[Senate Hearing 116-205]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 116-205
 
    VA MISSION ACT: IMPLEMENTING THE VETERANS COMMUNITY CARE PROGRAM

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 10, 2019

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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             U.S. GOVERNMENT PUBLISHING OFFICE 
 40-570 PDF             WASHINGTON : 2020 
 
 
        
        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Bill Cassidy, Louisiana              Patty Murray, Washington
Mike Rounds, South Dakota            Bernard Sanders, (I) Vermont
Thom Tillis, North Carolina          Sherrod Brown, Ohio
Dan Sullivan, Alaska                 Richard Blumenthal, Connecticut
Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
Kevin Cramer, North Dakota           Joe Manchin III, West Virginia
                                     Kyrsten Sinema, Arizona
                       Adam Reece, Staff Director
                Tony McClain, Democratic Staff Director
                
                            C O N T E N T S

                              ----------                              

                             April 10, 2019
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
Moran, Hon. Jerry, U.S. Senator from Kansas......................    10
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    12
Boozman, Hon. John, U.S. Senator from Arkansas...................    16
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    17
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    19
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    22
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    75

                               WITNESSES

Stone, Richard, M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs; 
  accompanied by Kameron Matthews, M.D., Deputy Under Secretary 
  for Health for Community Care, Veterans Health Administration; 
  and Jennifer MacDonald, M.D., VA MISSION Act Lead, Veterans 
  Health Administration..........................................     5
    Prepared statement...........................................     6
    Response to request arising during the hearing by:
      Hon. Patty Murray.......................................... 13,14
      Hon. Jon Tester............................................ 22,27
    Response to posthearing questions submitted by Hon. Jerry 
      Moran......................................................    28
Silas, Sharon, Acting Director for Health Care, Government 
  Accountability Office..........................................    28
    Prepared statement...........................................    31
    Response to posthearing questions submitted by Hon. Jerry 
      Moran......................................................    81
Atizado, Adrian, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    48
    Prepared statement...........................................    50
Randles, Merideth, Principal and Consulting Actuary, Milliman....    55
    Prepared statement...........................................    57
        Attachment A.............................................    66
    Response to posthearing questions submitted by Hon. Jerry 
      Moran......................................................    82

                                APPENDIX

American Federation of Government Employees, AFL-CIO (AFGE); 
  prepared statement.............................................    85
Caldwell, Dan, Executive Director, Concerned Veterans for America 
  (CVA); prepared statement......................................    86
Defense Health Agency, Department of Defense (DOD); prepared 
  statement......................................................    89
Nurses Organization of Veterans Affairs (NOVA); prepared 
  statement......................................................    90
Paralyzed Veterans of America (PVA); prepared statement..........    92
Farmer, Carrie M. and Terri Tanielian, The RAND Corporation; 
  prepared statement.............................................    94


    VA MISSION ACT: IMPLEMENTING THE VETERANS COMMUNITY CARE PROGRAM

                              ----------                              


                       WEDNESDAY, APRIL 10, 2019

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Tester, Murray, 
Brown, Blumenthal, Manchin, and Sinema.

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

    Chairman Isakson. I call this hearing of the Veterans' 
Affairs Committee of the U.S. Senate to order. I appreciate 
everybody being here today. Dr. Stone, especially, thank you 
for being here, and your entourage that is with you.
    We are glad to have our VSOs here and everyone else here to 
contribute to the hearing. I appreciate your being here. I want 
to thank the Committee Members who are here and those that are 
coming, which will be most of the Committee.
    It is a really important hearing. We are going to be 
talking about the MISSION Act, going into place. The official 
date it goes in place is actually an interesting date. It is a 
historic day--June the 6th of this year. The other June the 
6th, you will remember, was D-Day, so this is D-Day for the 
MISSION Act and D-Day for health care in the Veterans 
Administration, and this is a D-Day hearing, if we might have, 
to kick that off.
    We promised a number of Democrats who came to me, asking me 
to have this hearing, that we would do it. A number of other 
Senate Members, as well, have sought it. Everybody wants us to 
be successful. We want the VA to put this one behind them, to 
fundamentally change the service they deliver for the better, 
reliability for the better, participation for the better. So, 
timely care to a veteran is the primary thing we are providing 
and we provide a mechanism to do that which is as efficient as 
possible and avoids a lot of the problems we had in the past.
    I will tell you this, though. As one who was here when 
Bernie Sanders and John McCain were on the conference committee 
that produced the Choice Act, which was about 5 years ago now, 
they were trying to do what the MISSION Act does. The Choice 
Act did not work for a lot of reasons; many of them were 
intentional, not by the VA necessarily, but people who did not 
like Choice or did not like the way we were doing everything 
else.
    The MISSION Act is an amazing piece of legislation. It is 
comprehensive. It took a lot of testimony, as those of you who 
came to all of our meetings will tell you, but it worked, and 
we got the input of the veteran, we got the input of the 
professional, we got the input of the Veterans Administration, 
and we have a bill that I think has the opportunity to be 
mainstream and positive from here on out.
    We have no option but for it to be that. I will tell you 
this--we cannot fail. We cannot afford to take this opportunity 
and miss the draw. We have got to do it. I am going to see to 
it that we do what our main job is on the Committee, which is 
oversight. We have done a lot of bill passing. We have changed 
regulations and we have changed laws. We have done a lot of 
that. Now we are going to do oversight. We want to make sure 
that the outcomes for the veteran are improved, including the 
times they get seen, the chances they get to be seen, and the 
choices they get of who sees them. So, I am very interested in 
seeing that take place.
    Let me say one other thing. I am deeply troubled that we 
had two suicides in Georgia in the last 8 days. We had another 
one in Texas 2 days ago, if I am not mistaken, and there may 
have been others. Although that number is not an extraordinary 
number, vis-a-vis the number we have in total every year, which 
is about 22,000, but it is a lot. One life lost is too many. 
This Committee and the VA have been doing an admirable job, a 
great job, on trying to address the problem.
    I am really proud of this Committee because 3 years ago, 
when you called some of the hotlines around the country you got 
a busy signal, and that is not good on a hotline, or they would 
say, ``Please leave your voicemail and we will call you 
tomorrow.'' Well, if you are in danger for your life, if you 
are at risk for your life, that was not to happen.
    The VA has done a marvelous job of getting its hotlines and 
its teleconnections as accessible to veterans as you possibly 
could, and most people--I am not a physician but I will tell 
you that everybody tells you that when it comes to the act of 
suicide that the quicker someone who is at risk can talk to a 
professional, and get to a professional, the return on them 
saving their life is tremendously better than if it takes a 
long time to do so.
    So, I want for us to continue to do what we have been doing 
by making access to these professionals as easy as possible, 
using the benefits of telemedicine, using all the other 
benefits possible.
    What the VA has done is see to it that it had the doctors 
available to meet that challenge. But, we are sorry for the 
lives that were lost. We are sorry for the lives that were 
taken by the person that ended up killing themselves, but we 
want to make sure that we do not lose focus on ending veteran 
suicide, which is everybody's issue. It is the Secretary's 
issue, everybody at VA is for it, and it is everybody's issue 
in the country, because suicide is a huge problem.
    Those deaths did not go by without me noticing them, nor 
has it gone by me that we have got a job to do as long as we 
are here, which is to see to it that we do the best job 
possible of ending that, to all purposes.
    With that said I will turn it over to the Ranking Member, 
Senator Tester.

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

    Senator Tester. Thank you, Chairman Isakson. I would also 
add to that that I believe those three suicides happened in the 
last week and all happened on VA property, which makes it 
particularly gut-wrenching, and I think we will probably get 
into that a little more today.
    Dr. Stone, thanks for being here. I appreciate your service 
and I appreciate you being here. One of these years I hope to 
get you confirmed, which will be a good thing. I appreciate you 
bringing the two docs to your left and your right with you, 
too. I appreciate you guys' service also.
    You know, this Committee worked hand-in-hand with the 
Administration and veteran service organizations when we 
developed the MISSION Act. It was the result of compromise, it 
was a product of years of work, and it was because of the great 
leadership of our chairman, Chairman Isakson, that we were able 
to consolidate multiple VA Community Care programs into one 
streamlined program that makes sense for our veterans, for our 
community providers, and for our taxpayers.
    When the VA could not provide care in a timely manner the 
aim was to ensure that veterans could access quality care in 
their communities in a timely manner. In places like Montana, 
where the VA has failed to place enough emphasis on hiring 
physicians, the route to community care has always been 
critical.
    But, since the MISSION Act was signed into law I have had 
concerned that the VA's primary focus would be in supplanting 
in-house care, as opposed to supplementing that care when it 
makes most sense for our veterans. The VA is doing so without 
the benefit of having completed thorough market assessments 
that would confirm what the community can and cannot actually 
offer. In our rush, in the VA's rush to open to the private 
sector, my concern is that the VA is outsourcing its 
responsibility to ensure veterans receive--and this is what is 
really important in this whole MISSION Act thing--that they 
receive timely and high-quality care.
    When the VA sends veterans into the community without first 
knowing if that care can be provided in a timely manner it is 
outsourcing its responsibility, and when the VA sends veterans 
into community for care that would be of lower value, it is 
outsourcing that responsibility.
    In writing, the MISSION Act intent was never to send 
veterans into the community for care that was less timely and 
of lower quality than the VA can provide. In fact, we have 
specifically required the VA to ensure that community providers 
could meet the same access standards the Department established 
for itself. But, now we find that the VA is establishing one 
set of rules for itself and no rules for the private sector. I 
hope we get into that a little bit in today's hearing.
    And it is doing so while knowing that, on average, VA 
outperforms the private sector in terms of timeliness and 
quality, and you need to be commended for that. Not to mention 
that the VA is doing this without a firm grasp on how much it 
will cost the American taxpayers, and it comes on the heels of 
the VA saying it would consider the performance if its 
facilities were making resource allocation decisions.
    So, on one hand the VA does not have a clear understanding 
of how much the program will cost, and on the other hand the VA 
openly states that it would make funding decisions based on 
whether its facilities are meeting the standards it fails to 
enforce on the private sector. So, what I see is behavior that 
smacks of a deliberate effort not to implement the best policy, 
but to potentially carry out what I think is a political 
agenda.
    Dr. Stone, I know that you are a straight shooter and there 
is no doubt in my mind that the policies you advocate for are 
with the best interest of the veterans in mind. But, as the VA 
chief witness today, you will need to explain why the 
Department's access standards offer the best option for the 
veterans. I am not just talking about veterans who opt for the 
private sector. I am also talking about veterans who utilize VA 
care.
    You will also need to ensure the Committee that the program 
you are implementing will be ready to go on June 6. Right now 
it is not clear whether the technology the VA needs to carry 
out this program, such as the decision support tool, will be 
ready for implementation. And not just ready for use, but with 
the VA personnel appropriately trained on how it works. And, if 
it is not ready to go, and folks have not been adequately 
trained, does the VA have a viable backup in place? The VA has 
had a full year to get this program up and running. If veterans 
are going to see a delay in care because the program is not 
ready to go, I think the best time to tell us that is today.
    I want to thank you, Mr. Chairman, for calling what may be 
one of the most important VA Committee hearings this year.
    I cannot thank you enough, Dr. Stone, for your patience and 
for you being here today. Thank you.
    Chairman Isakson. Thank you, Senator Tester. I appreciate 
your support throughout this process. I am glad our witnesses 
are here today. I will introduce our first panel.
    First is Dr. Richard Stone, Executive in Charge of the 
Veterans Health Administration, and Executive in Charge is a 
pretty good title. It means the buck stops there. We are glad 
to have you here today to talk to us about the implementation 
of the MISSION plan, and we are particularly glad to have Dr. 
Kameron Matthews. Dr. Matthews, thank you for being here today. 
And we are glad to have Dr. Jennifer MacDonald, VA MISSION Act 
Lead, L-e-a-d, which means you are at the head of the parade, 
the tip of the spear. We are glad to have both of you here 
today to support Dr. Stone.
    Dr. Stone, the podium is yours for 5 minutes, or more if 
you need it, because we want to leave here with all the 
information we have asked for.

STATEMENT OF RICHARD STONE, M.D., EXECUTIVE IN CHARGE, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY KAMERON MATTHEWS, M.D., DEPUTY UNDER SECRETARY 
FOR HEALTH FOR COMMUNITY CARE, VETERANS HEALTH ADMINISTRATION, 
  AND JENNIFER MACDONALD, M.D., VA MISSION ACT LEAD, VETERANS 
                     HEALTH ADMINISTRATION

    Dr. Stone. Good afternoon, Chairman Isakson, Ranking Member 
Tester, and Members of the Committee. Thank you. Thanks for the 
opportunity to discuss the new Veterans Community Care Program 
under the MISSION Act. I am accompanied today by Kameron 
Matthews, M.D., who is the Deputy Under Secretary for Community 
Care, and Jennifer MacDonald, also a VA physician, who is the 
lead for the MISSION Act implementation.
    The MISSION Act is an unprecedented opportunity to enhance 
veterans' empowerment over their own health care. Under the 
MISSION Act, veterans and their families will be able to choose 
the balance of VA-coordinated care that is right for them.
    VA published regulations in February of this year with our 
proposed access standards for the new Community Care Program 
that will begin June 6. These designated access standards 
implement eligibility criteria that will determine whether a 
veteran who is under VA's care is eligible for care in the 
community.
    The proposed access standards support VA's goal of putting 
decisions regarding health care in veterans' hands and making 
sure that veterans have access to care when and where they are 
needed.
    VA's process for developing these designated access 
standards was not arbitrary. VA sought public written comment 
about the best design for this program and we held a public 
meeting to provide an additional opportunity for direct public 
comment. We carefully analyzed a wide range of Federal, State, 
and commercial systems. We collected best practices and 
determined these standards with the best interests of veterans 
and their health care needs as the primary deciding factor.
    From this process, the designated access standards we have 
proposed for Community Care under the MISSION Act are as 
follows:

     For primary and mental health care, VA proposes a 
30-minute average drive time standard, the same standard as is 
used in the TRICARE Prime and the same standard as is used by 
at least nine State Medicaid programs.
     For specialty care, VA is proposing a 60-minute 
average drive time standard that is also the same as TRICARE 
Prime and multiple State programs.

