performed treatments that are beyond the scope of
    the Choice authorization.
        VA has taken a number of steps to address this breakdown in
    communication. It is in the process of implementing a new authorization
    management system to eliminate the confusion regarding which provider
    veterans need to see. It has also worked with TriWest Healthcare
    Alliance and Health Net, Inc. to have contractors co-located with VA
    community care staff at VA medical facilities to address and issues in
    approving secondary authorizations or ensuring veterans are sent to the
    right doctors. The VFW has received good feedback from VA employees and
    veterans at facilities with co-located VA and contract staff.
        However, the underlying issue that causes this breakdown in
    communication is the fact that TriWest and Health Net are required to
    maintain their own systems to track Choice casework. VA transmits
    information to them instead of granting the contactors access to VA
    systems or using the same systems, which would eliminate the need to
    transmit data and documents between VA and the third party
    administrators. To avoid having to go through a third party when
    scheduling Choice Program appointments, VA has proposed to have its
    community care staff resume responsibilities for all the scheduling,
    which they have done in the past and continue to do under other
    community care programs.
        The VFW supports utilizing VA community care staff to schedule
    Choice Program appointments when possible, but it is unreasonable to
    expect VA to be able to staff up enough to keep pace with the expanded
    use of the Choice Program. For that reason, the VFW recommends VA build
    on its co-located staff model and rely on contracted staff to support
    VA's community care staff when demand for Choice Program care spikes.
    To ensure veterans are not negatively impacted when they are rolled
    over to contract staff, VA must ensure the contracted staff has access
    to the same systems as VA community care staff.
        As the VFW has highlighted in our two Choice Program reports, which
    can be found on our VA health care watch website, www.vfw.org/vawatch,
    the eligibility criteria for the Choice Program must also be reformed.
    The VFW firmly believes that VA must reevaluate how it measures wait
    times. In the VFW's most recent VA health care report, only 67 percent
    of veterans indicated they had obtained a VA appointment within 30
    days, which is significantly less than the 93 percent VA reported in
    its most recent access report. This is because the way VA measures wait
    times is not aligned with the realities of scheduling a health care
    appointment.
        VA uses a metric called the preferred date to measure the
    difference between when a veteran would like to be seen and when they
    are given an appointment. However, this completely ignores and fails to
    account for the full length of time a veteran waits for care. For
    example, when veterans call to schedule an appointment they are asked
    when they prefer to be seen. The first question they logically ask is,
    ``When is the next available appointment?'' If VA's scheduling system
    does not preclude them from doing so, schedulers have the ability to
    input the medical facility's next available appointment as the
    veteran's preferred date----essentially zeroing out the wait time. VA
    must correct its wait time metric to more accurately reflect how long
    veterans wait for their care.
        However, VA's wait time measurement must not be used as an
    eligibility criterion for the Choice Program. While the VFW agrees that
    using a clinically indicated date to determine eligibility is the right
    approach, we do not believe Congress or VA should dictate how long
    veterans must wait before receiving care from community care providers.
    Arbitrary thresholds such as 30-days or 40-miles do not reflect the
    health care landscape of our country. Veterans may not need to be seen
    within 30 days for appointments such as routine checkups. Likewise,
    such arbitrary thresholds do not account for veterans with urgent
    medical needs for which they need to be seen before 30 days, or
    veterans who suffer from disabilities which prevent them from traveling
    40 miles.
        A recent independent assessment on VA access standards by the
    Institute of Medicine (IOM) was unable to find a national standard for
    access similar to the Choice Program's 40-mile and 30-day standards.
    Instead of focusing on set mileage or days, IOM found that industry
    best practices focus on clinical need and the interaction between
    clinicians and their patients. That is why Congress should not dictate
    eligibility for community care with arbitrary or federally regulated
    access standards, such as 30-days or 40-miles. When and where a veteran
    needs to be seen is a clinical decision made between a veteran and his
    or her doctor.
        Several ideas have been proposed to replace the 30-day and 40-mile
    eligibility criteria for the Choice Program. Several Members of
    Congress have suggested that veterans should be free to choose between
    VA and community care providers whenever they want and every time they
    seek care. While this proposal may sound enticing, it is unsustainable
    because of cost and the VFW would vehemently oppose any proposal to
    pass that cost onto veterans. This choose your own adventure approach
    to health care also leads to veterans receiving fragmented health care
    that the Commission on Care determined leads to lower health care
    outcomes and endangers patient safety. Veterans deserve the highest
    quality health care possible, not fragmented care that fails to meet
    their health care needs.
        Other proposals have focused on allowing a certain segment of the
    veteran population or veterans who are in certain circumstances to
    openly choose whether to receive care from VA or community care
    providers. The VFW believes what is important is that veterans receive
    the care that fits their clinical needs and care that accommodates
    their preferences. This is best achieved by empowering veterans to have
    a discussion with their care teams every time they need an appointment.
        When scheduling veterans for medical appointments, whether it is
    with VA or a community care provider, VA must take into account
    veterans' clinical needs and personal preferences. If a veteran has an
    urgent care need that must be met within a 48 hours, that veteran must
    be seen within 48 hours. Additionally, VA must take measures to meet
    veterans' preferences when seeking care. For example, a male veteran
    who was sexually assaulted by a male may want to seek care from a
    female provider. VA should not have to interrogate veterans every time
    a veteran needs care, but it must give veterans the opportunity to
    discuss their preferences.
        This would also require VA care coordinators to be able to view the
    availability and characteristics of VA and community care providers. VA
    must invest in information technology systems that would allow it to
    compile appointment availability for community care and VA. Doing so
    would enable veterans to truly work with their care teams to determine
    what options are best for them.
        Overall, Congress and VA must take the lessons learned from the
    Choice Program and other community care programs such as Project ARCH,
    Project HERO, and PC3, to create a single, sustainable community care
    program. The VFW and our Independent Budget partners have proposed a
    veteran centric framework for how to integrate community care into the
    VA health care system, which can be found at www.vfw.org/vawatch. VA
    has outlined its vision for consolidating its community care programs
    in a report it was required to send Congress under Public Law 114-41,
    the Surface Transportation and Veterans Health Care Choice Improvement
    Act of 2015. It is time for Congress to act to ensure VA is able to
    transform the way it provides community care.
        In its consolidation report, VA requested authority to develop a
    nationwide system of urgent care at existing VA medical facilities, and
    to reimburse veterans for urgent care they receive from smaller urgent
    care clinics around the country to fill the gap between emergency care
    and traditional appointment-based outpatient care. Doing so would
    ensure veterans with acute medical conditions that require urgent
    attention, such as the flu, infections, or non-life threatening
    injuries, do not wait days or weeks for a primary care appointment.
    Establishing urgent care would also curb the reliance on emergency
    rooms for non-emergent care, which is more expensive for veterans and
    VA. The VFW urges Congress to consider and swiftly pass legislation
    authorizing VA to reimburse veterans for using community urgent care
    clinics.
        The VFW also urges Congress to swiftly pass provider agreement
    legislation. Authorizing VA to enter into non-Federal acquisition
    regulation (FAR) based agreements with private sector providers,
    similar to agreements under Medicare, would ensure VA is able to
    quickly provide veterans with care when community care programs like
    the Choice Program are not able to provide the care.
        Provider agreements are particularly important for VA's ability to
    provide long term care through community nursing homes. The majority of
    the homes who partner with VA do not have the staff, resources or
    expertise to navigate and comply with FAR requirements and have
    indicated they would end their partnerships with VA if required to bid
    for FAR contracts. In fact, VA's community nursing home program has
    lost 400 homes in the past two years and will continue to lose 200
    homes per year without provider agreement authority. This means
    thousands of veterans are forced to leave the place they have called
    home for years simply because VA is not able to renew agreements with
    community nursing homes. Congress must end this injustice by quickly
    passing provider agreement legislation.
        The VA health care system delivers high quality care and has
    consistently outperformed private sector health care systems in
    independent assessments. The VFW's numerous health care surveys have
    also validated that veterans who use VA health care are satisfied with
    the care they receive. In fact, our latest survey found that 77 percent
    of veterans report being at least somewhat satisfied with their VA
    health care experience. When asked why they turn to VA for their health
    care needs, veterans report that VA delivers high quality care which is
    tailored to their unique needs and because VA health care is an earned
    benefit.
        VA has made significant strides since the access crisis erupted in
    2014 when whistleblowers across the county exposed how long veterans
    were waiting for the care they have earned and deserve. However, VA
    still has a lot of work to do to ensure all veterans have timely access
    to high quality and veteran-centric care. Veterans deserve reduced wait
    times and shorter commutes to their medical appointments. This means
    turning to community care when needed, but also means improving VA's
    ability to provide direct care.
        The VFW thanks Congress for its commitment to improving VA's
    community care authorities and programs. VA also needs the resources
    and authorities to quickly recruit and properly compensate a high
    performing health care workforce, properly train its employees, hold
    wrongdoers accountable, and update its aging capital infrastructure.
    Community care must continue to supplement direct VA health care. This
    means VA and Congress must continue to invest in VA to ensure it
    remains a premier health care system.

        Mr. Chairman, this concludes my testimony. I will happy to answer
    any questions you or the Committee members may have.

        Chairman Isakson. Thank you for your testimony too.
        Mr. Stultz?

