    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

                           MISSION CRITICAL: CARE IN
                              THE COMMUNITY UPDATE

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

                                     HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                         WEDNESDAY, SEPTEMBER 25, 2019

                                   __________

                               Serial No. 116-36

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    40-992                     WASHINGTON : 2022

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                       MARK TAKANO, California, Chairman

    JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking
    KATHLEEN M. RICE, New York               Member
    CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
        Chairman                         AUMUA AMATA COLEMAN RADEWAGEN,
    MIKE LEVIN, California                   American Samoa
    MAX ROSE, New York                   MIKE BOST, Illinois
    CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
    ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
    SUSIE LEE, Nevada                    JIM BANKS, Indiana
    JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
    GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
        California                       STEVE WATKINS, Kansas
    COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
    GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
        Northern Mariana Islands
    COLIN Z. ALLRED, Texas
    LAUREN UNDERWOOD, Illinois
    ANTHONY BRINDISI, New York

                     Ray Kelley, Democratic Staff Director
                     Jon Towers, Republican Staff Director

                             SUBCOMMITTEE ON HEALTH

                     JULIA BROWNLEY, California, Chairwoman

    CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking
    MIKE LEVIN, California                   Member
    ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN,
    MAX ROSE, New York                       American Samoa
    GILBERT RAY CISNEROS, JR.,           ANDY BARR, Kentucky
        California                       DANIEL MEUSER, Pennsylvania
    GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
        Northern Mariana Islands

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

                            C  O  N  T  E  N  T  S

                                  ----------

                         WEDNESDAY, SEPTEMBER 25, 2019

                                                                       Page

                               OPENING STATEMENTS

    Honorable Julia Brownley, Chairwoman.............................     1
    Honorable Neal P. Dunn, Ranking Member...........................     3
    Honorable Mike Levin.............................................     9
    Honorable Gilbert Ray Cisneros, Jr...............................    13
    Honorable Anthony Brindisi.......................................    15
    Honorable Max Rose...............................................    17
    Honorable Conor Lamb.............................................    19

                                   WITNESSES

    Dr. Richard Stone, Executive in Charge, Veterans' Health
      Administration, Department of Veterans Affairs.................     4

            Accompanied by:

        Dr. Kameron Matthews, Deputy Under Secretary for Health for
            Commuity Care, Veterans' Health Administration

        Dr. Jennifer MacDonald, MISSION Act Lead, Veterans' Health
            Administration

    Ms. Sharon Vitti, President CVS MinuteClinic and Senior Vice
      President, CVS Health..........................................    22
    Mr. David J. McIntyre, Jr., CEO, TriWest.........................    24
    Lt. General Patty Horoho, CEO, OptumServe........................    26

                                    APPENDIX
                         Prepared Statements of Witness

    Dr. Richard Stone Prepared Statement.............................    39
    Ms. Sharon Vitti Prepared Statement..............................    42
    Mr. David J. McIntyre, Jr. Prepared Statement....................    45
    Lt. General Patty Horoho Prepared Statement......................    55

                           Submissions For The Record

    Mr. Adrian M. Atizado, Disabled American Veterans................    65
    Paralyzed Veterans of America....................................    68
    Mr. Ryan M. Gallucci, The Veterans of Foreign Wars of the United
      States.........................................................    69

                           MISSION CRITICAL: CARE IN
                              THE COMMUNITY UPDATE

                                  ----------

                         WEDNESDAY, SEPTEMBER 25, 2019

                  U.S. House of Representatives
                                 Subcommittee on Health
                                 Committee on Veterans' Affairs
                                                        Washington, DC.

        The subcommittee met, pursuant to notice, at 10:03 a.m., in
    room 210, House Visitors Center, Hon. Julia Brownley
    [chairwoman of the subcommittee] presiding.
        Present: Representatives Brownley, Rose, Brindisi, Levin,
    Lamb, Cisneros, and Dunn.
        Also present: Representative Roe.

            OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

        Ms. Brownley. Good morning, everyone, and thank you all for
    joining us here today for this oversight hearing to receive an
    update on VA's new Community Care Program, an urgent care
    benefit required by the MISSION Act.
        This new program and benefit have only been up and running
    for approximately 90 days. As a result, we don't have a lot of
    concrete data at this point; however, I thought it was
    important to check in on how things are going, especially as we
    have new partners in this endeavor.
        In 2014, in response to a wait time scandal that rocked the
    Nation, Congress passed the Veterans Access, Choice and
    Accountability Act of 2014, commonly referred to as the Choice
    Act. The implementation of the Choice program was fraught with
    numerous and widely reported challenges, which ultimately led
    Congress to completely overhaul VA's community care programs
    via the MISSION Act. Both the new Veterans Community Care
    Program and the urgent care benefit launched on June 6th of
    this year.
        While we commend and we truly do commend VA for launching
    these on time, and we are also impressed with the implemenation
    of new community care program so far, we must also acknowledge
    that there are opportunities and areas for improvement. These
    are areas that have been identified through site visits and
    listening to the concerns of veterans, VA employees, community
    providers, veterans service organizations, and other key
    stakeholders.
        Of particular concern is network adequacy. Staff has heard
    anxieties from multiple stakeholders on this topic. Given my
    work with the Women Veterans Task Force, I was particularly
    alarmed to hear of the challenge of enrolling specialty
    providers for gender-specific services such as high-risk
    maternity care and fertility treatments. While I understand
    that VA and its third party administrators may still be working
    to bring more providers into networks, a lapse in care in these
    areas can be incredibly detrimental to these veterans who need
    ongoing and continuous care.
        I have also heard some VA providers are still unclear as to
    when and how to apply the best medical interest standard.
    Without appropriate and instructive guidance on when and how to
    apply this standard, the risk of inconsistent use across the VA
    health care system increases and is likely to lead to
    unnecessary inequities in care for our veterans. This is
    particularly concerning given that of the 710,000 consults
    where the decision support tool was used to determine veterans'
    eligibility for care in the community, the overwhelming amount,
    534,000 of those were determined eligible based on the best
    medical interest standard.
        Another concern is with the decision support tool itself.
    The development of this software was rife with well-documented
    issues, which the full committee discussed earlier this year.
    This tool is intended to provide VA clinicians and veterans
    with information to make real-time decisions as to whether
    veterans are eligible to and whether they should obtain care in
    the community.
        While VA has noted that employees are using this tool
    approximately 30,000 times per day, issues with this tool
    continue as it can--as it can time out--sorry, my script is a
    little messed up here. Anyway, the timeout and the glitchy part
    of the tool has been--people have talked about that and this is
    leading many VA providers to forgo its use entirely.
        In lieu of this tool, committee staff have heard that some
    providers have developed a work-around by simply applying the
    best medical interest standard.
        Lastly, while the urgent care benefit has been well
    received by veterans, there are a few issues with how this
    benefit is being administered and advertised. There has been
    confusion over where and how veterans should obtain pharmacy
    benefits where they have obtained urgent care and a medication
    has been prescribed. In addition, the online urgent care
    locator is not always accurate.
        During secret shopping trips, committee printed out street
    addresses to facilities, only to find on arrival that they
    didn't exist. This directly impacts and delays a veteran's
    ability to utilize this benefit to obtain urgent and necessary
    health care.
        Furthermore, committee staff found that despite the
    development of signage to indicate an urgent care facility is
    in network, its usage is hit or miss, potentially causing
    further delays in accessing this benefit.
        That being said, I hope to have an honest and frank
    conversation today about how this community care program and
    benefit has been operating, the challenges VA and its partners
    currently face, and how we can help in addressing those
    challenges. We also want to hear from stakeholders like Optum,
    who is a new partner for VA in providing care to veterans, so
    we can learn more about how they are standing up their networks
    in Region 1, 2, and 3, and how the transition from TriWest to
    Optum has been going.
        Lastly, while the new Community Care Network is a much
    better program than Choice and the implementation of the
    program appears to be going much more smoothly than the
    implementation of the Choice program, we hope to hear from VA
    and partners like TriWest on how they are using lessons learned
    from the Choice program to improve provisions of care in the
    community to veterans through the community care networks and
    the urgent care network.
        I thank you all again for being here and, again, I want to
    emphasize the fact that we are very pleased about how this is
    going so far. I have highlighted some of the issues that we
    have heard from, so that we can address those and learn from
    them, and move on.
        With that, I now recognize Ranking Member Dunn for his
    opening remarks.

           OPENING STATEMENT OF NEAL P. DUNN, RANKING MEMBER

        Mr. Dunn. Thank you very much, Chairwoman Brownley. It is a
    pleasure to be here this morning for the first of what I expect
    will be a series of hearings this Congress on the
    implementation of the MISSION Act.
        The MISSION Act is a landmark piece of legislation, as the
    chairwoman pointed out. It was signed into law by President
    Trump last Congress after more than a year of bipartisan,
    bicameral work in this committee and with the Senate Committee
    on Veterans Affairs. It impacts and improves virtually every
    aspect of the Department of Veterans Affairs' health care
    system, from the alignment of the VA medical facilities to the
    system of caregiver support, to the flexibilities and
    authorizations that it makes easier for VA to hire clinical
    staff and support staff.
        The overarching goal of the MISSION Act is to increase
    access to care in the VA medical centers and clinics, and
    through the VA's partners in the community, and to empower our
    veterans to control their own health care decisions.
        To that end, today we discuss the consolidated Community
    Care Program that the MISSION Act created. That program went
    into effect D-date June 6th, just a little more than 3 months
    ago, and the rollout of the new government programs of this
    size and significance are often accompanied by delays and
    drama. However, the rollout of the MISSION Act Community Care
    Program has been accompanied by very little fanfare for the
    last 12 weeks. I hope that is a good thing; I hope the reason
    for that is it is all good news.
        For example, I know that veterans are enjoying the new
    urgent care benefit the MISSION Care Act provided them without
    having to travel or wait for an appointment at a VA medical
    center. However, I have heard some concerns from the providers
    in my district, and I mean both the doctors and the hospitals.
    They are telling me that they continue to struggle with getting
    their bills paid in a timely fashion. They get conflicting
    messages about whether they are appropriately credentialed as
    part of the VA's Community Care Network. And, most importantly,
    they continue to hear concerns about veterans who report
    waiting a long time to get to community care consults
    authorizations by the VA, and I hope to get to the bottom of
    that today.
        Three months is not a lot of time, as the chairwoman
    pointed out, so the data we have is limited at this point.
    Conclusions that we reach will be preliminary and this
    committee's ongoing oversight will be needed to make sure that
    things stay on track, especially as the VA transitions to new
    Community Care Network contracts and providers and managers.
        I am grateful to be here this morning with Dr. Stone and
    Dr. Matthews, two senior VA executives who have been leading
    this effort for the Department. I am also grateful to be joined
    by our second panel by the VA's new partners, Optum, TriWest,
    and CVS.
        Delivering high-quality care that our Nation's veterans
    deserve requires a collective effort on behalf of a grateful
    nation. I appreciate the work that all of you do to create a
    strong partnership to better serve our veterans.
        With that, I yield back.
        Ms. Brownley. Thank you, Dr. Dunn.
        Thank you, Dr. Roe, for joining us here today. As everyone
    knows, Dr. Roe is the ranking member of the committee as a
    whole, and if you would like to make any comments before we
    begin----
        Mr. Roe. No.
        Ms. Brownley. Well, thank you again for being here.
        On today's first panel we have Dr. Richard Stone, Executive
    in Charge of Veterans' Health Administration (VHA) . He is
    accompanied by Dr. Kameron Matthews, Deputy Under Secretary for
    Health and Community Care, and Dr. Jennifer MacDonald, VHA's
    MISSION Act Lead. We have got all the leaders on this important
    mission.
        Welcome to you all and, Dr. Stone, I now recognize you for
    5 minutes.

                       STATEMENT OF RICHARD STONE

        Dr. Stone. Good morning, Chairwoman Brownley, Ranking
    Member Dunn, members of the subcommittee, and thank you,
    Ranking Member Roe, for attending. Thank you all for your
    dedication to America's veterans.
        I appreciate the opportunity to discuss the implementation
    of the VA MISSION Act, and I am accompanied today, as the
    chairwoman mentioned, by Dr. Matthews and Dr. MacDonald, two of
    the key leaders in this implementation. I am very proud of the
    work that we have done across VA to ensure the MISSION Act is a
    success for veterans.
        When the Veterans Choice Act Program was enacted in 2014,
    access to care for veterans was a critical concern nationwide.
    Over the last 5 years, however, the VA has transformed. We have
    improved how we do all aspects of our business, from scheduling
    of appointments to referring veterans to specialists, thus
    resulting in enhanced services for our enrolled veterans.
        Today, we are not only providing care to veterans more
    quickly, we are also serving more veterans inside our system.
    Over Fiscal Year 2019 to date, VA has completed almost 59
    million ambulatory appointments. This is a 1.6 million increase
    over the same timeframe last year. That represents an increase
    of 3.1 percent in VA's in-house capacity over this fiscal year.
    VA is not privatizing and veterans are choosing VA.
        We will continue to ensure we meet veterans' needs for care
    in the years to come. Our priority remains the integration of
    veterans' care when and where they need it.
        On June 6th, we launched the new Veterans Community Care
    Program under the MISSION Act. This new program makes dramatic
    improvements in how veterans receive community care and will
    allow VA to deliver veterans world-class, seamless care aligned
    to each veteran's individual needs and their preferences.
        Launching on June 6th was no small feat, as VA is the
    largest health care system in the Nation. In response to the
    sheer size and geographic demands, and dispersion of this
    system and of this deployment, we established a Joint
    Operations Center with participation of all of VISNs and all
    key offices across the Department. The Joint Operations Center
    structure allowed VA to give our leaders and our employees at
    all levels the tools for success.
        During the lead-up to the launch, as well as on the go-live
    day of June 6th, the Joint Operations Center shared real-time
    performance across the Nation, and provided data about the
    status of implementation and the functioning of the Decision
    Support Tool with all leaders in order to resolve issues and
    coordinate actions necessary to ensure success. This
    coordinated effort is now being sustained.
        The Act consolidated a number of disparate authorities to
    purchase community care into one streamlined and seamless
    program that includes eligibility, authorization, appointments,
    care coordination, claims, and the payment of claims, while
    improving overall communication between veterans, community
    providers, and VA staff members. These changes will lead to a
    significantly better experience with community care for the
    veteran, for the provider, and for VA employees.
        In addition, a veteran may now elect to receive community
    care if the referring VA physician and the veteran decide that
    care in the community is in the veteran's best medical
    interest.
        Since the June 6th launch, VA has entered more than a
    million community care consults, and preliminary data shows
    that best medical interest of the veteran was a factor
    considered in more than 538,000 of these consults. This
    demonstrates that VA care teams are committed to put veterans'
    needs first, and we have actively used the new option for care
    that the MISSION Act has provided.
        VA has also implemented, as required in the MISSION Act, a
    robust network of urgent care providers. That is a great new
    benefit for our enrolled veterans who need immediate care. By
    the end of August 2019, almost 6,000 urgent care centers have
    now joined VA's Urgent Care Network, which is managed by
    TriWest. About 90 percent of this country's veterans are now
    covered by a network urgent care provider and so far more than
    16,000 veterans have used their benefit in more than 40,000
    visits.
        Madam Chairwoman, veterans' care remains our mission. We
    are committed to rebuilding the trust of America's veterans and
    will continue to work to improve veterans' access to timely,
    high-quality care from VA facilities, while at the same time
    providing veterans with more choice to access care where and
    when they need it.
        The bottom line is that the MISSION Act is a success. Your
    continued support is essential to providing superior care for
    veterans and their families.
        This concludes my statement. My colleagues and are prepared
    to answer any questions that you may have.