    VA further proposes appointment wait time standards of 20 
days for primary and mental health care, and we propose also 28 
days' wait time for specialty care. Veterans who cannot access 
care within these standards are eligible to choose either 
community providers or they may opt to continue to receive 
their care at a VA medical facility with their VA provider.
    These access standards will guide veterans and their 
providers in making choices about receiving care in the 
community. Veterans will have more choices, but VA will remain 
the integrator of veteran health care. Evidence has shown that 
even with more options veterans will continue to choose VA for 
their health care.
    So, while we increase veteran empowerment and choice, we 
are continuing to invest in our direct care delivery system. 
The tools that you have provided under the MISSION Act ensure 
that high-quality direct care is readily accessible for 
veterans who choose it. VA's recent achievements in expanding 
access to health care are supported by new authorities under 
the MISSION Act that focus on our underserved facilities, 
recruitment, and the retention of our health care providers.
    We are, in fact, the only health care system in the 
industry to make robust information about quality and access to 
health care fully transparent. Study after study has 
demonstrated that VA actually has shorter wait times, has 
higher quality, and has higher customer satisfaction when 
compared to the private sector. VA also provides a nationwide 
system of VA health care providers who are experienced with and 
devoted to veteran-specific health needs.
    We are committed to build the trust of America's veterans 
in VA health care, and we will continue to work to improve our 
patients' access to timely, high-quality care 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. Chairman Isakson, Ranking 
Member Tester, this concludes my statements. My colleagues and 
I are prepared to answer any questions that you may have.
    [The prepared statement of Dr. Stone follows:]
  Prepared Statement of Richard A. Stone, M.D., Executive in Charge, 
       Veterans Health Administration, U.S. Department of Affairs
    Good afternoon, Chairman Isakson, Ranking Member Tester, and 
Members of the Committee. Thank you for the opportunity to discuss the 
implementation plans for the new Veterans Community Care Program 
required by section 101 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
    Under President Trump, VA is embarking on the largest 
transformation and modernization of VA's health care system in the 
Department's recent history. The VA MISSION Act will transform elements 
of VA's health care system, providing Veterans with greater access to 
community care. But that increased access to community care is just one 
of the many ways the VA MISSION Act will change our Department and help 
VA better serve Veterans.
             transition to veterans community care program
    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 nationwide. The 
criteria for the Veterans Choice Program are primarily centered on VA 
in-house 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 has 
allowed us to serve over two million Veterans in communities across the 
country since it was established. During that time, VA has also 
continuously worked to improve Veterans' access to care in VA 
facilities and has made dramatic improvements in access during this 
time. 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 using the authority granted by the VA MISSION Act to 
give Veterans and VA providers more choices about how to ensure 
Veterans have access to the care they need.
    VA published a proposed rulemaking on February 22, 2019, that sets 
forth the proposed criteria for the new Veterans Community Care 
Program, which includes designated access standards. These designated 
access standards implement one of six eligibility criteria established 
by Congress that will determine whether a Veteran is eligible for 
community care to supplement the care that they are provided inside the 
VA health care system. The proposed designated access standards support 
VA's goal of putting decisions regarding care in Veterans' hands and 
making sure Veterans have access to care when and where they need it, 
through either a VA facility or community provider.
    It is important to note that the proposed Veterans Community Care 
Program does not supplant VA's mission to provide care in VA facilities 
to Veterans who have earned it. Over the past few years, VA has 
invested heavily in its direct delivery system, leading to reduced wait 
times for care in VA facilities. VA will work to ensure that care 
provided through VA facilities will remain the primary way by which 
enrolled Veterans receive health care and will remain the focus of VA's 
efforts. VA's proposed access standards will complement existing VA 
care by providing Veterans with greater choice to receive care in the 
community based on their individual needs and preferences.
                  proposed designated access standards
    VA's proposed designated access standards are based on 
consultations with and an analysis of the practices of Federal 
agencies, including the Department of Defense (DOD), the Department of 
Health and Human Services (HHS), and the Centers for Medicare and 
Medicaid Services, private sector organizations, and other non-
governmental entities. Last summer, VA published a Notice in the 
Federal Register seeking public comments, and last July, VA held a 
public meeting to provide an additional opportunity for public comment.
    By collecting information from both Government and commercial 
health plans, VA developed proposed access standards that will best 
meet the medical needs of Veterans. Based on this analysis, VA 
determined that the designated access standards should include 
appointment wait-time standards and average drive-time standards. The 
appointment wait-time and average drive-time standards VA proposes are 
based on recognized standards in other Government programs and non-
governmental organizations. VA did not propose to limit the designated 
access standards to certain services but instead proposed to include 
all primary care, mental health, non-institutional extended care, and 
specialty care services. We realized that the access standards needed 
to be simple and consistently applied. The designated access standards 
VA has proposed for implementation in June 2019 include the following:

     For primary care, mental health, and non-institutional 
extended care services, VA is proposing a 30-minute average drive-time 
standard.
     For specialty care, VA is proposing a 60-minute average 
drive-time standard.
     VA is proposing appointment wait-time standards of 20 days 
for primary care, mental health care, and non-institutional extended 
care services, and 28 days for specialty care from the date of request. 
These standards would apply unless a Veteran agreed to a later date in 
consultation with their VA health care providers. Eligible Veterans who 
cannot access care within the above standards would be able to choose 
between eligible community providers and care at a VA medical facility.
                additional proposed eligibility criteria
    As stated previously, the designated access standards are one of a 
few ways that Veterans and their providers might decide that getting 
care in the community best serves a Veteran's needs. VA has proposed 
the following additional eligibility standards for the Veterans 
Community Care Program:

     VA does not offer the required care or services;
     VA does not operate a full-service medical facility in the 
state in which the Veteran resides;
     The Veteran was eligible to receive care under the 
Veterans Choice Program and is eligible to receive care under certain 
grandfathering provisions;
     The Veteran and the referring clinician determine it is in 
the best medical interest of the Veteran to receive care or services 
from an eligible entity or provider based on consideration of certain 
criteria VA proposes to establish; or
     The Veteran is seeking care or services from a VA medical 
service line that VA has determined is not providing care that complies 
with VA's standards for quality.
            mission community care it, contract, and other 
                     projects status and timelines
    The VHA Office of Community Care (OCC) has been developing and 
deploying improvements to the Community Care Program to improve the 
experiences of Veterans, community providers, and VA staff. Work began 
in 2016 to develop a standardized operating model for the community 
care staff working in VA medical centers (VAMC) and in recent years, 
tools and technologies have been developed to support the upcoming 
implementation of the Community Care Network contracts. The operating 
model provides a standardized way to manage consults, referrals and 
authorizations, and perform care coordination to ensure good customer 
service.
    Even before the VA MISSION Act passed, OCC worked closely with VA's 
Office of Information and Technology (OIT) to discuss expected 
information technology (IT) requirements and systems that would either 
be impacted by the new law or created entirely as a result of the law. 
Since passage of the VA MISSION Act, OCC has worked closely with OIT to 
develop new tools such as a Decision Support Tool to aid VA staff in 
making community care eligibility determinations, as well to support 
enhancements to existing tools that will ensure that the capabilities 
necessary to implement the VA MISSION Act will be in place.
    Secretary Wilkie has made important decisions to ensure the 
availability of a provider network that meets the needs of Veterans as 
required by the VA MISSION Act. The expansion and extension of the 
TriWest contract ensures access to a network of providers for community 
care for our Veterans while VA undergoes the transition to the 
Community Care Network (CCN) contracts. After multiple delays, prior to 
Secretary Wilkie's arrival at VA, the acquisition process is on track. 
Community Care Network Regions 1 through 3 were awarded at the end of 
December 2018. VA has solicited proposals for Regions 4, 5, and 6. 
While Regions 2 and 3 awards are under protest, we are moving forward 
with implementation of Region 1 and expect to start health care 
delivery in our pilot sites at the end of June.
                         urgent (walk-in) care
    In addition to access to the Veterans Community Care Program, 
eligible Veterans will have access to urgent (walk-in) care that gives 
them the choice to receive certain services when and where they need 
them. To access this new benefit, Veterans will select a provider in 
VA's Community Care Network and may be charged a copayment. The 
proposed regulations for the urgent care provision were published in 
the Federal Register on January 31, 2019. VA is currently finalizing 
the regulation after review of public comments.
                     veterans' care is our mission
    With study after study demonstrating that VA actually has shorter 
wait times and higher quality when compared to the private sector, 
along with a nationwide system of VA health care providers who are 
experienced with and devoted to Veterans' specific needs, evidence 
shows that Veterans will continue to choose VA for their health care.
    As stated above, VA has made dramatic improvements to timeliness of 
care it provides to Veterans through the VA health care system since 
the access crisis in 2014. For example:

     VA completed over 58 million Veteran appointments in VA 
facilities in Fiscal Year (FY) 2018, an increase of 3.4 million since 
2014, meaning the amount of care VA is providing through its medical 
facilities is increasing and will continue to increase.
     VA has drastically cut wait times for primary care and two 
of three specialty care areas, which are now shorter than in the 
private sector. In 2017, the VA had a mean wait time that was 12 days 
shorter than wait times in the private sector (VA had a mean wait time 
of 17.7 days versus 29.8 days in the private sector). This was true in 
primary care, in which the VA had a mean wait time of 20 days versus 
the private sector that had 40.7 days. In dermatology, where the mean 
VA wait time was 15.6 days and the private sector was 32.6 days, and 
cardiology where the mean VA wait time was 15.3 days and the private 
sector was 22.8 days.\1\
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    \1\ Penn, M. (2019, January 18). Comparison of Wait Times for New 
Patients Between the Private Sector and VA medical centers. Retrieved 
April 5, 2019, from https://jamanetwork.com/journals/jamanetworkopen/
fullarticle/2720917
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     VA cut the time it takes to complete an urgent specialty 
appointment from an average of 19 days from referral in FY 2014 to 2.1 
days in FY 2018. That is a decrease of 88.9 percent. In the month of 
December 2018, the national average was 1.5 days.
     All VAMCs and Community-Based Outpatient Clinics (CBOC) 
now offer same-day services in primary care and mental health care. 
Same day services are for Veterans who are in crisis or have an urgent 
clinical need. This care might be provided over the telephone, via a 
face-to-face appointment, or by obtaining a prescription. This might 
also include making an appointment in specialty care.
     VA launched VEText in 2018, sending more than 71 million 
appointment reminders to Veterans reducing the no-show rate from 13.7 
percent to 11.7 percent, leading to more than 1 million additional 
appointments for other Veterans.
     Veterans can now directly schedule appointments in Mental 
Health, Audiology, Optometry, Podiatry, Nutrition, and Wheelchair-
Amputation Care clinics without a referral from Primary Care.
                               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. Chairman Isakson, this concludes my testimony. My 
colleagues and I are prepared to answer any questions you and other 
Members of the Committee may have.

    Chairman Isakson. Thank you very much, Dr. Stone. I want to 
start out by turning to the Ranking Member to go ahead. I want 
to let you go to the first question.
    Senator Tester. Well, this is probably a question that you 
are as interested in as I am, Mr. Chairman. It deals with the 
issues of suicide, and particularly the issues that happened in 
this last week when we had three veterans commit suicide on VA 
campus.
    Senator Moran and I authored major mental health 
legislation last month to address the significant number of 
veterans who are suffering from mental health conditions and 
are dying from suicide. We believe that we need an all-hands-
on-deck approach to addressing this problem, sooner rather than 
later.
    So, given these suicides that occurred on VA campuses, is 
there anything that is being done to make it easier for VA 
staff to recognize veterans in crisis outside the exam room?
    Dr. Stone. Senator, there are--there has been more than 260 
suicide attempts or suicides on our campuses. Two hundred forty 
of them have been interrupted where we have saved 240 veterans.
    Senator Tester. Amen.
    Dr. Stone. Unfortunately, more than 20 have been able to 
complete suicide on our campuses. Every one of these is a gut-
wrenching experience for our 24,000 mental health providers and 
all of us that work for VA.
    Stopping suicide is not something that is going to occur 
just on our campuses, and as the President has signed the 
Executive Order that places our Secretary in the lead for an 
interdisciplinary approach with all of American society to 
attempt to control this epidemic of suicides, we look forward 
to working on an interagency basis and with you.
    But I would ask, with your forbearance, if we could just 
take a moment, and if you have got a cell phone on you, if you 
would take that cell phone out and put the following telephone 
number in--1-800-273-8255. 1-800-273-8255. That is the Veteran 
Crisis Line.
    Now most lay people will say, ``I do not know what to do if 
a veteran is in crisis. I am not a trained medical 
professional. What do I do?'' Well, as a matter of fact, 
suicide often occurs when there is just intense loneliness. 
Picking up the phone and reaching out, or calling the Crisis 
Line, saying, ``What do I do?'' could stop a suicide and save a 
life.
    I wish it was as simple as me saying I could do more 
patrols in a parking lot that would stop this epidemic, but 
some of those suicides have occurred with suicide notes saying 
``I have come here to the campus because I know you will take 
care of me, and I know you will take care of my family.''
    Where have we failed that veteran? Where have we, as a 
community and society, failed that veteran is a very complex 
question, but I would hope with these comments and for your--
thank you for your forbearance in allowing me to give the 
number out for our Crisis Line.
    Senator Tester. No, I appreciate that, Doctor. I would just 
say that I do not think there is anybody that certainly serves 
in the Senate, certainly not on this Committee, that this is 
not one of the big issues that it is hard to find answers for.
    So, as you are in your position, and the folks to your left 
and to your right are in their position, and this Committee, 
along with the Veterans' Affairs Committee in the House did 
some amazing work last Congress, is there anything else that 
you need from us to address the issue of suicide, and mental 
health, generally?
    Dr. Stone. One of the things we need to be able to work our 
way through is three suicides a day occur in never-activated 
guardsmen and reservists. So, they have never been activated to 
Federal service so, therefore, are not considered a veteran.
    Senator Tester. Right.
    Dr. Stone. That usually occurs after age 30 and before age 
50, so their service may have ended a long time ago, but 
reaching never-activated guardsman and reservists is something 
that I think we need to talk our way through, of how we should 
view those. If we can take and extend emergency services to 
other than honorable discharges we sure ought to be able to 
offer those services to the never-activated guardsman and 
reservist.
    Senator Tester. Great, Mr. Chairman.
    Chairman Isakson. Senator Moran.
    Senator Moran. Thank you, Mr. Chairman.
    Chairman Isakson. Are you ready?
    Senator Moran. I am ready.

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

    Dr. Stone, thank you very much for your presence here on a 
very important topic. I appreciate and join my colleagues in 
concern about veterans who commit suicide and I look forward to 
working with the Chairman and certainly the Ranking Member on 
the legislation that we introduced. I put Veterans Crisis Line 
in my iPhone, as you indicated. I never thought about it, but 
it is an opportunity that if someone presents themselves to me 
I have someplace to go, and go quickly. So, thank you for 
highlighting that for me.
    I wanted to comment on something I heard you say just a 
moment ago, and I think it is pretty close to this quote. 
``Veterans will have more choices, but VA will remain the 
integrator of veteran health care.'' I think that is a desired 
goal on the part of all of us, and I thought you summarized the 
MISSION Act with those few words very well.
    I remember the testimony of one of the representatives from 
The American Legion when we had our hearing over in the 
Visitors Center, and the point that he made on behalf of The 
American Legion was that care that originates with the VA, even 
if it occurs in the community, is still Veteran Administration 
care. The importance to him of that was that the VA, and, 
therefore, Members of Congress and veteran service 
organizations, have control--someplace to go to when perhaps 
something is not quite right, the place that we can still 
complain, even when something happens in community care--the VA 
is still in charge.
    In many ways the use of your word ``integrator'' again 
reaffirms what I heard this representative from The American 
Legion say about this issue of care in the community. The VA is 
still in charge. The VA is still the place we can go to 
influence something that is happening to a veteran that we care 
about.
    I would welcome any comment if you wanted to highlight 
anything more about that. If not, I will ask you a couple of 
questions.
    Dr. Stone. Senator, I appreciate that. When I returned to 
the VA last summer people talked about foundational services. 
What is foundational about the VA? To me, what is absolutely 
unique about the VA health care system is the lifetime 
relationship we have with our patients. You are always a 
veteran, so we have got you for the whole lifetime, and we 
should be the experts in the complex disabilities that are 
caused by service.
    We know, in our chronic living facilities and in our 
nursing homes, that over 50 percent of those patients have 
degenerative disease of the spine, hips, and knees with chronic 
pain. It is the VA that understands that, therefore, even when 
we are buying care in the community, we should be the 
integrator that brings everything together for that veteran.
    Senator Moran. Thank you, Dr. Stone. Can you tell me at 
least some of the data that you utilized to determine drive 
times and wait times? What did you learn from the 2017 Merritt 
Hawkins Survey on wait times across 30 health markets? How did 
this information then help create the standards that will be 
utilized under your regulations?
    Dr. Matthews?
    Dr. Matthews. Thank you very much for that question. We did 
quite a broad-span market analysis. As Dr. Stone mentioned, we 
looked not only at public sector, but also a fair number of 
commercial plans, State insurance departments, marketplace 
expansion plans, even Medicare Advantage. All of these have 
wide-ranging approaches to network adequacy; in general, how 
they build their services for their beneficiaries, for their 
patients.
    In looking at those numbers, we definitely saw some general 
trends, then did a comparison of our own wait times and 
accessibility within our facilities, plus did that same sort of 
look at Merritt Hawkins, as you mentioned. Merritt Hawkins, of 
course, does a wide span of analysis in different metropolitan 
areas, some quite large like Boston, some smaller and a bit 
more suburban, if not closer to the rural side; and there is 
definitely no general trends of wait times across the board. 
So, that was not really much to rest on.
    So, instead, by again looking at the different comparison 
of plans, what we were hoping to do was to stick with an 
industry standard so that our veterans, perhaps even used to 
the same sort of standards that they had through TRICARE, 
through even other private payers, might have an expectation, 
one that is quite reasonable, about when they could actually 
receive care within a specific wait time or distance from their 
home address.
    Senator Moran. So, it is safe to say--I mean, I should be 
comforted by this, what you just said, I assume, because that 
means that decisions that are being made about what the access 
standards should be are based upon information across the board 
from other health care providers and other networks to make 
certain we are doing as well or better on behalf of veterans, 
that there is a science, in a sense, behind the decisions that 
were made in access standards?
    Dr. Matthews. That is accurate.
    Senator Moran. I also hope that means that we can better 
predict costs into the fair. Is that more than a hope? Is that 
more than an aspiration? It will improve the VA's ability to 
estimate its costs?
    Dr. Matthews. That is also accurate.
    Senator Moran. Mr. Chairman, my time has expired. However, 
I want to point out that Emily Wilson has been one of my staff 
members on veterans' affairs issues for the last 4 years, and 
this will be her last hearing, so I wanted to acknowledge her 
publicly, as a person who has cared greatly for veterans in 
Kansas and across the country. She has been an integral part of 
our work on this Committee. She is off to help folks at the 
Department of Defense and she will be missed. Emily, thank you 
for your service.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Moran.
    Senator Murray.