      STATEMENT OF GABRIEL STULTZ, LEGISLATIVE COUNSEL, PARALYZED
                          VETERANS OF AMERICA

        Mr. Stultz. Chairman Isakson, Ranking Member Tester, and
    Members of the Committee, Paralyzed Veterans of America
    appreciates the opportunity to be here today to discuss the
    evolution of the Choice Program.
        Our experience tells us that veterans prefer to receive
    their care from VA. We recognize, though, that VA cannot
    provide all types of services at all times in all locations.
    Care delivered in the community must remain a viable solution.
        As the Department continues the trend toward greater
    utilization of community care, Congress and the Administration
    must remain cognizant of the impact decisions will have on
    veterans who rely on VA the most.
        Choice cannot be viewed as a solution to all VA's problems.
    For veterans with spinal cord injuries who rely on VA's
    specialized services, the community is not always an option.
    Many times, there are no comparable services within a
    reasonable distance, and where it is available, the choice is
    often still clear for our members: VA remains the best option.
        Expanding care in the community has dominated the
    conversation over the last 2 years, but our members would be
    the first to tell you that this is only half the equation. VA's
    own services must improve side by side with the Community Care
    Program. The Secretary wants VA to become lean and competitive.
    He wants to modernize VA's IT and infrastructure. He wants to
    develop an integrated network that capitalizes on the vast
    Federal health care infrastructure, longstanding academic
    partnerships, and local providers to more effectively deliver
    care.
        We have consistently supported these efforts. A high-
    performing network ensures the sustainability of VA, and by
    extension, quality, accountable health care for future
    veterans. More importantly, it ensures the viability of VA's
    crown jewels: specialized services.
        Effective care coordination, convenient scheduling, and
    fluid exchange of health care records will not come without
    substantial investment. It also requires providing VA with the
    flexibility to deal with the legitimate obstacles like the
    aging infrastructure that it drags around like an expensive
    ball and chain.
        The Secretary's monumental announcement Monday that VA will
    purchase a new electronic health care record system was
    decisive and should greatly increase the probability of
    success.
        We also applaud his leadership in moving the Department
    away from the current 30-day, 40-mile eligibility standards in
    favor of a case-by-case clinical determination. Shifting the
    mindset of the Department away from arbitrary metrics to a
    focus on clinical outcomes is a worthwhile endeavor.
        One serious concern that continues to be overlooked is that
    when veterans receive treatment at a VA medical center or from
    a VA doctor, they are covered in the event of medical
    malpractice, but this protection does not follow the veteran
    into the community. The veteran must pursue standard legal
    remedies instead of VA's non-adversarial process.
        Adding insult to literal injury, veterans who prevail are
    limited to monetary damages instead of enjoying the other
    ancillary benefits available under Title 38. The disparity in
    outcomes and the different processes by which they are achieved
    are unacceptable. Ultimately, legislation designed to reform VA
    health care must incorporate the attributes that make its
    specialized services strong. External accreditation and
    comprehensive policies in VA's handbook govern the system. The
    outcome-based standards of care across the spinal cord injury
    system allows PVA to go into facilities and scrutinize the
    quality of care provided.
        When individual facilities are lagging behind, the evidence
    is not just anecdotal. We need a plan to ensure care in the
    community is held to the same standards for veterans.
        I will close by emphasizing that while much of the focus is
    key to addressing smooth integration of community care, access
    issues plaguing VA continue to be exacerbated by staffing
    shortages. The nurse shortage within the SCID system of care
    has reduced available beds and forced centers to limit the
    number of veterans they admit. The subsequent average daily
    census suggests there is a lack of demand in the system, when
    in reality veterans who want access are being turned away
    because those centers lack the staff to man available beds.
        At our urging, the Secretary took a big step a few days ago
    and agreed to immediately implement the new staffing
    methodology we have been calling for. This is what PVA is
    looking forward to seeing as we go forward. It demonstrates an
    intent to not only increase access to the majority of veterans,
    but to strengthen VA's own capacity to care for veterans who
    exist in far fewer numbers but have the greatest and most
    complex needs.
        PVA is here to see VA become successful in the long run. To
    get there, it needs to first modernize and develop a solid
    foundation, and we need to exercise a level of measured
    patience and support. We have to take the harder road here
    instead of gratifying ourselves with short-term successes.
        Mr. Chairman, this concludes my remarks. I would be happy
    to answer any questions you have.
        [The prepared statement of Mr. Stultz follows:]
          Prepared Statement of Gabriel Stultz, Legislative Counsel,
                         Paralyzed Veterans of America
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, Paralyzed Veterans of America (PVA) would like to thank you
    for the opportunity to offer our views on consolidating and improving
    the Department of Veterans Affairs' (VA) delivery of community care.
    The impact that veterans health care reform will have on present and
    future generations of veterans cannot be overstated, and we are pleased
    to be part of this important discussion.
        PVA's historical experience and extensive interaction with veterans
    around the country leads us to confidently conclude that veterans
    prefer to receive their care from VA. We recognize, however, that while
    VA remains the best and preferred option for most enrolled veterans, it
    cannot provide all types of services, in all locations, at all times.
    Care in the community must remain a viable option. But it also cannot
    be considered the failsafe for every situation. Few would give credence
    to the idea that the private health care system has excess capacity
    ready to absorb VA's excess patient load. More importantly, specialized
    services, such as spinal cord injury care, do not always have
    comparable services in the community. When access issues affect these
    systems of care, the veteran's ``choice'' is often simply to wait.
        Specialized services are part of the core mission and
    responsibility of VA. As the Department continues the trend toward
    greater utilization of community care, Congress and the Administration
    must be cognizant of the impact those decisions will have on veterans
    who need the level of complex care that, more often than not, only VA
    can deliver. This includes VA's decision to continue concentrating all
    its energy on expanding the Choice Program without demonstrating how it
    plans to make its own services more competitive with the private
    sector--a key component of the proposed high-performing network. We
    stand behind any effort to improve health care for all veterans, which
    is why we support in principle what VA is trying to accomplish. But the
    plans we are seeing evolve fall woefully short of improving health care
    for the most vulnerable populations, such as those with spinal cord
    dysfunction and polytrauma. Sidelining these concerns while everyone
    focuses acutely on the next iteration of Choice is insulting and
    demoralizing to our members.
        A few recent proposals warrant our attention at the outset. We do
    not, nor will we, support billing a veteran's third party health
    insurance for service-connected care received in a VA facility. This
    amounts to a wholesale abandonment of this country's responsibility to
    its wounded veterans. Using this tactic as a revenue generator would
    simply alleviate pressure on Congress to find the resources necessary
    to meet this sacred obligation. Congressional staff notified the
    Veteran Service Organization (VSO) community and attributed this
    proposal to VA officials.
        This idea has since been retracted, but replaced with an equally
    disturbing funding offset--the elimination of Individual
    Unemployability (IU) benefits for veterans eligible to collect social
    security benefits. It is beyond comprehension that the Administration
    would propose such a benefit reduction in order to pay for a program
    that sometimes provides health care for non-service-connected veterans.
    Does this Committee really believe that veterans with disability
    ratings between sixty and ninety percent should be the source of
    funding for the Choice Program? Eliminating IU benefits for veterans
    over the age of 62 provokes numerous questions for us. Will veterans
    who have statutorily protected evaluations (the 20-year rule) also be
    subject to reduction? Will those dependents using Chapter 35 education
    benefits based on their sponsor's IU rating be forced to drop out of
    school? Will those veterans on IU who are covered by Service-Disabled
    Life Insurance (a.k.a. RH insurance) at no premium be forced to now pay
    premiums in order to keep coverage? What about state benefits, such as
    property tax exemptions or state education benefits that are based on
    100% VA disability ratings? How will this proposal affect efforts to
    combat veteran suicide and homelessness? We hope this idea will be
    rejected in the strongest terms.
        These off-the-cuff ideas only serve to reinforce our belief that
    VA's community care team should continue to engage with VSO's as it
    plans for the future. For over two years, trust has grown through
    strong engagement at the policy level. We encourage the Secretary to
    make further engagement a priority.
        Any legislation designed to reform VA health care must incorporate
    or match the attributes that make VA's specialized services strong. For
    example, VA utilizes outcome-based standards of care across the spinal
    cord injury or disorder (SCI/D) system, which, in turn, allows us to
    measure and scrutinize the quality of care provided. The system is
    governed by comprehensive policies laid out in Veterans Health
    Administration (VHA) Directive 1176 and the corresponding handbook
    governing procedures. These authorities require VA to track the SCI/D
    population in a variety of ways, specifically capturing data on
    outcomes. When individual facilities are lagging behind, the evidence
    is not just anecdotal. VA's facilities are also accredited by the
    Commission on Accreditation of Rehabilitation Facilities (CARF) and The
    Joint Commission. When the entire system is questioned, Congress can
    commission an independent assessment, similar to the one carried out as
    part of the original Choice legislation. VA officials can also be
    called to testify about the conditions of care in VHA facilities.
    Congress should examine more closely how VA will monitor the quality of
    care veterans are receiving in the community. This question goes beyond
    a plan for care coordination. If VA is unprepared to retain ownership
    of responsibility for care delivered in the private sector, Congress
    will be helpless in conducting adequate oversight.
        Many advocates for greater access to care in the community also
    minimize, or ignore altogether, the impact that pushing more veterans
    into the community would have on the larger VA health care system, and
    by extension the specialized health services that rely upon the larger
    system. We cannot emphasize enough that all tertiary care services are
    critical to the broader specialized care programs provided to veterans.
    The SCI/D system of care and other specialized services in VA do not
    operate in a vacuum. If these services decline, then specialized care
    is also diminished. Veterans with catastrophic disabilities rely almost
    exclusively upon VA's specialized services, as well as the wide array
    of tertiary care services provided at VA medical centers. Making VA's
    own facilities lean and competitive must not be taken for granted; it
    must be a significant part of the conversation about expanding access
    to care in the community.