        [The Prepared Statement Of Richard Stone Appears In The
    Appendix]

        Ms. Brownley. Thank you, Dr. Stone. I will now recognize
    myself for 5 minutes.
        I have three questions that I am going to try to get in in
    this 5 minutes. If we can be succinct in our answers, I would
    appreciate it.
        The first is, which I mentioned in my opening remarks, is
    this--you know, the transition that we are experiencing through
    third party administrators and making sure that for any veteran
    who is in the middle of an episode of care that that transition
    is smooth, so that that episode of care, there are no
    interruptions there. I talked about maternity care and
    fertility treatments, but really it is for any treatment.
        My first question is, what are you doing to ensure that
    veterans are receiving seamless treatment through their episode
    of care during this transition?
        Dr. Matthews. Excellent question. Thank you so much,
    Congresswoman. This is of utmost importance to us, as well as a
    clinician myself. This was very much a part of how we crafted
    the transition plan between the current Patient-Centered
    Community Care (PC-3) contract, but outgoing as well, as well
    as Community Care Network (CCN).
        Current episodes of care in which veterans are in the
    community, of course maternity, oncology, but even primary care
    and the like, those are allowed to continue until the full
    completion of their episode of care under the Third Party
    Administrators (TPA) that granted the actual episode of care.
    There will be no switching in the middle.
        What we are managing closely and offering care coordination
    around is to make sure that those same providers are hopefully
    available in the new network, that they are willing to contract
    with Optum as we make that transition in Regions 1, 2, and 3.
    Unfortunately, we can't necessarily guarantee that they would
    be open. It is a kind of bilateral contractual decision for
    them to enter the new network, but we will continue to
    encourage it and work with them. Optum has been a great partner
    in this transition.
        That, again, no care will be disrupted and we will do
    everything possible to make sure that those same providers are
    available in the new network.
        Ms. Brownley. Thank you.
        The next question is on the Decision Support Tool. At the
    beginning and the kickoff of this program, we said after the
    big full committee when we talked about this for a long time,
    we said--you said that the Decision Support Tool, if it is not
    up and operating, we would revert back to other legacy systems
    to be able to accomplish what we need to accomplish.
        That doesn't seem to have actually happened in practice, at
    least the feedback that we have received. Clearly the feedback
    is that also on this tool, it works some of the time, not all
    of the time, and we have been reverting to this best medical
    interest eligibility, you know, criteria.
        Do you agree with that assessment and, you know, how are we
    going to address this so that the preponderance of these visits
    aren't based on best medical interest?
        Dr. Stone. Chairwoman, the Decision Support Tool there was
    a lot of concern about. Look, this is a department that hasn't
    had a great track record rolling out new software systems that
    we developed ourselves. I think the concern was well placed,
    but using an agile development model and the utilization of the
    Joint Operations Center that gives complete visibility across
    the Nation of performance in all areas at all times of the day
    has allowed not only the implementation of the DST, but also
    the ability to use the Decision Support Tool and update it.
        On October 1st, we will release our 13th update to the
    Decision Support Tool and, when we release that, we are
    continuing to respond to the needs of clinicians and the
    concerns of clinicians. If you remember my previous testimony
    before you, there was a lot of concern about were we going to
    slow the system down. As a matter of fact, we are seeing
    efficiencies with use of the Decision Support Tool.
        Now, there have actually been 1.2 million community
    consults since June 6th, in 1 million the Decision Support Tool
    has been used. We were seeing about 40,000 usages a day of the
    Decision Support Tool the first week. I think there was some
    kicking of the tires of the system and some getting used to
    opening the page, some of the providers were opening it
    multiple times; it is now being opened consistently 30,000
    times a day.
        Even though best medical interest, which is a key--if I was
    seeing you as a patient, your best medical interest should be
    at the absolutely top of my list--it has actually been used
    about 350,000 times as the sole criteria. There has been
    multiple other usages, including drive time, hardship for the
    patient, lack of availability of services.
        I don't mean to go on too long, I know you want to get one
    more in.
        Ms. Brownley. Well, I agree with you on the best--we want
    the best for our veterans and that is a good reason to choose
    community care. I just want to make sure that, you know, the
    whole system is operating, and I don't want veterans to be
    under the illusion that all you need to do is say this is what
    I want and you will receive it. I think we need that balance.
        I am not going to have a chance for my last question, but,
    Dr. Stone, I want you to know that I am going to harp on this
    issue and you are not going to be able to answer it right now,
    but it is on wait times.
        I don't like the way the VA does wait times when you are
    going to a VA facility and how that is calculated, I don't
    think it makes sense to the veteran in terms of how it is
    calculated, and I want to make sure that we have a reasonable
    approach to wait times on the community care side. As far as
    I'm concerned, from the time a veteran calls to the time a
    veteran receives the appointment, that is wait time, all the
    other stuff in between I think needs to be eliminated. I think
    the best way we are going to be able to evaluate that program
    as we move forward is that we have a common-sense approach to
    wait times, so that our veterans who we are serving can respond
    to us and, if they are happy, we are happy, but that wait time
    thing I think needs to be clarified.
        I will move on. Dr. Dunn, you have 5 minutes.
        Mr. Dunn. I would like to associate myself with those
    remarks about wait times, that certainly is an ongoing area
    that I hear complaints about back home.
        Dr. Stone, in discussion with General Horoho yesterday I
    learned that the VA is currently working on contract
    modifications to the CCN contract that supports transplant care
    in the community, as was directed by law. When will that
    modification be completed?
        Dr. Matthews, sorry. I got the wrong doctor.
        Dr. Matthews. No, not at all, sir. We are looking for that
    to be complete in the coming weeks. Being that Optum is not
    fully deployed nationwide, we do have some time to actually
    make sure we work through the excellent network that they are
    able to provide through their Centers of Excellence and make
    sure that rates are appropriately negotiated on their part,
    fitting the requirements of MISSION Act with regard to provider
    education.
        As far as the Optum contracts, we are looking in the
    coming----
        Mr. Dunn. I will be interested to see the modifications in
    that this is a subject that is dear to my heart. You know, in
    Florida there are no VA transplant centers. If a veteran in
    Miami needs a transplant, they are going to drive past 12 or 14
    great transplant centers----
        Dr. Matthews. Right.
        Mr. Dunn.--you know, to get to a transplant center.
        Dr. Matthews. I am very excited about the network that
    Optum will be bringing to the table.
        Mr. Dunn. Excellent. The modifications that are being done
    for Regions 1 through 3 currently, I guess those are the only
    ones that have been rolled out, those will be included--those
    modifications will apply to 4 through 6?
        Dr. Matthews. Yes----
        Mr. Dunn. Okay.
        Dr. Matthews.--yes, we will do the same.
        Dr. Stone. If I could add just a bit of our information? We
    have a lot of concern. We are a social safety net for veterans
    that may not qualify for other transplant groups. There have
    been 194 veterans that have gone on the transplant list since
    June 6th; of those, those veterans chose 60 percent of the time
    to be solely on the VA transplant list. In----
        Mr. Dunn. Is that because of coverage or locality? I mean,
    almost everybody wants to go to the closest one near them,
    right?
        Dr. Stone. Well, not necessarily; 31 percent have asked to
    go on both lists, both the commercial list and the VA, and
    about 9 percent have asked to only go on the commercial list.
    We are watching this closely. We do about a thousand
    transplants a year and evaluate about 3,000 veterans as
    potential candidates; because of the presence of co-
    morbidities, as you well know and are well aware from your
    professional work in delivering care, you know, this can be a
    very complex situation. So----
        Mr. Dunn. It can be, and it is one of the reasons why I
    wanted to make sure it works well. We will be following up on
    the transplant as this rolls out.
        Also, Dr. Stone--again, I think Dr. Stone--what if any
    mechanisms are you putting in place to ease the care? There are
    certain veterans that live on the edge of these Regions 1
    through 6, they might get some of their care in Region 3, some
    in 4. What provisions are you making for people who live on the
    edge?
        Dr. Matthews. Sure. It is meant to be extremely seamless
    for the veteran, sir. The contractual obligation of the State
    lines is purely who is paying the claim. From the veteran's
    standpoint, when they receive the referral after they have seen
    their VA provider or even called in, they will have an
    appointment scheduled with a provider and that's it.
        Mr. Dunn. It doesn't matter where, Okay.
        Dr. Matthews. It doesn't matter if they live in one region
    or the other.
        Mr. Dunn. That was a concern I had. The other thing,
    concern is timeliness of reimbursements to our community
    providers. That is not just doctors, it is hospitals, that I
    have checked both the providers and the hospitals back in my
    home time. They are--I am going to be honest with you, they are
    bitter about the time it takes to get reimbursed by the VA,
    both the hospitals and the doctors, and I would like to have
    you elaborate on what you are doing to address that problem.
        Dr. Stone. 15 months ago when I returned to the VA, we were
    processing 175,000 claims a month, we are now processing for
    payment approaching 2 million claims a month through both our
    director work, as well as our contract support. We are very
    proud of the fact that TriWest, as the primary vendor at this
    point, is processing 98 percent of current claims in less than
    30 days----
        Mr. Dunn. I have heard this number, I swear I have heard
    this number, and I can't find those doctors who are being
    reimbursed in a timely fashion and I talk to a lot of doctors.
        Dr. Stone. All right. I will let Kam give some additional
    clarification of any numbers, but we believe that we have
    substantially improve this system where----
        Mr. Dunn. I would love to have somebody--in the 15 seconds
    remaining to me, I would like to have somebody come by my
    office from your office, and I will sit down with spreadsheets
    of aged accounts on VA bills from a number of providers in my
    home district and from the hospitals, and, you know, say
    explain to me how this fits into your 98-percent-on-time
    payments. I mean, we are talking 180 days, that is what my guys
    are staying.
        Dr. Matthews. Sir, I would be happy to have my staff come
    meet with you with----
        Mr. Dunn. Thank you very much.
        I yield back, Chairwoman Brownley.
        Ms. Brownley. Thank you, Dr. Dunn.
        Mr. Levin, you are now recognized for 5 minutes.
        Mr. Levin. Thank you, Chair Brownley. I appreciate you
    holding this hearing to monitor the implementation of VA's new
    Community Care Program and urgent care benefit.
        I want to start by discussing an issue that has been
    present since implementation of the now defunct Veterans Choice
    Program and I have heard this from veterans in my district in
    Southern California. The issue is this: in the past, we have
    not adequately educated veterans how to use community care
    programs. Specifically, as a result, some veterans have sought
    care from community providers without the necessary
    authorizations, result in denied claims and unforeseen
    expenses.
        The MISSION Act required VA to develop and administer an
    education program that teaches veterans about their health care
    options. It also required VA to evaluate the effectiveness of
    this education program on an annual basis.
        Dr. Stone, what has the data shown so far? For example, are
    we seeing a decrease in claims for unauthorized care?
        Dr. MacDonald. Congressman, I will take this question.
    Thank you for this important question and point.
        Veteran education and, as we frame it now, really veteran
    engagement; not just educating, but listening to veterans and
    having that inform how we do business has been at the core of
    our entire approach to the MISSION Act.
        You are completely right that we had room to grow in this
    area and that veterans needed more information from us, and
    they needed to hear it in a way that met their needs from a
    modality perspective, not just in paper, but meeting the online
    needs of our younger and newer veterans who may want to see
    that information in a different format. They also needed it to
    be in a way that spoke to their experience, not just to the
    mechanics of the system that serves them. We have changed that
    for the MISSION Act.
        As Dr. Stone was saying earlier, through the Joint
    Operations Center we pulled colleagues together, our training
    colleagues, our education colleagues; did outreach with Veteran
    Service Organizations (VSOs) , did Facebook Live events; sent
    out emails; sent out My Healthy Vet messages; sent out
    brochures and books, and put all of these in facilities; and
    had the most robust and comprehensive education plan that we
    have had for a rollout of this type.
        However, we are not stopping there. We know that there are
    still people who need this information. Data is showing us,
    yes, although we are not seeing claims specifically from the
    MISSION Act, our signals, what we are watching on social media
    and other places, are showing us satisfaction with the
    information that has been provided, and we are hearing that
    from VSOs as well.
        We are confident that this has been an initial success, but
    we are still aiming to grow. We need to put communications in
    English and in Spanish, as we did for this effort; we need to
    reach veterans from New York City to Guam; and we need to do
    that in a way that meets them no matter what era they are, no
    matter what age they are, no matter what modality they choose.
        Thank you for this, and it is something we are very focused
    on.
        Mr. Levin. Thank you, I appreciate that.
        In addition to educating veterans, we also have to educate
    VA providers, particularly regarding the eligibility criteria
    they use to refer veterans to the community.
        I understand there is some confusion among clinicians about
    how to apply the best medical interest criterion. Dr. Stone,
    what guidance has the Central Office provided on this and other
    criteria, and have you told providers where to go for follow up
    questions?
        Dr. Stone. Yes, we have. We have actually provided more
    than 2 million certified training episodes as part of this work
    through multiple different training modalities. That was
    actually executed in the months up to go-live by our Employee
    Education System (EES), our training group for professional
    management. We have been able to track literally the
    participation throughout this. We also have had multiple of
    those providers come back and do additional training, from
    MISSION Act 101 to literally all of the criteria that go into
    referring veterans to the community.
        I think probably one of the best pieces of data to come
    back so far is 48 hours ago the Veterans of Foreign Wars (VFW)
    released a survey of their 300,000 members, of which about
    7,000 responded that they used our care and their relative
    satisfaction level, it was extraordinarily transformative from
    previous years, and I know that that has been made available to
    the committee.
        Mr. Levin. Thank you. I will try to squeeze in my last
    questions with the time I have left.
        I am concerned by the process for charging copayments for
    urgent care. Following each visit, the urgent care clinic bills
    the third party administrator, which is in my district TriWest,
    then TriWest bills VA and, finally, VA bills the veteran. I
    understand that as of now, over 3 months since VA launched the
    urgent care benefit, VA has not received any claims from
    TriWest. This process is further drawn out if there are issues
    processing the claim.
        Dr. Stone, how long would you estimate this process will
    take if everything goes smoothly, how long could it take if
    there are issues with processing?
        Dr. Matthews. Thank you for the question, sir. There is an
    actual correction to that, we have received claims as of--daily
    now. TriWest actually submits their claims through another
    clearinghouse sort of group and we have had more than 20,000
    claims coming through now. That is why we can actually speak to
    actual visit numbers.
        The copayments are billed by VA, as they have been for
    other community care services. So those veterans who have been
    facing copayments in the past would be very familiar with the
    processes that we use, that we actually bill copayments even
    after we bill other health insurance that they may have, so
    that we can even deduct that copayment from the revenue that we
    receive from the other health insurance. Admittedly, though,
    the veterans that are newer to copayments under this benefit,
    we definitely have had broad-spread education through both VSOs
    as well as an online platform to let them know how these
    copayments would work, that they would be billed even after VA
    pays the claim through TriWest to the provider.
        Mr. Levin. Thank you.
        I am out of time, Chair, but I thank you for holding this
    hearing. I thank our witnesses and I look forward to an ongoing
    dialog on these issues. Thank you.
        Ms. Brownley. Thank you, Mr. Levin.
        I now recognize Dr. Roe for 5 minutes.
        Mr. Roe. Thank you, thank you, Madam Chairwoman.
        Just a couple things to start with. I want to thank the VA.
    I have been on this committee almost 11 years and this is the
    smoothest rollout of a massive bill. I think you are to be
    commended and I want to--Dr. Stone, always the chief always
    gets the kudos, but I would like to thank Dr. Matthews and
    MacDonald. I know they have worked very hard, and your staff
    has, to make sure that this is as seamless as possible.
        Dr. Dunn, I think I agree with you on the payment. I wonder
    if some of that is not legacy and certainly I think the
    payments has picked--I have had the same issue in my hometown,
    but I think that is much better now, I really believe that.
        A couple things I want to go over just very quickly with
    you all and, Dr. Stone, you can take this, if you want to. Do
    you have any indication at this point in the MISSION Act
    implementation process as to whether the access standards that
    the VA has put in place for the new Community Care Program are
    appropriate, achievable, and working as intended to ensure
    access for veterans?
        Dr. Stone. I would say, yes, they are achievable and have
    been achieved for the most part. In mental health, a 20-day
    access standard, 139 of our 141 sites are meeting the 20-day
    access standard. In primary care, 93 of 141 sites are meeting
    the primary care access standard of 20 days. Where we are
    struggling is within various subspecialty and specialty care
    areas, in frankly the same areas as the rest of the Nation is
    struggling, and we would be happy to break those numbers out
    for the record.
        Mr. Roe. Thank you for that. The next part of that
    question, the follow-on is, how do you assure the quality of
    care in the community, how are you all monitoring that?
        Dr. Stone. The quality of care--and I will defer to Dr.
    Matthews and Dr. MacDonald and some of the work that they have
    been doing on this--it is very difficult to see. We are the
    most transparent health care system in the Nation and it is
    very difficult to see timeliness in the community, it is also
    difficult to see quality outcomes.
        I will defer to Dr. Matthews and then----
        Mr. Roe. Before she starts, I mean, our practice has those
    standards built into it via the Accountable Care Organizations
    (ACOs) that we have been involved in. Do you have access to--in
    other words, if my practice saw a VA patient, we know what
    those quality metrics are with Medicare, are they the same? We
    could just transfer those right over. We can show you in a
    heartbeat if the standards are the same.
        Dr. Stone. Tremendously variable, including some ACOs that
    are simply implementation of an electronic record would qualify
    for participation in the ACO successfully. I will defer to Kam.
        Dr. Matthews. Our entire intent--our intent is exactly as
    you pointed out, sir, to really be in line with industry
    standards, Medicare being at the front there, in order for us
    to have some consistency from practice to practice. I have to
    agree with Dr. Stone, ACO to ACO, there is a lot of
    differences.
        We also would like to make as logistically easy as
    possible. That perhaps we can get that data through Centers for
    Medicare and Medicaid Services (CMS), we could get that through
    other ways that it is already publicly reported as through
    Hospital Compare, which of course VA already lists a lot of its
    own quality metrics there as well too. The idea is not to be
    even more burdensome to our community partners.
        Mr. Roe. I agree with that.
        One last thing before my time expires. Dr. Stone, the VA
    medical center in my hometown, which does a wonderful job, I
    might add, recently made the eye clinic an open-access clinic;
    in other words, you just walk in. That sounds like a good idea
    and I am supportive of your efforts to make eye care more
    accessible, but some veterans in my district are now waiting
    hours in the eye clinic before they are able to be seen because
    there are so many other veterans showed up by the time they get
    there. In some cases, veterans are telling my office, if they
    are traveling up to 2 hours to get to the clinic and then they
    are turned away because the clinic is up to capacity.
        That is not--I don't think that is how they are supposed to
    work. Have you heard of this before? If so, what are we going
    to do about it?
        Dr. Stone. We certainly are trying to work our way--and I
    go back to the chairwoman's opening comments on access to care
    and how we measure timeliness, I think I share exactly her
    concern. We have worked hard to move toward an open-access
    system. An open-access system is not a brown bench system that
    literally people show up 2 hours before we unlock the front
    door and then stand in line. That is not what we want.
        We are using a model across four different areas,
    Indianapolis is one where it is running very well, that we hold
    about 30 percent of appointments open for same-day
    appointments. As part of the way we have grown too, well over
    20 percent of our appointments this year, over 12 million, have
    been same-day appointments.
        Mr. Roe. I would suggest that my local hospital sort of see
    what they are doing in Indianapolis and open a percent of
    those.
        My time has expired and I am going to have to go to another
    committee hearing. I would want to say one other thing and I
    will yield back very quickly. I do think--and the next panel is
    going to speak on it and I won't be here for that, but I think
    that the urgent care benefit that was put in there is one of
    the best things that was put in there. I look at the average
    cost of $65 to go to an urgent care center, that is a great
    benefit for veterans; it is convenient for families and people
    that are busy. I want to commend you all for making that more
    accessible and I think anything you can do to make that work
    better would be something I would encourage you to do.
        I yield back.
        Ms. Brownley. Thank you, Dr. Roe, and thanks for joining us
    this morning.
        Mr. Cisneros, you are recognized for 5 minutes.
        Mr. Cisneros. Thank you, Madam Chairwoman. I thank you,
    Drs. Stone, Matthews, and MacDonald for all being here today to
    testify.
        Dr. Stone, thank you for--well, let's just say, as you are
    aware, in 2017, VHA developed a staffing tool to help VA
    medical centers estimate how many community care staff they
    would need to keep up with the expected workload for processing
    community care referrals during the Vietnam Choice Program. Now
    with the MISSION Act there is a whole new set of eligibility
    criteria; has the VA considered updating the staffing tool
    based on the new criteria?
        Dr. Stone. Yes, we have, and we are in the process of
    completely transforming how we do human resources and workforce
    management, and I would be happy to go into that at some length
    and meet with you about that.
        Mr. Cisneros. All right, that would be good.
        How are you certain that the VA medical centers are
    adequately staffed to handle the current and expected workload,
    how are we----
        Dr. Stone. It is partly wait time and, second, it is the
    satisfaction of veterans with their accessibility to care.
    Veterans are choosing to come to us, we have grown by over
    80,000 enrolled veterans this year. What is remarkable in that
    is over 70 percent of newly enrolled veterans are over age 65,
    so they are Medicare eligible, but yet they are choosing us.
    That has created some very interesting dynamics and really
    driven the growth of about 13,000 hiring, so we have grown by
    about 13,000 over the last year.