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

    Senator Murray. Thank you very much, Mr. Chairman.
    Chairman Isakson. Senator Murray, let me interrupt for 1 
second. I see a vote has just been called. Is that correct?
    Staff. I do not know.
    Chairman Isakson. Not yet, or is about to be called?
    Senator Murray. I will just ask two questions then.
    Chairman Isakson. Well, no. I was just going to say, when 
it is, Senator Tester left to be there and then I will go 
replace him. We are going to keep the Committee meeting going.
    Senator Murray. OK. Great.
    Chairman Isakson. Thank you.
    Senator Murray. Thank you, Dr. Stone. Dr. Stone, the VA 
seems really eager to move forward with closing facilities, but 
has so far been unable to explain what criteria will be used in 
making those decisions. VA has not described if or how it will 
make investments in improving or expanding care in the VA 
system, and this year's budget request certain does not 
prioritize that.
    A fundamental principle guiding our work in this space 
since the original Choice Act is that expanding Community Care 
has to be done in tandem with investments in the VA health 
system. So, I wanted to ask you, when will we see a 
comprehensive strategy to build and strengthen the VA system 
for the long term?
    Dr. Stone. Part of the MISSION Act is that we provide to 
you, by the 6th of June, our first look at a strategic plan. 
That strategic plan cannot be informed by our market area 
assessments because they will not be finished until midyear 
2020. So, although we have got 31 market area assessments 
currently to be completed, the next two waves of those market 
area assessments will not finish up for about a year.
    Senator Murray. Well, what specific criteria are you 
actually using in evaluating the market assessments?
    Dr. Stone. So, there are more than 1,500 different data 
points to evaluate the markets, everything from the demand 
signal from our veterans, to how many veterans are going to 
live in a community, what is their age, and what their 
predicted demand for health care would be, what their reliance 
on the VA will be. As you know, our veterans, about 80 percent 
of them, have other health insurance so they split between 
their other health insurance and us. Right now, about 38 
percent of their care we provide, about 62 percent is provided 
by their other health insurance, on average.
    We will look at those data points. We will also look at the 
relative age of our facilities, what the potential investment 
needs to be, and are we in the right place? We talked about San 
Francisco. In San Francisco we have a beautiful site on top of 
a mountain, but there is not a veteran in San Francisco in that 
area. They have to drive about 2 hours to get to us. Are we in 
the right location?
    Senator Murray. OK. I understand that. If you could just 
get us what the specific criteria is so we understand how you 
are making these decisions.
    Dr. Stone. We are required by the statute, in publishing 
regulation that will lay all of that out, and we are required 
to share that with you before we publish them.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
       Richard Stone, M.D., Executive in Charge, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Response. The criteria referenced in MISSION Section 203(a) 
requires the Secretary, ``no later than February 1, 2021, and after 
consulting with Veterans Service Organizations, publish in the Federal 
Register and transmit to the Committees on Veterans Affairs of the 
Senate and the House of Representatives the criteria proposed to be 
issued by the Department of Veterans Affairs in assessing and making 
recommendations regarding the modernization or realignment of 
facilities of the Veterans Health administration.''
    Currently, the market assessments use the ``Vision'' and ``Guiding 
Principles'' developed and endorsed by the Executive In Charge to aid 
in the conduct of the market assessment work and associated development 
of potential opportunities. We anticipate using these Guiding 
Principles as a stepping stone as the criteria are created in close 
collaboration with the Office of Construction and Facilities 
Management, the Office of Asset Enterprise Management. There is a close 
partnership with these offices, and a collaborative sub-committee of 
the Market Assessment IPT that's been stood up to address Capital and 
Facility specific ideas that evolve as the market assessment work 
continues.

    Senator Murray. OK. I appreciate that.
    I also wanted to ask you, a high-quality decision support 
tool is critical to the success of the community care program. 
Given VA's track record on scheduling I am very concerned that 
a manual process is going to result in widespread delays and 
mistakes, yet the U.S. Digital Service (USDS) found some 
serious flaws in VA's development of the decision support tool, 
including that the VA did not even begin actively developing it 
until January. That is 6 months after the MISSION Act was 
signed.
    USDS actually recommended scrapping the current decision 
support tool and making a different approach to address the 
most complicated eligibility criteria first, and they 
recommended ensuring veterans can see their eligibility 
themselves and for VA to create a process to resolve those 
disagreements.
    Time is running out before the Community Care Program is 
set to launch. I wanted to ask you if you have fully 
implemented all of the U.S. Digital Service recommendations, 
and second, will the decision support tool that meets those 
recommendations be ready when the Community Care Program goes 
live?
    Dr. Matthews. Thank you for that question. We definitely 
appreciated USDS's input with regard to the decision support 
tool. We are still moving forward with OINT's development of 
the tool. We have had multiple demos, including the interfaces 
that the decision support tool actually supports, and we 
actually have already started trainings on an online and 
virtual basis of providers in the field as well as program 
officer leaders.
    So, we do have full intent to have DST deployed by June 6.
    Senator Murray. Have you implemented all the USDS 
recommendations?
    Dr. Matthews. No, we have not.
    Dr. MacDonald. Senator, if I may add, we invited USDS to 
the table, the Department did, in an aim to have all of the 
talent available to veterans at the table to implement this 
with excellence and with an ease of these tools enabling these 
actions for our providers moving forward. We very much 
appreciated the devotion and the energy that they showed in 
doing the discovery sprint in a short 2 weeks' time. It is 
difficult to understand some of the complexities in our IT 
system. They brought a lot of expertise to the table that 
needed further discussion with our IT individuals.
    That has taken place and we have learned and grown from the 
report. We have worked in collaboration with them to make sure 
that the tool we are delivering on June 6 is excellent and does 
save providers time such that providers, as we sit here and 
engage with veterans, that we have more time to focus on the 
veteran in front of us.
    Senator Murray. OK.
    Dr. MacDonald. And, yes, training has begun, Senator.
    Senator Murray. OK. Thank you. My time has run out but I 
would like to include in the record the report by the USDS, Mr. 
Chairman.

    [The U.S. Digital Service report was received and is being 
held in Committee files.]

    Dr. Stone. With your tolerance, Mr. Chairman, let me just 
add one thing. You have got three doctors here talking about IT 
systems. That is probably dangerous.
    U.S. Digital Services brought up some very interesting 
ideas on API interfaces that could lead us into a wave of the 
future. I think you are going to see a traditional approach to 
the first phase of this, for June 6.
    Senator Murray. Done by hand?
    Dr. Stone. No, no, no; a traditional automated approach. 
But then, there is an additional ability to integrate, that 
Digital Services brought up, that we would be happy to share 
with you, or our IT people share with you offline, that moves 
this to the next level and potentially gets us to a veteran-
facing tool that might have huge value for the future.
    Senator Murray. OK. Thank you.
    Dr. Stone. Thank you, Mr. Chairman.
    Chairman Isakson. Dr. Stone, let me just interrupt for 1 
second and then we are going to go to Senator Boozman. If I am 
not correct, please correct me. But, I was going to ask a 
question a little later. I have been waiting but you just 
prompted me to go ahead and ask one right now.
    I was going to ask, are you going to be ready June 6 to 
deliver what the MISSION Act asks for? Are you going to have 
all the tasks that you have been given done? And from the 
answers you have given, as well as some others we received, the 
answer to that question already is no. And, I do not say that 
negatively. I am just saying it sounds to me you are at a 
sprint. It is a big pill to swallow, and there is a lot to be 
done.
    One of those things with the VA is the technology issue, 
which you are all dealing with. And one of the great things 
people like me can do is complain about technology, while I 
cannot do anything about it because I do not understand it.
    Here is what I do understand. We have to respect the fact 
that there are technology programs. We learned from trying to 
make the Cerner decision that the only way to fix that problem, 
in terms of medical IT, was to get a totally new system. The VA 
is populated with a lot of systems that were bought that are 
now old and antiquated. Some are inoperable. Some have 
difficulties doing the tasks themselves.
    Are you going to be able to be as functional as you want to 
be, given what you have got, given the resources you have, 
knowing that down the line you are going to have to get more 
equipment and better equipment to replace it?
    I am sorry for the long question, but I wanted to----
    Dr. Stone. Sir, this is as complex a legislation as you 
could possibly have. The automated systems to run Community 
Care require 11 different software systems, 10 of which we have 
got in the field today. The 11th, the decision support tool, 
sort of brings them all together. Some were fielded as far back 
as last fall; some we are fielding as we speak.
    Are we going to get it all right? No. Are we going to 
deliver care on June 6? Yes. The question is are we going to be 
as efficient as we should be? Are there going to be wait times 
that will grow because of this? We are confident that we are 
doing everything we possibly can to hit June 6 running.
    Today we will deliver about 310,000 visits in our direct 
care system. We will also buy 50,000 visits today. On June 6, 
our anticipation is those numbers will be about the same. So, 
we will have about 360,000 contacts, or one-third of a million 
contacts with veterans that day. We will get this right, and we 
will get better every day. I am not going to sit before you and 
say we are going to have everything right on June 6. There will 
be something that does not go in the right direction and we 
have got to get corrected.
    Chairman Isakson. And, part of our job is to help you do 
that. I personally appreciate the thoroughness and the candor 
of that answer.
    Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Mr. Chairman. I want to follow 
up on that. We do appreciate all of you and appreciate your 
hard work. We have got three excellent doctors here and you 
have got a bunch of Committee Members that have been around for 
a while. We have seen roll-outs in the past in the VA, and they 
have been kind of rough. In fact, we have seen roll-outs in 
government, period, in all kinds of different things, and they 
have been pretty rough also.
    The problem is that the Committee has become the backstop, 
you know, in regard to pushing things along and providing the 
resources if we do have a problem.
    In Arkansas there is a lot of excitement about the MISSION 
Act. I have talked to countless veterans and VSOs, private 
sector health care providers around Arkansas. So, there is a 
lot of looking forward to it. To be honest, they do not have 
much information yet.
    I guess a question would be with the implementation only 9 
weeks away, what is the plan for engaging providers who are 
currently providing community care? Again, they do not 
understand what is going on. What is being communicated to them 
about the changes, and should they expect to see--what should 
they expect to see and the timeline?
    Dr. MacDonald. Thank you for that question, Senator. Any 
change at this scale in a system our size must be taken 
seriously. And, at the core of our approach to the MISSION Act 
is, of course, veteran centricity, but also we think about our 
providers and our employees undertaking this change. We want to 
make sure that they not only have the tools in their hand that 
they need to implement this, but that they have the knowledge 
and the awareness of why we are doing this: that this is a new 
era of veteran empowerment; that they are able to sit down with 
a veteran, one-to-one, as we do as physicians, and say to that 
veteran, ``I am able to help you make a choice that is in your 
best medical interest.''
    We have started communicating on that front. We have given 
the field a toolkit to use, and we have launched training as 
well on the key tools that are new to them, specifically the 
decision support tool. Just in this past month, and 
accelerating over the next couple of months, through and beyond 
June 6, Senator, we will continue that campaign.
    Senator Boozman. OK. How about outreach to veterans? Are we 
outreaching? Do they know what to expect on June 6? Are we 
doing anything proactive in that regard to the veteran 
community?
    Dr. MacDonald. Absolutely, Senator, and actually Section 
121 of the MISSION Act directs us to do exactly that. We have 
developed a robust plan to reach veterans across all eras and 
in various modalities as different eras may need. So not just 
through print materials, not just a poster in a facility, but 
also online and in other spaces where they may need information 
about VA, about the new benefits, care, and services that they 
can receive under the MISSION Act.
    We are also engaging and very much appreciate our veteran 
service organization partners as they have offered to have 
several of their delegates trained such that the message and 
education can be amplified for the veterans that they 
encounter.
    Senator Boozman. Arkansas is in Region 3 of the Community 
Care Network, so we are impacted by the CCN contract that was 
awarded but is under protest. We understand that the VA has 
worked with the current third-party administrator to act as a 
backstop until the CCN contracts are up and running.
    How will that impact veterans and providers in Arkansas? 
What is expected the current TPA, including terms of scheduling 
and processing of payments? When will the transition be 
complete and what, if anything, will change for the veterans 
and community providers between the original contract, the 
interim plan, and the new contract?
    Dr. Matthews. Great question. A lot of information packed 
in there.
    We are ecstatic that TriWest really stepped to the plate 
and became a partner for us nationwide through June, until such 
time as Region 3 in Arkansas and, of course, Region 2, as well, 
until such time as those contracts come out of protest, and, 
actually, until the new contract is deployed, TriWest will 
continue to stand by us as a partner, is working with us to 
modify their contract, to accept the new mission requirements 
so that there will be a seamless administration of this 
program, regardless of which third-party administrator we are 
working with.
    There are differences between the Community Care Network 
contract, which is still pending for Regions 2 and 3, and, of 
course, TriWest, but TriWest has really come to the plate to 
make them more streamlined, because, of course, their contract 
originally included the Choice Program. So, we are quickly 
folding down the Choice Program in their contractual language, 
and again, our hope and TriWest's full intent is to make it as 
seamless of a transition as possible, when indeed that 
transition occurs to the next contractor. As of June 6, TriWest 
will be offering services in Regions 2 and 3.
    Senator Boozman. Good. Thank you very much. We do 
appreciate your hard work. I think I can speak on behalf of the 
Committee, we really do want to help you. This is a huge 
undertaking and it is just going to take everybody working 
together to get it done. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman.
    Senator Blumenthal.

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

    Senator Blumenthal. Thank you, Mr. Chairman, and I want to 
thank you for having this hearing, and, as usual, conducting it 
and the Committee in a bipartisan way, which is really the 
hallmark of the Veterans' Affairs Committee. So, as always, my 
appreciation.
    This epidemic of veteran suicide is hardly new. You would 
agree with me, wouldn't you, Dr. Stone?
    Dr. Stone. I would, sir.
    Senator Blumenthal. Tragically so, one of my first major 
pieces of legislation here, years ago, was the Clay Hunt 
Veteran Suicide Prevention Act, which I created with the late 
John McCain, Senator McCain of Arizona. And, I am a supporter 
of the Tester-Moran act, the measure that has been proposed, 
and other measures. But, the fact of the matter is that 20 
veterans every day, maybe more, in the greatest country in the 
history of the world, continue to take their own lives.
    The mantra that we have heard from the VA, again and again 
and again, over the years, prior to your coming here, has been, 
``Well, they are outside the system. They are not part of the 
VA health care system,'' which, of course, begs the question of 
``what are you doing to reach them?'' That is why it is 
important that you stress the Suicide Prevention Line. That is 
why it is important that the VA use all of the resources, not 
just a fraction, that we have appropriated for outreach. 
Unfortunately, the VA, over the years, has failed to use those 
resources. We had a hearing with Secretary Wilkie, when I think 
a lot of us expressed our profound dissatisfaction with that 
failure.
    But, the question is very pertinent today because in the 
MISSION Act a lot of veterans will be going outside the VA 
health care medical system, for lack of a better term. They 
will be going to non-VA doctors. The reason why they love the 
VA health care system is because it knows them. It is schooled 
and trained in how to care for veterans. I can tell you about 
Connecticut; our veterans deeply appreciate the quality of care 
that they receive in West Haven.
    So, my question to you is, assuming that a lot of veterans 
are now going to be going to other docs, what standards will be 
imposed to assure that those doctors are trained to recognize 
the symptoms of potential suicide--depression, Post Traumatic 
Stress? I may not be using the right scientific and medical 
language but I think you know where I am going with this 
question.
    Dr. Stone. Sir, I appreciate the way you have characterized 
this because it is exactly the problem. There is not another 
health care system other than the VA that understands the 
complexity of service or the fact that if you go down to the 
World War II memorial and you look at one of the Honor Flight 
groups, it does not take you very long to pull the scab off of 
the traumatic events from 70 years ago of one of those 
veterans.
    This is not something that we can simply give a course to a 
private physician, and it is why we must be the integrator of 
care. We can buy transactions of care, whether it be for 
psychiatric illness, we can buy a transaction of care, but the 
veteran needs to be integrated into our system for a full 
understanding of the complexity of these problems, and how 
difficult they are to care for, and that they have a lifetime 
problem.
    Senator Blumenthal. Maybe the answer to my question--and I 
am just thinking out loud here--is to say that certain kinds of 
issues and challenges should be referred back to the VA health 
care system. If it takes 35 minutes or 65 minutes to drive to a 
VA facility, you know, maybe that is better than 15 minutes to 
someone who is going to say, you know, ``You are waking up with 
sweats and anger? Take two aspirin and call me in a week.''
    Dr. Stone. I think you have characterized that well and 
that is why these discussions are best done between a provider 
and a patient, and then the best interest of that patient is 
taken into effect.
    If I might, and with your permission, Ranking Member 
Tester, we are in the process of recording local public service 
announcements. One of your members, Senator Sullivan, has taken 
advantage of that. I think the Chairman is also scheduled to do 
one of those. We would ask each of you to consider whether a 
public service announcement that we can reach out into your 
communities would be very helpful to us.
    Senator Blumenthal. I will commit to do it right now.
    Dr. Stone. Thank you, sir.
    Senator Blumenthal. As many times and as often, as widely, 
wherever you would like to do it.
    Dr. Stone. We will work with your staff and extend that 
same invitation to each of you, because your connections to 
your communities is what we need. And, this is not just about 
the six that are engaged with us in health care; this is how do 
we reach the 14 that are not engaged with us. We cannot just 
say, ``Well, they were not in our health care system.'' We must 
be able to reach out. This is the beauty of the President's 
Executive Order, placing us in the centerpiece of trying to 
correct this across all 20 that are doing self-harm.
    Senator Blumenthal. While I have you here I need to just 
say, although it is not directly related, when Secretary Wilkie 
was sitting where you are in our last hearing I asked him about 
the West Haven surgical equipment processing facility, which he 
committed would be available, the mobile facility, by June. I 
hope that is still your expectation and your promise.
    Dr. Stone. Sir, it is my promise. They have gone to two 
shifts. After our last discussion they have gone to two shifts 
a day of sterilization. I know they have struggled with their 
vendor to meet the June date. Their numbers are coming up. We 
are monitoring their numbers on a weekly basis. I know what I 
promised you and what the Secretary promised you. That is the 
right thing to do. The veterans in that community deserve to be 
cared for where they want.
    Senator Blumenthal. Thank you, and I would just like to 
know if that date is going to slip that you let me know, 
because I will do some public service announcements--
unsolicited public service announcements for the vendors.
    Dr. Stone. Thank you.
    Senator Tester [presiding]. Senator Brown.

           HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, and because we are about 12 
minutes into a vote I have two questions, two main questions 
for you, Dr. Stone. I am going to just read the questions and 
then have to leave to go vote. My staff is here and the record 
will reflect it. It is a little rude, but it is the only way I 
can figure out how I can do it, so thanks.
    Thanks to the Chairman and Ranking Member for having this 
oversight hearing. It is really, really important.
    We passed VA MISSION Act, as you know. It contained a 
comprehensive overhaul of the Community Care authorities into a 
new Veterans Community Care Program. We have tried to learn 
from our mistakes made in the Choice Program about arbitrary 
eligibility criteria relating to wait times and driving 
distances, all of which you know. We tried to provide veterans 
the best source of information for whether they should research 
Community Care consultation with their own VA provider.
    Over 10 months, the VA has neglected to inform veterans and 
VSOs and Congress in the most transparent way, often limiting 
the information provided regarding resources and decisions. VA, 
in our mind, has failed to incorporate feedback from VSOs and 
health care providers prior to unveiling the proposed access 
standards a couple of months ago, in February.
    By VA's own analysis, VA facilities scored 59 out of 100 
when assessed for whether they could meet the expanded 
requirements set forth related to scheduling and care 
coordination. My office, like others, I assume, have received 
lots of calls and letters during the Choice Program related to 
scheduling and care coordination, as you know.
    The questions are this. I would like to know how VA plans 
to meet veterans' needs and ensure that the proposed access 
standards do not lead to further privatization of the VA by 
pushing more veterans into the community because VA lacks 
internal administrative and medical capacity, and also explain 
how you plan to hold community providers to the same access and 
quality standards as the VA, per the MISSION Act requirements.
    That is one set of questions; again, I apologize for doing 
this. I wanted to follow up, though, after listening to Senator 
Blumenthal--we are concerned that the VA access standards, 
coupled with less resources for internal VA staffing, could, 
over time, lead to a hollowing out of VA facilities and, in 
turn, need more Community Care. Our intent was never to have 
Community Care displace the VA.
    I think there are some with the political philosophy in 
this body that would like to do that. It does not serve 
veterans. It certainly undermines what the VSOs want. 
Understanding many VA facilities provide exceptional 
specialized care, Senator Blumenthal and I worked on the 
Veterans Community in Section 133 of the MISSION Act, which 
stipulates that VA must establish competency standards, as you 
know.
    The other question I have is how will VA craft a program 
that allows veterans to go into the community when deemed 
necessary by their provider without compromising or draining 
resources from the critical fields within the Veterans 
Administration?
    So, if you would just--the three of you take those 
questions. The general and Ann are here to listen and it will 
be reflected in the Committee record. So, thank you so much.
    Dr. Matthews. Thank you very much for that question. The 
first section of your question with regard to the readiness of 
our facilities to move forward with the changes really over the 
last year and a half the Office of Community Care, as well as 
operations in management have been working with facilities to 
assure that they are moving forward with the appropriate 
staffing that would be necessary to take back a lot of these 
scheduling and care coordination services. That requires, of 
course, hiring of staff over time, and the majority of 
facilities have done so.
    As we moved away from the HealthNet contract--as many of 
you, I am sure, remember and wish to forget--we actually did 
see a swift uptake of a lot of those services by the facilities 
themselves. I mean, Ranking Member, your State alone has jumped 
into that task quite well, and the former HealthNet areas did 
indeed take up that challenge. There are a small number now, 
numbering 17, facilities that are using TriWest to assist with 
scheduling for the short term. As they move into the new IT 
systems, with regard to automated referrals, automated 
authorizations, their workload will change and decrease, and 
indeed they will move away from having to do a lot of the 
administrative minutiae and focus on that care coordination, 
scheduling for the veterans, if indeed that is what they 
request.
    We fully anticipate that the 17 sites will be moving away 
from TriWest scheduling assistance by this summer, and as we 
deploy into the Community Care Network all facilities will be 
providing these services on their own.
    The readiness score is really--the 59 out of 100 that the 
Senator quoted was a national average. We have that broken down 
at the facility level, even at the VISN level, so network 
directors are also accountable, and we are monitoring those on 
a weekly basis, just to assure, again, that their 
administrative services are coming up to bar. We are seeing 
increasing scores across the board.
    With regard to the competency standards that the Senator 
mentioned, Section 133 of the MISSION Act, of course, required 
that VA institute competency standards for community providers 
for veteran-specific conditions, specifically PTSD, military 
sexual trauma, and Traumatic Brain Injury. We have been working 
with, of course, our renowned subject matter experts within VA.
    We have those competency standards defined and we will be 
including those in the TriWest contract so that moving forward 
the network providers who, of course, treat those issues--so, 
of course, focusing more on mental health, just because of 
those named conditions, but also, in the future, contracts as 
well as Community Care Network deploys will be modifying those 
contracts as well. It is difficult to modify the contracts 
before they are actually awarded, so there is, unfortunately, a 
delay on how those will get implemented, because we would have 
to work with the actual awardee in order to do so.
    We fully expect that the third-party administrators help us 
enforce these competency standards, make sure, of course, that 
providers are meeting quality assurances as far as 
credentialing, but this additional specialty training and focus 
is necessary to treat veterans. We can see it as a 
continuation, of course, of our ability in the VA, but in a 
supplemental fashion, and so the requirement of these standards 
is well appreciated, and community providers are responding 
accordingly.
    Dr. MacDonald. Additionally, on Section 133, we are 
providing general training for providers in addition to the 
specific PTSD, Traumatic Brain Injury, and military sexual 
trauma training that will be provided for mental health 
providers. We are providing general training that specifically 
elevates military culture and ensures that when a veteran 
chooses to be seen in the community that that community 
provider has a consciousness of what that veteran has 
experienced. Included in that general training, as well, is 
suicide prevention, yet another way we are aiming to amplify 
this message and ensure that even beyond VA, even beyond our 
direct system, that veterans are receiving the best care 
possible and that providers are well informed and able to 
respond when there is a need.
    One additional note, to the Senator's question about the 
direct care and community care and the equivalence of standards 
across both. We very much believe that in VA it is our 
responsibility to be in the lead on wait times and on quality. 
We see ourselves as one integrated system with a direct care 
aspect and a community care aspect.
    It is our responsibility, as Dr. Stone has highlighted, to 
be the integrator of care across those two systems and to 
ensure that wherever a veteran is empowered to seek that 
balance of their care that is right for them that they are 
receiving that quality and timeliness, and, therefore, we aim 
to be in the lead and setting the standard for that.
    Senator Tester. Before I go to Senator Sinema, a couple of 
things on the previous questions that I asked.
    Dr. Stone, you brought up the fact that guard and 
reservists that had not been deployed do not have access to the 
VA. I have got a bill that will fix that. It is S. 711, I 
believe it is. If we could get your support or your input on 
that, that would be much appreciated.
    And, the other point that I just kind of wanted to clear up 
before I move to Senator Sinema is that Dr. MacDonald, you had 
mentioned that the VSOs had been offered training opportunities 
on the tool. Which VSOs?
    Dr. MacDonald. Senator, at breakfast with the VSOs who 
regularly join Dr. Stone, we had a discussion about this and 
they actually, themselves, offered to have their delegates 
trained. I am happy to take that for the record and get you a 
specific list.
    Senator Tester. That would be good. That way we can double 
back with the VSOs whom you have offered it and see if they 
have taken you up on it.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Jon Tester to 
                  U.S. Department of Veterans Affairs
    Response. The following organizations were present: AMVETS, 
American Legion, DAV, PVA, VFW, VVA, MOAA, WWP, NACVSO, NASDVA, MOPH, 
AFSA. VA will be working with these organizations moving forward to 
identify training opportunities. We have subsequently offered training 
to all VSOs who regularly engage with VA, and initial MISSION Act and 
Community Care training was conducted via Adobe Connect May 6, 2019.

    Senator Sinema.

         HON. KYRSTEN SINEMA, U.S. SENATOR FROM ARIZONA

    Senator Sinema. Thank you, Mr. Chairman, and thank you for 
the witnesses and your testimony today.
    As Americans, the blessings we enjoy every day are the 
direct result of the sacrifices that are made by our Nation's 
veterans. I was actually just reminded of this fact last month. 
I had the privilege of re-enlisting my little brother, Gunner's 
Mate First Class Sterling Sinema, into the Navy. I am reminded 
that together we must ensure that our veterans receive the 
benefits and care they have earned, including quality mental 
health services and timely medical attention they deserve.
    We know, particularly in Arizona, that veterans can carry 
the scars of service, both visible and invisible, for years 
after they transition into civilian life. As the individuals 
responsible for providing care to former servicemembers, I know 
each of you understand the incredible responsibility that you 
bear.
    The MISSION Act represents the most deliberate and 
significant update to the veterans health system in decades, 
and I am committed to partnering with the VA to ensure that we 
get it right. Many of the problems the MISSION Act was designed 
to address, including the national wait time crisis, as you 
know, were first identified in my home State of Arizona.
    Dr. Stone, Secretary Wilkie has already accepted my 
invitation, but I hope that you will also accept my invitation 
to visit our facilities in Arizona to ensure the VA's effort to 
implement the MISSION Act is successful. We want to address 
extended wait times, but also include a plan to resource 
facilities that right now do not meet the new standards.
    For instance, at the Hayden VA medical center in Phoenix 
the wait time for a new patient is 43 days, and in Kingman, AZ, 
new patients are facing a 47-day wait for services.
    So, I am interested in supporting policies that get 
veterans in front of medical providers faster, but the long-
term health of the VA depends on providing the clinical and 
support staff all the tools that they need to meet the 
standards that you all have set for them.
    So, Dr. Stone, my first question is I know that you already 
agree that the overwhelming majority of the staff at VA medical 
centers in my State of Arizona are dedicated to ensuring that 
veterans get the care they need. But, for the facilities that 
cannot currently meet the access standards that you all have 
established, how do you plan to provide the resources that 
clinical and support staff need in order to meet the assessment 
standards that the VA has established? And what percentage of 
existing patients will be eligible, under the wait time 
standards, and what percentage of eligible veterans do you 
think will choose to receive community care if those wait time 
standards are not met swiftly?
    Dr. Stone. Let me take the easy part of that question, and 
that is, yes, I accept your invitation to come out to Phoenix.
    Senator Sinema. Wonderful. Come soon. It is getting hot.
    Dr. Stone. Thank you.
    I think, second, we have taken a hard look at these wait 
time standards, as the Secretary has identified them. In some 
areas of the delivery system we are doing very well and in 
others we are struggling. Your communities are growing so 
quickly----
    Senator Sinema. Yes.
    Dr. Stone [continuing]. That we have had a very difficult 
time keeping up with the demand. And as you have identified, 
Senator, you know, it was Phoenix that was the centerpiece of 
what was wrong with our bureaucracy and our ability to respond 
to rapid growth. That community is still growing, at dramatic 
levels, and our ability to grow new space and a new footprint 
is inhibited by a bureaucracy that can take us 4 to 7 years to 
open a new footprint in leased space.
    But, let me defer to Dr. MacDonald who can talk a little 
bit about these access standards as well as sort of where we 
are doing well and where we are struggling, plus how we are 
approaching it.
    Senator Sinema. Thank you.
    Dr. MacDonald. Yes, I will first highlight, Senator, that 
we have a core focus on primary care and mental health. In 
primary care, more than half of our facilities are meeting our 
wait time standards right now, but we intend for that to be all 
of our facilities meeting the wait time standards.
    In mental health we are meeting that standard in 139 of 141 
facilities, but again, 139 out of 141 is not enough. We want it 
to be 141. We want it to be everywhere such that every veteran 
has access.
    The MISSION Act did give us new authorities and new ability 
to deliver on that promise, which we intend to provide across 
the Nation, in every space, no matter how rurally or in an 
urban setting a veteran chooses to live. The MISSION Act gave 
us new ability for recruitment, retention, and relocation 
authority such that we can hire providers into areas where that 
has traditionally been challenging.
    It also gave us, in Section 151, anywhere-to-anywhere 
telehealth, and we are pairing that with the underserved 
facility work that MISSION Act also requires, such that we have 
a comprehensive strategy to grow and build services in those 
facilities that have traditionally struggled to find providers.
    In addition to that, there is a productivity initiative 
underway in VA such that we are maximizing and using every 
bookable hour of the staff that we currently have available. 
So, on both aspects, the investment and productivity first and 
the growth beyond that through the new authorities in MISSION 
Act, we intend to grow those services no matter where a veteran 
lives.
    Senator Sinema. I appreciate that response.
    One of the concerns that we continue to see in Arizona is 
that, as you mentioned, Dr. Stone, and, Dr. MacDonald, as you 
also noted, Arizona is a particularly difficult place to meet 
those standards because of the rapid growth. And in our more 
urban settings, particularly in Phoenix, we have additional 
growth during the winter months by snowbirds who visit Arizona 
and seek their care at our facilities.
    One of the things we have struggled with is that we do not 
see an influx of additional staffing during those winter months 
but we see a huge increase in our percentage of veterans who 
want to receive care.
    Right now, in Arizona, it is around 50 percent of veterans 
who get their care from the VA, and if we see that continue to 
increase, which I know the VA is working to invite more 
veterans, particularly younger veterans to receive their care 
at the VA, while we also continue to have this influx of 
snowbirds, which will grow, not shrink, over the years, I think 
it would be wise for the VA to provide special consideration to 
communities that have unusual growth during certain times of 
the year, because of the nature of, well, living in the 
greatest State in the country.
    Dr. Stone. I agree with you completely. It is one of the 
reasons that we have increased our funding in telehealth so 
dramatically and why what you gave us in Federal supremacy and 
our ability to really conduct telehealth across the Nation, 
from any place in the Nation, is so essential for us. You know, 
we had about 750,000 veterans that took advantage of telehealth 
last year. We are going to get up to about 20 percent of our 
veteran population in order to respond to these demographic 
moves.
    But, it goes back to one of the opening questions that was 
asked by the Ranking Member: how do we approach the sustainment 
of the system? You know, I lived, early in my life, in a time 
where people lived in communities forever. They did not change. 
There were generational houses, from generation to generation. 
That does not happen anymore. We have to have the ability to 
follow where veterans are, though we are not very good at it. 
And, there are a number of areas that we can discuss, well 
beyond the few minutes that I am over, sir, on this--in order 
to discuss sort of how to respond to these demographic moves 
that are so dramatic in your State.
    Senator Sinema. I appreciate that.
    Mr. Chairman, My time has expired. If I might, as I prepare 
to head to the floor to vote, I would also just want to 
emphasize the importance of ensuring that we are utilizing all 
the tools the MISSION Act gave for locality pay. In places like 
Kingman, AZ, and our Prescott VA Hospital, we are unable to 
recruit and retain the highest quality staff that we need 
because of the remoteness of the location.
    As you know, in Arizona, while 65 percent of our population 
lives in Maricopa County and has access to the Phoenix VA, the 
other individuals live so far away from these facilities that 
it is difficult to get to a VA facility, and it is incredibly 
difficult to find highly-qualified individuals who want to work 
in those remote locations. So, it is really important for us to 
ensure that these employees are compensated fairly to do the 
difficult work they are doing in these remote parts of our 
country.
    Dr. Stone. Senator, you are right. I think you have given 
us the tools, though. I think the tools--not just locality pay 
but enhanced educational loan repayment that you have given us 
all add to our ability to get this done. We are also deep in 
discussions with a number of medical schools, including the 
historically black colleges and universities, to support 
positions that might allow us to draw people in, and especially 
to the great areas of your State that need care.
    Senator Sinema. Thank you so much. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator. A couple more questions 
and then we will get to the next panel.
    Dr. Stone, we have talked before, and it has been talked 
about at this Committee meeting, about quality of care and 
timeliness of care. I think in your opening statement you 
pointed out the fact that you guys keep track of that stuff, 
but a lot of folks in the private sector, it is hard to get 
that information. Would that be a fair characterization of what 
you said?
    Dr. Stone. Sir, not to belabor my answer but it is a fair 
characterization, yet if I might add----
    Senator Tester. Yeah.
    Dr. Stone [continuing]. I have great respect for our 
commercial colleagues.
    Senator Tester. Absolutely. Yeah, yeah.
    Dr. Stone. Yet, they are not held to the standard that we 
are, nor--you know, a veteran can look at us pretty easily and 
figure out what is happening in our institution.
    Senator Tester. So, the question revolves around the idea 
that we are doing this whole MISSION Act for the sole purpose 
of timely quality care. And, if we do not have that private 
sector information it may be better for that veteran to stay 
with VA care and have that appointment, even though it is past 
the 20-day period or the 28-day period.
    When do you think you will know, as somebody who is going 
to integrate this health care, on how long it will take for the 
private sector to see a veteran, on average, so you can inform 
the veteran, so that they are not thinking, ``Well, I am going 
to go to the community care and get taken care of,'' when, in 
fact, they might have to wait longer than they would have 
waited if they had just stayed with the VA.
    Dr. Stone. Right now wait times are not transparent across 
the Nation and in the commercial sector. We will gather that 
data in real time.
    Senator Tester. Do you have any idea when that data might--
--
    Dr. Stone. In 180 days. About 6 months.
    Senator Tester. About 6 months. OK.
    So, let's talk about what happens when something goes 
wrong. If you are at a VA facility, you file an 1151, which 
allows for compensation for injuries. It is fairly transparent 
and people know what is going on. When a veteran goes into the 
community for care, something goes wrong--correct me if I am 
wrong--I think the veterans are on their own to seek redress. 
And, if I am wrong, you correct me on that.
    Dr. Matthews. I would be happy to correct you, sir.
    Senator Tester. Sure.
    Dr. Matthews. We have actually instituted, over the last 12 
months, a new patient safety structure that involves not only 
our traditional patient safety team in the facilities but the 
community care staff to work with our third-party 
administrators to do the appropriate investigations and 
oversight of any issues that arise while a veteran is receiving 
care in the community. A lot of this, of course, hinges on the 
partnership with that provider. They may not be willing to 
share information. But moving forward we will be actually 
requiring that as part of participation in our relationships, 
contractually, that they take part in these patient safety 
conversations.
    Senator Tester. OK. Let's say something goes upside down in 
the private sector. What does a veteran do?
    Dr. Matthews. A veteran definitely speaks either to their 
patient advocate, their primary care provider, reports it 
through any means necessary within the facility. The facility 
staff is trained to take that incident report and start initial 
investigation through the patient safety structure so that we 
can actually gather information to assure that veteran is not 
facing harm.
    Senator Tester. OK. So, if it is with the VA they can file 
a compensation claim. Can they file a compensation claim with 
the VA if something goes badly in the private sector?
    Dr. Matthews. I would need to get back to you on that, sir. 
I would need to check our liability and all that.
    Senator Tester. Or does the contract specifically state you 
can file the claim with the VA and the VA would get the money 
from the person who screwed up?
    Dr. Stone. Sir, we are going to get that for you, but I 
think you have got to go through the tort system. I think that 
this is----
    Senator Tester. So, they would be outside the VA.
    Dr. Stone. I think so.
    Senator Tester. The veteran would be outside the VA.
    Dr. Stone. My impression--and we are going to correct this 
if I am wrong----
    Senator Tester. No, no.
    Dr. Stone [continuing]. But, my impression is you have got 
to go through the tort system.