        PVA, along with our Independent Budget (IB) partners, Disabled
    American Veterans (DAV) and Veterans of Foreign Wars (VFW), developed
    and previously presented to this Committee a framework for VA health
    care reform. It includes a comprehensive set of policy ideas that will
    make an immediate impact on the delivery of care, while laying out a
    long-term vision for a sustainable, high-quality, veteran-centered
    health care system. Our framework stands on four pillars: 1)
    restructuring the veterans health care system; 2) redesigning the
    systems and procedures that facilitate access to health care; 3)
    realigning the provision and allocation of VA's resources to reflect
    the mission; and 4) reforming VA's culture with workforce innovations
    and real accountability. With this perspective, we offer our views on
    consolidating and strengthening the delivery of care in the community.
    i. restructuring the system in a way that establishes integrated health
     care networks designed to leverage the capabilities and strengths of
      existing local resources in order to provide more efficient, higher
                      quality and better coordinated care.
        PVA strongly supports the concept of developing a high-performing
    network that would seamlessly combine the capabilities of the VA health
    care system with both public and private health care providers in the
    community. This approach is gaining consensus among stakeholders,
    including the most recent and current VA Secretaries, the IB, most
    major VSO's, the Commission on Care, and congressional leadership. As
    stakeholders coalesce around this concept, though, the dynamics that
    govern the boundaries of this network need to be thoroughly explored.
        PVA believes, like many stakeholders and Members of Congress have
    stated, that the definition of an integrated VA network is one that
    utilizes private providers to supplement, not supplant, the VA health
    care system. Unfettered choice of provider granted to all veterans is
    not a realistic or financially viable basis for a healthy VA health
    care system capable of sustaining critical, veteran-centric,
    specialized services. It is cost-prohibitive and, in many cases, leads
    to fractured care as veterans attempt to navigate the private health
    care system without managed care coordination. We believe that the
    design and development of VA's network must be locally driven using
    national guidance, and it must reflect the demographics and
    availability of resources within that area. VA has taken the first
    steps toward this goal by conducting test run analyses using three
    individual VHA facilities and their surrounding health care markets. A
    solicitation for information was also issued to help VA develop its
    acquisition strategy to procure this analysis nationwide on a continual
    basis. We look forward to seeing this process develop.
        VA will be able to make greater strides, especially in rural areas,
    if given the ability to bring more community providers into the fold
    with flexible provider agreements. The current requirement that
    providers enter into agreements with VA governed by the Federal
    acquisition regulation (FAR) system has suffocated VA's attempts to
    expand access to care in a timely manner. Smaller health care provider
    organizations otherwise disposed to serve the veteran population are
    especially resistant to engaging in the laborious FAR process. And yet
    they remain vital to filling the gaps in health care services in
    certain areas.
        The same flexibility should be applied to VA's ability to manage
    its capital infrastructure. The recent report issued by the U.S.
    Government Accountability Office (GAO) entitled ``VA Real Property''
    highlights the variety of challenges VA faces in trying to keep up with
    the ever-evolving broader health care system.\1\ Whether it is
    adjusting capacity to reflect migration patterns of aging veterans or
    dealing with underutilized facilities that cannot be demolished due to
    a historical designation, VA must be afforded the appropriate tools to
    respond to changes in its operating environment. It is unfortunate that
    the Secretary's comments related to ``closing 1,100 facilities'' were
    met with widespread panic instead of a realization of how hard it is
    for VA to dispose of underutilized infrastructure and reinvest the
    proceeds where the money is needed.
    ---------------------------------------------------------------------------
        \1\ U.S. Government Accountability Office. (April 2017). VA Real
    Property--VA Should Improve Its Efforts to Align Facilities with
    Veterans' Needs. (Publication No. GAO-17-349). Retrieved from https://
    www.gao.gov/assets/690/683938.pdf on May 6, 2017.
    ---------------------------------------------------------------------------
        Care coordination is another piece that has a direct correlation
    with quality health care outcomes. This is one of VA's strengths, and
    it must continue to own the responsibility for care coordination for
    veterans. VA's proposed Plan to Consolidate Community Care Programs
    revolved around the patient's circumstances, specifically the intensity
    of coordination needed and whether the non-VA care was being provided
    based on a wait time or geographical distance.\2\ In light of VA's push
    toward removing the 30-day/40-mile standards for determining
    eligibility for community care, this feature should be revisited to
    accommodate the next iteration of governing criteria. We will continue
    to support a policy that includes VA's direct involvement in care
    coordination for complex cases being handled by community care
    providers.
    ---------------------------------------------------------------------------
        \2\ Department of Veterans Affairs, Plan to Consolidate Programs of
    Department of Veterans Affairs to Improve Access to Care, October 30,
    2015, pp. 21-24, http://www.va.gov/opa/publications/
    va_community_care_report_11_03_2015.pdf.
    ---------------------------------------------------------------------------
        PVA has another serious concern that has consistently been
    overlooked in the expansion of community care access. When veterans
    receive treatment at a VA medical center, they are protected in the
    event that some additional disability or health problem is incurred.
    Under 38 U.S.C. Sec. 1151, veterans can file claims for disability as a
    result of medical malpractice that occurs in a VA facility or as a
    result of care delivered by a VA provider. When PVA questioned VA as to
    whether these protections are conferred to veterans being treated in
    the community, VA officials confirmed in writing that this protection,
    as a matter of law, does not attach to a veteran receiving care in the
    community. If medical malpractice occurs during outsourced care, the
    veteran must pursue standard legal remedies instead of VA's non-
    adversarial process. Adding insult to literal injury, veterans who
    prevail in a private action are limited to monetary damages instead of
    enjoying the other ancillary benefits available under Title 38 intended
    to make them whole again. These include treating the resulting injuries
    as service-connected conditions, such as a botched spinal surgery
    resulting in paralysis where the veteran did not provide adequately-
    informed consent. It also includes access to adaptive housing and
    adaptive automobile equipment benefits should the veteran require these
    features. Furthermore, the limits on these monetary damages vary from
    state to state leading to disparate results for similarly-situated
    veterans. The disparity in outcomes and the different processes by
    which they are achieved are unacceptable. Congress must ensure that
    veterans are treated equally and that these protections follow the
    veteran into the community.
     ii. redesigning the systems and procedures that facilitate access to
          care in a way that provides informed and meaningful choices.
        PVA supports the Secretary's leadership in moving the Department
    away from the current 30-day/40-mile eligibility standards in favor of
    a case-by-case clinical determination. Access decisions dictated by
    arbitrary wait times and geographic distances have no comparable
    industry practices in the private sector. This change would shift the
    organizational mindset and focus of VA to clinical outcomes instead of
    catering to arbitrary metrics governing access to care in the
    community. We have consistently advocated for this proposition before
    Congress and the administration, stating that eligibility and access to
    care in the community should be a clinically-based decision made
    between a veteran and his or her doctor.
        This approach requires us to confront the difficult question of how
    a decision is reached in the absence of arbitrary, but clear,
    delineations for eligibility. As the Commission on Care's report
    demonstrated, variations in how liberally access is granted to
    community care providers can have a drastic impact on cost.\3\ In the
    most expansive scenario, where VA maintains a loosely-managed network
    of providers and veterans have an unmitigated choice to receive care in
    the community, the Commission's economists found that the cost would be
    more than $1.0 trillion over a decade.\4\ It is impossible to
    rationalize this outcome as sustainable or consistent with good
    governance.
    ---------------------------------------------------------------------------
        \3\ Commission on Care, Final Report, June 30, 2016, Appendix A, p.
    171-190.
        \4\ Id.
    ---------------------------------------------------------------------------
        An objective starting point is to allow veterans to go outside VA
    when a particular medical service is not provided in that facility.
    When VA does provide the needed service, though, the decision should be
    made by the doctor in consultation with the veteran. Providers should
    be able to sit down with a veteran and consider things such as access
    and availability of services and the urgency of that veteran's
    situation. The veteran should also have the opportunity to voice
    concerns over how a certain care plan will adversely or inadvertently
    impact him or her. Access to transportation, geographic distance and
    travel time can often present unreasonable obstacles to care for
    veterans. For example, a thirty-mile trip to a VA facility might seem
    reasonable on paper, but a doctor administering a treatment plan that
    requires the veteran to commute three times per week may have good
    grounds to object to that determination.
        Providers should have the ability to help educate veterans and make
    decisions in the context of the patient's specific circumstances. They
    should be able to take action when it is clear that VA offers a needed
    service, but a particular veteran's situation requires a higher level
    of expertise than what that doctor or facility can offer. Arbitrary
    standards should not prevent a doctor from sending a veteran out to the
    community when the need is urgent and VA is not prepared to administer
    the care in a timely fashion.
        Some veterans might have reservations about their provider, i.e.
    VA, having the final say in whether they are eligible to utilize the
    Choice Program, but it is a marked improvement over the current process
    where bean-counting bureaucrats make decisions behind closed doors for
    veterans who appear to be just another number in the queue. A more
    pointed concern is the past institutional bias exhibited by VA
    employees for administering care directly in VA at all costs. VA has
    long had authority to contract for care, but in prior years employees
    demonstrated a reluctance to utilize this tool to the point that it
    eventually prevented timely access to care for many veterans. This
    behavior, though, was largely attributed to mid-level bureaucrats
    making decisions driven by how the funding was administered. The
    current funding arrangement under the Choice Program produced a welcome
    side-effect of removing the incentive to avoid contracting care out to
    the community. Over the last two years, VA's institutional behavior has
    been modified to a degree, and it has become more comfortable with
    contracting for care when the need exists.
        Once the clinical parameters are determined, eligible veterans will
    have meaningful choices among the options developed within the high-
    performing network and the ability to schedule appointments that are
    most convenient for them. When you pair this decisionmaking process
    with a well-managed, integrated network and the structural