        Now, there has been a lot made of the fact that we have
    43,000 open positions across the entire enterprise. In health
    care, the average turnover rate each year is about 11 percent,
    for us it is about 9 percent, between nine and nine and a half
    percent. So if we are going to stay at 9 percent, better than
    the commercial marketplace, we will always have about 30,000 to
    31,000 openings, plus the growth that we have will run our
    openings up into the low 40,000; right about where we are.
        Now, we have some very difficult areas of the country where
    we have trouble; recruiting gastroenterology, neurology,
    neurosurgery, orthopedic surgery are all difficult for us, and
    that is a fairly complex methodology to repair that,
    including--and I know you had Mr. Sitterly up here, Hon.
    Sitterly up here talking recently--we need some relief from the
    multiple different regulations that we hire under, under Title
    38, Title 5, hybrid Title 30, it is very difficult for us to
    hire effectively.
        Mr. Cisneros. Dr. Stone, you also State in your written
    testimony that the VA estimates that more than 16,000 veterans
    have used the urgent care benefit so far and there have been
    approximately 44,000 urgent care encounters based on the number
    of times urgent care clinics have called to check veterans'
    eligibility. This averages out to about 2.75 visits per veteran
    in just less than 90 days or so since the urgent care benefit
    went live, which does sound like a lot of urgent care visits in
    3 months. Do you think veterans are starting to use urgent care
    as a replacement for VA primary care?
        Dr. Stone. That is not what we want. Urgent care is great
    for an acute sore throat, but it is not good for integrated
    health care that you see your provider who gets to know you and
    understands the complexity of just how complex veteran health
    care is.
        We do know, and we have got some great data from TriWest on
    this, we have got 11 veterans that have already used urgent
    care ten times in the first 3 months. The vast majority have
    used it appropriately, the vast--well over 90 percent have used
    it one or two times and it is a great benefit for them. We need
    to track this closely and we need to health care manage that
    veteran or those 11 veterans that have been there ten times
    already.
        Mr. Cisneros. As part of that management, are veterans
    aware that there will come a point in these urgent care visits
    that the VA will start billing them----
        Dr. Stone. Yes.
        Mr. Cisneros.--for their copay?
        Dr. Stone. Yes, sir.
        Mr. Cisneros. They are made aware of that, they have that
    information?
        Dr. Stone. Yes.
        Mr. Cisneros. Even the ones who went 11--10 times, the 11
    veterans who went 10 times?
        Dr. Stone. I can tell you that we do a weekly update on
    this. We made a decision this week to reach out directly to
    those 11 veterans and discuss with them how we might provide
    them care more effectively than the urgent care centers.
        Dr. MacDonald. Congressman, to that question, we sent out a
    quite robust round of messaging on this specific point close to
    June 6th, but we have reiterated that since then and we
    continue to, because we know that this will become an issue for
    some as they cross that third visit threshold, so we will
    continue that pace.
        Mr. Cisneros. All right. Well, I am out of time, so thank
    you very much.
        Ms. Brownley. Thank you, Mr. Cisneros.
        Mr. Brindisi, you are recognized for 5 minutes.
        Mr. Brindisi. Thank you, Madam Chair. Thank you, Dr. Stone,
    Dr. Matthews, Dr. MacDonald. I want to talk to you about a
    parochial issue, but one that is very important to constituents
    that I represent in upState New York. We talked about this a
    little bit before, the last time you were before the committee,
    the full committee with Secretary Wilkie back in April, and it
    involves the Bainbridge Clinic in Chenango County and upstate
    New York, which is in my district. This is a clinic which has
    been slated for closure and to be moved to a neighboring county
    that has a little more population density.
        We began a discussion about market area assessments, which
    you had indicated you were a big fan of, the Secretary was a
    big fan of, and I indicated to you all that this particular
    Community Based Outpatient Clinic (CBOC) is not having a market
    area assessment done until 2020. I want to go through what we
    talked about back then and then read to you a letter that I
    received from VHA subsequent to our discussion.
        We had an exchange, Dr. Stone, where I asked you, ``As I
    understand it''--this is from your testimony on April 3rd of
    2019--my question was, ``As I understand it, there is not a
    market area assessment that is going to take place until at
    least 2020 in this region, so why move forward with moving the
    CBOC until you do a market area assessment to determine the
    needs of the community?''
        You responded, ``I understand and I am in full agreement
    with the Secretary on the market area assessments. Please
    remember, though, that the lease on this facility is not up
    until 2021, so we would be through a market area assessment
    before we decided on that move.''
        I then asked, ``Okay. Can I get a commitment from you today
    that you are not moving the CBOC until at least 2021?''
        You responded, ``Unless I am substantially misunderstanding
    the issue.''
        We then followed up with a letter to VHA and got a response
    on April 29th, 2019 that contradicts your testimony from just a
    few weeks earlier where it says that the build-out for the
    clinic that you are relocating to should be completed and the
    move would be done in December 2019/January 2020 timeframe,
    which is a year before the lease ends; it is a move that is
    also done before a market area assessment has taken place.
        I have constituents back home, you know, saying, okay, we
    are okay until 2021, according to your testimony, then we have
    a letter saying, no, the move is happening December 2019 or
    January 2020. Can you answer why the discrepancy between your
    testimony and subsequent communications from VHA?
        Dr. Stone. The lease does end in 2021, it was my
    understanding that we were not going to vacate that lease in
    advance. I have found out since then that there is very
    substantial problems within that building with privacy and they
    have great difficulty, especially with female veterans and
    privacy. That doesn't mean that--frankly, I haven't been
    informed that we were vacating early, but there was substantial
    discomfort with that area.
        I also am aware that the MISSION Act requires that I
    continue to make business decisions and don't delay business
    decisions until we go through the entire Asset and
    Intrastructure Review (AIR) Commission, market area
    assessments, decisions from the President, and decisions from
    you in Congress, that we continue to make decisions and move
    forward.
        I would be more than happy to sit with you; in fact, I
    would like to come up and visit the area. You brought up during
    that testimony difficulties in public transportation and how
    difficult it would be. There is a greater density of veterans
    in the next county. You brought up some very good points, if I
    remember April, about public transportation, the ability of
    veterans, what percentage of veterans were taking public
    transportation.
        I think we can reconcile this, but I am not aware that we
    are vacating that building in December of this year. We will
    resolve this in the next 24 hours with your staff and my staff
    will have it, but it is not our intention to change unless I
    just can't deliver appropriate privacy in that building.
        Mr. Brindisi. Right. I would encourage you to come up, I
    would love to have you there, because I think you can see
    firsthand--I have visited the clinic and you can see firsthand.
    I think some of the challenges that they have encountered there
    can be rectified within that existing location and I think it
    would be helpful for you to come up and tell the folks at the
    Albany VA, please, put the brakes on this a little bit until we
    have a chance to really see if some of the issues can be worked
    out. I don't want to have VA stay in a location that is not
    conducive to serving the needs of the veterans in that
    community, but I also think that some of the analysis that has
    been done in the region is flawed and I would like to point
    that out to you.
        Dr. Stone. With the chairman's forbearance for just a few
    seconds. You introduced the subject by saying this is
    parochial. All of these decisions, because they affect
    veterans, are local and we are trying to be as responsive as we
    can to it.
        Mr. Brindisi. Thank you, Dr. Stone.
        Ms. Brownley. Thank you, Mr. Brindisi. Thank you, Dr.
    Stone, for your quick response to Mr. Brindisi. I understand
    the issue and CBOCs and locally, and how much that means to
    each and every veteran who resides there. Thank you very much.
        Mr. Rose, you are now recognized for 5 minutes.
        Mr. Rose. Thank you.
        Dr. Stone, I want to talk to you a little bit about
    referrals. I know that you are a believer in integrated care, I
    know you are a believer in treating the entire person and the
    value of one health care system treating the patient, moving
    across the nodes on the continuum of care. I am concerned when
    someone under our new system, when a veteran gets care from the
    private sector. Are we finding that they are then referred back
    to the VA for specialty care, for mental health treatment, if
    necessary, treating multiple comorbidities potentially, or that
    they are referred within that hospital or health care system?
        Dr. Matthews. Great question, Mr. Rose. Actually, we have a
    very defined process. The community providers do need to submit
    requests for services, RFS, back to the VA for authorization of
    care to determine whether or not the veteran is indeed eligible
    for community care in the new necessary service, whether or not
    we are able to provide it within the VA ourselves.
        No, the care does not stay out in the community, but----
        Mr. Rose. That is my concern, actually----
        Dr. Matthews. Sure.
        Mr. Rose.--is that we can be putting ourselves down the
    road to a bifurcated care system. Let's entertain the
    hypothetical, right, that you say, yes, this person does need
    specialty care or this person does need another form of primary
    care, at that point does the VA step in and say, we are going
    to do it, thank you for the referral?
        Dr. Matthews. Yes, they can.
        Mr. Rose. Now, at this point, that veteran is caught
    between two systems. They have got a primary care physician and
    the VA has taken over another form of specialty care with two
    Electronic Medical Records (EMRs) . Those EMRs are not shared,
    right? Two different systems. How do you envision that working?
        Dr. Matthews. Sure. I think care coordination is definitely
    the piece----
        Mr. Rose. Who is in charge of that care coordination?
        Dr. Matthews. VA is.
        Mr. Rose. Care coordination is a word that is thrown out a
    lot, we hear it all the time----
        Dr. Matthews. Sure.
        Mr. Rose.--but with two separate EMRs, two separate health
    care systems, does that mean that the VA has a care coordinator
    that is tasked with that case every single time that there is
    two different systems controlling health care?
        Dr. Matthews. Yes. The VA will stand as the integrator of
    care. This is not unlike, honestly, what occurs in the private
    sector as well. As a primary care doc, I am referring to other
    hospitals. The Patient Aligned Care (PAC) team, the primary
    care model is responsible for coordinating that care. The
    Community Care Office also assists in making sure that there is
    appropriate communication. We have new IT systems to
    communicate with those providers as well.
        The VA, yes, can pull that care back into VA, but, again,
    based on the eligibility of the veteran. If the veteran is
    indeed eligible to receive that new service in the community
    and chooses to do so, they can continue to receive it in that
    outside hospital.
        Mr. Rose. Are we operating on then an affiliation-based
    system almost, that every single private community doctor would
    work on an affiliation agreement with the VA?
        I am trying to get an understanding of what the system is
    as we go down this road. Is this similar to what Federally
    Qualified Health Centers (FQHCs) have to go through where they
    don't operate hospitals, they don't operate often high-level
    specialty care, and so they are just referring out and then
    trying to figure out things from there? They will operate on an
    affiliation agreement. They will only refer to specific
    hospitals----
        Dr. Matthews. Exactly.
        Mr. Rose.--and they will have a system in place?
        Dr. Matthews. No. I am very familiar, I used to be a Chief
    Medical Officer (CMO) at an FQHC, so I am very familiar with
    what you are talking about--no, it is actually quite different,
    because of course we are a direct-service system, we of course
    make the determination along with the veteran of whether or not
    they would receive that care in VA or not. Our contracted
    partners in the community are there to supplement services that
    the VA can't provide.
        Mr. Rose. Are you taking those partners into account, their
    opinion into account as to whether that patient goes to the VA
    or goes to where they want to refer them to?
        Dr. Matthews. No, because typically the clinical necessity
    determination of whether that care is actually necessary, that
    does remain with VA. As any time I refer out to an orthopedic
    surgeon and I don't necessarily want to take their
    recommendation as a clinician separate from VA, I would then
    make sure that I follow up with the veteran.
        Mr. Rose. There is a clear profit motive involved here, you
    know, that we have many----
        Dr. Matthews. I agree.
        Mr. Rose.--it is just the normal way of business that they
    will want to refer----
        Dr. Matthews. Exactly.
        Mr. Rose.--within either their affiliations or their
    systems.
        Dr. Matthews. Which is why VA will maintain oversight of
    both clinical necessity and assisting the veteran to determine
    where they would like to receive that care.
        Mr. Rose. Just lastly, so what systems do we have in place
    in the absence of a shared EMR?
        Dr. Matthews. A new system that we have rolled out, it is
    not fully utilized yet, but our Health Care Referral Manager is
    an off-the-shelf system that is cloud-based, like other portals
    that a lot of private systems use, where the community provider
    can upload as well as download medical documentation, do direct
    messaging. So this cloud-based system we are really looking
    toward----
        Mr. Rose. Have you guys implemented like HIPAA waivers into
    your workflow?
        Dr. Matthews. Yes, of course.
        Mr. Rose. Okay. Then that could also----
        Dr. Matthews. Exactly.
        Mr. Rose. Okay.
        Dr. Matthews. Actually through our health information
    exchange that VA has and actually under the MISSION Act, we are
    actually in an opt-out mode for providers to actually use our
    Health Information Exchange (HIE), so that they can see the
    documentation----
        Mr. Rose. Okay.
        Dr. Matthews.--from the veterans on an opt-out scale.
        Mr. Rose. All right, great. Thank you, that is very
    helpful.
        Ms. Brownley. Thank you, Mr. Rose.
        Mr. Lamb, you are now recognize for 5 minutes.
        Mr. Lamb. Thank you to all the witnesses.
        I have kind of a similar line of questioning, so we can
    probably pick up where Mr. Rose left off, but first I just want
    to clarify something. I have talked to some providers in
    different parts of Pennsylvania so far and the impression that
    I got is that the typical case for community care involves a
    veteran seeing a primary care doc within the VA and then a
    referral from there, whereas some of the questions that you
    just heard sort of implied that people were getting primary
    care in the community. At least within Pennsylvania, I got the
    impression that primary care in the community was very unusual
    and that most primary care was happening in the VA still; is
    that your impression?
        Dr. Matthews. That is definitely the case.
        Mr. Lamb. Okay.
        Dr. Stone. That is our intent----
        Mr. Lamb. Right, that seems to make sense.
        Dr. Stone.--because of the complexity of veterans' care,
    that primary care, internal medicine should be the glue that
    holds the care together in an integrated basis.
        Mr. Lamb. Great. That seems like a good emphasis to me and
    a good control.
        My next question I think is related, but it is looking down
    the road a little bit. We do have, you know, these incredibly
    different incentives within the VA system and outside of it
    when it comes to the way patients are treated and the way that
    fee-for-service medicine works outside the VA is just a
    different type of practice. I have heard the concern expressed
    from doctors within the VA that I have talked to about--you
    know, the way one put it to me is, sometimes the best thing
    that we can do for one of our patients is to hold off or do the
    sort of least intrusive or most minimal thing----
        Dr. Matthews. Conservative, yes.
        Mr. Lamb.--and that decision just doesn't always look the
    same in the private sector. The concern that was raised to me
    was, once these networks are built and the payment is
    streamlined and the VA becomes known as a reliable payer in the
    community care context, what safeguards do we have to make sure
    that private physicians are not just sort of racking up fees
    and services once a person gets in their hand?
        Dr. Matthews. Sure. Excellent question and definitely our
    concern as well. We are really looking to develop a more robust
    utilization management sort of set of procedures and even IT
    systems, so that we can monitor the care that providers are--
    the services that they are providing and otherwise either
    educate or even no longer refer to them if indeed we question
    really their intent behind perhaps not choosing conservative
    treatment when it is more appropriate, especially from a
    clinical necessity standpoint.
        Again, going back to Mr. Rose's point and my response, all
    requests for secondary services VA does need to authorize as
    well too. That, again, with primary care in the community it is
    a little bit different, but for an orthopedic surgeon, for
    instance, if they submit authorization to have a procedure done
    and VA does not agree, we will not authorize. We do have at
    least that checks-and-balance in place.
        We have to balance that, however, with the way the rest of
    the industry works, of course. Right? That we tend to authorize
    things in bundles in the private sector and of course we don't
    want to make it more difficult for our community providers as
    well. A lot of this is about the communication between the
    community providers and the VA team.
        Dr. MacDonald. If I may follow----
        Mr. Lamb. Yes. Go ahead.
        Dr. MacDonald.--onto this for just a brief moment,
    Congressman. This is such a critical point.
        As we have approached this roll out of the MISSION Act, we
    have seen really a shift in not only VA thinking, but in our
    partners' thinking as well. This is a new era of veteran
    empowerment, if you will. VA has been a leader in making
    information transparent and putting that in the hands of
    veterans previously. Now we are helping them make informed
    choices.
        To your question about safeguards, in addition to what Dr.
    Matthews said, I believe there is twofold additional
    safeguards.
        First of all is veteran experience. If we are the most
    convenient, the best experienced meeting veterans where they
    are, not just in a facility, but via Telehealth. If we are
    meeting them in their living room versus them having to go out
    down the street and be referred for care in that manner, we are
    the most convenient option and we also fit into their lives the
    best. We meet them where they are. That experience will help to
    safeguard this system and it is something we are aiming
    directly at.
        The second piece is that at Dr. Stone's lead, we look at
    the data for the system daily and we convene the entire
    leadership of the Veterans Health Administration weekly. That
    includes network directors from every single network across the
    country, and many of their medical center directors as well. We
    look at this, and we analyze it, and we agonize over it, and we
    make strategic decisions from it.
        Those additional safeguards, in addition to what is
    mechanically in place, we think would be strategically
    important going forward.
        Mr. Lamb. Okay. Thank you very much. I appreciate what you
    have done in the last few months. I had a pretty good
    experience visiting VA hospitals in the initial roll out of
    this, so I know you are engaged.
        I am I think most specifically concerned about chronic pain
    and stress patients, and whether they will receive the sort of
    holistic and gradual care before turning to dangerous
    prescription medicines, especially outside the VA as within it.
    I don't need you to say anything else on that.
        I just want to make sure our eyes are on the ball there and
    we keep revisiting how that is going.
        Thank you. I yield back.
        Ms. Brownley. Thank you, Mr. Lamb.
        Before we move to the next panel I just, again, want to
    thank all of you for being here. I feel like before you leave,
    since we have the A team here, and I really wanted to ask just,
    you know, two questions really.
        First, if you could just summarize briefly for us, you
    know, the challenges that you see just in the next 3 months.
    You know, what are the challenges, and how are you seeing
    progress nationally? You know, we all know if you have seen 1
    VA, you have seen 1 VA. I am asking, you know, how are we doing
    nationally? Do we have strong spots and weak spots and, if we
    do, if we have the weak spots--and I believe that, you know,
    there are probably some weak spots in here somewhere if we are
    going to be honest with each other.
        Then how are we working with those locations to bring them,
    you know, to bring them up to speed?
        If you could just be brief. I think those are important
    questions before we leave to just, to get a snapshot of where
    we are going.
        Dr. Stone. I think there are weak spots in any delivery
    system. What I worry a lot about is TriWest has been an
    extraordinary partner and, frankly, a great partner to restore
    the trust that we lost from previous vendors who failed to pay
    bills on time. You heard that here as part of this.
        I worry a lot about the relationship with a new vendor
    coming in. I am assured that I have a long-standing
    relationship with the leadership of that new vendor that is
    coming in and that Optum has a great track record as does their
    parent company, a great track record of what they provide.
        I worry about that.
        I also worry about the fact that, frankly, there is a
    perversion in the commercial sector of the incentives toward
    care. We have been very gratified at the fact that we have been
    able to drop the amount of usage of opioids, dramatic
    reductions in opioids and benzodiazepines, and provided a safer
    environment.
        Therefore, we must deliver a network that really does
    provide mental health primary care in a manner that really
    provides the care integration that veterans deserve.
        Our veterans have incredibly complex conditions based on
    the fact that 70 percent of them have been to combat. The
    presence of chronic pain, the presence of a history of military
    sexual trauma really requires our system to be at the forefront
    of the delivery of care.
        I know I have gone on longer than you wanted, but this is
    the key issue that you bring up of what the future of this
    system should be.
        I will defer to my colleagues.
        Dr. MacDonald. Madam Chairwoman, if I may? I will be brief.
        To your question of where might we have strong spots, where
    might we have weak spots, we have heard the narrative a couple
    of times externally, well, now that MISSION Act is over, what
    are you tackling next. In our view, MISSION Act has just begun.
        As I said, we are looking at this data every single day at
    Dr. Stone's direction, and we are now working facility by
    facility with network directors involved, taking a look at the
    decision support tool data, the access data, the community care
    consult data, the internal consult data making sure that not
    only is the data what we would expect for that population and
    the geographical needs that might exist there, but that our
    processes are consistent from end to end.
        We are taking a comprehensive look at this and not resting
    on our laurels because there has been a success on June 6th,
    but rather pressing ahead and working to enhance this so that
    it is everything it needs to be and can be sustained from here
    out.
        Ms. Brownley. Thank you all very much. I really do believe
    you are the A team, and I believe in you and I look forward to
    another hearing here in the short future again to check in on
    how we are doing. Of course we all are going to be hearing from
    our veterans locally and that is--I think we all think that
    that is a pretty good test in terms of how we are doing.
        I do thank you for being here. I thank you for the hard
    work you have done and accomplished so far, and look forward to
    continued success.
        With that we will move to the next panel. We will give a
    moment for transition here.
        [Pause]
        Ms. Brownley. Welcome to the second panel and thank you
    also for being here today. We have Ms. Sharon Vitti, President
    of CVS MinuteClinic and Senior Vice President of CVS Health.
        Also here today is Mr. David McIntyre, the President and
    Chief Executive Officer of TriWest Healthcare Alliance.
        Lastly, we have Retired Army Lieutenant, General Patty
    Horoho for her first appearance before the committee who is the
    Chief Executive Officer of OptumServe.
        I thank, again, each of you for joining us today and I know
    this will be a fruitful discussion.
        Ms. Vitti, you are now recognized for 5 minutes.