    [The information requested during the hearing follows:]
 Response to Request Arising During the Hearing by Hon. Jon Tester to 
                  U.S. Department of Veterans Affairs
    Response. Treatment by a non-VA physician at a non-VA facility 
under the MISSION Act would not qualify for section 1151 benefits. We 
note in relation to both VA's current community care authorities and 
the MISSION Act that, in Ollis v. Shulkin, 857 F.3d 1338 (Fed. Cir. 
2017), the court carved out a limited exception pertaining to negligent 
referrals to non-VA providers in relation to the ``event not reasonably 
foreseeable'' provision of 1151. VA employees acting within the scope 
of their employment are protected by the Federal Tort Claims Act, which 
is an injured person's exclusive remedy in such a scenario; contractors 
are not protected from personal liability by the Federal Tort Claims 
Act. Veterans injured by non-VA providers may pursue a tort claim in 
accordance with state law, and non-VA providers have protection through 
their own insurance coverage.

    Senator Tester. Well, I think that is also information the 
veteran needs to know if something goes wrong. It becomes a 
little bit more complicated, in my opinion. I am not a veteran, 
but it sure appears that way to me.
    Well, I want to thank you all for being here. I certainly 
appreciate it. Sorry about the herky-jerkiness of this hearing 
with the votes going on, but it is the nature of the beast. 
Nothing personal, OK?
    We are going to stay in touch and make sure that we 
continue to be involved as you implement, and hopefully, as 
always, you will communicate back to us when you need help. 
This is a big step for the VA. I think we took a big step in 
Congress last year, and now we have got to make sure it works. 
If it does not work then you and I are both in trouble, right?
    Thank you all very much.
    If you have something to say, Dr. Stone, you can.
    Dr. Stone. Just our thanks. Thank you, sir.
  Response to Posthearing Questions Submitted by Hon. Jerry Moran to 
       Richard Stone, M.D., Executive in Charge, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Question 1. Do you believe that the MISSION Act will improve the 
quality of Veteran care?
    Response. Yes. The Department of Veterans Affairs (VA) is 
leveraging the authorities in the VA MISSION Act of 2018 (MISSION Act) 
to grow into an optimized, Veteran-centric network of care and 
services. VA is one integrated system with direct and community aspects 
of care delivery, and the MISSION Act strengthens VA's ability to 
deliver excellence in both arenas. Veteran empowerment is at the core 
of VA's approach, and eligible Veterans will now be able to choose the 
balance in the system that is right for them. The MISSION Act also 
enables VA to deliver unprecedented access and a range of care options 
through our facilities and in the community. In addition, it 
strengthens our ability to furnish care through telehealth. Veterans 
served by VA uniquely face the physical and psychological impacts of 
military service and leveraging these new authorities to enhance care 
and meet Veterans where they are is critical to Veteran experience and 
health outcomes. The MISSION Act further enhances VA's ability to 
manage the complex care many Veterans need, and VA aims to lead the 
U.S. health care industry in care coordination.

    Question 2. At this point, what challenges do you anticipate to 
encounter when MISSION Act takes effect?
    Response. Any change in an organization of VA's scale must be 
approached with detailed strategy and unwavering focus. VA is committed 
to delivering on this significant implementation on June 6, 2019, and 
we have prioritized this effort among leaders and staff at all levels 
across the country. With robust implementation planning, thorough 
training, and dedicated leadership attention, VA expects to minimize 
challenges related to new process implementation. VA will work to 
immediately address any issues that may arise and will continue to 
enhance delivery of care beyond the initial date of implementation.

    Senator Tester. Absolutely. We will have the next panel 
come up and I will introduce you as we do the transfer. 
[Pause.]
    I have been told that they are waiting on the second vote 
so I think Chairman Isakson will be here as soon as they call 
that vote and he casts it and then whistles back here to the 
hearing room.
    In the meantime, I think we are going to get started with 
the statements. I want to introduce the witnesses for Panel II.
    First we have Sharon Silas, who is the Acting Director for 
Health Care from the Government Accounting Office, otherwise 
known as the GAO. Then, we have Adrian Atizado, who is the 
Deputy National Legislative Director for the DAV, the Disabled 
American Veterans. Next, we have Merideth Randles, who is a 
Principal and Consulting Actuary for Milliman.
    I think we will start with you, Ms. Silas, with your 
opening statement. I am not going to cut you off, but if you 
could try to keep it to 5 minutes and your entire written 
statement will be made a part of the record.
    Thank you all for being here. We look forward to hearing 
your statements.
    Ms. Silas?

  STATEMENT OF SHARON SILAS, ACTING DIRECTOR FOR HEALTH CARE, 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Silas. Thank you. Chairman Isakson, Ranking Member 
Tester, and Members of the Committee, thank you for the 
opportunity to be heard today to discuss the findings from two 
of our reports on the Veterans Choice Program, the challenges 
that the VA has faced in implementing that program and the 
lessons learned that can help inform the implementation of the 
new Veterans Community Care Program, or VCCP.
    Congress established the Choice Program in 2014 to address 
longstanding challenges with veterans' access to health care 
services at VA medical facilities. In 2018, Congress passed the 
MISSION Act, establishing the VCCP, which requires VA to 
consolidate the Choice Program with other Community Care 
Programs by June 6, 2019. GAO believes that VA's experience 
implementing and administering the Choice Program over the last 
4 years can help inform the agency's implementation of the new 
VCCP.
    Specifically, in 2018, we issued two reports and made a 
total of 12 recommendations addressing issues with the 
implementation and administration of the Choice Program. These 
reports offer a detailed review of the program and identify a 
number of operational and oversight weaknesses with the process 
for referring and scheduling veterans' medical appointments, as 
well as ensuring timely payments to community providers.
    First, in our June 2018 report, we identified numerous 
factors that adversely affected veterans' access to care 
through the Choice Program. For example, from the onset, VA's 
implementation of the program included an unnecessarily complex 
referral and appointment scheduling process that made it nearly 
impossible to meet VA's statutory requirement that veterans see 
a provider within 30 days when a clinician deemed the care was 
necessary.
    Specifically we found that veterans could potentially wait 
up to 70 calendar days to receive care if staff took the 
maximum allowed time to complete the referral and appointment 
scheduling process established by the VA.
    In addition to relying on an overly complex referral and 
appointment system, VA did not have enough trained staff, nor 
the tools, or the technology for the staff to efficiently 
coordinate and communicate across the program. The program also 
experienced insufficient contractor networks of community 
providers to meet veterans' health care needs.
    Second, we found that VA could not systematically monitor 
the timeliness of veterans' access to care through the Choice 
Program because it lacked complete, reliable data to do so. The 
data limitations GAO identified included, for example, 
incomplete data on the timeliness of processing referrals and 
authorizations for care, and inaccuracies with the dates used 
to measure the timeliness of care.
    Although VA has taken actions to help address some of these 
issues we have identified, not all issues have been fully 
resolved. Based on these findings, we made 10 recommendations 
focused on improving VA's monitoring of access to care and wait 
times, more clearly communicating changes to policy and 
guidance, and facilitating seamless information sharing 
throughout the program. All 10 recommendations from this report 
remain open.
    In September 2018, we also reported on the timeliness of 
payments of claims to Choice providers, which are important to 
guaranteeing that a sufficient number of providers participate 
in the contractors' networks.
    Although VA has taken actions to address challenges related 
to paying providers, such as updating its payment system and 
educating providers on the claims processing requirements, we 
still identified concerns. For example, we found that 9 of 15 
providers included in our review continued to experience 
problems contacting the VA to resolve medical claims issues. 
However, VA told us that they do not collect data on, or 
monitor contractor compliance with meeting customer service 
requirements. Based on this review, we made two recommendations 
that continue to remain open.
    VA has told us that they have taken steps to address all 12 
of our recommendations in preparation for the implementation of 
the VCCP. However, many of those recommendations rely on the 
implementation of new IT systems and awarding six new contracts 
for the program, of which three have been recently awarded.
    In summary, launching the VCCP in 2019 is a large and 
complex undertaking which comes with many risks and challenges. 
VA's experience with the Choice Program provides an opportunity 
to avoid the missteps made with the implementation of that 
program, and from the onset ensure that there are enough 
trained staff and the proper processes, policies, and 
technology in place to effectively monitor the VCCP and ensure 
that the program is providing veterans with timely access to 
care.
    This concludes my prepared statement. I would be happy to 
answer any questions that you may have. Thank you.
    [The prepared statement of Ms. Silas follows:]
 Prepared Statement of Sharon Silas, Acting Director for Health Care, 
                    Government Accountability Office

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Senator Tester. Thank you, Ms. Silas. And, before I get to 
Mr. Atizado I just want to say--I want to thank Dr. Matthews 
and Dr. MacDonald for staying here for this panel. Oftentimes 
agencies leave when a second panel comes in. It is important 
that you are here to listen, so thank you for being here.
    Mr. Atizado, you are up next.