    flexibilities discussed above, it becomes possible for VA to be a
    competitive and sustainable enterprise. Of course, we must point out
    the obvious fact: none of this is possible unless we are able to get
    veterans out of the waiting rooms and in with the doctor to have this
    discussion.
        PVA and our fellow IBVSO's also continue to advocate for adding
    urgent care services to the standard medical benefits package to help
    fill the gap between routine primary care and emergency care. This is
    consistent with current health care trends, and greater utilization
    could provide a relief valve to VA emergency services, the Choice
    Program, and the system as a whole. VA previously proposed in its Plan
    to Consolidate Community Care Programs a more common sense
    determination of what constitutes reimbursable emergency and urgent
    care, thereby expanding access, but it came with the imposition of
    cost-sharing for otherwise exempt veterans. We strongly oppose co-
    payments for veterans who are currently exempt. Using co-payments as a
    means to discourage inappropriate use of emergency care by service-
    connected veterans is not an acceptable method of incentivizing
    behavior.
        The Secretary was previously weighing the idea of allowing enrolled
    veterans to utilize urgent care in the community at the veteran's
    discretion. Instead of using co-payments to control costs, there would
    be a limit of two authorized urgent care visits per year. We supported
    this and encouraged the Secretary to explore the concept further.
    Unfortunately, the proposal has evolved to provide access to
    ``community walk-in care clinics within the community care network.''
    It remains unclear whether this is a departure from urgent care in
    favor of retail minute clinics, and whether it has also curtailed the
    number of eligible providers to those who are ``within the community
    care network.'' Given the disparity in quality and scope of care
    provided between urgent care and retail minute clinics, we would
    encourage this Committee to seek further clarification from VA.
       iii. realigning the provision and allocation of va's resources to
                              reflect the mission.
        We stated in the beginning of this testimony that VA cannot provide
    every type of service in every locality, nor should it. In the broader
    health care system, patients in some hospitals face greater risk of
    death and complications because the surgical team conducts too few
    procedures. The doctors, and the members of their team, are unable to
    maintain their skills. The same is true for VA. Some medical centers
    successfully continue to expand the services they offer. Others follow
    suit but fail to recognize their limitations or true demand levels, and
    it directly impacts the quality of care throughout the entire facility.
    Right-sizing facilities and developing a balanced network of community
    providers has a direct impact on risks and health care outcomes. VA
    should have the ability to aggressively deal with these failures.
    Before condemning an entire medical center or clinic, though, it should
    break down its analysis to the service line level and determine where
    it should make adjustments or cuts, as well as where it should be
    growing.
        While much of the focus is keyed to addressing smooth integration
    of community care, we reiterate that the access issues plaguing VA have
    been exacerbated by staffing shortages within the VA health care
    system. PVA is proud to have been an integral part of the efforts that
    led to reinstating the capacity reporting requirement for VA's
    specialized services during the last Congress. Evaluating VA's capacity
    to care for veterans requires a comprehensive analysis of veterans'
    health care demand and utilization measured against VA's staffing,
    funding, and infrastructure. However, VA's capacity metrics fail to
    properly account for the true demand on its system. The metrics are
    based on deflated utilization numbers that have been suppressed through
    census caps and limited patient admission.
        The nurse shortage within the SCI/D system of care has precluded
    these centers from fully utilizing available bed space and forced
    centers to reduce the amount of veterans they admit. A decrease in the
    daily average census at some centers naturally follows, suggesting that
    there is a lack of demand in the system. In reality, veterans who want
    to access care are turned away because those centers lack the staff to
    man available beds.
        A reduction in capacity to provide services is the immediate effect
    of staffing shortages. But second and third order effects follow and
    create a negative feedback loop that is detrimental to the entire SCI/D
    system of care. As staffing thins and those remaining behind attempt to
    cover more responsibility, individual patients receive less attention
    and staff burn out. It impacts morale and eventually erodes the overall
    quality of care. As this cycle takes hold, demand for care in these
    facilities shrinks. When VA calculates demand under these conditions,
    the new demand metrics have been artificially depressed and tend to
    justify reduced staff, further perpetuating the downward spiral.
        By our estimates, VA needs an additional 1,000 SCI/D nurses. These
    estimates are not abstract; they are drawn from the regular, in-depth
    site audits our medical services staff conduct across the VHA system.
    At the SCI/D leadership meeting held in December 2016, nearly every
    chief and nurse executive answered in the affirmative when asked if
    empty beds would be filled if more nursing staff were hired. In
    May 2017, PVA leadership met with the heads of Nursing and SCI/D
    services. Both individuals stated that their own projections called for
    an additional 920 SCI/D nurses. The Secretary himself admitted the need
    and announced at our annual convention that VA would be hiring an
    additional 800 SCI/D nurses. Actions, though, speak louder than words.
        The pathway to proper staffing begins with the revision and
    recertification of VHA Directive 2008-085, Spinal Cord Injury Center
    Staffing and Beds, which required updating in December 2013. Despite
    our constant advocacy, it remains antiquated. A modernized nurse
    staffing methodology is available. It was developed and field tested in
    order to address clinician understaffing at virtually every SCI/D
    facility. It factors in the increasing medical needs of an aging
    population and wait times for inpatient annual physical exams and
    extended care. If VA truly intends to strengthen its ``foundational''
    services, this is where it needs to start. It should be part and parcel
    of building a new Choice framework, not an afterthought.
        We note that VA ventured down this road unsuccessfully in the past.
    A GAO report in October 2014 revealed that VA utterly failed to address
    staffing shortages after years of trying to implement a nationally
    standardized methodology for determining an adequate and qualified
    nurse workforce.\5\ Specifically the report found a lack of oversight
    and a failure to ensure preparedness for implementing the staffing
    methodology, including the necessary technical support and resources.
    Simply put, PVA is not persuaded that these obstacles cannot be
    overcome. This Committee should not be either.
    ---------------------------------------------------------------------------
        \5\ U.S. Government Accountability Office. (October 2014). VA
    Health Care--Actions Needed to Ensure Adequate and Qualified Nurse
    Staffing. (Publication No. GAO-15-61). Retrieved from www.gao.gov/
    assets/670/666538.pdf on March 2, 2017.
    ---------------------------------------------------------------------------
        With the capacity reporting requirement reinstated, Congress now
    has the means to conduct effective oversight and ensure VA stays ahead
    of the curve in determining where shortages exist and what gaps must be
    filled. Congress should start immediately by determining how VA plans
    to abide by the newly reinstated reporting requirement. This Committee
    might also inquire as to why VHA Directive 1176, VHA Handbook 1176.01
    and VHA Handbook 1176.02 all remain expired.\6\
    ---------------------------------------------------------------------------
        \6\ VHA Directive 1176, defining policy for the Spinal Cord Injury
    and Disorders System of Care, expired in October 2015; VHA Handbook
    1176.01, defining procedures for the Spinal Cord Injury and Disorders
    System of Care, expired in February 2016; VHA Handbook 1176.02,
    defining procedures for Spinal Cord Injury and Disorders Extended Care
    Services, expired in June 2012.
    ---------------------------------------------------------------------------
        Without strong Congressional oversight and the provision of
    adequate resources, history will repeat itself. These types of issues
    are not new, and the Independent Assessment's report in September 2015
    repeated findings similar to those in a report from a bipartisan
    Presidential task force back in 2003: there is a disconnect in
    alignment of demand, resources and authorities. Beyond simply providing
    more and more funds, though, PVA supports certain changes being
    requested by VA that would impact how those funds are spent.
        One change would increase efficiency and accuracy in funding by
    allowing VA to record non-VA care obligations at the time of payment
    instead of when the care is authorized. The current practice requiring
    VA to project obligations at the time of authorization incentivizes
    over-obligation to avoid violating the Anti-Deficiency Act and
    ultimately results in forgoing funds previously provided by Congress--
    money which could otherwise be spent on medical care.
        The second change we support is giving VA the flexibility to
    allocate funds in a way that accommodates shifts in demand for health
    care services. While consolidation of community care programs might
    obviate the need to lift restrictions on using Choice Program funds to
    reimburse community providers operating under Patient-Centered
    Community Care (PC3), any consolidation effort should permit VA to
    develop internal capacity if utilization patterns demonstrate
    increasing demand for care in VA facilities.
        With this in mind, we believe that Congress must also reject
    continued funding of the Choice program through a mandatory account and
    place it in line with all other community care funded through the
    discretionary Community Care account established previously. This will
    eliminate competing sources of funding for delivery of health care
    services in the community, while maintaining visibility on spending
    through the Choice program.
        iv. reforming va's culture with transparency and accountability.
        It is no secret that VA's administrative bureaucracy has ballooned
    in recent years. Arguably, resources devoted to expanding
    administrative staff have significantly jeopardized the clinical
    operations of VA. We believe serious consideration needs to be given to
    rightsizing the administrative functions of VA to free critical
    resources and dedicate them to building clinical capacity.
        Additionally, VA has struggled with the notion of accountability.
    Too often, VA staff who should be terminated are ``removed,'' but not
    in the way the ordinary citizen in the workforce would envision that
    action. VA has allowed too many VA employees who have compromised the
    public's trust to collect a full paycheck while under reassignment in a
    position that is neatly tucked away from public view, or to simply
    retire with full benefits, in some cases only to become VA contractors
    who make even more money with far less accountability. The public has
    grown tired of this happening. So have America's veterans. We implore
    Congress to provide the new VA secretary whatever authority he needs to
    prevent this from continuing.
        PVA believes that substantial reform in health care can be
    achieved, and the time is ripe to accomplish this task. Our
    organization represents veterans with some of the most complex issues,
    and we cannot stress enough that moving forward should not be done at
    the expense of the most vulnerable among them. We must remain vigilant
    and appreciate the benefits of bringing together the variety of
    stakeholders who are participating and bringing different perspectives
    and viewpoints--it is a healthy development process that ensures
    veterans remain the focus. Thank you for the opportunity to present our
    views on these issues.