                       STATEMENT OF SHARON VITTI

        Ms. Vitti. Good morning. Chairwoman Brownley, Ranking
    Member Dunn, and members of the subcommittee, thank you for the
    opportunity to testify today and just share CVS Health's role
    and experience in expanding care for our Nation's veterans.
        My name is Sharon Vitti and I serve as President of
    MinuteClinic and Senior Vice President of CVS Health. I am
    pleased to be here today to provide an overview of
    MinuteClinic's partnership with the U.S. Department of Veterans
    Affairs. Support for our country's veterans and members of the
    military is core to CVS Health's mission to help people on
    their path to better health.
        Our support of the MISSION Act is one example of the many
    ways we stand with veterans, active military and their family.
    Since 2015, CVS Health has hired almost 15,000 people with
    military experience and more than 5,000 military spouses.
        We provide charitable support to military and veteran
    focused organizations, including the National Guard, Operation
    Reinvent, and the USO. We are deeply honored to be recognized
    by the Military Times which named CVS Health to its 2019 list
    of best companies for veterans seeking a civilian job.
        Providing veterans with convenient access to quality urgent
    care is a shared goal of the VA and of CVS Health. Our work
    with the VA began in 2016, with a 1-year pilot funded by the VA
    health system in Palo Alto, California. This pilot leveraged 14
    local MinuteClinic sites to provide access to treatment for
    minor illness, minor injuries, and skin conditions for local
    veterans.
        Throughout the pilot we developed a system to
    electronically send information about the veterans visit to the
    VA through the e-Health Exchange. This allowed us to maintain
    continuity of care with VA providers and respect the existing
    patient provider relationship.
        Under the pilot, veterans were screened for eligibility
    when they called the VA triage line. If their condition met the
    criteria, the veteran was offered the opportunity to be treated
    at a MinuteClinic. Over 550 visits were conducted over 6 months
    with an average in-clinic wait time of less than 20 minutes.
        Veterans could also fill their prescriptions associated
    with their MinuteClinic visit at the co-located CVS pharmacy,
    if desired. The pharmacy followed the VA formulary and applied
    standard VA co-pays.
        Following the success of this pilot, we partnered with the
    VA's Office of Community Care, the Phoenix VA and TriWest to
    enable veterans to receive care at 24 MinuteClinic's in the
    Phoenix area. We later expanded this pilot to additional
    regions.
        The MISSION Act provides the framework needed for the
    national expansion of this urgent care access for veterans.
    Veterans can now access urgent care and walk-in medical
    services under their VA benefits without pre-authorization.
    Veterans who meet certain eligibility criteria can also receive
    care at a MinuteClinic. We typically treat acute conditions
    where prompt care can avoid more serious health issues and keep
    costs down.
        Following the MinuteClinic visit, MinuteClinic is able to
    make available the full record of medical services
    electronically to the VA with the veteran's consent.
        Our 3,000 nurse practitioners and physician's assistants
    are trained to welcome and care for veterans in over 1,100
    MinuteClinics across 33 states and the District of Columbia.
    Approximately 8 percent of our providers proudly declare being
    a veteran or having a military spouse.
        Under the MISSION Act we have provided care for more than
    5,600 veterans. Combined with the veterans we cared for during
    the pilot and under CHOICE, we have provided care for more than
    9,500 veterans since our partnership began 3 years ago.
        CVS Health deeply values its partnership with the VA and
    the opportunity to provide care to those who have served. We
    couldn't be prouder of the program we have created together and
    appreciate Congress and this committee for recognizing this
    program and the benefits it offers to veterans.
        We look forward to working with TriWest and Optum within
    the MISSION Act to continue to connect veterans with greater
    access to quality health care while ensuring they are still
    linked with their VA care providers.
        We appreciate the opportunity to testify and look forward
    to your questions.
        Thank you.

        [The Prepared Statement Of Sharon Vitti Appears In The
    Appendix]

        Ms. Brownley. Thank you, Ms. Vitti. I know this is your
    first appearance, too, so thank you again for being here.
        Mr. McIntyre, you are now recognized for 5 minutes.

                  STATEMENT OF DAVID J. MCINTYRE, JR.

