[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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                     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 [email protected].

    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.
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    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.
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    \5\ https://www.dav.org/learn-more/news/2015/setting-a-new-
framework-for-reforming-va-health-care/
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                                 ______
                                 
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.

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