        Chairman Isakson. Well, thanks to all of you for your input
    and your outstanding testimony, and we appreciate your
    compliments about the work of the Congress yesterday and the
    Senate by passing accountability, and hope to continue that
    record of achievement throughout this year.
        Mr. Fuentes, have you seen the movie ``Hidden Figures''?
        Mr. Fuentes. I have.
        Chairman Isakson. Have you seen it, Mr. Atizado?
        Mr. Atizado. Yes, sir.
        Chairman Isakson. Have you seen it, Mr. Steele?
        Mr. Steele. No, sir.
        Chairman Isakson. I am going to buy you a ticket.
        Have you seen it, Mr. Stultz?
        Mr. Stultz. No, sir.
        Chairman Isakson. You will get a second ticket. You all can
    go together.
        Mr. Stultz. Sounds good. [Laughter.]
        Chairman Isakson. I really enjoyed the testimony.
        When Senator Murray started her testimony--and I am sorry
    she is not here now--questioned pilot projects as maybe being a
    stalking horse for privatization or taking stuff out of the VA,
    it made me think of the movie ``Hidden Figures.'' ``Hidden
    Figures'' is a true story about three African American women
    who worked for the Redstone Rocket Program in Alabama in the
    1960s on the performance of the rocket that took John Glenn
    into outer space and brought him home again. They kept trying
    and trying and trying to get all the mathematicians, the white
    male mathematicians, to come up with the right formula to bring
    that Redstone safely to home, and they just could not do it.
        These three African American women who worked in the same
    department but were segregated in their work were very good
    mathematicians, and one of the people in frustration--in fact,
    Kevin Costner, played the director of the project--said, ``Why
    don't we give them a chance to see if they can do it?''--
    another word for a pilot program.
        In a few short weeks, those three women figured out the
    answer to how you get John Glenn from Cape Canaveral into space
    and back home safely again. It was through the assignment of a
    responsibility to a pilot group within the organization who had
    been victims of prejudice and fear of the past, not the
    opportunity of the future.
        So, I just want to say this. When I read the testimony of
    Secretary Shulkin and the use of the word ``pilot,'' I did not
    see a boogeyman. I did not see a problem. I saw an opportunity.
        We have an opportunity in this Choice bill to learn from
    the experiences we have had within the VA and learn from the
    experiences outside the VA to how we can better deliver health
    care to every veteran who is eligible for it in the ways of the
    21st century, and the 21st century hospitals are doing it a lot
    differently than they were in the 20th century. VA is going to
    have to be the same way.
        So, do not let the term ``pilot project'' be a ruse or a
    stalking horse for something that you fear. It is an
    opportunity to solve a problem that you want to get rid of, and
    I want us to be open minded enough as they were in Alabama in
    the early 1960s at the Redstone Rocket Factory to figure out
    and to look outside of the box, to get over their prejudice,
    and find a solution within their own midst through what was
    then, admittedly, a pilot project. I just wanted to make that
    observation.
        The second observation I want to make, when I got elected,
    the Ranking Member originally was Richard Blumenthal, and he is
    a great American, but there's none better than Jon Tester. Jon,
    I know how to bread and butter my bread, and I am going to
    bread it right now so he gets all the credit he can get. Jon
    Tester is great one. We have got a lot of challenges ahead of
    us that we have got to do.
        But, the first problem I inherited was the problem of the
    hospital in Denver. If you remember, it had a cost overrun of
    $800 million. It was a hospital that was supposed to cost $600
    million, and it was going to cost $1.4 billion. It is now being
    finished at a significant overrun but not as big as it was
    going to be, and what happened is, when Richard and I took the
    reins, the first thing we did was get on an airplane, flew to
    Denver to look at the problem firsthand, and come back and ask
    ourselves rhetorically what can we do to get out of this--we
    got to finish it; it has started--and how can we deliver the
    best--have what we finish deliver the best services to our
    veterans.
        I am proud to say the hospital, I think, is on its way to
    being completed with some pretty significant savings because we
    made some good decisions on what we did not let the VA do in
    the future and what the VA is now doing now. My only point for
    saying that is there is no problem too big that cannot be
    solved if people who are willing to solve it sit down together
    and work together to do it.
        I am sure, because of what we did on the accountability
    bill, what we are going to do in terms of speeding up and
    getting rid of the problems that we have had in terms of
    appeals, I am sure we are going to be able to do the same thing
    on Choice. I pledge to all of you and the VSOs that Jon and I
    will be soldiers in your army to see to it that we do not fear
    pilot projects, but we learn the lessons of pilots to make the
    VA perform even better for you without being a threat to
    destroy your VA, but to make your VA better in the future.
        I did not mean to make a speech, but I thought that was a
    pretty good example.
        And if you want to go to the movie, Mr. Stultz, Mr. Steele,
    I will be glad to buy your ticket because it is a damn good
    movie; let me tell you.
        Jon Tester--I am sorry--Bernie Sanders.
        Senator Sanders. Thanks, Mr. Chairman. You are right.
        Chairman Isakson. Congratulations on your new book, by the
    way.
        Senator Sanders. Thank you. Not only will we get these guys
    tickets to the movie, we will get them copies of the book as
    well. You will pay for that----
        Chairman Isakson. Right. [Laughter.]
        Senator Sanders. Let me kind of ask you. You see, I think,
    Mr. Chairman, I am a former mayor, and I believe in pilot
    projects. I am a former mayor. We did it. You learn a lot from
    them. Sometimes they work; sometimes they do not. But, at the
    end of the day, you have got to know what your goals are and
    what you want to achieve. You cannot do a pilot project without
    having a goal in mind.
        I think what I think the veterans community fears very
    much, Mr. Chairman, is not unrealistic. We have seen over the
    last many years, efforts to privatize Social Security. We have
    seen efforts to voucherize Medicare. The President's budget
    calls for an $800 billion cut in Medicaid. There have been
    efforts to privatize part or all of the U.S. Postal Service.
        So, if these guys come before us and they say, ``Hey, we
    are a little bit nervous about some efforts to privatize the
    VA, the largest, what is essentially a socialized health care
    system, government-run health care system,'' they are not
    paranoid about this. They have legitimate concerns.
        But, let me start off by asking you a question that I
    always do at hearings. The bottom line here is that in a
    country which has massive health care problems--got 28 million
    people who have no health insurance. We have more people who
    are underinsured; we have people who cannot afford prescription
    drugs. Every day, hundreds of people are dying in private
    hospitals because of inadequate--mistakes being made, et
    cetera, et cetera.
        Let me start with The American Legion, Mr. Steele, and go
    down the line. For your members who walk into the VA--and I
    understand the problem of timeliness, getting people in when
    they need to be. It is something we all agree on, and we are
    all working on. We want people to get in when they should. Once
    they get in, how do they feel about the quality of care in the
    VA?
        Mr. Steele. I have spoken to many of our members, and
    almost uniformly, they speak highly of the VA care, and they
    love their VA. It is just that simple.
        Mr. Atizado. I could not have said it any better than that,
    sir.
        Senator Sanders. Mr. Fuentes?
        Mr. Fuentes. Senator, from our surveys, 75 percent of
    veterans who use VA health care system report being satisfied
    with that care. It is not absolutely perfect. There are ways to
    improve it, but overwhelmingly, veterans like the care that
    they receive.
        Senator Sanders. Mr. Stultz?
        Mr. Stultz. Senator, our members rely on VA more than any
    other population of veterans, and I think that is proof of how
    they feel.
        Senator Sanders. All right. I think, Mr. Chairman, what
    these guys have just said is enormously important. Look, no
    hospital in America does not have problems. Correct? Every day,
    there are problems. We know that. VA is the largest integrated
    health care system in the United States. They have got problems
    every single day, but it is very important to hear from people
    who use the facility to say that, by and large, when people get
    into the system, they enjoy it, and they feel that the system
    is working well for them.
        Our job is to improve what already works reasonably well
    and not to dismember it, which is a fear that I think many
    service organizations have, and it is a fear that I share.
        Second question. In Vermont, I talked to a lot of veterans
    who have serious oral health problems. All right. The VA covers
    service-connected oral health issues. If you get your teeth
    knocked out, VA does a pretty good job. But, if you do not have
    service-connected oral health problems and your teeth are
    rotting, VA does not provide services. Is that an area where
    you think VA could be expanding and that would meet the need of
    many veterans?
        Mr. Atizado. Senator Sanders, thank you for raising that
    issue.
        Our members have spoken on this issue quite clearly. We
    have a very specific resolution about dental care. I cannot
    speak to the history of why it is such a fragmented,
    cumbersome, administratively burdensome, and quite frankly,
    antithetical to VA's philosophy of holistic care, but that is
    what it is today. It needs to get fixed.
        Mr. Fuentes. Dental care is an integral part of health care
    and must be treated as such within the VA health care system.
        Importantly, I would want to point out that the proposal to
    cutoff IU at retirement age, one of the largest concerns that
    we have received from those veterans who are, frankly, scared
    that their benefits are going to be taken away, is that they
    are going to lose dental.
        Senator Sanders. OK. So, what I am hearing from you--I do
    not want to put words in your mouth--is that I agree with Mr.
    Fuentes that when we talk about health care, we talk about
    dental care. I mean, dental care is part of health care. Am I
    hearing from you correctly that everything being equal, you
    would like to see dental care be expanded as a benefit within
    the VA? Is that a fair statement?
        Mr. Stultz. Senator, I would just chime in and say that we
    would have to look at it a little bit closer to see if that is
    where we want VA to start allocating resources.
        I mean, we advocate that specialized services be taken care
    of with the highest priority, notwithstanding the importance of
    oral health care.
        Senator Sanders. All right. Your concern is that we take
    from Peter to pay Paul?
        Mr. Stultz. Essentially.
        Senator Sanders. Yes.
        Mr. Stultz. It always is, almost.
        Senator Sanders. All right. But, some of us believe that
    when people put their lives on the line to defend this country,
    it should not be just taking from Peter to pay Paul. That we
    can take care of Peter and Paul, and in this case, we can
    provide health care, general health care benefits to all of our
    veterans.
        Thank you very much, Johnny.
        Chairman Isakson. Thank you, Senator Sanders.
        Senator Tester.
        Senator Tester. Take it from Peter and Paul, give it to
    Peter and Paul from Sam. [Laughter.]
        Look, I want to ask--first of all, thank you. I thank every
    one of you for your testimony today. I thought it was very
    insightful.
        As we said when we had the joint hearings with the House
    Veterans' Affairs Committee, we should be taking our direction
    from you. So, I very much appreciate your testimony.
        I want to quote Secretary Shulkin from the first panel.
    Jerry Moran had asked him a question. Senator Moran had asked
    him a question, and this was Secretary Shulkin's response. I
    want to know your opinion of the response, if you agree with
    it, disagree with it, and why, either way. I quote, ``At some
    point in the future, if you design a system right, giving
    veterans complete choice, I believe in principle is the
    direction we should be headed in but not in 2017.'' What is
    your belief in that?
        Mr. Steele. Well, I can certainly see how that could be
    seen two different ways. I think the good-faith way would be
    he--Secretary Shulkin along with this Committee, Congress, and
    the VSOs need to modernize VA so that when veterans are
    presented with a choice, they will prefer VA. If the VA is set
    up to succeed like that, the Secretary succeeds, then there
    would be no problem with that.
        To speak to Chairman Isakson's, we would not have to fear
    that because there would be no hidden agendas. It would just be
    the veteran preferring VA. That is it.
        Senator Tester. Anybody else like to comment?
        Mr. Fuentes. The VFW is absolutely confident that Secretary
    Shulkin is committed to improving the VA health care system and
    its ability to provide direct care. If that is accomplished, if
    you have a strong, robust VA health care system----
        Senator Tester. Yes.
        Mr. Fuentes [continuing]. That is not going to be a concern
    whatsoever.
        Even now, about 50 percent of veterans who meet the 30-day
    or 40-mile criteria still prefer to go to VA. So, even now, you
    see that veterans are wanting to and continue to choose VA over
    the private sector. But, if you have a robust VA health care
    system, which I am sure is exactly what Secretary Shulkin wants
    to create, having this unfettered choice is not going to be a
    concern.
        Senator Tester. Mr. Stultz, would you like to comment?
        Mr. Stultz. Thank you, Senator.
        My first thought goes to the fact that the Secretary wants
    to move toward a high-performing network that closely
    integrates with the community, and I think when we realize that
    goal--let us say the Commission on Care's estimate of 10 years
    to reach that point where we have got a solid network. By the
    time we realize that goal, I think veterans are going to have a
    meaningful choice: ``I have private health care insurance, and
    I have VA insurance. I have meaningful choices, although I
    cannot just pick up and go to any doctor I want.'' I think that
    is where we reach the point where veterans are satisfied.
        Senator Tester. Good.
        I talked about the budget a little bit with Secretary
    Shulkin, and I am sure you guys are aware that in the budget,
    33 percent goes to community care, I think 1.3 percent to VA
    care. What would you want to tell the President right now
    through the Secretary about that budget as organizations, by
    the way, that represent a vast swath of veterans in this
    country?
        Mr. Atizado. Thank you for that question, Senator Tester.
        I think the first thing I would say to the President is,
    first and foremost, thank you for giving the VA the increase
    compared to the other agencies in the budget that did not fare
    very well. I think that sends a very strong message of this
    President's commitment to veterans and the Department of
    Veterans Affairs.
        But, I would urge him to relook some proposals that we
    believe could be strengthened, whether it be this reduction in
    compensation to pay for community care or the bifurcation of
    the funding resources for community care, one being
    discretionary and one being mandatory. For those around the
    room who have been around for a while--can appreciate the finer
    points of the long-term impacts that this may have--and hope
    that those be reconsidered.
        Senator Tester. Anybody else like to comment? You do not
    have to if you do not want to. That is fine.
        You are itching, Mr. Fuentes.
        Mr. Fuentes. We have said to the President that we are very
    thankful for increased funding for VA health care and support
    his focus on mental health care, veterans suicide,
    homelessness, and a number of other issues. We do not support--
    and actually, we oppose--requiring veterans to pay for
    improvements.
        Senator Tester. OK. Last question, if I might. I want to go
    the same route as Rounds and Blumenthal.
        Tell me what happens--any one of you or all of you,
    whatever you want--tell me what happens when a veteran receives
    care in a VA facility and something goes wrong.
        Mr. Stultz. I will take that one, Senator. Chapter 38,
    Section 1151 allows you to file a medical malpractice claim,
    like any other disability claim that you present to VA. With
    that comes a non-adversarial process, which obviously is a
    benefit in and of itself.
        You not only are compensated for that injury, but it is
    treated as a service-connected injury, so you pull health care
    benefits related to that injury for the rest of your life as
    well as any disability compensation.
        Senator Tester. Do you have any idea about how often that
    happens in the course of time, where something goes wrong
    within the VA? Is it more often? Basically, I am looking to see
    if it is more often or less often than the private sector.
        Mr. Stultz. Actually, I cannot answer that. I am sorry.
        Senator Tester. I have got staff that will check that out.
        Now can you tell me what happens when a veteran goes out in
    the community and something goes wrong?
        Mr. Stultz. They are left to--I will put it bluntly--fend
    for themselves like any other citizen. The result is that you
    have a disparity in process and results when you have similarly
    situated veterans, same injury, same procedure. One gets
    monetary damages, and that can be capped, depending on what
    State they are suing in, so----
        Senator Tester. Though you may not know the answer to this,
    because I do not know that we have been doing this long enough
    for an answer, but maybe we have. If something goes wrong, is
    it treated like a service-connected injury by the VA if it is
    done in the private sector?
        Mr. Stultz. No, it is not.
        Senator Tester. It is not.
        Mr. Stultz. We have specifically--we have analyzed the
    statute. We have looked at case law, and then we have presented
    VBA--not VHA, VBA makes those decisions, and they confirmed
    our----
        Senator Tester. Well, I just want to close by saying the
    first panel was very, very good, and I want to thank Dr.
    Shulkin because he is still here. I want to thank you for
    staying here, Dr. Shulkin, with your team. I think it is
    really, really important.
        I really want to thank the VSOs. I did not serve. The
    Chairman has; I did not. So, I really depend upon you to tell
    us what your members are saying, which you have today. I
    appreciate that a lot.
        I look forward to working with the Chairman and this entire
    Committee to developing a bill that makes the VA stronger and
    allows the VA to have limited amount of red tape, not only for
    you guys, but for the providers to be able to fill in the gaps.
    Hopefully, we will get there. With your help, we will.
        Thank you all, and thank you, Mr. Chairman.
        Chairman Isakson. Well, thank you, Senator Tester. I want
    to thank Secretary Shulkin again for his being here and staying
    through the testimony of the VSOs. That is a compliment to the
    VSOs, but it is a real tribute to the Secretary. We appreciate
    you doing it.
        To the VSOs, thank you. I agree exactly with what Senator
    Tester said. Your information is of immense value to us in
    making the decisions we have to make. I may have served, but
    that has now been 40 years ago. So, I would much rather be
    knowing what is going on today in the field than what was going
    on 40 years ago, so you are a blessing to me as well.
        Thanks to all of you for being here today. Thanks to the
    men and women, who serve us, in harm's way.
        Let us not forget yesterday was the 73rd anniversary of D-
    Day, which was the beginning of the great victory in Europe. We
    owe everything to our veterans, and most importantly, we know
    that.
        Thank all of you very much, and this meeting is now
    adjourned.
        [Whereupon, at 4:41 p.m., the Committee was adjourned.]
                                    ------