        Mr. McIntyre. Thank you, Madam Chairwoman, Ranking Member
    Dunn, and distinguished members of the subcommittee. It is our
    privilege to appear before you on behalf of our non-profit
    owners, team of dedicated subcontractors and nearly 3,500
    employees, most of whom are veterans or veteran family members,
    to discuss the implementation of VA's MISSION Act Community
    Care programs.
        Thank you for your leadership in providing the road map to
    the next generation of VA, and for your insistence that we all
    stay focused and leaning forward on effectively executing that
    which was envisioned in the new law.
        Our company, which has been serving the health care needs
    of those who have served and their families for nearly a
    quarter of a century, has been proudly supporting VA in its
    journey of the last 6 years. I will tell you it has been quite
    a journey.
        This chapter of our company's journey has been the
    privilege of our lives. Serving those who have sacrificed so
    much on all of our behalf, including this generation's warriors
    who have leaned forward to defend freedom since September 11,
    2001.
        I want to thank the amazing team at VA for their
    dedication, focus, perseverance and endurance in working at the
    necessary task of beginning to reset the enterprise they
    inherited so that it might become more effective and deliver
    better on this Nation's commitment to its heroes. It is an
    honor as fellow citizens to be a part of your team. We are not
    here to privatize VA as a company, but rather to support VA in
    strengthening their ability to make sure that veterans get what
    they need.
        Inspired by those we are collectively privileged to serve,
    I am pleased to report to this committee that the nationwide
    network of community providers which we have constructed,
    including 24,000 OBGYN providers and mammogram screening
    providers in most communities, has just now delivered as of
    yesterday almost 1 million appointments since June 6th in
    support of VA. The network for urgent care, which has been
    discussed this morning, has now delivered as of yesterday more
    than 51,000 encounters in every State and every territory in
    this great country.
        Based on our work so far with VA, Congress and the VSOs, I
    believe it is fair to say that the words you have articulated
    this morning are true, and that is this has been a relatively
    smooth implementation, very smooth compared to Choice and the
    early crises that we all faced. We were part of that struggled
    and challenged journey.
        I think we would all agree based on the crisis that
    unfolded in our home town of Phoenix where, among others, we
    served 3,300 urology patients in 30 days, it was absolutely
    necessary to get started, even though it was going to be
    complicated and difficult for all involved.
        As you know, one of the things that you and VA sought to do
    was to consolidate together the community care programs and
    turn them into one. That is no small feat. That brings new
    tools. It brings process changes, which take time to implement
    and refine. Shortcuts or trying to do things too fast are never
    smart. From our experience, it also brings a requirement for
    reeducation, modification and refinement, some of which you
    have heard about under way earlier today.
        For our part, our core responsibility was to make sure that
    there is a network of providers in the community able and ready
    to serve. They are. We are sending back less than 1 percent of
    the care that has been requested by VA for no network provider,
    and that is across the country.
        We are paying our bills on time because if you ask people
    to serve, you have a responsibility to make sure that they get
    paid on time and accurately. As Dr. Stone articulated
    accurately, we are paying 98 percent of our bills in less than
    30 days.
        There is historical Accounts Receivable (AR) and it is our
    privilege to work with VA to try and resolve that for the great
    providers who are leaning forward.
        We also second built out the urgent care network. We are
    not quite finished. What has been really fascinating over the
    last 6 months is to watch the development of new locations all
    over the country. Wal-Mart announced last week in Georgia that
    it was standing up a new design. Watch what happens over the
    next year as they expand that footprint across the country.
    This is a good thing, not a bad thing. That means that we have
    to stay very focused on exactly where are these as they stand
    up so that we can get them under contract.
        Our personal commitment is that veterans will not have to
    drive more than 30 minutes from their house to get to a place
    that exists. Today, we are at 90 percent of that being factual.
    Our goal is to make sure that we get to a point where every
    veteran is able to go at a place that is near their home in
    order to get what they need.
        I want to welcome our new teammate from Optum to the table.
    I am looking forward personally to having the opportunity to
    continue to work with General Horoho who I knew as Army Surgeon
    General. Our company has a responsibility to make sure that we
    keep things stable. We had the privilege of stabilizing, given
    the removal of HealthNet. We have done that as a team, and we
    intend to keep it stable. We have worked through with VA and
    Optum the ability to keep that moving as we go forward.
        I look forward, ma'am, to being able to hand these great
    Americans over to you and your places of responsibility so that
    they shall be served, but that is not going to be a disruption
    to their continuity of care as we move forward, as was
    discussed previously.
        Thank you for holding this hearing. Thank you for the
    opportunity to appear. I look forward to engaging with any
    questions or discussion that you would like to have.
        Thank you.

        [The Prepared Statement Of David J. Mcintyre, Jr. Appears
    In The Appendix]

        Ms. Brownley. Thank you, Mr. McIntyre, and I will say I
    think you are part of the A team, too. I think you might have
    been involved in community care longer than some of the people
    in the VA who are administering it. We thank you for all of
    your hard work.
        With that, Lieutenant General Horoho, you are now
    recognized for 5 minutes. Welcome to the team.

              STATEMENT OF LIEUTENANT GENERAL PATTY HOROHO

        General Horoho. Thank you.
        Good morning, Chairwoman Brownley, Ranking Member Dunn,
    members of the subcommittee. I am Patty Horoho, CEO of
    OptumServe. I am honored to be here today to discuss our role
    in implementing the VA's community care network. On behalf of
    the more than 335,000 men and women of Optum and United Health
    Group, we welcome this opportunity to discuss our partnership
    with the VA.
        We have a long and proud history of serving our Nation's
    military and veterans. While our work on delivering health care
    to veterans as part of the community care network officially
    began 8 weeks ago, I want to highlight recent milestones and
    describe the road ahead.
        I would first like to express our appreciation to the
    members of this subcommittee, the full committee and Congress
    for passing the VA MISSION Act into law. We are committed to
    working with you, the VA and the veterans' community to make
    your vision a reality.
        I would also like to recognize our strategic partners,
    including Dr. Stone, Dr. MacDonald and Dr. Matthews, and those
    at the VA who care for our Nation's veterans. We are grateful
    for their dedication and honored to partner with them.
        Our deep partnership with the VA is critical in achieving
    our shared goal of improving the quality and convenience of
    care delivered to our Nation's heroes that honors their
    sacrifice.
        Community care provides the opportunity to better connect
    systems of care in a way that maximizes capabilities across the
    health system. It can ensure care and information is
    coordinated, connected and compassionate. I understand
    firsthand the compassion and the commitment the VA medical
    staff brings to the exam room every day, and the importance of
    coordinated care across the health system.
        My father served honorably in World War II, Korea and
    Vietnam, and later developed a number of illnesses, some
    associated with Agent Orange exposure. To treat these illnesses
    he received care both from the VA and from health care
    providers in our community. One system did not fully treat my
    father, nor did they work independently of each other. Rather,
    the partnership between the VA, his health care providers in
    our community and our family allowed him to live the best life
    he could while managing his illnesses.
        As a veteran, retired soldier, wife of a veteran, daughter
    of a veteran, and now the proud mother of an Army 2nd
    Lieutenant Infantry Officer, I am personally committed to the
    success of VA Community Care. My leadership team at OptumServe,
    which is comprised of veterans from every branch of service and
    our community care program office staff where 43 percent are
    veterans, are equally committed.
        We are honored to touch every point in a veteran's journey
    through the programs that we support. It starts when sons or
    daughters step up to raise their right hand, to ensuring a
    reservist is medically ready for deployment, to disability exam
    when a service member transitions from active duty, and now to
    the veteran receiving care through the VA Community Care
    providers.
        Central to our responsibility is to deliver a quality and
    robust network of health care providers and facilities that
    make up the community care network.
        We are leveraging our entire enterprise to build this
    network, and we are working closely with the VA and local
    medical centers to contract with quality providers that have a
    history of working with veterans. We have recruited more than
    3,800 providers in Region 1 with more than a third in rural and
    highly rural areas. When we complete the full development over
    the next 9 months, we expect to partner with more than 900,000
    providers across Regions 1, 2 and 3 representing a
    comprehensive and deep network across all health services.
        We are also making it simpler for a provider to care for a
    veteran. We are removing administrative burdens and making it
    easier for them to get paid on time. That is why we have
    implemented a billing and payment system that is familiar to
    them. After they care for a veteran, they electronically bill
    Optum and Optum pays them.
        We already do this today, processing 2.8 billion claims
    every year with 99.5 accuracy representing $178 billion for
    health systems and health plans across the Nation. We are
    committed to make this process as familiar and accessible as
    possible.
        Madam Chair, members of the subcommittee, I would like to
    leave you with 3 thoughts: 1, we have to get this right for our
    veterans; 2, we have to get this right for our VA and
    providers; and, 3, we have to get this right for the American
    people.
        Thank you for the opportunity to be here today, and I am
    honored to be on this panel with Dave McIntyre and Sharon
    Vitti. I look forward to your questions.
        Thank you.

        [The Prepared Statement Of Patty Horoho Appears In The
    Appendix]