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

    Mr. Atizado. Thank you, Senator Tester. Ranking Member 
Tester, Chairman Isakson, distinguished Members of the 
Committee, first, I would like to thank you for inviting DAV to 
testify at this hearing to examine VA's progress in 
implementing the Veteran Choice Program required by the MISSION 
Act. As we all know, it is due by June 6.
    DAV is a non-profit veteran service organization. We are 
comprised of over one million wartime service-disabled 
veterans, and today's hearing is critical for us and our 
membership because most of our members not only choose but they 
rely--if not most as well as entirely on the VA for care.
    As you know, DAV worked closely with this Committee, with 
Congress, and VA in helping not only to craft, but enact the VA 
MISSION Act. We continue to believe that, if fully and 
faithfully implemented, this landmark law will move us beyond 
just giving veterans choice, that it can and should empower 
veterans to make more informed decisions. But, it appears VA's 
proposed rules may not achieve these goals.
    Title I requires VA to be the primary provider and 
coordinator of care in a high-performing integrated network 
which combines the strengths of VA as well as the best of which 
the community can offer. This is all, of course, to offer 
veterans seamless access to high-quality as well as coordinated 
care in a timely manner.
    VA is making progress implementing Title I of the VA 
MISSION Act, but with less than 8 weeks before the new law is 
set to take full effect we do not believe that the new wait and 
drive-time eligibility standards can be easily and efficiently 
implemented without serious risk.
    We base our assessment on several factors that raise doubt, 
including VA's performance in successfully developing IT 
solutions on time, as well as the USDS--U.S. Digital Services--
report on VA's compliance with Section 101 of the MISSION Act, 
VA's performance in implementing, operating, and improving the 
Veterans Choice Program, including GAO's reports on problematic 
weaknesses in the operation and oversight of the Choice 
Program, as well as VA's performance in accurately measuring 
wait times.
    As my co-panel just mentioned, there is a misalignment with 
the timeline for transition to the Veteran Community Care 
Program with only three of the six regional contracts having 
been awarded. We have considered VA's proposed rule and its 
inconsistencies with the law; and within the proposed 
regulations itself it is lacking several basic elements that 
are important to our veterans, especially as it is required by 
the MISSION Act. These are things such as requiring private 
providers to meet the same time, same distance, and quality 
standards required of VA.
    The proposed rule is insufficiently justified and uses 
assumptions that are far from reality. We have serious doubts 
VA will have the sufficient resources, staffing, and clinical 
space, as well as the executable plan to train and educate all 
those involved to have a smooth and successful transition to 
the new Community Care Program.
    Simply, VA's proposed rules raise more questions than 
answers to us and leaves out critical pieces that would 
otherwise ensure veterans who meet the new eligibility 
standards are, in fact, able to receive timely, highest 
quality, and coordinated care.
    Weighing all these factors, we believe VA is not, nor will 
likely be sufficiently prepared within 8 weeks without 
compromising some form of quality and risking unnecessary 
disruptions in receiving the care ill and injured veterans 
need.
    Just to be clear, the majority of the law can and should 
move forward, particularly the urgent care benefit, expansion 
of the caregiver program, and the improved organ donor and 
transplant program. Moreover, VA should move forward with other 
access standards required by the MISSION Act, as the 
grandfathered 40-mile rule when services are not available at 
the VA facility, when veterans experience unusual and excessive 
burdens in traveling, and when it is in the veteran's best 
interest.
    However, we believe this Committee must consider whether VA 
should withdraw the proposed wait and drive-time standards or 
otherwise delay its implementation until VA has tested and 
certified that this new standard is not only feasible but 
sustainable, and that both VA and private providers can meet 
these standards together.
    With what is at stake for ill and injured veterans across 
the country, we believe it is far better to get this right than 
to rush forward and play catch-up when things do not work.
    Mr. Chairman and Members of the Committee, thank you again 
for allowing DAV to testify at this important hearing. I would 
be happy to answer any questions you have.
    [The prepared statement of Mr. Atizado follows:]
   Prepared Statement of Adrian Atizado, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairman Isakson, Ranking Member Tester, Distinguished Members of 
the Committee: Thank you for inviting DAV (Disabled American Veterans) 
to testify at this hearing to examine the Department of Veterans 
Affairs (VA) progress in implementing title I of Public Law (P.L.) 115-
182, the VA Maintaining Internal Systems and Strengthening Integrated 
Outside Networks Act of 2018, or the VA MISSION Act of 2018.
    DAV is a non-profit veterans service organization comprised of over 
one million wartime service-disabled veterans that is dedicated to a 
single purpose: empowering veterans to lead high-quality lives with 
respect and dignity. Today's hearing is critically important to our 
organization as most of our members choose and rely heavily or entirely 
on VA health care.
    Mr. Chairman, as you know, DAV worked closely with this Committee, 
Congress and VA in helping to craft and enact the VA MISSION Act, and 
we continue to believe that--if fully and faithfully implemented--this 
landmark law can improve both the access to and quality of veterans 
health care. However, with just eight weeks before the new law is set 
to take full effect--we are not confident VA will be ready by June 6, 
2019 to fully implement new wait and drive time access standards that 
will significantly enlarge VA's community care program.
    While many parts of the law can and should move forward--
particularly the urgent care benefit, caregiver assistance expansion 
and existing access standards contemplated in the VA MISSION Act--the 
new designated access standards proposed by VA are not yet ready to be 
rolled out. Based on recent VA reports to Congress on access and 
quality standards, as well as the U.S. Digital Services report on VA's 
progress of implementation, it has become clear that VA is not yet 
prepared, nor likely to be prepared within eight weeks, to implement 
significantly more complex and expansive access standards without 
risking serious disruption to veterans health care. VA does not yet 
have sufficient resources nor operational plans in place to ensure 
seamless clinical care coordination for the increased number of 
veterans who can and will seek care through the new Veterans Community 
Care Program (VCCP) established by the MISSION Act. Therefore, until VA 
can certify to veterans and to Congress that it can meet the proposed 
lower wait time access standards; has properly tested and can 
successfully operationalize the new drive-time standards with minimal 
disruption; and safely coordinate the clinical care of the increased 
number of veterans who use the VCCP networks, VA should continue to use 
the existing access standards of the Veterans Choice program.
    Title I of the VA MISSION Act, requires VA to establish an 
integrated community care program by June 6, 2019--just eight weeks 
from today. The VA MISSION Act was enacted into law on June 6, 2018, 
and since that time, VA has issued requests for information from the 
public on health care access standards,\1\ health care quality 
standards,\2\ and for the Program of Comprehensive Assistance for 
Family Caregivers.\3\ VA has also issue a change of agency practice 
pertaining to medical records confidentiality under 38 U.S.C. 7332,\4\ 
and has proposed rules for Urgent Care \5\ and the Veterans Community 
Care Program.\6\
---------------------------------------------------------------------------
    \1\ 83 Fed. Reg. 30818-30819, Jun 29, 2018; 83 Fed. Reg. 30819-
30821, Jun 29, 2018.
    \2\ 83 Fed. Reg. 42983-42984, Aug 24, 2018; 83 Fed. Reg. 42982-
42983, Aug 24, 2018.
    \3\ 83 Fed. Reg. 60966-60968, Nov 27, 2018.
    \4\ 84 Fed. Reg. 407-407, Jan 28, 2019.
    \5\ 84 Fed. Reg. 627-633, Jan 31, 2019.
    \6\ 84 Fed. Reg. 5629-5650, Feb 22, 2019.
---------------------------------------------------------------------------
    DAV has tried to engage VA on nearly all of these issues in a 
multitude of meetings but the Department continues to limit the amount 
of information they share. We also continue to be kept at arm's length, 
limiting the information the agency should use when developing policies 
and procedures--information such as the veterans' perspective steeped 
in considerable institutional knowledge and experience, constructive 
advice and prudent recommendations--that defines a truly collaborative 
stakeholder relationship. From our vantage point, we believe VA is 
indeed making progress in implementing title I of the VA MISSION Act of 
2018, but the Department seems unlikely to meet the June 6 deadline set 
by law without sacrificing quality and endangering veterans' health 
outcomes.
    For example, we are pleased with VA's quick work to implement 
Section 105 of the VA MISSION Act by proposing regulations for the new 
urgent care benefit for veterans--a policy DAV has long advocated for--
which will help provide veterans with additional local access for non-
emergency care.
    However, we strongly oppose VA's proposal to charge service-
connected disabled veterans a copayment per urgent care visit, 
beginning with the 4th visit in any calendar year. VA posits in the 
preamble of the proposed regulation that it will dismiss the 
longstanding and principled covenant not to charge copayments to 
service-connected disabled veterans who were injured or made ill 
defending our Nation by simply noting that ``[c]opayments are a common 
feature of health care, including VA health care. They are an important 
mechanism for guiding behavior to ensure that patients receive care at 
an appropriate location.'' \7\
---------------------------------------------------------------------------
    \7\ 84 Fed. Reg. 627 at 630.
---------------------------------------------------------------------------
    Rather than respecting this hallowed promise not to impose the cost 
of care on service-connected veterans and finding a solution to address 
its concerns regarding patient behavior, we believe VA chose poorly not 
to adopt a solution used in the Department of Defense's (DOD's) urgent 
care program, which we discussed at length with the leadership of VA. 
DOD's program offers a Nurse Advice Line available 24 hours a day, 7 
days a week at no cost to direct beneficiaries to address patient 
behavior and help them seek the most appropriate level of health care 
needed to treat the medical conditions of the beneficiaries, including 
urgent care services. The success of this advice line in DOD has 
potentially greater benefit in the VA health care system, which serves 
patients that are generally older and more clinically complex. 
Likewise, staff have access to the veteran's medical records. It is 
concerning to DAV that VA's decision reflects a priority to advance on 
what is expedient at the expense of what is right.
    Similarly, section 132 of the VA MISSION Act amends 38 U.S.C. 7332, 
which protects certain sensitive diagnoses (i.e., drug abuse, 
alcoholism or alcohol abuse, infection with the human immunodeficiency 
virus, or sickle cell anemia) from being disclosed unless expressly 
authorized by the patient, by providing a new exception to the 
requirement that a patient must expressly authorize VA to disclose 
medical records containing a sensitive diagnosis. The exception removed 
VA's requirement when VA is billing a third-party for medical care cost 
recovery.
    When engaging VA on section 132, before the notice to change the 
Department's practice was issued on January 19, 2019, we inquired how 
VA would implement and enforce the provision stating ``[a]n entity to 
which a record is disclosed under this subparagraph may not disclose or 
use such record for a purpose other than that for which the disclosure 
was made or as permitted by law.'' Subsequently, VA chose to ignore 
this provision in the notice to change VA's practice and there has been 
no notice or publication to date about what the procedures are should a 
veteran or other individual discover that sensitive information has 
been used beyond the purposes for which it was disclosed, and what the 
process is once the VA is so notified.
    Other sections in the VA MISSION Act of great importance to DAV and 
that VA is making progress on is the improvement and expansion of the 
comprehensive family caregiver support program. We were pleased to hear 
at the Senate Committee on Veterans' Affairs hearing two weeks ago that 
VA is still aiming to certify the IT system and initial expansion by 
the October 1, 2019, deadline. However, we still have concerns as to 
whether VA will truly be able to meet the deadline, particularly in 
light of conflicting messages from VA and recent history in delayed 
implementation of IT solutions for this program.
    The VA Caregiver Support Program currently uses the IT system known 
as the Caregiver Application Tracker (CAT), which was rapidly developed 
due to time constraints on implementing the program and was not 
designed to manage a high volume of information as is required today. 
We are aware VA has requested a reprogramming of nearly $96 million in 
Medical Care funding to the IT Systems account, which includes just 
over $4 million to continue development and stabilization of CAT, while 
in its FY 2020 budget submission, VA is requesting $2.6 million to 
update the Caregivers Tool (CareT) to support the first phase of 
expansion.
    As this Committee is aware, VA notified Congress in April 2017 that 
CareT, which at that time was expected to fully automate the 
application and stipend delivery process for the program, experienced 
significant delays associated with external dependencies and lost 
prioritization among competing projects. As a result, a new contract 
had to be drafted to continue work pushing the delivery of CareT out 
one year to June 2018. Yet during VA's briefing on its budget request 
for FY 2020 and 2021, staff announced CareT would likely not be 
certified until June 2020. VA is well aware veterans and caregivers 
have waited for nearly a decade for equal treatment and it is simply 
unacceptable to ask them to wait longer.
    With continued delays in IT development, we question the wisdom of 
having two different standards in deploying IT solutions supporting the 
VA Caregiver Support Program projected to serve thousands of veterans 
and their caregivers compared to the lower standard of deploying the IT 
solutions supporting the VCCP projected to serve millions of veterans 
and their caregivers.
    As VA has been implementing title I of the VA MISSION Act, we see 
these types of decisions being repeated. In the VA health care system, 
too many veterans are experiencing uneven and delayed access to high 
quality veteran-centered care. There just simply are not enough 
clinical teams and clinical space to care for our Nation's veterans. 
Even before the Veterans Choice program was established, VA facilities 
had limitations on the services it could offer due to a variety of 
factors, including the size of facilities and the types of providers 
that can be recruited. VA's legacy purchased care programs such as fee 
basis, now commonly referred to as Individual Authorizations, were 
generally used to address a VA facility's shortcomings such as limited 
availability of clinical services, the distance that veterans would 
have to travel to receive care at a VA facility, and the amount of time 
veterans had to wait for an appointment.
    Additionally, the manner in which VA historically referred veterans 
to community care was fragmented. VA did not track how long it took for 
veterans to be seen when referred to a community provider, whether the 
quality of care they received in the community is equal or better than 
VA, how such care impacted veterans' health outcomes, or veterans' 
satisfaction. We frequently heard complaints that due to limited 
resources, VA providers were not allowed to send veterans to the 
community, resulting in delayed access to needed care. DAV and our 
Independent Budget (IB) partners called for increased resources, 
improving how VA uses community care by creating a high-performing 
integrated health care network, and asked Congress and the VA to ensure 
a veteran, with the help of their VA clinical team--not government 
bureaucrats--decide when and from whom they should receive care in the 
community.
    For fiscal year 2014, VHA received the highest ever funding level 
of $54 billion in advance appropriations, with additional funds from 
the Consolidated Appropriations Act enacted in January 2014. However, 
by April 2014, the waiting list scandal and access crisis erupted at 
the Phoenix VA Medical Center (VAMC) and by August, Public Law 113-146, 
the Veterans Access, Choice, and Accountability Act of 2014, was 
enacted to establish, in 90 days, the temporary Veterans Choice 
Program. The purpose of the Act was to mitigate the crisis by ensuring 
veterans had access to care in the community paid for by VA while 
strengthening the VA health care system. This new program was set to 
expire until such time as the initial $10 billion deposited in the 
Veterans Choice Fund estimated to be expended by mid-August 2017.
    This Committee is well aware of the troubled implementation and 
execution of the Veterans Choice Program, ranging from the adequacy of 
the provider networks, participating providers not being paid timely, 
veterans experiencing as long if not longer waiting times seeking care 
in the community as well as being chased by collection agencies because 
the community providers were just not being paid for authorized care. 
Moreover, our calls to ensure the taxpayers are getting the best value 
for the resources appropriated, and for true care coordination and 
transparency in the quality of care veterans are receiving from 
community providers have not been adequately answered.
    The multitude of reports from the Government Accountability Office 
(GAO) review since the inception of the Veterans Choice Program bear 
out the difficulties of hasty implementation. Of note was GAO's report 
observing the tracking and of obligations and projected utilization 
leading to the VA's FY 2015 funding gap of $2.75 billion. While VA 
developed new processes to prevent funding gaps for 2016, the agency 
was still unable to adequately project its resource needs, resulting in 
another funding crisis. This Committee's unwavering commitment to 
ensure veterans' health care needs are met had to react under emergency 
circumstances on not one, but two separate occasions to provide VA $2.1 
billion in August 2017 \8\ and another $2.1 billion just a few months 
later in December 2017.\9\
---------------------------------------------------------------------------
    \8\ P.L. 115-46
    \9\ P.L. 115-96
---------------------------------------------------------------------------
    We remember distinctly the first funding crisis when then-VA 
Secretary Shulkin made clear in public statements and congressional 
testimony that the Veterans Choice Program would likely run out of 
money before the end of FY 2017. In response, Congress' deliberations 
included a proposal to appropriate $2.0 billion to the Veterans Choice 
Program, which would be offset from other programs in VA's budget.\10\ 
DAV, along with eight other veterans service organizations (VSOs) sent 
a letter to Congress opposing the terms of the legislation and 
thankfully, leaders of this Committee and in the House Veterans' 
Affairs Committee found a compromise without penalizing veterans by 
cutting other earned benefits.
---------------------------------------------------------------------------
    \10\ https://docs.house.gov/billsthisweek/20170724/S. 114.pdf
---------------------------------------------------------------------------
    The lessons here are clear, there are some in Congress willing to 
shift resources from VA programs to pay for veterans to see a private 
doctor if they are facing long waits or travel distances. It seems 
disingenuous to say on one hand that VA programs are fully funded and 
on the other, provide an additional $10 billion to send veterans who 
cannot be seen by VA in a timely manner to get the medical care they 
need in the private sector. In addition, VA's ability to estimate and 
make projections for the Veterans Choice Program remains suspect.
    Over the course of 18 months following enactment, laws were passed 
making several technical changes \11\ to the statutory authority for 
the Veterans Choice Program; however, we are still helping veterans who 
are being chased by collection agencies or otherwise being directly 
billed by community providers because they have not been paid for the 
care they provided to veterans under the Veterans Choice Program.
---------------------------------------------------------------------------
    \11\ P.L. 113-175, Public Law 113- 235, Public Law 114-19, Public 
Law 114-41, Public Law 115-26.
---------------------------------------------------------------------------
    In light of this, we had expected VA to propose regulations that 
would make clear how VA will establish and operate what Congress, the 
veteran community and the VA all agreed was the next evolution in the 
Department's efforts to purchase care for veterans in the private 
sector: a high-performing integrated network that combines the strength 
of the VA health care system with the best of community care to offer 
seamless access and coordinated care. Instead, the regulation creates 
more questions than answers.
    It appears VA's proposed rules lack several basic elements 
important to veterans, such as simple and transparent processes for 
determining eligibility for care in the community, how veterans care 
will be coordinated, how veterans will be provided information about 
the quality of community providers in the network so they can make an 
informed decision. Veterans are most interested in information about a 
provider's track record on the condition for which they are seeking 
care as well as interpersonal skills, identifying the best providers in 
the community, and determining the adequacy of the network of community 
providers. Finally, there must be a process in place to hold 
accountable and the community provider to the same standards to limit 
exposing veterans to disparities in care.
    As opposed to avoiding complicated and ambiguous procedures to be 
implemented with administrative simplicity in determining veterans' 
eligibility for community care, VA has proposed rules expanding both 
the number and complexity of eligibility based on six criteria.\12\ One 
of these six designated criteria is also the subject of numerous 
substantive comments from the public and from elected officials. The 
wait time assumptions are suspect and drive time criteria is opaque and 
predisposed to result in arbitrary eligibility determinations, all of 
which will also likely contribute to dangerous fiscal uncertainty.\13\
---------------------------------------------------------------------------
    \12\ VA proposed 38 CFR Sec. 17.4010(a)(1)-(5)
    \13\ VA proposed 38 CFR Sec. 17.4040
---------------------------------------------------------------------------
    For example, VA's cost estimate for wait time assumes a 29 percent 
increase in primary care providers and a 14 percent increase in mental 
health providers. VA also estimates no additional expenditures for the 
28-day appointment time for specialty care because it is sufficiently 
similar to the 30-day access provision under the Veterans Choice 
Program. However, VA's budget request for FY 2020 shows an increase of 
only 1,068 physicians and 2,943 registered nurses, which for the sake 
of discussion we will assume are all advanced practice nurses--a mere 
4.8 percent increase.\14\ For its FY 2021 request, VA will increase 
staffing for these two categories by 5.3 percent. These diverging 
assumptions will likely exacerbate VA's miscalculation of the workload, 
required staffing, and cost estimate for its designated wait time 
standard.
---------------------------------------------------------------------------
    \14\ Congressional Submission VA Budget Request for FY 2020 Funding 
and FY 2021 Advance Appropriations, Volume II: Medical Programs and 
Information Technology Programs; Page: VHA-174.
---------------------------------------------------------------------------
    VA also proposes to use an average drive-time criteria rather than 
distance, to provide ``a more consistent standard of access for urban 
and rural Veterans.'' VA proposes to use a proprietary software not 
generally available to the public and the proposed rules do not 
adequately explain how ``average drive time'' will be calculated for 
the purposes of eligibility for the Veterans Community Care Program--an 
apparent lack of transparency that appears to guard against independent 
evaluation.
    It is also unfortunate VA is unnecessarily proposing a new and 
untested drive time criteria in lieu of using an existing criteria and 
improving upon it. Specifically, the distance criteria under the 
Veterans Choice Program had been steadily improved over the years. The 
remaining concern over this criteria is to change the distance 
calculated from the veteran's residence to a VA health care provider 
for the required care or service. The administrative simplicity and 
transparency of this criteria are compelling arguments against the 
newly proposed drive time standard.
    DAV continues to insist that the high-performing integrated network 
contemplated under the VA MISSION Act allow the best providers in VA 
and in the community to be identified. We believe veterans would be 
most interested in a type of physician score card: one that reports 
information about a provider's track record on the condition(s) for 
which the veteran is seeking care as well as the information on the 
provider's interpersonal skills.
    Unfortunately, VA's proposed regulations do not speak to this 
critical aspect of the VA MISSION Act. Without these physician level 
quality measures, we believe at minimum, the regulations should require 
competency standards. VA and community providers in the high-performing 
integrated network should meet the same qualification standards for 
each discrete discipline. We strongly recommend network providers must 
complete a general training course on military culture, suicide 
prevention, and on other key issues in providing care such as VA's 
Opioid Safety Initiative. These courses should be free and available 
online counting toward continuing medical education requirements. 
Providers treating mental health conditions prevalent in the veteran 
population such as Post Traumatic Stress Disorder, conditions related 
to military sexual trauma or Traumatic Brain Injury should be required 
to complete condition-specific courses covering assessment, evidence-
based treatment, management of comorbid conditions, and information on 
complementary VA resources. We believe it is reasonable to have 
exemptions to these required training courses for individuals with 
direct and relevant VA or military experience or training.
    To this end, we are compelled to question how and when VA will make 
public the tiered network of community providers intended ``[t]o 
promote the provision of high-quality and high-value hospital care, 
medical services, and extended care services under this section,'' \15\ 
as well as establishing a monitoring system for the quality of care and 
services provided through the network of community providers.\16\
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    \15\ 38 U.S.C. Sec. 1703(g)
    \16\ 38 U.S.C. Sec. 1703(h)
---------------------------------------------------------------------------
    Correspondingly, the same provisions in the VA MISSION Act 
requiring identification and stratification of providers also intends 
for all providers in the high-performing integrated networks be held to 
the same standards--for both access and quality. More specifically, we 
believe at minimum those standards the VA is held to should equally be 
applied to community providers. Not holding VA and its community 
provider partners to the same standards could lead to delayed care, 
lower quality care and worse health outcomes for veterans. It appears 
instead VA is creating a double standard allowing community providers 
to meet lower and nonspecific access and quality requirements.
    VA has bundled care coordination for the VCCP in to the 
Administrative Costs of the program totaling $588 million over 5 years. 
However, the proposed regulation is largely silent on what veterans 
should expect in terms of care coordination. In its preamble, VA 
indicates it will continue to sharpen its focus on directly providing 
those services that are most important to the coordination and 
management of a veteran's overall medical and health needs. Some 
aspects of care coordination are described in terms of managing 
authorizations and episodes of care in the community as well as 
identification of a ``VA care coordination team'' for a veteran opting 
for care in the community, but little else is provided detailing this 
critical part of care.
    Seamless care coordination is one of the most common and 
frustrating issues veterans experience today when seeking care in the 
community through the Veterans Choice Program. We find it objectionable 
that VA asserts itself as the coordinator of veterans medical and 
health needs, yet does not correspondingly treat such a vital and 
distinctive component of VA's health care delivery system. We believe 
elevating the expectation of providing care coordination to all 
enrolled veterans through regulation is the first step VA should take.
    In conclusion, we are forced to question whether VA's progress in 
implementing title I of the VA MISSION Act, which requires the 
establishment and operation of an integrated high-performing network 
that will improve veterans' health outcomes and quality of life, is 
gained at the expense of other critical factors to meet the June 6 
deadline set in law.
    It is not clear the proposed VCCP will improve veterans' health 
care outcomes. Likewise, there is no assurance of care coordination 
beyond the sharing of medical information, and no assurance of funding 
or staffing to ensure veterans they will be treated fairly and equally 
in terms of eligibility determinations, the quality of care they 
receive and the timeliness of such care.
    Prior to rolling out this program on June 6, VA should be able to 
demonstrate community providers in the VCCP meet the same access and 
quality standards to which VA holds itself accountable. VA should 
guarantee the integrated network can meet a new and shorter wait time 
access standard prior to designation. VA should first test and evaluate 
new drive time access standards prior to designation. The Secretary 
should certify that VA has the necessary funding, staffing, information 
technology and clinical care coordination plans in place prior to 
making the new Access Standards effective. Until VA is able to satisfy 
these requirements, we believe the current access standards under the 
Veterans Choice Program should be adopted.