        [The posthearing responses follow:]
     Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
      Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
                                    Affairs
        Question 1.  The program VA has described is a drastic change from
    the current program. The program described would not only get rid of
    the 30-day and 40-mile eligibility rules, but also includes adopting
    industry standards, providing access to urgent care clinics, and gives
    Veterans a choice if the VA medical center or clinic doesn't offer the
    service.
        a. Under the current Choice Program, VA relies on a Third-Party
    Administrator--or TPA--to administer the program. What role would a TPA
    provide in the program described?
        b. Specifically, what would the contractor's duties be and how
    would that differ from the current program?
        Response. Under the new program, the role of the contractors would
    be to establish and maintain a network of qualified healthcare
    providers, as well as complete claims processing, provider payments,
    and data reporting for the care provided within the network. The
    contractors would use an industry-standard credentialing process for
    network healthcare providers.

        Question 2.  By moving toward a clinical needs, convenience, and
    quality of care model, it is clear the VA wants to build the Doctor-
    Patient relationship back in to the decisionmaking process.
        a. How will VA ensure that consistent guidance is sent out to all
    VA providers?
        Response. The VA Office of Community Care (OCC) uses, and will
    continue to use, regular conference calls and a SharePoint site to
    communicate guidance and information about procedures to the field
    leadership, including VHA Chiefs of Staff, and staff. This information
    includes but is not limited to clinical business processes, contractor
    performance, data analysis, financial updates, and network issues. This
    regular communication furthers education, promotes discussion, and
    provides an opportunity to resolve questions.
        Additionally, to promote consistency, the Office of Clinical
    Integration actively collaborates and partners with all Clinical
    Program offices to incorporate their feedback into guidance regarding
    clinical business processes. VHA Chiefs of Staff will be asked to
    distribute the guidance and educate their providers. Also, providers
    will be required to document requests for community care in a
    standardized manner that includes their clinical rationale for
    requesting care in the community.
        b. In the past VA has issued guidance to the field but never
    followed up on how it is implemented. How will you guarantee the proper
    oversight is conducted to ensure the guidance issued is implemented
    correctly?
        Response. OCC has developed solutions that will enable it to better
    monitor utilization of tools and clinical business processes. This will
    include collection of data to evaluate the timeliness with which staff
    performs key steps in these processes. The Consult Tool Box and One
    Consult Model reporting tool assist with tracking and analyzing
    performance data from across the organization. OCC will work closely
    with the field to review results, adjust tools and other clinical
    business process as needed, and thus improve our service to our
    Veterans, VA and community providers and other VA staff.

        Question 3.  VA's testimony states if a VA facility doesn't offer
    the service then the Veteran (in consultation with the provider) would
    be offered community care. However, VA has a long history of looking to
    provide that service at another VA facility before sending a Veteran to
    the community.
        a. Would the proposed change VA intends to make change this
    practice of first looking for another VA facility to provide the care?
        Response. VHA continues to increase accessibility to medical care
    at all VHA facilities and VHA's practice of considering other VA
    facilities will continue when doing so is consistent with applicable
    eligibility criteria for community care.
        b. If so, how would you ensure this is implemented at the facility
    level?
        Response. Each VHA facility will review individual requests for
    medical care and make appropriate clinical determinations, based on
    each Veteran's medical condition and the nature of the care required,
    about the most appropriate way to furnish the care. The determination
    whether to furnish care within VA or in the community will take into
    consideration such factors as distance, the frequency of the needed
    procedure, and VA's ability to provide the care.

        Question 4.  In testimony provided by the Paralyzed Veterans of
    America (PVA) states, ``A more pointed concern is the past
    institutional bias exhibited by VA employees for administering care
    directly in VA at all costs.'' He goes on to state that this behavior
    has been ``modified to a degree'' and VA employees have become more
    comfortable with using care in the community. What will VA do to ensure
    the cultural changes noted in PVA's testimony continue to make sure
    more VA employees embrace the use of care in the community?
        Response. VHA continues to develop guidance and communicate with
    staff about the benefits of and need for community care. The principles
    underlying the new community care program would be quality, Veteran's
    preference, and access. VHA emphasizes these principles in
    communications to employees. These principles would also be
    incorporated into the referral system VA providers use to request
    community care. In addition, VHA will continue to foster positive
    relationships between VA providers and community providers; this will
    create open communication and promote a better understanding of the
    benefits of providing community care as part of an integrated
    healthcare system.
                                     ______

      Response to Posthearing Questions Submitted by Hon. Dan Sullivan to
      Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
                                    Affairs
        Question 5.  Secretary Shulkin, you recently came out with a list
    of buildings the VA considered ``vacant or underutilized'' and it
    included a domiciliary in Anchorage, Alaska. I believe it was wrongly
    added because it's neither vacant nor underutilized, in fact this
    domiciliary is usually full, with 48-50 of 50 beds filled. If closed,
    it would devastate the local VA's ability to provide residential
    substance abuse treatment for Alaskan Veterans and there's not another
    facility available as an option. Are consultations made with the state
    VA prior to making these determinations, to ensure that the assessment
    is accurate?
        Response. The Domiciliary at the Anchorage, AK VA campus, also
    identified as Building 3001, is in use to treat Veterans, and VA has no
    current plans to close or dispose of this building. VA maintains a
    list, updated annually, of buildings that have been identified as
    vacant or underutilized using square footage data from VA's Capital
    Asset Inventory database. Based on this data, Building 3001 has been
    identified as underutilized. Building 3001 was identified as
    underutilized based upon its utilization ratio. The utilization ratio
    is a mathematical calculation determined by evaluating the required
    square footage needed to deliver the functions divided by the actual
    size of the building. In Anchorage, the total Domiciliary program
    (including Building 3001) is 51,340 square feet, whereas the square
    footage needed to deliver the functions as determined by workload data
    would be 25,200 square feet, resulting in a utilization ratio of
    49.08%. This utilization ratio is barely below the 50% utilization
    threshold VA uses to declare a building underutilized and therefore
    Building 3001 is included in the list of underutilized buildings.
    However, inclusion on this list does not indicate that VA has made
    plans to, or is considering, closing Building 3001. As stated above, VA
    currently has no plans to close or dispose of Building 3001. VA will
    continue to evaluate if additional efficiencies can be gained in the
    building to improve space utilization, either through reconfiguration
    of space or possible consolidation of additional functions into the
    space.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
      Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
                                    Affairs
        Question 6.  The goal of the Choice program was to fill an
    immediate gap and give VA time to determine where best to buildup its
    capacity. As part of the Choice Act, $5 billion was included for
    increased staffing and clinics. Currently, all but $595 million of that
    $5 billion has been expended, yet there are still some 45,000 vacancies
    remaining, with 36,000 of those representing ``front-line'' care, that
    is doctors and nurses and other medical professionals. Clearly that $5
    billion has not been sufficient to deal with the problem. To what do
    you attribute to the difficulty in filling these vacancies? What steps
    is the VA taking in order to fill these vacancies? Given the number of
    vacancies at VHA, why does the Administration's budget direct billions
    outside the VA?
        Response. The 30,000+ vacancies cited in QFR6 are actually
    continuous--that is, most of those original vacancies have long since
    been filled, while new ones have emerged. With 325,000 employees, VHA
    has one of the largest workforces in the Federal Government. For years,
    VHA has consistently averaged a turnover rate of approximately 9%,
    which corresponds to a vacancy rate of approximately 33,000 positions
    at any given point in time. VHA typically hires approximately 35,000-
    40,000 employees in a given fiscal year. As fast as VHA fills existing
    vacancies, new vacancies emerge through employee lifecycle events such
    as retirements, resignations, and transfers to other Federal agencies.
    (Based on analysis of BLS reports for comparable institutions in the
    private sector, VHA's 9% turnover rate is less than half that of what
    is observed in the private sector.) Even with the 9% loss each year,
    VHA continues to successfully hire for these vacancies. This success is
    evidenced by VHA's workforce having increased by an average of 3.5%
    employees and 3.6% FTE annually over the last five years. VHA continues
    to promote an aggressive National recruiting program; partnering with
    facility leadership; utilizing innovative marketing strategies,
    leveraging of Title 38 direct hire and pay setting options; and related
    actions at all levels.

        Question 7.  Of the $5 billion authorized in the Choice Act for
    hiring healthcare professionals:

        a. How many physicians have been hired by VHA?
        Response. As of May 31, 2017, 1,692 physicians have been hired by
    VHA.
        b. How many specialists focusing on Traumatic Brain Injury, spinal
    cord injury, amputee/prosthetics have been hired?
        Response. As of May 31, 2017, 265 occupation and physician
    specialties related to Traumatic Brain Injury, spinal cord injury and
    amputee/prosthetics have been hired by VHA.
        c. How many registered nurses and nurse practitioners have been
    hired?
        Response. As of May 31, 2017, 2,912 registered nurses and nurse
    practitioners have been hired by VHA.
        d. How many mental health professionals have been hired?
        Response. As of June 2017, 1,908 mental health professionals were
    hired under the VACAA hiring initiative.
        e. How many staff have been hired to treat survivors of sexual
    assault?
        Response. Military sexual trauma (MST) is the term used by VA to
    refer to sexual assault or repeated, threatening sexual harassment
    experienced by a Servicemember during military service. MST is an
    experience, not a diagnosis or a condition in and of itself, and
    Veterans may react in a wide variety of ways. Because MST is associated
    with a range of mental health and physical health conditions, numerous
    types of providers and clinics throughout VA provide MST-related
    treatment. Therefore, when treating ``survivors of sexual assault,'' VA
    is treating survivors that have a wide variety of health conditions
    that emerge as the result of the sexual assault (i.e. there is not
    ``sexual assault treatment'' per se). Additionally, most providers who
    deliver MST-related mental health care do so in the context of broader
    mental health programs (e.g. general mental health clinics, mood and
    anxiety disorder clinics, PTSD clinical team, etc.) where they treat
    both patients who have experienced MST and patients who have not; as
    such, MST-related mental health care represents only a portion of the
    total care they provide. Given these factors, it is not possible to
    provide a precise number of providers who have been hired (either in
    the past or newly) to provide care to survivors of MST.
        However, VA does track care that is related to MST, and from fiscal
    year (FY) 2014 to FY 2016, there was an increase of 29% in the total
    number of MST-related mental health encounters provided to Veterans.
    There was also an increase of 14.2% in the number of unique providers
    providing MST-related mental health care during this same period (FY
    2014 to FY16). It should be noted, however, that it is not known
    whether the increase in unique providers providing MST-related care is
    related to new hires or existing providers.

        Question 8.  Please provide a breakdown of the current vacancies by
    position at VHA which are considered ``frontline care.'' Please provide
    an analysis of the vacancies in underserved areas.
        Response. VA currently does not have an information system that can
    identify a specific number of vacancies per facility or occupation.
    Secretary Shulkin recently announced the establishment of a fully
    functioning Manpower Management Office by December of this year, which
    will be a critical step in establishing a Position Management system.
    While the manpower management process will determine and fund personnel
    needs, VA's new human capital management system, HR-Smart, in
    conjunction with other new H.R. IT systems, will enable the ground-
    level implementation of structural changes and filling of positions.
    Last, the new Human Capital Operating Plan will track progress on
    strategies to onboard, train and retain a workforce matching VA's
    objectives.

         VA's Manpower Management Office is scheduled to be stood
    up by December 2017, and forthcoming manpower management policies will
    guide much of this work.
         HRSmart's Manager Self-Service functionality is scheduled
    to go live June 2018 and is planned to be fully implemented by January,
    2019.
         The draft FY18-19 Human Capital Operating Plan is
    scheduled to be delivered to OPM by late September, 2017, and the final
    version delivered to OPM in February, 2018.