        Ms. Brownley. Thank you, Lieutenant General, and I will now
    recognize myself for 5 minutes.
        I have 2 quick questions right up front that I wanted to
    ask really probably of Mr. McIntyre since you have been in the
    trenches here. I want to know, we are hearing that the
    providers are now getting paid on a timely basis. I want to
    know how you are getting paid. Are you getting paid on a timely
    basis?
        Mr. McIntyre. The VA is doing a remarkable job in turning
    what has been a very challenged road for all of us. We are
    getting reimbursed in 18 days by the VA. We have one remaining
    issue that we are working. We actually have a call on that
    issue this afternoon, and that is that we have been pushing
    back a little bit the work to try and put a reconciliation
    process in place on both sides so that we can handle
    overpayments and underpayments that go between the two of us.
    We necessarily pushed that back to stay focused on the
    providers on the front end----
        Ms. Brownley. These are short questions----
        Mr. McIntyre.--and getting the mechanics----
        Ms. Brownley.--Mr. McIntyre. I hear that you are getting
    paid. The answer is----
        Mr. McIntyre. Yes, ma'am.
        Ms. Brownley.--yes. Okay.
        [Laughter.]
        Mr. McIntyre. We are paying and we are getting paid.
        Ms. Brownley. There were a couple of VSOs who submitted
    written statements for this hearing today.
        Mr. McIntyre. Yes, ma'am.
        Ms. Brownley. One of them pointed out this issue of, or a
    concern with community providers around the gold standard as
    they claimed it to be within the VA, meaning that physicians,
    mental health experts understand the veteran, have been trained
    in that perspective, and a concern that going to community care
    professionals veterans aren't going to receive the same type of
    gold standard. We are talking, you know, this is back to
    quality care. This is----
        Mr. McIntyre. Right.
        Ms. Brownley.--more about really understanding veterans.
        Can you speak to that?
        Mr. McIntyre. You bet.
        Ms. Brownley. Briefly.
        Mr. McIntyre. Absolutely. There is a requirement that you
    put in the MISSION Act that has VA and us compelled to make
    sure that all providers in America understand who veterans are
    and what things they might want to know to make sure that they
    meet their unique needs.
        Having said all of that, and now having facilitated the
    delivery of 16 million appointments since the start of our work
    at the side of VA, in all categories of care what I would say
    is there are always veterans who should only be served in VA.
        Part of the trick for all of us over time, the challenge,
    is to figure out who are they and how do we make sure they are
    first in line in VA, not third in line, so that we can make
    sure that those that are most at risk for things that are
    unique as a veteran always end up in the VA enterprise.
        Ms. Brownley. Thank you. Thank you very much for that.
        Lieutenant General, I wanted to just ask you. I enjoyed our
    conversation briefly on the phone the other day. Tell me what
    Optum is doing to really reassure some of the skittish
    community providers who now are being introduced to their third
    party administrator. What are you doing to make sure that those
    providers are going to feel comfortable joining the network?
        General Horoho. Yes, ma'am. We have a very robust,
    strategic outreach. We are leveraging our network of 1.3
    million providers across United and we are talking to them to
    let them know what is different.
        What is different is that they will be paid by Optum first
    when they submit a claim, and then we will submit our claim to
    the VA. We are talking to them that the reimbursement rate has
    now increased from 85 percent to 100 percent with Medicare. We
    are also talking to them about the privilege that each of them
    would have by being able to treat our Nation's heroes.
        We are finding, you can see with our number of 308,000
    providers willing to join, we are finding that they are willing
    to be part of our network and to serve.
        Ms. Brownley. Thank you.
        This issue that came up with the first panel in terms of
    episode of care and that not being interrupted, how are you
    managing that?
        General Horoho. We are in agreement and we are working very
    closely with TriWest and with the VA. We look at this as a
    partnership. If a veteran is approved for care in the
    community, then that continuum of care will continue. If it was
    with TriWest it will continue with TriWest even if we have
    taken over in those regions.
        Ms. Brownley. Thank you. Thank you very much.
        I think with that my time is up and I will yield to Dr.
    Dunn for 5 minutes.
        Dr. Dunn. Thank you, Chairwoman Brownley.
        You took a lot of the great questions there I was going to
    ask. I appreciate you doing that.
        I will note that a number of your providers are physician--
    the physician providers are veterans as well. You know, as an
    old Army sub they don't often--they are not going very far
    outside the circle, I think, to come to the community care
    programs a lot of the time.
        General Horoho, we have heard a few reports from Region 1
    that some of the providers are under the impression that they
    have to join the United provider network in order to join the
    Optum veterans' network. Is that true? If it is not true----
        General Horoho. You know, part of what we have done is that
    our contracts have both seals. They have the United seal and
    the Optum, and it is part of the contract narrative. If they
    have already been part of Optum, they are still underneath that
    contract and they don't need to switch over, or if they were a
    part of United.
        It is more of clarifying the language so that they
    understand that if they are already part of our network, we are
    contracting them within community care.
        Dr. Dunn. Okay. The reimbursement goes to Medicare from
    whatever it was before?
        General Horoho. The reimbursement, they will, after they
    visit and they take care of one of our Nation's heroes, they
    will submit a claim. That claim will then be paid by us and
    then the VA will pay Optum.
        Dr. Dunn. Excellent. This is for both Mr. McIntyre and
    General Horoho, if a veteran is referred to one of your
    networks and they want to see a certain provider, can you
    ensure that choice? Is that something you can do and, if so,
    how?
        Mr. McIntyre. General. Okay.
        Today the way it works is we have a panel of providers in
    each community. It is broad. It is deep in terms of specialties
    and numbers. The veteran absolutely gets to get involved in
    choosing which specific provider they would like to see. Our
    systems are set up that way, and that is the way in which the
    provider appointing process works.
        Dr. Dunn. Good. That is allowed. I just wanted to make
    sure----
        Mr. McIntyre. Correct.
        Dr. Dunn.--that was. I assume the same is true for Optum?
        General Horoho. The VA can go into our system, see the
    providers and make that----
        Dr. Dunn. Excellent.
        General Horoho.--make that choice for the veterans.
        Dr. Dunn. Mr. McIntyre, your testimony had said that all of
    a sudden June 6th the request for community care outstripped
    the projections. Yet in the first panel we heard that it was
    like an uptake of 3 percent or 3.7 percent, something like
    that. How do I reconcile those 2 bits of information?
        Mr. McIntyre. The piece I was focused on was the piece that
    arrives in our domain for which we are responsible for
    appointing. We do appointing still in the country, which is a
    human endeavor, for about two-thirds of the country. It would
    be the work that flowed through our network for which
    appointing was responsible--yeah well for which we are
    responsible for appointing.
        In the mental health space, our prior experience--prior to
    June 6th--actually was bested by about 4 times in terms of the
    demand that came into the community.
        Dr. Dunn. Did we enlarge the--I guess we did.
        Mr. McIntyre. You----
        Dr. Dunn. We enlarged the mental health----
        Mr. McIntyre. You shrunk the access standards, and we were
    all collectively trying to make sure that people got served in
    those more narrow access standards.
        Dr. Dunn. I just got the 2 different interludes. The
    impression from the----
        Mr. McIntyre. Sure.
        Dr. Dunn.--2 numbers was different.
        Let me also, again, Mr. McIntyre, if I can ask, this is now
    going right to my region, your Region 3. We are having trouble
    with credentialing. I have providers who have been credentialed
    with TriWest. They have been providing VA care. They made the
    deadlines for getting all their new credentialing in for the
    PC3 credentials, and then 6 months later they still haven't
    been credentialed and they are showing up as not certified VA
    providers even though they have been historically. They
    continue with you, TriWest, from before and now.
        Mr. McIntyre. That doesn't make any sense.
        Dr. Dunn. I didn't think so either.
        Mr. McIntyre. I am sure it exists. I would love to sit with
    your staff or with you and----
        Dr. Dunn. Please do. Please do because you can----
        Mr. McIntyre.--figure out exactly who are they.
        Dr. Dunn. Yes. There is----
        Mr. McIntyre. We will get in touch with them.
        Dr. Dunn.--some rather large groups of physicians----
        Mr. McIntyre. Yes, sir.
        Dr. Dunn.--who are feel that they have been--you know, half
    of them got, you know, a group--so, I mean, I know they know
    how to do the application. You have a group of 70 physicians--
    --
        Mr. McIntyre. Yes, sir.
        Dr. Dunn.--only half of them made it across the finish
    line.
        Mr. McIntyre. We will look forward to that.
        Dr. Dunn. I appreciate that. I had one more question. Oh,
    yes. How long, and for both of you, how long does it take to
    get an authorization from the time the veteran says, okay, we
    need an authorization code, Community Care. How long does it
    take in TriWest and how long does it take in Optum?
        Mr. McIntyre. I can answer that from the standpoint of what
    we do with an authorization and when it actually gets to the
    point of care. We have a couple of day process. When we ingest
    an authorization it comes from VA. We put it through a
    process----
        Dr. Dunn. What is the timeline? We are down to 3 seconds
    here.
        Mr. McIntyre. To go from authorization to full
    appointment----
        Dr. Dunn. Well, no. Actually to get the authorization, to
    ask for the authorization and get it just in the VA.
        Mr. McIntyre. 2 days to come through our process.
        General.
        General Horoho. With Community Care now the VA makes those
    scheduling appointments, so we don't have visibility of that.
        Dr. Dunn. Oh, so you are not----
        General Horoho. As soon as the----
        Dr. Dunn.--there yet?
        General Horoho. As soon as they determine eligibility,
    though, the VA can go into the system, see our providers,
    schedule an appointment and then our providers----
        Dr. Dunn. Any delays are actually before they get to
    TriWest or Optum? They are in the VA.
        General Horoho. In new Community Care.
        Dr. Dunn. Okay. All right. Thank you.
        Thank you. I yield back.
        Ms. Brownley. Thank you, Dr. Dunn.
        I just wanted to follow up on that line of questioning. I
    am interested from the time of auth--how long it takes for the
    authorization, not from the authorization to appointment, but
    from the request of authorization to being authorized.
        I will let you mull that over, and I will ask Mr. Lamb 5
    minutes.
        Mr. Lamb. Thank you, Madam Chairwoman.
        I am interested in the answer to that question as well,
    too, so if you know it and want to answer on my time, that is
    totally fine.
        Mr. McIntyre. If you go back about a year and a half to 2
    years, the process took 90 days in the VA environment and 90
    days in the TriWest environment to get from end to end. That
    was completely unacceptable.
        The VA spent time on their side of that boundary line. We
    spent our time on our side of the boundary line. I think it
    would be a good idea to have us sit down together and map out
    what that looks like with the various component parts. Why does
    it look the way it is? Where are we? Get your input on whether
    we make additional adjustments or whether you are satisfied
    with where we currently are.
        Mr. Lamb. Okay. That is great. I hate to cut you off, but
    it just sounds like we don't know the answer to the timeline
    yet. We will get back to it when you have that.
        General, I think this is a question for both of you, but,
    General, Optum is going to be serving Pennsylvania where I am
    from. Let's say that you have a pain doctor who may have other
    parts of their practice, too, but let's say that they are a
    pain management type of doctor in Western Pennsylvania. They
    are considering joining the Optum network to serve veterans.
        What, if any, safeguards are in place to make sure that
    that doctor is not someone who overprescribes opioids, or
    casually prescribes them, or has poor prescribing practice, or
    a record of poor treatment of the people? I mean, I am
    basically asking what sort of oversight and investigation, if
    any, is done before this person is allowed entry?
        General Horoho. Thank you for that question. We have--our
    first priority is leveraging those physicians that are in our
    network, and we make sure that they are accredited.
        Mr. Lamb. Do you mean, that are in your----
        General Horoho. In the United health----
        Mr. Lamb.--Optum----
        General Horoho.--network.
        Mr. Lamb.--health network already. Okay.
        General Horoho. Priority.
        Second are those that have a relationship with the veteran
    and they want to be part of our network, then we can reach out
    to them. Anyone that is joining the network gets reviewed
    through our accreditation process before they are allowed to
    practice. They have----
        Mr. Lamb. Is that--sorry. Is that the same process you
    would use like if someone wanted to be part of United?
        General Horoho. Yes.
        Mr. Lamb. Is it basically the same thing?
        General Horoho. It is one standard. We are also looking at
    leveraging our choice plus providers which have a higher
    standard of care and quality. We have all of them that are
    trained in opioid usage. We also have a providerexpress.com
    where they can go online and read about opioid training. We
    make sure that we are monitoring the usage. We also have----
        Mr. Lamb. I am sorry. What do you mean monitoring the
    usage?
        General Horoho. We can look at frequent prescribers. We
    also can look within community care that they can use
    complimentary alternative medicine. They can use biofeedback.
    They can use massage, tai chi. We try to encourage
    complimentary alternative medicine first. Then also when they
    are in the community it is a 14 day prescription. They can't
    prescribe more than that for that episode of care.
        Mr. Lamb. Okay. That is great. Do you actually look at
    historical metrics of how much that person has prescribed let's
    say in the last 5 years or the last decade before they are
    allowed entry to the network?
        General Horoho. We do have within our data analytics to be
    able to monitor that data and to be able to look at sole source
    providers as well.
        Mr. Lamb. Okay. I guess what I am asking is pretty
    specific. It is not about----
        General Horoho. Okay. I am sorry.
        Mr. Lamb.--monitoring. It is about before the person is
    allowed entry, is it a requirement that you look at how much
    they have prescribed in the last 10 years and make a judgment
    about what that looks like compared to the average?
        General Horoho. I will take that for the record to make
    sure----
        Mr. Lamb. Sure. Yes. That is a----
        General Horoho.--I am giving you accurate information.
        Mr. Lamb.--pretty specific question. The reason I am asking
    you is just because I think where we live in particular, there
    was a lot of really poor practice for a very long time and not
    everybody was investigated, not everybody was prosecuted. A lot
    of those people are still practicing and nothing has ever
    happened to them. I wouldn't want them to gain admission or
    access to this group of patients without those questions being
    asked about how, if at all, they have changed their practice.
        If you are able to follow up with us on that about sort of
    what happens at the beginning to safeguard that, I would really
    appreciate that.
        General Horoho. Absolutely.
        Mr. Lamb. Thank you.
        General Horoho. Thank you.
        Mr. Lamb. Madam Chairwoman, I yield back.
        Ms. Brownley. Thank you, Mr. Lamb.
        There are no other members here, so before I excuse the
    panel I had 2 questions that I wanted to ask. Ms. Vitti, you
    haven't been asked a question so I want to make sure that I ask
    one.
        I think from what I am hearing and certainly hearing from
    Mr. McIntyre that, you know, we are working on getting to 100
    percent in terms of coverage. Now that Optum is on board I just
    want to hear from you, are you engaged with Optum to make sure
    that--I know you are in 33 states. We have got some more to go
    here. Are you working with Optum to make sure that those
    providers are there throughout the country?
        Ms. Vitti. Thank you for the question.
        We have had a great partnership with TriWest and we have--
    we are starting to build a great partnership with Optum. For
    this particular program we have worked with Optum and United on
    other aspects of our business. We already have a relationship.
        I think with both the partnerships we have been able--they
    have been very gracious and interested in learning about what
    we have encountered and what we have built in our pilots and
    incorporating that in the process going forward.
        I have been very impressed with both organizations being
    focused on making it easy and seamless for the patients and the
    providers. I expect that that will be the ongoing relationship
    that we have.
        Ms. Brownley. Well, terrific. I agree with Dr. Roe and his
    opening comments when he was here to say that this urgent care
    piece is such an important addition to services for our
    veterans within this MISSION Act.
        As we are overseeing this whole operation we are going to
    be looking very closely at the urgent care piece, too, because
    we don't have any experience with this. This is our first
    experience and we want to make sure that we get it right. I
    have great hopes that we will.
        Again, I think just in a similar fashion to my questioning
    along with the first panel, I wanted to just end here by asking
    Mr. McIntyre, from--you know, from your perspective what do you
    think are the key sort of lessons learned? You have been in
    this space longer than anybody else. What would you say are the
    lessons learned?
        Mr. McIntyre. I think collaboration is really important. I
    think looking back and trying to figure out where the
    challenges have been and applying those lessons as you design
    what you are doing presently, and then refining going forward
    as a team and keeping a very open communication and identifying
    gaps and working those issues. That is literally what has been
    led by VA through this process, particularly of the last 12
    months. And it has been a privilege to be a part of that.
        I think from a threat perspective, making sure that we get
    to a place where we understand what does it take for the life
    cycle to go from that encounter with the provider in the direct
    system to the boundary line to move the patient into the
    community, and then making sure that the pieces come back the
    other direction. That's really got to be the core fundamental
    of what we are all doing.
        I didn't want to leave people with the impression that we
    are still at 90 days on each side of that because we are not.
    There has been a lot of work done and it has been incredible
    work by people. It is very tight now, but it can probably be
    tighter. I think it is important to be transparent about what
    that looks like.
        Ms. Brownley. Thank you very much.
        I, on that particular piece, too, I look forward to working
    with you on it. As I said in my beginning comments is that, you
    know, this wait time issue, this is something that I really do
    want to resolve because I think, you know, just having a
    measurement from the time the veteran calls to the time he or
    she receives the appointment is the basis by which, whether it
    is within the community care piece or within the VA, is really
    important. That is the important measurement that we need to
    move going forward.
        Quite frankly I think when we compare ourselves to a
    private industry, you know, I don't think it is bad if it is
    taking 30 or 40 days if that is the reality because that is--in
    reality that is what is happening in the private market.
        I just think that that has to be the measurement going
    forward.
        I will just close by saying thank you to all of the
    witnesses for being here. I thank Dr. Matthews and Dr.
    MacDonald for staying through the second part of this. I
    appreciate that. That is an example of collaboration. I think
    we have gained some valuable insight into the implementation of
    the MISSION Act.
        It is, I must say it is very nice to chair a committee, to
    review a program where we are leaving with a sense of hope and
    that this program is really going to--is working and is going
    to work. Not to say that we don't have a lot of work to do, but
    it is very nice to be in a hearing where the outlook is
    positive.
        Again, I thank you all for being here and a very productive
    meeting. With that I will ask Ranking Member Dr. Dunn if he has
    any closing comments.
        Dr. Dunn. Thank you, Chairwoman Brownley.
        I want to echo the note of hope there at the end. I think
    it is actually a great deal, very rewarding for us to have
    worked so hard on this MISSION Act in the last session and now
    to oversee its implementation.
        You get the sense that we are keen--here we are just 3
    months in and we already have a hearing on oversight. We are
    keenly interested in knowing that this is working well. We
    can't get too much input from you, so bring it on. We would
    love to see this help our veterans. It would be really--it
    would feel good to stomp out some of the complaints that we get
    from the veterans on their wait times and access to care and
    things like that.
        I want to welcome General Horoho to the team. She is a
    former Army Surgeon General. That kind of would have been my
    boss except that, ooh, I was older than her.
        [Laughter.]
        Dr. Dunn. I was before your time.
        I appreciate the chance to work with all of you and get
    information from you.
        I look forward to working with you, Chairwoman Brownley.
        Ms. Brownley. Thank you, Dr. Dunn, and thank you again to
    all of the witnesses. With that all members will have 5
    legislative days to revise and extend their remarks and include
    extraneous material.
        Without objection the subcommittee stands adjourned. Thanks
    again.

        [The Prepared Statement Of Disabled American Veterans
    Appears In The Submissions For The Record]

        [The Prepared Statement Of Paralyzed Veterans Of America
    Appears In The Submissions For The Record ]

        [The Prepared Statement Of Veterans Of Foreign Wars Of The
    United States Appears In The Submissions For The Record]

        [Whereupon, at 11:51 a.m., the subcommittee was adjourned.]

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                     Prepared Statement of Richard A. Stone

        Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members
    of the Subcommittee. I appreciate the opportunity to discuss
    implementation of the VA Maintaining Internal Systems and Strengthening
    Integrated Outside Networks (MISSION) Act of 2018. I am accompanied
    today by Dr. Kameron Matthews, Deputy Under Secretary for Health for
    Community Care, and Dr. Jennifer MacDonald, Veterans Health
    Administration (VHA) MISSION Act Lead.
                                  introduction
        The Veterans Choice Program, which was established in 2014 in
    response to the access crisis at VA, expanded VA's authority to provide
    Veterans with access to care in their communities. At that time, access
    to care was a critical concern in many locations Nation-wide. The
    eligibility criteria for the Veterans Choice Program were primarily
    centered on internal VA wait times of 30 days or more or a Veterans'
    residence being more than 40 miles from the closest VA medical facility
    with a full-time primary care physician.
        The Choice Program came at a critical time for VA, and it allowed
    VA to serve over two million Veterans in communities across the country
    after it was established. VA has also continuously worked to improve
    Veterans' access to care in VA facilities and has made dramatic
    improvements since the Choice program was implemented. Improved access
    to care in VA facilities and continued input from Veterans using VA
    community care programs enabled VA to identify opportunities to serve
    Veterans. VA learned that an expanded community care program
    supplements VA care and better reflects the dynamic realities of health
    care and the needs of Veterans in their local markets.
        We are now using the authority granted by the VA MISSION Act to
    give Veterans and VA providers more choices in an effort to ensure
    Veterans have access to the care they need. On June 6, 2019, the new
    Veterans Community Care Program was implemented in accordance with the
    VA MISSION Act of 2018. This new program makes dramatic improvements to
    how Veterans receive community care, allowing VA to deliver world-
    class, seamless customer service either through a VA facility or a
    community provider, based on each Veterans' individual needs and
    preferences.
        I am proud of the efforts that VA has taken in the initial launch
    of the program, and although it is still early to fully quantify, we
    are seeing demonstrated improvements in how VA delivers Veterans'
    community care after just 3 months.
                                  improvements
        VA began implementing the MISSION Act on June 6, through the
    integration of multiple existing programs into a consolidated community
    care program. Of note, the Veterans Choice Program ended on June 6,
    2019, but some of its elements were adopted into the new program. Under
    the new Veterans Community Care Program, a covered Veteran is eligible
    to receive community care if he or she meets any of six enumerated
    criteria, as opposed to the more restrictive two criteria from the
    Choice Program mentioned previously. Among the new eligibility criteria
    under the MISSION Act, a Veteran may elect to receive community care if
    he or she and his or her referring clinician decide that community care
    is in his or her best medical interest. That change alone, the ability
    for VA to allow community care any time it is in the Veterans' best
    medical interest, is a vital change in VA's community care offerings
    that allows Veterans and providers more flexibility to meet the
    Veteran's needs than we have ever had before.
        VA heard the concerns of Congress and Veterans about making sure
    that this important new option of using the best medical interest
    criterion was implemented in the Veteran-centric way that Congress
    intended. Since June 6, VA has successfully entered more than a million
    community care consults, and preliminary data shows that the best
    medical interest criterion was a factor considered in 538,000 community
    care consults, and it was the sole factor in the eligibility for more
    than 340,000 of those consults. This demonstrates that VA care teams
    are committed to put Veterans' needs first under the new program and
    are leveraging the new options for care that the MISSION Act has
    provided.
        Drive time has also been a factor in about 347,000 of community
    care consults since the MISSION launch. With respect to the other
    criteria, about 86,000 consults have factored in a Veteran being
    grandfathered under the Choice Program, 5,000 factored in that the
    service was unavailable at the desired VA location, and 2,000 factored
    in medical hardship. These early data show that the greater flexibility
    under this program have been valuable to Veterans and providers.
        VA is establishing a new Community Care Network (CCN) of contracted
    community providers for the Veterans Community Care Program that will
    be administered through third party administrators (TPA). CCN is VA's
    new approach to doing business with community providers that we
    developed from lessons learned under the Choice Program and other past
    community care authorities. CCN is improving the Veteran Community Care
    program by de-centralizing our contracts with community care providers.
    CCN consists of six regional contracts that each provide a credentialed
    network of community providers within that region to provide care to
    Veterans. Consistent with the lessons learned under prior programs, VA
    has enhanced its business practices under these contracts with the TPAs
    to ensure that the they pay VA's valued clinical partners in the
    community in a timely manner. VA has also launched new state-of-the-art
    commercial software to ensure that our payments to the TPAs are timely.
    Once CCN is fully implemented, VA will directly coordinate with
    Veterans to schedule community care appointments and support care
    coordination--and some Veterans will even be able to schedule their own
    appointments. CCN deployment in Region 1 started in Philadelphia at the
    end of June 2019 with dental services and was expanded to all services
    at the end of July in both Philadelphia and White River Junction,
    Vermont. It will be deployed to remaining sites in Region 1 in the fall
    of 2019, and there are currently more than 52,000 active providers in
    the network.
        VA is modernizing its information technology (IT) systems for the
    Veterans Community Care Program to replace a patchwork of old
    technology and manual processes that previously slowed down the
    administration and delivery of community care. The new IT systems
    streamline all aspects of community care--eligibility, authorizations,
    appointments, care coordination, claims, payments--while improving
    overall communication between Veterans, community providers, and VA
    staff members. Even before the MISSION Act passed, VHA was working
    closely with VA's Office of Information and Technology (OIT) to begin
    planning for expected IT requirements and systems that would either be
    impacted by the new law or created entirely because of the law. Since
    passage of the MISSION Act, VHA and OIT have worked together to ensure
    that staff in VA facilities had the necessary tools and technological
    capabilities to implement the MISSION Act starting on June 6, 2019.
        Deployment of many tools that supported implementation of the
    MISSION Act started before June 6, 2019. For example, a tool known as
    the Provider Profile Management System (PPMS) was deployed nationally
    in Fiscal Year (FY) 2018 and provides VA staff and Veterans with a
    directory of VA providers, Department of Defense (DoD) providers, and
    community providers who are part of VA's network. This year, VA has
    deployed a new referral and authorization system, Health Share Referral
    Manager (HSRM), that streamlines information sharing between VA and
    community providers and expanded its deployment of Electronic Claims
    Adjudication Management System (eCAMS), a tool that modernizes VA's
    claims processing systems and improves both timeliness and accuracy of
    payments to community providers. All of these tools are helping VA
    implement a modernized approach to providing community care under the
    MISSION Act.
        VA developed one entirely new IT tool to help implement the new
    Veterans Community Care under the MISSION Act, the Decision Support
    Tool (DST). DST helps VA identify and document Veterans' eligibility
    for community care, as well as the basis for their eligibility. The
    tool interfaces with other systems including PPMS, the enrollment
    system, and the scheduling system, to identify Veterans who are
    eligible for community care. This tool deployed in production on June
    6, 2019. However, having learned from past implementations, and hearing
    the concerns of Congress, Veterans, and VA staff about ensuring that
    the staff had adequate training and preparation for the software
    launch, users were provided training and a ``sandbox'' in May 2019 so
    that they could become familiar with the tool prior to production use.
    This training and sandbox testing prepared VA for a successful launch
    of the tool on June 6.
        Overall, early data shows that Veterans are using the Veterans
    Community Care Program under the MISSION Act only slightly more than
    they were using community care before the June 6 launch. VA will
    receive more data from providers in the coming months to better
    understand trends in Veterans' choices and preferences with the new
    program. I am proud that inside our health care system, VA has
    completed over 53 million appointments Nation-wide as of mid-August of
    this fiscal year, which is more than 1.6 million higher than the same
    timeframe in Fiscal Year 2018, or an increase of 3.1 percent. While VA
    continues to provide greater choice in the community, we also remain
    committed to ensuring that Veterans have exceptional access to care
    inside our facilities.
                                  urgent care
        As part of the VA MISSION Act of 2018, VA now offers an urgent care
    benefit that provides eligible Veterans with greater choice about
    meeting their health care needs and improved access to timely, high-
    quality care. Veterans can use this option for minor injuries and
    illnesses, such as colds, sore throats, and minor skin infections.
    Veterans are eligible for the urgent care benefit if they are enrolled
    in VA health care and have received care through VA (from either a VA
    or community provider) within 24 months prior to seeking urgent care.
    Although it is too early for us to examine definitive data, we estimate
    that more than 16,000 Veterans have used this benefit and there have
    been a total of 44,000 urgent care encounters, based on eligibility
    checks by providers.
        The contracted network currently includes almost 6,000 urgent care
    providers Nation-wide, and TriWest Health Care Alliance, one of VA's
    TPAs, continues to recruit more providers into the network each day.
    Eligible Veterans can receive urgent care under this benefit without
    prior authorization from VA, when seeing a provider that is part of the
    network. VA offers the urgent care benefit to Veterans in addition to
    the opportunity to receive prompt care from a VA provider--Veterans can
    get same-day services for primary care and mental health needs in-house
    at all VA facilities.
        The urgent care benefit covers treatment of non-emergent symptoms
    such as flu-like symptoms (coughs and colds), wheezing, sprains, sore
    throats, painful urination, bumps and bruises, ear pain, and mild skin
    irritations, which are typically addressed by urgent care facilities
    and walk-in retail health clinics. The urgent care benefit also covers
    diagnostic services like X-rays, some lab testing, and some
    medications. The availability of services depends on the array of
    services that the contracted providers offer, so the specific services
    available to Veterans in a given area may be limited by the
    capabilities of the participating providers. VA urges Veterans to avoid
    using urgent care to manage chronic conditions or longer-term care
    needs through this benefit.
                           challenges va has overcome
        One of the challenges in implementing the new Veterans Community
    Care Program, both before the initial June 6 launch and as our programs
    continue to develop, is ensuring that all stakeholders received
    appropriate communication regarding the transition to the new program--
    especially Veterans. VA as an organization reached out directly to
    Veterans using multiple means of communication, including direct
    mailing, email, secure messaging through VA's health portal, Community
    Veterans Engagement Boards, and social media. By mail alone, VA
    contacted about 9 million Veterans with educational materials about the
    new program. To overcome the challenges of educating the public about
    changes under the MISSION Act, VA has partnered in new ways with
    Veterans Service Organizations and other external partners, working
    with them to help amplify VA's messages and provide outreach, training,
    and materials for distribution to Veterans. VA also engaged community
    providers prior to the new program launch through monthly provider
    newsletter updates, briefings and outreach through professional
    associations.
        Internally, each VA facility has designated a MISSION Champion to
    serve as the local lead for implementation. This MISSION Champion's
    role includes engaging staff, providing VA Central Office with direct
    feedback, and distributing key materials (including a robust field
    implementation guide), as well as guiding training and operational
    rehearsals. VA set ambitious training goals for all Veteran-facing
    staff and I am proud to say that our dedicated staff far exceeded our
    goals, both in terms of the number of people who tooktraining, and how
    quickly they completed it. On June 6, VHA leaders deployed to more than
    30 sites to be shoulder to shoulder with field leaders across the
    launch. VA continues to refine and reinforce messaging and work with
    partners, including Veterans Service Organizations, to ensure that
    Veterans, VA employees, and community providers have all the
    information they need for continued success.
        VA is a large entity with specialists that work in many separate
    parts of the organization. The MISSION Act required and still requires
    many significant changes to VA's operations. To address the challenges
    of implementing the MISSION Act and bring together these experts, a
    Joint Operations Center (JOC) was established, with participation from
    all Veteran Intergrated Services Networks (VISNs) and all key offices
    across the Department. This command center is focused on frontline
    needs to develop a common operating picture for the enterprise--
    bringing about unprecedented cross-functional collaboration and rapid
    progress. During the lead-up to the launch, as well as on the go-live
    day of June 6, the JOC shared real-time data with the experts needed
    resolve issues and escalated and coordinated actions necessary for
    operational success.
        As an example of the power of the JOC, as discussed above, Congress
    had raised some concerns about VA's ability to launch the DST software
    by June 6. VA's launch of the DST was successful, but it also was not
    without technical glitches in some areas. The fact that the software
    was ready for launch and that VA was able to recover from those
    glitches is a key victory of the JOC approach. This was due to JOC-
    facilitated communication between VHA and OIT that enabled direct field
    feedback during development and in early testing that led not only to a
    solid product by June 6, but also enabled VA to develop and train
    people across the organization on how to give Veterans what they needed
    even in the event of a software failure. Given the success of the JOC
    for the June 6 launch, VHA leadership continues to convene the JOC on a
    weekly basis--refining implementation and preparing for the launch of
    other key MISSION Act components. In the future, the JOC will similarly
    be utilized for the progress and launch of other key VHA initiatives.
        Another challenge that VA continues to address is building a
    network of urgent care providers that is accessible to the Veteran
    population. VA is dependent on the urgent care provider community in
    joining the contracted network. TriWest Health Care Alliance, one of
    VA's TPAs, is continually working to expand the network; however, they
    are reliant on providers being both present in the communities and
    interested to work with TriWest to serve Veterans. In some parts of the
    country, such as rural areas, there are limited urgent care or walk-in
    clinic providers. VA continues to work with TriWest to identify areas
    that need urgent care provider coverage to focus their outreach. As of
    the end of August 2019, almost 6,000 urgent care centers had joined the
    TriWest network.
                                   conclusion
        Veterans' care is our mission. We are committed to rebuilding the
    trust of Veterans and will continue to work to improve Veterans' access
    to timely, high-quality care from VA facilities, while providing
    Veterans with more choice to access care where and when they need it.
    Your continued support is essential to providing this care for Veterans
    and their families. This concludes my testimony. My colleagues and I
    are prepared to answer any questions you may have.
                                     ______

                       Prepared Statement of Sharon Vitti

        Chairwoman Brownley, Ranking Member Dunn, and Members of the
    Subcommittee, thank you for the opportunity to testify today and to
    share CVS Health's role and experience in expanding access to care for
    our Nation's veterans.
        My name is Sharon Vitti, and I serve as President of CVS
    MinuteClinic and as Senior Vice President at CVS Health. In this role,
    I lead all aspects of MinuteClinic care delivery, business operations,
    and strategic development.
        CVS Health is the Nation's premier health innovation company
    helping people on their path to better health. Whether in one of our
    pharmacies or through our health services and plans, CVS Health is
    pioneering a bold new approach to total health by making quality care
    more affordable, accessible, simple and seamless. CVS Health is
    community-based and locally focused, engaging consumers with the care
    they need when and where they need it. Our innovative health care model
    increases access to quality care, delivers better health outcomes, and
    lowers overall health care costs.
        Our support of the MISSION Act is one example of the many ways we
    stand with veterans, active military and their families. We have
    several Workforce Initiatives programs dedicated to recruiting,
    training, and retaining veterans to build a pipeline of workforce
    talent. Since 2015, CVS Health has hired almost 15,000 people with
    military experience and more than 5,000 military spouses.
        In addition, we provide charitable support to military and veteran-
    focused organizations, including the National Guard, Operation
    Reinvent, and the USO. And, colleagues can connect through the CVS
    Health Colleague Resource Group BRAVE, which is comprised of nearly
    1,400 members with a passion to serve those who have served our
    country.
        We were recently recognized for our efforts to support veterans and
    military members. In May, Military Times named CVS Health to its 2019
    list of best companies for veterans seeking a civilian job.
        With that as background, I am pleased to be here today to provide
    an overview of MinuteClinic's partnership with the U.S. Department of
    Veterans Affairs (VA). Support for our country's veterans and members
    of the military is central to the work we do at CVS Health, whether
    through our workforce programs or our efforts to connect this
    population with easily accessible, high-quality care.
                       shared vision for expanding access
        Addressing the growing need to provide veterans with convenient
    access to quality urgent care in their communities is a shared vision
    for the VA and CVS Health. The program in place today originated in
    2016 with a pilot funded by the VA Health System in Palo Alto,
    California. Palo Alto utilized discretionary funds for a 1-year program
    that leveraged 14 local MinuteClinic sites to provide access to
    treatment for minor illnesses, minor injuries, and skin conditions. The
    initial months of the pilot were devoted to the development of
    criteria, information sharing protocols, and training materials,
    including defining the list of eligible services and creating
    educational materials to assist VA nurses with triage.
        A critical first step was to ensure the capability was in place to
    quickly convey information about the veterans' visit to the VA
    electronically so we could maintain continuity of care for the veterans
    we provided care for and keep VA providers informed of the veterans'
    health status. As a result of our work together with the VA in Palo
    Alto, we established the connectivity that today makes it possible for
    us to provide information about a veteran's visit directly to the VA
    through the e-Health Exchange.
        In addition to establishing standards and protocols, we focused on
    ensuring a positive experience for the veterans we serve by working
    closely with both the VA and our own CVS Health colleagues with prior
    military service to create a welcoming environment and to ensure our
    services are viewed as an extension of their coordinated care with the
    VA.
        We began to see veterans in our clinics during the second half of
    the pilot.
        Veterans were screened for eligibility when they called the VA
    triage line and, if their condition met the criteria, the veteran was
    offered the opportunity to be treated at a MinuteClinic. Over 550
    visits were conducted during this roughly 6-month operational phase
    with an average in-clinic wait time of less than 20 minutes.
        Under the pilot, veterans who desired to do so could also fill
    prescriptions from their MinuteClinic visit at the co-located CVS
    Pharmacy. The pharmacy followed the VA formulary and applied standard
    VA co-pays.
                       expansion under the choice program
        The Palo Alto pilot generated considerable interest from other VA
    service areas, including the VA Health System in Phoenix, Arizona. In
    April 2017, we partnered with the VA's Office of Community Care, the
    Phoenix VA, and TriWest, the third-party CHOICE administrator for the
    region, to enable veterans to receive care at 24 MinuteClinics in the
    Phoenix area.
        Operating under the CHOICE Program helped us identify and create
    new protocols for billing and pharmacy access, which were crucial to
    future program expansion. As an example, pharmacy services were not
    included in the CHOICE program. To maintain the same seamless veteran
    experience as created in the Palo Alto pilot, the VA's emergency
    prescription fill authority was approved to allow veterans to receive
    their initial first-fill of prescriptions written in conjunction with
    their MinuteClinic visit at the pharmacy of their choice.
        Our partnership with the Phoenix VA further demonstrated that
    MinuteClinic filled a need for veterans and offered another convenient
    access point for care within the broader community care network. Once
    proven in Phoenix, the program resumed operation in Palo Alto and
    expanded to additional regions, including Santa Clarita, California and
    Corpus Christi, Texas.
                        enactment of the va mission act
        The John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
    Maintaining Internal Systems and Strengthening Integrated Outside
    Networks Act of 2018, or VA MISSION Act, (P.L. 115-182) provided the
    framework needed for the national expansion of urgent care access for
    veterans. Under the MISSION Act, veterans can now access urgent care
    and walk-in medical services under their VA benefits without pre-
    authorization. Veterans who meet certain eligibility criteria can
    receive care at any MinuteClinic location. Following the visit,
    MinuteClinic is able to make the full record of medical services
    provided available to the VA with the patient's consent.
        We provided comments to the VA throughout the regulatory process
    and worked closely with the VA to provide location data and technical
    assistance to ensure a successful launch on June 6, 2019. Since the
    ``go-live'' date, we have provided care for more than 5,600 veterans in
    all 33 states and the District of Columbia in which we operate
    MinuteClinics. Combined with the veterans we cared for during the pilot
    and under CHOICE, we have provided care for more than 9,500 veterans
    since our partnership with the VA began 3 years ago.
        Our experience suggests there is a high level of knowledge among
    veterans about MinuteClinics and the types of conditions we treat. We
    typically treat for acute conditions where prompt treatment can avoid
    more serious health issues and additional costs. The top conditions for
    which veterans visit a MinuteClinic are cough, sore throat, sinus
    infection, rash, and ear ache. Veterans also have demonstrated a good
    understanding of the structure of the new benefit as well as the intent
    that urgent care augments, not replaces, their relationship with VA
    providers.
                                   conclusion
        CVS Health deeply values its partnership with the VA and the
    opportunity to provide care for those who have served. Starting with a
    shared vision, we are proud of the program we have created and
    appreciate the opportunities we have had to work with the VA Office of
    Community Care, the Palo Alto and Phoenix VA Health Systems, TriWest
    and now Optum to meet the needs of veterans.
        We also appreciate Congress and this Committee for recognizing this
    program and the benefits it offers veterans when drafting the VA
    MISSION Act. Our participation in the MISSION Act provides deserving
    veterans across the country greater access to quality health care when
    and where they need it, while ensuring they are still linked with their
    VA care providers. We are proud to be able to support Congress and the
    VA in bringing this meaningful and impactful program forward to help
    improve the health of our Nation's veterans.
                                     ______

                  Prepared Statement of David J. McIntyre, Jr.