    Mr. Chairman, that concludes my testimony and I would be happy to 
answer any questions that you or Members of the Committee may have.

    Senator Tester. Thank you, Mr. Atizado.
    Ms. Randles, you are up.

    STATEMENT OF MERIDETH RANDLES, PRINCIPAL AND CONSULTING 
                       ACTUARY, MILLIMAN

    Ms. Randles. Good afternoon, Chairman Isakson, Ranking 
Member Tester, and distinguished Members of the Committee. 
Thank you for the opportunity to discuss Milliman's role in the 
development of the Department of Veterans Affairs expenditure 
estimates associated with the MISSION Act Community Care access 
standards.
    My name is Merideth Randles and I am a principal and 
consulting actuary with Milliman, an international firm of 
actuaries and consultants. Our firm is broadly acknowledged to 
be the leading consulting firm to health care insurers and 
providers in the United States.
    Health care utilization and expenditure projections are at 
the core of the actuarial consulting that we, as health care 
actuaries, provide to our clients. As a firm, we have served 
thousands of clients in the area of health care modeling 
through in-depth expertise around the specific needs, 
characteristics, and health care delivery environment of the 
population at risk.
    I am a Fellow in the Society of Actuaries and a member of 
the American Academy of Actuaries. I began consulting with VHA 
in 1995, and was involved with the inception of the Enrollee 
Health Care Projection Model, VA's actuarial health care 
forecasting model, in 1998. This involvement continued as the 
model became integral to VHA's budget formulation and strategic 
planning processes. I have supported VA in the valuation of a 
multitude of legislation, policies, and program initiatives, as 
well as briefings to governmental stakeholders.
    VA's Enrollee Health Care Projection Model was used to 
estimate the cost for the MISSION Act access standards. This 
model is a health care demand projection model and uses 
actuarial methods to project veteran enrollment, utilization of 
VA health care, both specifically for VA facility and community 
care and the associated costs of that care.
    The methodology underpinning the model is similar to 
approaches used by private health insurers, Medicare, and 
Medicaid. The model incorporates detailed demographic data 
specific to the VA Enrollee Health Care population, health care 
trends, economic conditions, and other drivers of change in the 
health care utilization and costs.
    As the model was first developed in 1998, the current model 
is now informed by 20 years of VA experience, along with the 
expertise of VA's actuarian consultants at Milliman. The model 
is updated annually with emerging experience data and used to 
produce multiple enrollment, utilization, and expenditure 
scenarios each year. These scenarios are widely used by VA for 
important stakeholder needs, and the model now supports 90 
percent of VA's medical care budget.
    The VA system is different from most health care programs 
in that, as referenced earlier, over 80 percent of veteran 
enrollees have other health insurance such as Medicare or 
employer-sponsored insurance. Therefore, VA is often called 
upon to provide only a portion of a veteran's health care 
needs. The term ``reliance'' in this context refers to the 
portion of enrollee's total health care need that they expected 
to receive through VA, at either a VA-operated facility or 
through community care, rather than through other health care 
sources.
    Fiscal year 2017 experience data indicates that through 
both VA facility care and community care VA provided 36 percent 
of the health care services used by enrollees, while other 
health insurance provided the remaining 64 percent.
    Upon separation from the military, veterans navigate the 
U.S. health care system in a fashion similar to the general 
population, with the notable exception that they also have 
access to VA. Given this choice, current reliance levels are a 
testament to how many veterans value the care and services VA 
has to offer.
    Every percentage point increase in reliance represents 
significant budgetary resource requirements. In estimating the 
impact from MISSION, we considered the experience of the Choice 
40-mile enrollees. These enrollees received enhanced 
eligibility to access care in the community, and, by 
definition, have limited geographic access to VA facility care, 
as compared to the average enrollee. Therefore, it is 
reasonable to assume that enrollees eligible for similar access 
under MISSION's drive-time standards will have similar 
utilization and reliance behaviors.
    Since 2015, ambulatory inpatient utilization has increased 
significantly for these Choice enrollees, and is expected to 
increase further. But, I will emphasize that this utilization 
growth is for all VA-sponsored care, both within VA facilities 
and in community care. Further, utilization of VA facility care 
by these Choice enrollees has been stable and did not decline 
over this period. Finally, there have been no material impacts 
on enrollment due to the Choice Program.
    I have provided extensive details regarding the actuarial 
methodology developed for the MISSION impact estimates within 
my written testimony, and I welcome your questions. Thank you.
    [The prepared statement of Ms. Randles follows:]
   Prepared Statement of Merideth Randles, FSA, MAAA, Principal and 
                   Consulting Actuary, Milliman, Inc.
    Good afternoon, Chairman Isakson, Senator Tester, and distinguished 
Members of the Committee. I am pleased to be here today to discuss 
Milliman's role in the development of the Department of Veterans 
Affairs' (VA's) expenditure estimates associated with the MISSION Act 
community care access standards.
                             about milliman
    My name is Merideth Randles and I am a principal and consulting 
actuary with Milliman, an international firm of actuaries and 
consultants. Milliman has been evaluating financial risk for clients 
since 1947. Our firm is broadly acknowledged to be the leading 
consulting firm to health care insurers and providers in the United 
States. Health care utilization and expenditure projections are at the 
core of the actuarial consulting that we, as health actuaries, provide 
to our clients. As a firm, we have served thousands of clients in the 
area of health care modeling, and with each effort accounting for the 
specific needs, characteristics, and health care delivery environment 
of the population at risk.
    Our health care clients consist of the majority of the health 
insurers in the Nation, including Blue Cross Blue Shield plans, health 
maintenance organizations (HMOs), and health insurance companies. In 
addition, our consultants provide cost modeling services to many health 
care providers, including hospitals, physician groups, pharmacy benefit 
managers, and other provider organizations. Our firm contracts with a 
number of governmental agencies to assist them with health care cost 
forecasting, including state Medicaid programs, state mental health 
agencies, state employee plans, state insurance departments, numerous 
county and municipal entities, and Federal agencies, such as the 
Department of Defense, Centers for Medicaid and Medicare Services (CMS) 
and notably, the Department of Veterans Affairs.
    I have 24 years of health actuarial experience and I have been 
consulting with Milliman for the entirety of my career. I am a Fellow 
in the Society of Actuaries (FSA) and a member of the Academy of 
Actuaries (MAAA). I have been involved with the Veterans Health 
Administration (VHA) as a consultant since 1995 when they first began 
exploring ideas on how to plan for and estimate the impact of 
eligibility reform legislation. I was involved with the inception of 
the Enrollee Health Care Projection Model (EHCPM), VA's actuarial 
health care forecasting model, in 1998, and continued this involvement 
as the EHCPM became integral to VHA's budget formulation process and 
was used to support other key initiatives, such as Capital Asset 
Realignment for Enhanced Services (CARES) and the President's 
Commission on Care. I have supported VA in the evaluation of a 
multitude of legislation, policies, and program initiatives, as well as 
briefings to veteran service organizations (VSOs) and governmental 
stakeholders such as the Office of Management and Budget (OMB), 
Government Accountability Office (GAO), Congressional Budget Office 
(CBO), Executive Office of the President (EoP) and congressional staff.
    Over the years, VA and Milliman have developed a strong 
partnership. Milliman brings specialized expertise, access to extensive 
amounts of data, and first-rate research to the modeling effort. VA 
experts provide valuable input, analysis, and subject matter expertise 
used to develop the model assumptions and related projections. In 
addition, VA experience data is incorporated into many of the analyses. 
This partnership of subject matter experts and data from both VA and 
Milliman is a powerful combination that provides VA with the best 
resources to develop utilization and cost estimates for the veteran 
enrollee population. In particular, this collaborative experience has 
led to a deep and extensive understanding of the veteran enrollee 
population and the dynamics driving their use of health care, both 
inside and outside of VA.
    The remaining testimony presents an overview of the Enrollee Health 
Care Projection Model (EHCPM) as well as a brief section defining the 
concept of veteran reliance on VA, which is foundational to the 
evaluation of the proposed MISSION standards. The discussion then 
proceeds into specific details regarding the methodology and 
assumptions used to estimate the expenditure impacts associated with 
MISSION.
               va's enrollee health care projection model
    The VA EHCPM was used to estimate the costs of care for the MISSION 
Act access standards. The EHCPM is a health care demand projection 
model and uses actuarial methods and approaches to project veteran 
enrollment, utilization of VA health care (VA facility and community 
care), and the associated expenditures of providing that care. The 
modeling approaches underpinning the EHCPM are similar to approaches 
used by private insurers, Medicare, and Medicaid. The EHCPM 
incorporates detailed demographic data specific to the VA enrollee 
population, health care trends, economic conditions, and other drivers 
of change in health care costs and utilization. As the EHCPM was first 
begun in 1998 with the onset of VA's enrollment eligibility reform and 
adoption of a comprehensive medical benefits package, the current model 
is now informed by 20 years of VA experience and the expertise of VA's 
actuarial consultants at Milliman. The EHCPM is updated with emerging 
experience data annually and used to produce multiple enrollment, 
utilization, and expenditure scenarios each year. These scenarios are 
widely used by VA for important stakeholder needs, such as:

     Supporting 90% of VA's medical care budget (some budget 
elements are external to the model, such as construction and 
equipment).
     Informing strategic planning, including the Market 
Assessments.
     Use by the Commission on Care to cost proposed system 
changes.
     Generating key data provided to Congressional Budget 
Office to support independent costing.
     Producing projections integral to programmatic planning, 
policy development, and legislative costing.

