[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
       
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                    Available via http://govinfo.gov
                    
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     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

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                     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.]  
      
     
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                         A  P  P  E  N  D  I  X

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                    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
      
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                 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.

                                 [all]