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                    ------

                       Prepared Statement of Patty Horoho

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

                     Additional Submissions for the Record

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

                           Submissions for the Record

                                  ----------

                    Prepared Statement of Adrian M. Atizado

        Chairwoman Brownley, Ranking Member Dunn, and Members of the
    Subcommittee:
        Thank you for inviting DAV (Disabled American Veterans) to submit
    testimony for this oversight hearing of the Department of Veterans
    Affairs progress with respect to implementation of the new Veterans
    Community Care Program, which went live on June 6, 2019, and VA's new
    urgent care benefit.
        Comprised of more than one million wartime service-disabled
    veterans, DAV is a congressionally chartered non-profit national
    veterans service organization that is dedicated to a single purpose:
    empowering veterans to lead high-quality lives with respect and
    dignity. We are pleased to offer our views on the Veterans Community
    Care program.
                             va urgent care benefit
        As this Subcommittee is aware, DAV worked closely with VA to
    include urgent care as part of its plan required under section 4002 of
    Public Law (P.L.) 114-41 to consolidate all non-Department provider
    programs by establishing a new, single program to be known as the
    ``Veterans Choice Program.''
        We are pleased Congress included DAV's recommendation to provide
    veterans an urgent care benefit under section 105 of P.L. 115-182, the
    John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
    Maintaining Internal Systems and Strengthening Integrated Outside
    Networks Act of 2018, or the VA MISSION Act of 2018.
        The urgent care benefit is intended to offer eligible veterans
    convenient care for certain, limited, non-emergent health care needs
    from qualifying non-VA entities or providers. Eligible veterans include
    any enrolled veteran who has received care under chapter 17 of title 38
    U.S.C. within the 24-month period preceding the furnishing of care
    under this section where such care includes: care provided in a VA
    facility; care authorized by VA performed by a non-VA provider;
    emergency room care authorized by VA performed by a non-VA provider;
    care furnished by a State Veterans Home; or urgent care under this
    proposed section. Qualifying non-VA urgent care providers include any
    non-VA entity that has entered into a contract, agreement, or other
    arrangement with VA to provide urgent care.\1\
    ---------------------------------------------------------------------------
        \1\  38 U.S.C. Sec. 1725A was further amended by P.L. 115-251 to
    allow walk-in care providers to have a contract, agreement or other
    arrangement with VA and aligned the copayment requirements accordingly.
    ---------------------------------------------------------------------------
        We applaud TriWest Health Care Alliance's (TriWest) initial effort
    and continuing hard work to build a network to what is currently about
    6,000 urgent care providers nationwide. According to TriWest, they are
    nearing their maximum achievable goal of 92 percent of veterans to have
    access to an urgent care or retail clinic, if one exists, within a 30-
    minute drive. Moreover, TriWest developed a new online training course
    and simple to use quick reference guide for network urgent care
    providers to understand the processes and procedures on the VA urgent
    care benefit. We are pleased to report DAV members who have used this
    benefit have expressed positive comments about their experience from
    their eligibility determination at the point of service and
    satisfaction with the care they received. In addition, we have not
    received any reports to date of inappropriate billing of veterans using
    the VA urgent care benefit.
        However, we remain disappointed in VA's decision to charge urgent
    care copayments to service-connected veterans, who are generally not
    required to pay copayments under other VA health care programs. In
    DAV's view, service-connected disabled veterans have already paid
    through their service and sacrifice and should not have additional
    copayment or cost-sharing requirements imposed by the Federal
    Government.
        While we appreciate VA's desire to incentivize appropriate health
    behavior, we strongly urge VA to provide positive rather than punitive
    incentives. Rather than charge veterans who have become ill or injured
    due to military service in order to limit their use of this urgent care
    benefit, VA should take a more veteran-centric approach to controlling
    costs by establishing a national nurse advice line to curtail
    overreliance on costly emergency room care. The Defense Health Agency
    (DHA) has reported that the TRICARE Nurse Advice Line has helped triage
    the care TRICARE beneficiaries receive. Beneficiaries who are uncertain
    if they are experiencing a medical emergency and would otherwise visit
    an emergency room, call the nurse advice line and are given clinical
    recommendations for the type of care they should receive. As a result,
    the number of beneficiaries who turn to an emergency room for their
    care is much lower than those who intended to use emergency room care
    before they called the nurse advice line.
        By consolidating the nurse advice lines and medical advice lines
    many VA medical facilities already operate, VA would be able to emulate
    DHA's success in reducing overreliance on emergency room care to
    decrease the current cost-sharing scheme as well as more quickly prompt
    clinical teams to associate any health information rendered from this
    encounter. Furthermore, this care delivery design would change the
    urgent care benefit from an episodic nature to an integrated benefit
    that is part of VA's continuum of care.
        Finally, VA should assess its telehealth program to determine the
    feasibility of providing virtual urgent care services, particularly for
    certain veteran patient populations such as chronic care patients. Such
    a platform combined with a mobile app would allow veterans to connect
    with VA and schedule a visit online or in person. Also, providing this
    type of care would allow for easier integration with VA's electronic
    health record and could help incorporate elements of remote patient
    monitoring.
                       va veteran community care program
        Regarding the implementation of section 101 (38 U.S.C. Sec. 1703)
    of the VA MISSION Act of 2018, DAV believes it is too early to assess
    veteran's experience with care furnished in the still-developing
    Community Care Network (CCN) established under the Veteran Community
    Care Program.\2\ Only 9 out of 142 VA medical facilities are utilizing
    the CCN as of September 17, 2019.
    ---------------------------------------------------------------------------
        \2\  Region 1 Phase 1 includes Philadelphia and White River
    Junction VAMC went live on July 29, 2019. Region 1 Phase 2
    ---------------------------------------------------------------------------
        To implement section 101, VA intends to award Community Care
    Network (CCN) contracts to provide eligible veterans non-VA care across
    six regional boundaries aligned to State lines, including Alaska and
    the Pacific Territories. On December 28, 2018, OptumServe Federal
    Health Services (Optum) was awarded contracts with a base period ending
    September 30 of the Fiscal Year in which the award is made and seven 1-
    year options for regions 1, 2, and 3, covering Veteran Service
    Integrated Networks 1, 2, 4-10, 12, 15, 16, 19 and 23. Subsequently
    however, protests were filed for regions 2 and 3 VA's work with Optum
    had to stop while CCN work for region 1 continued. It has been less
    than 5 months since the Government Accountability Office (GAO) denied
    these protest for OptumServe to continue work to deliver on these
    contracts.
        The contract for region 4, covering VISNs 16, 17, 19-22, which was
    awarded to TriWest on August 7, 2019, is being challenged by Wellpoint
    Military Care Corporation and remains under protest. The Request for
    Proposal (RFP) for region 5 was just posted on September 19 with
    proposals due on October 21, 2019.\3\ No RFP has yet been issued for
    region 6.
    ---------------------------------------------------------------------------
        \3\  www.fbo.gov/notices/6ce4a8fa78d382982974f6d80dd1dd8f
    ---------------------------------------------------------------------------
        In advance of awarding CCN contracts and implementing CCN networks
    across all six regions, VA's contract with Triwest to expand its
    network of Patient Centered Community Care and Veteran Choice Program
    providers across all CCN regions was used as a ``bridge contract'' to
    ensure veterans continue to have access to care during the transition
    to the new Veterans Community Care Program. We understand the current
    option year for this bridge contract expired September 20, 2019 with
    one final option year available through September 30, 2020. It is
    imperative Optum develop and deploy its network of providers that is at
    least equal or better that the one it is replacing by the final option
    year. Our concern regarding region 4 will heighten if the Government
    Accountability Office decision that is anticipated to be issued by the
    end of November 2019 sustains the protest with the TriWest bridge
    contract set to expire 10 months later.
        DAV is currently unable to assess the progress of both VA and Optum
    in implementing the high-performing integrated network required under
    the VA MISSION Act of 2018 or gather sufficient and valid information
    from veterans of their experience in using CCN. We requested copies of
    these contracts withholding sensitive or proprietary information at the
    time of award. Still, VA cited concerns regarding the protest status of
    regions 2 and 3 for not releasing copies of the any awarded contract
    including region 1. We then requested the contracts' Performance Work
    Statement (PWS) and the Quality Assurance Surveillance Program (QASP)
    to better understand the program and communicate to our members what
    they should expect. Unfortunately, we just received redacted copies of
    CCN contracts for regions 1 and 4, even though the contract for region
    4 is currently under protest.
        In our experience, the QASP determines how VA will focus on the
    level of performance required by the PWS, which at times differ from
    the method used by the contractor to achieve a level of performance.
    This is where we generally see weaknesses in the validity and
    reliability of the data and gaps in the surveillance process itself
    that may hinder identification of trending issues ill and injured
    veterans may experience with CCN and formulation of appropriate
    corrective actions.
        Further, we are unable to fully assess the implementation of the
    Veterans Care Agreements under section 102 of the VA MISSION Act of
    2018, as policies and procedures to help guide field implementation are
    still being developed. We are encouraged that VA's Office of Community
    Care is working to resolve issues that have been raised.
        While CCN is still being developed, it may be helpful for the
    Subcommittee to review VA's Community Care Patient Survey that was
    initiated in March 2016 to assess veteran experiences with VA Community
    Care, including care through the Choice Program. This survey includes
    questions regarding veteran experiences with the process of obtaining
    non-VA care (eligibility, referral, making the first appointment,
    billing and out-of-pocket payments), provider communication with the
    veteran, and very basic provider-patient coordination of care. There is
    a 3-to 6-month lag to associate the referral to a non-VA provider and
    the survey for that non-VA visit, analyze the data and generate the
    report. This delay should be accounted for if the survey is used as a
    sort of proxy to describe the State of CCN implementation in light of
    Optum network's deployment schedule.
        We remain concerned about the lack of guidance to veterans and VA
    medical centers regarding the required care coordination with and
    competency standards for non-VA health care providers as required under
    sections 101 and 133 of the VA MISSION Act of 2018. For example, VA
    mental health providers caring for veterans with PTSD have to meet
    strict qualification standards. In addition to graduating from
    discipline accredited graduate and training programs, the mental health
    provider must undertake training in suicide prevention and military
    culture. Certain mental health providers must complete advanced
    training to provide evidence-based psychotherapy, which includes an 3
    day in-person workshop followed by at least 6 months of ongoing
    training and weekly followup from an expert who maintains progress
    notes or audio recording reviews of the provider trainee's clinical
    sessions. This gold standard training model has been developed and used
    in VA based on numerous studies measuring clinical performance and
    showing sustained quality of care in comparison to mental health
    providers that participate in one-time training workshops whose
    practice reverts back to pre-training quality. Ignoring these standards
    shortchanges veterans and taxpayers of high-quality and high-value
    care, and fragments what otherwise should be an integrated high-
    performing health care network.
        We urge VA and the Subcommittee to ensure CCN achieves the high-
    performing integrated network envisioned by the VA MISSION Act, and
    that there is no double-standard between VA and non-VA health care
    providers in terms of the quality and safety of care that ill and
    injured veterans receive.
        Finally, we are concerned with VA's testimony to this Subcommittee
    on September 11, 2019, that implementing two provisions of the MISSION
    Act--the Veterans Community Care Program under Sec. 1703 and the urgent
    care benefit under Sec. 1725A--both of which expand access to timely
    care, particularly for urgent or emergent conditions--may relieve some
    of the need for VA facilities to have extended hours of operation.
        We urge VA facilities not implement such a policy that would reduce
    or delay ill and injured veterans access to high-quality care when they
    choose to receive such care in their local VA medical facility. We
    believe veterans who choose VA should be able to receive care and
    services at VA. For many veterans, extended operating hours are the
    only times during their busy lives that they can receive the care they
    need. Any reduction of these hours would make VA less veteran centric
    and appear more concerned about themselves than the veterans they are
    meant to serve.
        Madame Chair, this concludes DAV's testimony. Thank you for
    inviting DAV to submit testimony for the record of today's hearing and
    we look forward to working with this Subcommittee to ensure veterans
    continue to receive timely, high quality care from VA and its community
    partners.
                                     ______

            Prepared Statement of the Paralyzed Veterans of America

        Chairwoman Brownley, Ranking Member Dunn, and members of the
    Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
    you for this opportunity to share our views on the Department of
    Veterans Affair's (VA's) rollout of the new Veterans Community Care
    Program (VCCP) and Urgent Care benefit.
        Poet Thomas Carlyle once said, ``Silence is golden'' and for the
    most part, that has been our experience since VA implemented the VCCP.
    Aside from anecdotal reports of problems, the launch appears to have
    unfolded relatively problem-free. In preparation for this hearing, we
    surveyed our National Service Officers (NSOs) and asked the following
    questions:

            1. Do veterans believe the VCCP has improved access to VA
            health care?

            2. Is VA honoring veterans' requests to be referred to an
            authorized network community health provider?

            3. Has the rollout of the VCCP had any impact on Bowel and
            Bladder contracts?

            4. Have you received any comments, positive or negative, from
            veterans about the VCCP?

            5. Have you received any comments, positive or negative, from
            veterans about the new Urgent Care benefit?

        Sixty of our NSOs responded to the our survey. The overwhelming
    majority of responses received for questions 1, 2, 4, and 5 were ``no''
    or ``none.'' The consistency among their responses seems to suggest
    that it may be too soon to determine how well the VCCP is meeting the
    needs of veterans.
        However, a number of respondants did identify a concern with VA's
    Bowel and Bladder (B&B) program. Veterans with spinal cord injuries or
    disorders (SCI/D) often experience gastrointestinal problems, including
    neurogenic bowel, peptic ulcer disease, impaction, diarrhea, and
    incontinence. Many of these complications may result in hospitalization
    and some can be life-threatening. Complaints related to
    gastrointestinal dysfunction are quite common following an SCI/D and
    they always negativly impact the veteran's quality of life. Therefore,
    VA established the B&B program to assist SCI/D patients with bowel and
    bladder care, which can be provided by an authorized health care
    provider or a family member trained and certified by a VA SCI Center.
        With the implementation of Veteran Care Agreements (VCA) required
    by the VA MISSION Act (Public Law 115-182), VA medical centers sent
    letters to caregivers and family members authorized by VA to provide
    B&B care to veterans. It tells them that they are now required to get a
    National Provider Identifier (NPI) in order to continue to receive
    reimbursement for B&B care provided. They are being directed to obtain
    the NPI and submit a signed VCA to VA not later than September 30,
    2019. A copy of one of these letters is provided with our statement for
    your review.
        An NPI is a unique ten-digit identification number required by the
    Health Insurance Portability and Accountability Act (HIPAA) for covered
    health care providers in the United States. Covered providers, health
    plans, and health care clearinghouses (public or private entities that
    process or facilitate the processing of health information) must use an
    NPI in administrative and financial transactions adopted under HIPAA.
    Unfortunately, caregivers and family members were only recently
    notified of the need to obtain an NPI; thus, there may not be enough
    time to get the information in by the deadline. Understandably, we are
    very concerned that those who provide these critical services to PVA
    members will not be paid and have raised our concerns to VA.
        Aside from the information we have received from our NSOs, little
    information has been provided by VA since they launched the VCCP and
    the Urgent Care benefit. VA has kept us informed about the awarding of
    contracts for the six community care regions and the status of
    contractors' efforts in those regions. However, we have received little
    information about how either the VCCP or the Urgent Care benefit is
    working from VA's perspective.
        Again, PVA thanks you for the opportunity to provide this update on
    how well the VCCP is working. We would be happy to take any questions
    you have for the record.
      information required by rule xi 2(g) of the house of representatives
        Pursuant to Rule XI 2(g) of the House of Representatives, the
    following information is provided regarding Federal grants and
    contracts.
                                fiscal year 2019
        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$193,247.
                                fiscal year 2018
        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$181,000.
                                fiscal year 2017
        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$275,000.
                         disclosure of foreign payments
        Paralyzed Veterans of America is largely supported by donations
    from the general public. However, in some very rare cases we receive
    direct donations from foreign nationals. In addition, we receive
    funding from corporations and foundations which in some cases are U.S.
    subsidiaries of non-U.S. companies.
                                     ______

                     Prepared Statement of Ryan M. Gallucci

        Chairwoman Brownley, Ranking Member Dunn, and members of the
    subcommittee, on behalf of the women and men of the Veterans of Foreign
    Wars of the United States (VFW) and its Auxiliary, thank you for the
    opportunity to provide our feedback on the Department of Veterans'
    Affairs (VA) implementation of the MISSION Act of 2018.
        Since 2015, the VFW has regularly surveyed its members on their
    health care options, experiences, and preferences to best understand
    not only the VA health care landscape, but also how veterans make their
    health care decisions. As a result, the VFW has published a series of
    reports entitled ``Our Care,'' which present a snapshot of veterans'
    care.
        With the implementation of the MISSION Act on June 6, 2019, the VFW
    decided it was time to once again commission a survey of our members,
    once again asking about their health care decision-making to evaluate
    whether improvements to the veterans' health care system are working
    and what further improvements may be necessary.
        This year's survey not only reiterated questions on care
    experiences from our past ``Our Care'' surveys, but the also included
    logic-based questions on innovations unique to the MISSION Act, like
    community care consolidation and the new urgent care benefit.
        In lieu of a statement, the VFW submits the ``Our Care 2019''
    report for the record on how the VFW believes the MISSION Act has
    affected veterans' health care decision-making. The report can be found
    online at the VFW's VA Health Care Watch web page: www.vfw.org/VAWatch
        The VFW would be happy to answer any questions the subcommittee may
    have on this report, our methodology, and our findings.

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