        Question 9.  The number of Veterans needing care is expected to
    continue rising over the next several years. I strongly agree that we
    need to find short term fixes to the problem of long wait times, but
    our long term goal must be to strengthen the VA healthcare system
    itself. Why are we not putting another $5 billion into the VA to
    strengthen VA's healthcare delivery system, a promise made by the
    President on the campaign trail? Instead, the budget's emphasis is on
    directing resources outside the VA, something VSOs are have rightly
    raised concerns about. If we're increasing support for community care
    by around 30%, but increasing support for hiring and retention by under
    2%, that doesn't seem to me to reflect a commitment to strengthen the
    VA healthcare system. How do you justify a budget that is clearly at
    odds with the promises made by the Administration to Veterans?
        Response. In the FY 2018 budget, total resources for VA facility
    care are increasing by 7.1% from FY 2017 to FY 2018, while total
    resources for community care are increasing by 8.3%. Our budget request
    supports the Administration's priority of delivering high quality
    healthcare to our Nation's Veterans.
        For FY 2018 and FY 2019, VA has five sources of funds for its
    Medical Care accounts:

        1. Annual Congressional Appropriations (Medical Services, Medical
    Community Care, Medical Support and Compliance, and Medical Facilities)
    net of any Congressional rescissions and transfers to other
    appropriations
        2. The Medical Care Collections Fund (Medical Services and Medical
    Community Care)
        3. Mandatory Appropriations from the Veterans Access, Choice and
    Accountability Act (VACAA)
        4. Unobligated balance carryover amounts from the previous year
    (all four Medical Care accounts)
        5. Reimbursements from other agencies for services provided
    (Medical Services, Medical Support and Compliance and Medical
    Facilities).

        Amounts from these five sources combine to create the total
    Obligation Authority for VA Medical Care in a specific fiscal year. The
    easiest way to compare year-to-year ``Purchasing Power'' in the VA
    Medical Care Budget is to look at the ``Obligations by Object'' tables.
    These tables compare estimated total obligations by fiscal year for the
    period reported in the President's Budget.
        The following table is extracted from the detailed Obligations by
    Object tables in the FY 2018 President's Budget.

        The information above shows an increase of $4.3 billion in VA care
    funding from FY 2017 to FY 2018 as opposed to an increase of $965
    million in Medical Community Care funding. As the ``Personnel
    Compensation & Benefits, and FTE'' table indicates, in FY 2018 over
    $36.7 billion will be obligated supporting nearly 315,000 FTE of which
    7,000 will be new hires. In FY 2019, $38.4 billion will be obligated to
    support over 317,000 FTE of which nearly 3,000 are new hires.

        Question 10.  Looking at the ``Community Care Redesign,'' it seems
    to me that it sends a message to people already working in the VA that
    their work is not really valued, thereby making hiring and retention
    even more difficult. As I'm sure you're aware, it has been pretty
    consistently shown that, by almost every measure, VA healthcare is as
    good, or better, than care in the private sector. For just one recent
    example, in an extensive 2016 study examining the VA's performance in
    healthcare procedures versus its private sector counterparts, the Rand
    Corporation found that ``in a tally of 83 different measures covering a
    variety of types of care, including safety and effectiveness of
    treatment, the quality of VA healthcare exceeded that of non-VA care.''
    How does the President's budget seek to strengthen VA's health delivery
    system, and empower the agency to expand the areas of care where it
    excels?
        Response. VA is committed to providing high-quality care within VA
    and in the community and is driving performance excellence through
    continual comparison with the community on metrics that matter to the
    Veteran. In this sense, the Veteran is empowered with a choice for
    their healthcare and VA is motivated at all levels of the organization
    to ensure that we continue to exceed those expectations. It also serves
    as an accountability function- VA hospital directors are incentivized
    to focus on quality in particular service lines to remain consistent
    with regional performance averages.
        With that as the accountability function, VHA is moving toward a
    new Quality Governance Model as a support function for facilities to
    improve if they are at or near quality thresholds for particular
    services. This model encourages improvement at the local VA healthcare
    facility unit level on quality, safety, access and satisfaction metrics
    most important to the Veteran. The clinical care team is empowered to
    make process changes to achieve better outcomes and patient
    satisfaction. The governance model promotes the opportunity to share
    experiences and practices across the organization, thus driving overall
    care to higher levels.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
      Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
                                    Affairs
        CVS Minute Clinics Pilot--Dr. Shulkin, last year the Palo Alto VA
    began a pilot with CVS to provide care for Veterans at 14 CVS Minute
    Clinics in the San Francisco Bay Area and Sacramento and was recently
    expanded to Phoenix.

        Question 11.  Can you share with the Committee your thoughts on the
    pilot?
        Response. The CVS Minute Clinic Pilot, which is also called the
    Convenient Care Referral program, is a very promising proof of concept
    initiative that is still being refined and evaluated for expansion to
    other locations in the new fiscal year.

        Question 12.  Would you consider expanding it to Hawaii? We have
    many CVS locations under the Longs Drugs brand across the state that
    would provide Hawaii Veterans a more convenient option for routine
    care?
        Response. VA is evaluating the success of the current initiative,
    and if successful, VA would support expansion of this initiative.
                      native hawaiian health care centers
        Recently, my staff coordinated a call with representatives from
    TriWest and the Native Hawaiian Health Care Centers on their experience
    with the Choice program. During the conversation, a few issues
    regarding outreach as well as reimbursement for specific services were
    brought up.

        Question 13.  One of the key provisions in the Choice Act I worked
    to get included was the inclusion of NHHCC as providers eligible for
    reimbursable services. However, utilization to date has been low for a
    variety of reasons including outreach. Dr. Shulkin, does the VA have
    ways in which they assist Choice providers around the country with
    outreach? If so, can I get a commitment that the VA will work with the
    NHHCCs to strengthen outreach initiatives?
        Response. VHA's Office of Community Care (OCC) and its contractors
    maintain public websites with information regarding provider
    eligibility to participate in the Choice Program and how to register as
    a Choice provider. OCC also engages with hospital and trade
    organizations to provide outreach to providers and healthcare systems
    regarding the Choice Program and community care as a whole. The
    contractors work closely with VA medical centers to provide outreach to
    local providers such as NHHCCs based on the needs of Veterans locally.
                  va reimbursement of native hawaiian medicine
        Regarding reimbursement under Choice, I understand from the NHHCCs
    that lomilomi, which is a massage technique and just one part of
    traditional Native Hawaiian Healthcare Centers have been seeking. I'm
    aware that reimbursement for such a specific service is contingent upon
    the proper authorization, claims submission, and appropriate coding.

        Question 14.  Dr. Shulkin, could I receive a commitment from you
    that the VA, along with TRiWest will continue working with the Native
    Healthcare Centers in developing a way so they may be reimbursed for
    the lomilomi service?
        Response. Lomilomi is a form of massage therapy. It is not
    currently included in the VA medical benefits package and so is not
    available under the Choice Program. VHA has a process for determining
    whether a service should be included in the medical benefits package
    that takes into account recommendations from the field if they meet
    certain criteria.
                                     ______

    Response to Posthearing Questions Submitted By Hon. Joe Manchin III to
      Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans
                                    Affairs
        Question 15.  How, if at all, do you see the repeal of the
    Affordable Care Act affecting VA Healthcare? For example, do you expect
    to see an uptick in enrollment?
        Response. Any impacts on Veterans or VA would depend on the
    specific legislative changes enacted by Congress.

        Question 16.  Will the new non-VA care system you proposed utilize
    third party administrators for scheduling? If not, do you believe you
    have the workforce and other resources to handle non-VA care referrals
    and scheduling?
        Response. VA will take the lead for scheduling locally and it will
    be supported by the third-party administrators when VA issues the
    optional task for Appointment Scheduling and Comprehensive Care
    Coordination. The Community Care Network Request for Proposal includes
    an optional task for support from the third-party administrators for
    these functions if VA medical facilities require additional support for
    them.

        Question 17.  The VA plan for community care does not address
    Emergency Care. Why doesn't the plan address emergency care and can we
    expect a plan on this soon?
        Response. VA has existing reimbursement authority for emergency
    treatment furnished by non-VA providers, 38 U.S.C. 1725 and 1728.

        Question 18.  In the new VA plan, you shift metrics from mileage
    and appointment time to services and quality of services offered. Can
    you further explain how you make sure every Veteran, regardless of
    where they live, will have access to the very best care--VA or non-VA?
        Response. Under the proposed Veteran CARE program, eligibility for
    community care would be based on factors that include a Veteran's
    individual clinical need, determined in consultation with their
    provider, and VA's ability to timely provide the service. In addition,
    Veterans will be eligible to receive community care through an
    innovative program if local service lines are performing below
    community standards. This program will be initially conducted with a
    limited number of clinical services, and no VA medical center will have
    more than five service lines subject to this program. Finally, eligible
    Veterans would have access to community walk-in clinics for minor
    medical needs.

        Question 19.  In July 2016, the Department for Health and Human
    Services made a decision to remove the HCAHPS survey questions
    regarding pain management from the hospital payment scoring
    calculation. This was all in an effort to eliminate any perception that
    hospitals may not receive full Medicare payments because they did not
    prescribe opioid pain medications to patients. If you use HCAHPS scores
    to grade VA medical centers level of care, will you be using pain
    management questions in your calculation?
        Response. VA does use the Hospital Consumer Assessment of Health
    Providers and Systems (HCAHPS) in tracking Veteran Experience at our
    hospitals, but the item on Pain Management is not currently used for
    scoring facility performance in our Strategic Analytics for Improvement
    and Learning (SAIL) report. The only item from HCAHPS that is scored in
    SAIL for FY 2017 is the Overall Rating of the Hospital, which is scored
    as the percent of Veterans who give the hospital a 9 or 10 on a 0 to 10
    point scale.
                                     ______

    Posthearing Questions Submitted by Hon. Mazie K. Hirono to Jeff Steele,
     Assistant Director, National Legislative Division, The American Legion
        Question 1. You testified that the Choice Act effectively exposed
    VA's practice of managing to budget as opposed to managing to need. Can
    you speak more about this issue and provide examples?

        Question 2. You indicated that the American Legion supports an open
    and more competitive VA. What recommendations would you make to achieve
    this goal?

        [Responses were not received within the Committee's
    timeframe for publication.]
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
    Adrian Atizado, Deputy National Legislative Director, Disabled American
                                    Veterans
        Question 1. Mr. Atizado, you testified that timely and cost
    effective access to needed health care services is essential and that a
    lack of coordination of care between VA and community providers exists.
    Can you provide examples of how a lack of care coordination has
    critically impacted services and what actions are needed for
    improvement?
        Response. Coordinated health care is care provided in a planned way
    that meets the needs and preferences of the patient. When care is well
    coordinated, the veteran patient, family, caregivers, and the clinical
    team communicate with each other so that everyone has the information
    they need, and they all know who is responsible for providing various
    aspects of the veteran's care.
        Problems with scheduling care, sharing pertinent health
    information, and communication between the veteran patient, family
    caregiver and health care teams leads to fragmentation of medical care
    and duplication of services often resulting in higher costs, lower
    quality, and may threaten patient safety. There is higher risk of
    adverse consequences due to fragmented care for veteran patients in the
    VA health care system because it serves an especially vulnerable
    population that has more chronic medical conditions, behavioral health
    conditions, and individuals of lower socioeconomic status than the
    general medical population.
        Veterans who receive all their care from VA can generally expect to
    receive well-coordinated care compared to the private sector, yet care
    is often highly fragmented among those combining care secured through
    private health plans, Medicare, TRICARE, and VA. This fragmentation
    often results in lower quality, threatens patient safety, and shifts
    cost among payers.\1\
    ---------------------------------------------------------------------------
        \1\ ``The Impact of the Affordable Care Act on VA's Dual Eligible
    Population,'' Patricia Vandenberg et al., Department of Veterans
    Affairs, accessed June 2, 2016; ``Veterans and the Affordable Care
    Act,'' Journal of the American Medical Association, 307, no. 8, (2012):
    789-790, accessed June 20, 2016
    ---------------------------------------------------------------------------
        The most recent addition to VA's authority to purchase care in the
    community through the Veterans Choice Program has yielded numerous
    complaints from individual patients specifically regarding care
    coordination including: Scheduling, such as blind scheduling where an
    appointment is made without discussing with the veteran and their
    family caregiver if they are able to make the appointment;
    Inappropriate health information sharing, such as sharing information
    not pertinent to the care for which the veteran is being referred or
    too much information requiring the provider to spend unnecessary time
    to search for pertinent or meaningful medical information; Adequacy and
    sufficiency issues of the referral network, such as providers listed in
    the network when they are no longer part of the network or the only
    available network providers are not closer to the veteran than VA.
        We believe the immediate solution to ensure proper care
    coordination is for VA to fully resume its role as the coordinator and
    primary provider of care. The long-term solution to ensure veterans
    care is properly coordinated is to reform VA medical care into a high-
    performing integrated health care system using other Federal and
    community providers to deliver care when necessary.

        Question 2. You stated that DAV does not believe that the Choice
    Program should be expanded to new categories of veterans for clinical
    and fiscal reasons. Can you expand on that statement and offer some
    guidelines on potential collaborative efforts going forward?
        Response. In addition to care coordination issues highlighted in
    our response to the previous question, our primary clinical concern
    related to the Choice Program is the quality of care veterans receive.
    Oversight of the quality of care the VA health care system directly
    provides to veterans includes many important perspectives such as the
    work by the Government Accountability Office, VA Office of Inspector
    General, Veterans Service Organizations and Congress. Yet there has
    been barely equivalent oversight of the quality of care veterans
    receive through the Choice Program.
        Unlike the Choice Program, the VA is an integrated health care
    system. Integrated health care systems have several features that lead
    to the delivery of less expensive or higher quality care than non-
    integrated providers: Comprehensive medical records are accessible to
    all providers and in all care locations, providing better information
    on which to make clinical decisions and making it easier to avoid
    delivering duplicative or potentially conflicting services;
    Collaboration among doctors and coordination of care among locations
    should be easier for both doctors and patients when the care is all
    provided ``under one roof,'' and; Doctors' performance can be measured
    (and correspondingly rewarded) using factors that contribute to the
    overall health and improvement of patients, such as timely provision of
    care and adherence to treatment guidelines.\2\
    ---------------------------------------------------------------------------
        \2\ ``Effects of Integrated Delivery System on Cost and Quality,''
    American Journal of Managed Care, vol. 19, no. 5 (May 2013)
    ---------------------------------------------------------------------------
        According to a 2016 RAND Corporation study reviewing published
    scientific literature examining the quality of care provided at VA
    compared to other facilities and systems found that the VA health care
    system generally performs better than or similar to other health care
    systems on providing safe and effective care to patients.\3\
    ---------------------------------------------------------------------------
        \3\ ``Comparing VA and Non-VA Quality of Care: A Systematic
    Review,'' Journal of General Internal Medicine, 2016.
    ---------------------------------------------------------------------------
        We believe there may be an erroneous assumption that credentialed
    network clinicians are equivalent to cost-effective, quality care.
    While there is a higher likelihood that certified/licensed/credentialed
    clinicians provide cost-effective quality care, there has been no study
    indicating care received in the Choice Program is the same as or better
    than the veteran-centric evidenced based care VA provides.
        Our primary fiscal concern is due to the amount of funds for both
    the Choice Program and for the VA health care system. Currently, VA
    projects funding available for the Choice Program will be extinguished
    by mid-August this year. In addition, this year's budget request for VA
    notes the impact of the Choice Act with an increase of 1.89 percent in
    reliance on VA versus their other health care options,\4\ a roughly a
    $2.65 billion increase in needed resources.
    ---------------------------------------------------------------------------
        \4\ Department of Veterans Affairs Volume II Medical Programs and
    Information Technology Programs Congressional Submission FY 2018
    Funding and FY 2019 Advance Appropriations, pages VHA-364, 366
    ---------------------------------------------------------------------------
        Because there is no concrete long-term viable solution to ensure a
    smooth transition from the current state of VA community care to the
    future state of a high performing integrated VA health care system
    comprised of other Federal and community providers, even a limited
    expansion of the Choice program would add significant fiscal costs, at
    a time when both the amount of requirements placed on the VA health
    care system as well as the growing demand for VA care is greater than
    resources provided by Congress.
        To serve as a guide in developing the future of VA Community Care
    for veterans, DAV and our Independent Budget partner organizations
    developed our proposed Framework for Veterans Health Care Reform.\5\ To
    care for millions of veterans who use and rely on VA for health care
    benefits and services, the Department must be empowered to implement
    realistic, long-term reforms by creating an integrated high performing
    system based on a modernized VA health care system. This will require
    Congress, VA, and Veteran Services Organizations to agree on the end
    goal of VA Community Care for veterans, and to work together to set
    realistic expectations to achieve them.
    ---------------------------------------------------------------------------
        \5\ https://www.dav.org/learn-more/news/2015/setting-a-new-
    framework-for-reforming-va-health-care/
    ---------------------------------------------------------------------------
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
      Carlos Fuentes, Director, National Legislative Service, Veterans of
                       Foreign Wars of the United States
        Question 1. Mr. Fuentes, you stated that the VFW hears from
    veterans regarding issues they would like to see addressed. One area
    described was the VA's wait time measurement. Can you provide some of
    the feedback received on the VA's current role in determining how long
    a veteran must wait before receiving care?
        Response. The VFW's health care surveys have identified a
    misalignment between the amount of time veterans perceive they wait for
    care and the amount of time VA reports veterans have waited for their
    appointments. In a survey from October 2017, nearly 70 percent of
    veterans reported waiting less then 30 days for a VA appointment.
    However, VA data showed that 93 percent of appointments being scheduled
    within 30 days. The difference is between what veterans perceive their
    wait times to be and how VA measures wait times.
        VA uses the preferred date metric to report wait time. While this
    metric has improved since the access crisis erupted in 2014, it still
    remained flawed and susceptive to data manipulation. VA records the
    number of days that laps between the day a veterans says he or she
    wants to be seen (preferred date) or when a doctor determines a veteran
    must be seen (clinically indicated date) and the date the veteran is
    seen. Thus, a veteran who calls to make an appointment on the first of
    the month who says he or she wants to be seen with seven days, but
    isn't seen until the 14th has a VA recorded wait time of seven days,
    instead of the 14 days that the veteran perceives he or she has waited.
        What is important to VFW members is that they get the care they
    need when they need it. That is why we have advocated for the
    elimination of the 30 day wait time eligibility determination for the
    Choice Program and asked the Congress make Choice Program eligibility
    based on the needs and preferences of individual veterans in
    consultation with their care teams. VFW members have also asked the VA
    hire more doctors and expand internal capacity so they can have the
    option of receiving timely care at VA--their preferred option--rather
    than having to receive care through the Choice Program.

        Question 2. You recommended that there be an objective starting
    point in allowing veterans to go outside the VA when particular medical
    service is not provided in that facility. What are some of the
    scenarios where these decisions should be made?
        Response. The VFW firmly believes that when and where veterans
    receive care must be determined through a discussion between veterans
    and their health care team. Arbitrary eligibility metrics like 30 days
    and 40 miles do not accurately reflect the nature of seeking health
    care. In many instances 30 days may be too long, like a veterans who
    has chest pain and needs to get an MRI. For other veterans, waiting
    more than 30 days for a routine checkup may not be a concern.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
     Gabriel J. Stultz, Legislative Counsel, Paralyzed Veterans of America
        Question 1. You testified that PVA strongly supports the concept of
    developing a high-performing network that would seamlessly combine the
    capabilities of both public and private health care providers. Can you
    provide examples of this approach? And are there efforts underway to
    coalesce around the concept?
        Response. Much of the health care delivered in the United States is
    facilitated through managed care networks and other payer models
    separate from the provider functions, the goal being to ensure that
    members within a plan have the full spectrum of care available to them.
    VA is unique in that it is both payer and provider, and it is one of
    the few public entities charged with providing direct health care
    services. For these reasons, and because of VA's mandate to provide
    direct care to veterans spread across the country, it is difficult to
    draw direct comparisons or find examples within the industry.
        The evolution of the Choice Program itself demonstrates the concept
    to a degree if one considers the interaction between VA and the third-
    party administrators who employ a network of providers to facilitate
    access to care in the community where gaps in service exist. A critical
    distinction, however, is that the proposal to develop a high-performing
    integrated network contemplates a prospective process that analyzes
    both VA's capacity, its service priorities and local market resources
    to determine the network's makeup. The current process is more
    reactionary, with third-party administrators filling gaps as veterans
    unable to access care within VA are presented.
        VA must employ a network comprised of both public and private
    resources in order to keep up and effectively navigate a complex and
    ever-changing health care environment. Stakeholders have generally
    coalesced around this concept at this point in time. Over the last two
    years, VA's community care team has incorporated the veteran service
    organizations (VSO) into its planning efforts, collecting valuable
    feedback and gaining trust from stakeholders. Throughout this process
    VA and the VSO community have demonstrated to Congress a desire to move
    VA in a direction that integrates aspects of the community to better
    align resources and fill gaps in service. Members of Congress have
    likewise indicated support for this concept, often reiterating that
    utilization of private providers should supplement, not supplant, the
    VA health care system. Our interaction with the community care team has
    waned slightly with the change in administration. We believe firmly
    that robust and frequent collaboration should be restored at the policy
    level to ensure that the network developed reflects the true priorities
    and mission of VA.

        Question 2. You recommended that there be an objective starting
    point in allowing veterans to go outside the VA when a particular
    medical service is not provided in that facility. What are some of the
    scenarios where these decisions should be made?
        Response. VA's latest planning iteration contemplates eligibility
    determinations based on three categories. The first is a clinical
    determination made on a case-by-case basis. The second is focused on
    the quality of care being delivered within VA, specifically at the
    service line level. The third category focuses on offering convenient
    options for certain low-intensity types of care, such as the
    administration of immunizations. My comments related to rendering
    veterans eligible when a particular service is not available in their
    local facility fall under the first category--clinical determinations.
    If a veteran seeks care from his or her facility, and the care team
    determines that the particular service the veteran needs is not offered
    at that facility, VA cannot simply abrogate its duty to provide that
    service. VA must supplement its own resources by engaging with a
    private provider to serve that veteran. The scenarios, therefore, are
    limitless. If, for example, VA does not provide urology services, and
    the veteran has a urinary disorder, the veteran would be authorized to
    seek care in the community. VA's tentative proposal contemplates two
    other considerations under the clinical determination category: 1.
    access, which deems a veteran eligible if the service cannot be
    provided within a clinically-appropriate timeframe, and 2. feasibility,
    which considers the full picture of the veterans treatment needs and
    whether care within a VA facility is feasible and will lead to the best
    outcome for the veteran.

                                A P P E N D I X

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