    Currently, the EHCPM projects utilization and costs for more than 
120 health care services. In addition to the full range of services 
provided under a typical commercial or Medicare health plan, VA offers 
several specialized services without direct counterparts in most health 
care systems including specialized mental health services, other VA 
programs, and longer-term nursing home care or home-based care, known 
as long-term services and supports (LTSS).
    The EHCPM projections are based on the expected utilization of 
health care services for veteran enrollees. Therefore, the projections 
start by first estimating who is expected to enroll each year from the 
veteran population. These projections are made at a detailed level, 
including age band, gender, priority level, county of residence, and 
special conflict status. These detailed enrollee projections then 
become the membership base upon which estimates of total health care 
utilization are built. Similarly, the utilization and cost estimates 
are then built specifically for VA facility and community care at a 
detailed demographic and service level. Future projections reflect the 
expected demographic changes in the enrollee population, health care 
trends, VA program implementation, and current policy decisions.
    Within the EHCPM utilization is projected for each service using 
units particular to each service, such as visits, procedures, bed days, 
etc. In addition, each service is represented using relative value 
units (RVUs). RVUs are an industry standard metric used to represent 
the relative intensity of resources required to provide a service as 
compared to another. For example, a flu shot has fewer associated RVUs 
than an outpatient surgery, though both are counted as a VA 
appointment. Therefore, RVUs provide a more accurate representation of 
workload and cost impact than appointments. Moreover, they provide an 
accurate way for different services to be aggregated and measured over 
time. Throughout this testimony, many of the system-wide assessments of 
workload trends and VA use are measured based on RVUs.
                    veteran enrollee reliance on va
    The VA system is different from most health care programs in that 
veteran enrollees generally do not obtain all of their health care 
through VA because most enrollees have other health care insurance 
(OHI). In fact, over 80% of veteran enrollees have other health 
insurance in addition to VA health care. This is mainly comprised of 
coverage via Medicare, commercial insurers, TRICARE, Medicaid, and 
Indian Health Service (IHS). Given that most veterans are able to 
choose among multiple health care providers, this means that VA often 
is called upon to provide only a portion of a veteran's health care 
needs. The term reliance in this context refers to the portion of an 
enrollee's total health care need that he or she is expected to receive 
through VA at either a VA operated facility or through community care, 
rather than through other health care sources. Reliance is measured at 
the enrollee and service level, as enrollee reliance behavior varies 
from enrollee to enrollee as well as from service to service for any 
given enrollee. Figure 1 illustrates the measurement of reliance for a 
particular type of service for two enrollees.
        figure 1--measuring enrollee reliance on va health care
        
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Reliance refers to the portion of an enrollee's total health care need 
        that he or she is expected to receive through VA (facility or 
        community care) rather than through other health care sources

    Formal enrollment for VA eligibility began in fiscal year (FY1999). 
Since that time, VA's master enrollment file (MEF), as well as the 
comprehensive set of all health care encounters recorded within the VA 
system has been analyzed on an annual basis. In addition to this, 
several years ago, VA collaborated with CMS to merge the Medicare fee-
for-service (FFS) claims experience for veteran enrollees with VA's 
encounter data, allowing for a complete capture of enrollee health care 
between the two health care systems. The resulting dataset provides an 
invaluable insight into the level of overall health care utilization 
demanded by enrollees, as well as the portion of this care provided by 
VA and the portion provided by Medicare.
    While some enrollees use VA exclusively for all of their health 
care needs, roughly half of the Medicare eligible enrollee population 
accesses health care services from both VA (either a VA facility or 
community care) and Medicare during the same year. Over the three-year 
period from 2014 to 2016, nearly 60% of enrollees ages 65 and over 
(approximately half of the enrollee population) used both VA care and 
non-VA care, while approximately 20% did not use any VA care and an 
additional 20% used VA exclusively for all of their care. Further, for 
those enrollees who utilize both sources of care, there is a wide range 
of partially reliant users, as some enrollees only obtain a few 
services from VA and others get almost all of their health care 
services from VA. The range of these outcomes is presented in Figure 2.
       figure 2--range of enrollee reliance for ages 65 and over
       
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                       why do veterans choose va?
    Upon separation from the military, most veterans navigate the U.S. 
health care system in a fashion similar to the general population, with 
the notable exception that they also have access to VA. Given this 
choice, current reliance levels are a testament to how many veterans 
value the care and services that VA has to offer. Many factors 
influence a veteran's decision to choose VA. Some reasons why veterans 
may choose VA as their source of health care include:

     The no copay or small copay cost (depending on priority 
level) of obtaining services, medical equipment, and prescriptions, 
which is a richer benefit than Medicare fee-for-service (FFS) or the 
average commercial plan.

     Specialized treatment and care coordination for a service-
connected disability.
     Specialized programs and supplies, such as residential 
rehabilitation and compensated work therapy, bed-based blind 
rehabilitation, Post Traumatic Stress Disorder (PTSD) and military 
sexual trauma treatment, and hearing aids (most of these services are 
non-existent outside of VA).
     Dedicated veteran providers and facilities.
     The fellow veteran patient population.
     For approximately 20% of veterans, VA plays a critical 
role as their only source of health care. For the remaining 80% VA 
plays a safety net role during loss of OHI.

    Even small changes in enrollee reliance behavior represent 
significant changes in the level of care provision and resource 
requirement for VA. In recognition of this, VA includes a series of 
questions related to veteran access of VA within its annual Survey of 
Enrollees. Figure 3 demonstrates the diversity of ways that enrollees 
plan to use VA health care in the future.
         figure 3--planned future use of va health care system
         
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Source: 2017 Survey of Enrollees

                      current va enrollee reliance
    The VA data match with CMS, as well as annual survey data collected 
across the veteran population, allows us to measure reliance at a 
health care service level. Aggregating services based on their relative 
resource requirements using RVUs, it is estimated that overall veteran 
reliance on VA was 36% in FY 2017. This estimate indicates that VA 
provided 36% of the health care services used by enrollees and other 
health insurance provided 64%.
                 figure 4--2017 enrollee reliance on va
                 
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    The VA sponsored care shown in Figure 4 includes care enrollees get 
in VA facilities as well as community care. Figure 5 presents the 
percentage of utilization provided through VA facility care and 
community care. In FY 2017, 73% of all VA sponsored care used by 
enrollees was for services available through both VA facilities and 
community care. Within these services, 24% of health care was purchased 
in the community and 76% was provided in VA facilities.
    figure 5--fy 2017 utilization provided through va facility vs. 
                             community care
                             
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Services only provided in VA accounted for 25% of utilization in FY 
2017. These services include services unique to VA such as VA special 
mental health outpatient and inpatient programs, blind rehabilitation 
and spinal cord injury programs, recreational therapy, case management, 
nutritional counseling, and prosthetics and orthotics services, as well 
as home and community based LTSS and pharmacy and prosthetics products 
which VA does not purchase in the community.
    Services only purchased in the community accounted for 2% of 
utilization in FY 2017. These services include home and community based 
LTSS: community adult day health care, home hospice care, home respite 
care, homemaker/home health aide programs, purchased skilled home care, 
maternity care and ambulance.
    It also is important to note that reliance behavior varies 
significantly within the veteran enrollee population. Here are some 
examples from recent reliance studies:

     Average reliance for priority 1a enrollees (70% or more 
service-connected disability rating) is 50%, while it is 18% for 
priority 8 (high income, no service-connected disabilities).
     For enrollees under age 65, average reliance on inpatient 
services is 40%, while reliance on office visits is 55%. For ages 65 
and over, average reliance on inpatient services is 20%, while reliance 
on office visits is 40%.
     Average reliance is 47% for enrollees under age 65, while 
it is 32% for those ages 65 and over
           figure 6--reliance of veteran enrollees by service
           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    In conclusion, the above information regarding enrollee reliance 
behavior demonstrates why legislation, policies, or initiatives that 
have the potential to impact enrollee reliance must be carefully 
considered. Even a relatively small shift in reliance represents a 
substantial increase in VA's budget. Under the current budget 
environment, every percentage point increase in reliance represents 
significant resource requirements. For example, doubling reliance from 
36% to 72% would necessitate a doubling of VHA's current resource 
requirements. Given this dynamic, experience has shown that policies 
that increase access to VA provided care will increase veteran reliance 
and VA's resource requirements.
                mission access standards cost estimates
    With the passage of the MISSION Act, VA was compelled to establish 
several standards for implementation. To estimate the impact of these 
standards, VA and Milliman started with the 2018 VA EHCPM. Thus, the 
estimates take into account enrollee demographics, health care trends, 
current enrollee reliance, and other drivers accounted for within the 
model.
    VA evaluated several MISSION Act provisions allowing enrollees 
access to community care. Two of the standards are when the VA facility 
does not offer the care required by the enrolled veteran, and the best 
medical interest provision. For purposes of estimating cost impacts 
associated with the access standards, these two standards were 
considered by VA to be a continuation of current practice, so no new 
expenditures were indicated. The remaining MISSION access provisions 
are expected to incur new costs. The proposed access standards were 
published in the Federal Register on February 22, 2019. The Regulatory 
Impact Analysis that accompanies this proposed rule can be found as a 
supporting document at http://www.regulations.gov and is available on 
VA's website at http://www.va.gov/orpm/, by following the link for ``VA 
Regulations Published From FY 2004 Through Fiscal Year to Date.'' This 
notice includes reference to Milliman's expenditure impact analysis of 
the proposed standards. The projected additional expenditures 
associated with these standards resulting from the actuarial analysis 
are repeated below in Figure 7 for reference.
  figure 7--actuarial pricing of proposed va mission access standards
  
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    An overview of the proportion and count of VA enrollees who are 
potentially eligible for each standard is provided in Figure 8.
       figure 8--va enrollees eligible for each mission standard
       
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                     grandfathered choice enrollees
    The MISSION legislation allows the grandfathered Choice enrollees 
to continue to receive community care. These grandfathered enrollees 
include those eligible under the 40-mile distance access standard as 
well as enrollees who live in a state with no full-service medical 
facility. Approximately 685,000, or 7%, of enrollees will be eligible 
under this provision.
    While the explicit grandfathering provisions in the MISSION Act for 
this population are restricted to a five-state subset after two years, 
VA assumed that the additional language, allowing for community care 
when ``in the best medical interest of the covered veteran,'' would 
effectively allow for a continuation of the 40-mile provision for all 
those currently eligible under Choice. Therefore, the increases in 
reliance assumed in FY 2019 and beyond for these enrollees were 
attributed to the MISSION Act and included in the estimates above.
    VA assumes that existing 40-mile enrollees will continue to 
increase their reliance on VA beyond the increased levels seen under 
the Choice program. These enrollees are expected to reach approximately 
50% reliance on VA for their health care, which is similar to the 
reliance level for priority 1 enrollees. Further, these enrollees are 
expected to continue to get care from VA facilities, but growth in 
reliance due to the 40-mile provision is entirely in community care.
    The actual VA health care utilization experience of the 
grandfathered Choice enrollees since the onset of the Choice program 
has provided invaluable insight into the reliance changes that are 
expected to continue for this population into the future. This 
experience also informed the expectations for the defined group of 
enrollees that will become eligible for similar community care access 
under the new drive-time standards. Several of these relevant 
similarities and outcomes are discussed within the ensuing drive time 
standard section.
                          drive time standards
    The proposed drive time standards are 30 minutes to primary care/ 
mental health (PC/MH) and 60 minutes to specialty care (SC). To 
estimate the enrollees eligible under this standard, VA established 
where each enrollee lives and their average drive time to primary, 
secondary, and tertiary VA facilities (using geographic information 
software), resulting in the following:

     12% of enrollees are eligible under both standards.
     20% of enrollees are eligible under the PC/MH standard.
     31% of enrollees are eligible under the SC standard.
     39% of enrollees are eligible under one or both standards.

    Costs for the drive time standards were produced using the 
population size of each group and their anticipated increases in the 
use of different categories of health care services. A detailed 
discussion of the approach and assumptions taken to estimate the 
expenditures associated with the drive time standards is included as 
Attachment A within this testimony [follows Figure 10 data]. This 
discussion highlights the commonalities between the proposed drive time 
standard population and the grandfathered Choice population which 
informed the utilization and reliance assumptions for these estimates, 
some of which are presented in Figure 9.
     figure 9--using choice experience to inform mission estimates

 
------------------------------------------------------------------------
                                             Drive Time Eligible Under
      Grandfathered Choice Enrollees          Both Standards (but not
                                                   grandfathered)
------------------------------------------------------------------------
 Distance eligible (40-miles)       Drive time eligible
                                            (30 min/60min)
------------------------------------------------------------------------
 Enhanced access to community       Enhanced access to
 care                                       community care
------------------------------------------------------------------------
 7% of enrollee population          8% of enrollee
                                            population
------------------------------------------------------------------------
 Ambulatory utilization increased   Ambulatory
 46% from FY 2015 through 2018 and is       utilization expected to
 expected to increase further based on      increase 50% in total
 recent experience
------------------------------------------------------------------------
 Inpatient utilization increased    Inpatient
 29% from FY 2015 through 2018 and is       utilization expected to
 expected to increase further based on      increase 25% in total
 recent experience
------------------------------------------------------------------------
 Ultimate reliance levels           Ultimate reliance
 expected to be approximately 50%           levels expected to be
                                            approximately 50%
------------------------------------------------------------------------
 Ambulatory and inpatient           Ambulatory and
 utilization within VA facilities from FY   inpatient utilization within
 2015 through 2018 was stable and did not   VA facilities will continue
 decline                                    as projected by the EHCPM
                                            (no decline due to MISSION)
------------------------------------------------------------------------
 No material impact on enrollment   No enrollment impact
                                            anticipated
------------------------------------------------------------------------

Wait Time Standards
    The proposed wait time standards are 20 days for primary care/ 
mental health and 28 days for specialty care. Further, all enrollees 
may become eligible under the wait time standard because any enrollee 
may potentially face a wait time for necessary care.
    To produce the cost estimates, VA estimated the number of providers 
that would be required to reduce the primary care/ mental health wait 
times to the standard. This workload these providers would generate was 
then translated into community care workload, and then costed at 
community care rates for the portion of enrollees not already eligible 
under drive time standards (to avoid double-counting). The 28-day 
standard for specialty care was determined to be sufficiently close to 
the current 30-day standard that no additional costs were assumed.
    The estimates of the impact of wait time eligibility criteria under 
the MISSION Act are national level estimates. VA capacity and wait 
times vary significantly by service and by facility and can change 
throughout the year, and from year to year, due to the loss of 
providers, hiring of new providers, increases in productivity, and 
expansion or renovation of space. Therefore, it is not possible to 
project the specific services triggering the wait time criteria at the 
local facility level. However, the national estimates provide credible 
estimates of the type and volume of services that will need to be 
purchased in the community. Finally, no adjustments were made to the 
projected levels of care that these enrollees are expected to receive 
from VA facilities. It is expected that these enrollees will continue 
to use VA facility care as projected by the EHCPM.
Deficient VA Facility Quality/Timeliness (VA Facility service line 
        quality standards)
    Under this provision, enrollees can access community care if they 
need specific care from a facility and the service line responsible for 
this care does not meet the quality standard. Thus, all enrollees are 
potentially eligible for this access. However, the provision will be 
restricted to a limited number of facilities and service lines each 
year. VA estimated this provision by assuming it impacts 12 primary 
care service lines per year (in reality, it would be a mix of service 
lines). These estimates will change when quality standards are 
finalized, though as seen in Figure 7 they represent a small fraction 
of the total estimated MISSION cost impact.
MISSION Standards Impact on Reliance
    Implementation of all MISSION access standards is expected to bring 
the average reliance for the entire enrollee population from 36% to 40% 
by 2021.
            figure 10--mission standards impact on reliance
            
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    The recent experience of those eligible for community care under 
the Choice 40-mile provision provides valuable insight into the 
expected utilization response under community care eligibility. Again, 
referring back to the previous discussion on reliance, most enrollees 
currently get a significant amount of their health care from the 
community via other health insurance. To the extent that VA community 
care eligibility poses little disruption to the care that they are 
already receiving in the community, VA's low cost sharing compared to 
their current OHI becomes an incentive to have VA cover the cost of 
these claims.
    The estimates assume VA's Community Care Network (CCN) contract 
will be implemented in accordance with VA's estimated contract pricing 
and schedule. If the implementation timing of the contract changes, 
that change would impact the cost estimates. Administrative costs for 
the CCN and first-party and third-party collections offsets are not 
included in the EHCPM-based MISSION estimates.
   Attachment A--Drive Time Distance Standard Methodology Discussion
    To give the Committee an understanding of the process and 
methodology used to arrive at the drive time standard cost estimates, 
the following section details the development of the projected 
expenditures of $3.0 billion in FY 2021.
    The proposed drive time standards for primary care, preventive 
care, and mental health are that access be within a 30 minute drive. If 
this type of care is not available at a VA facility within a 30 minute 
drive, then the care could be provided within the community--referred 
to as community care. The equivalent standard proposed for specialty 
care is 60 minutes. As a point of reference, in FY 2018 the average 
drive time to a VA facility was 21.6 minutes for primary care and 48.7 
minutes for specialty care.
    The number of enrollees in each county eligible under each 
provision were measured by VA. Milliman then calculated the percentage 
of enrollees nationwide that would be eligible for care under either 
the primary care or specialty care drive time standards (excluding 
those currently eligible for community care access under the Choice 40-
mile provision), resulting in these estimates for the following five 
groups of enrollees:

     Group 1: 7% of enrollees, eligible for community care due 
to the Choice 40-mile provision. The expenditure impact of continued 
community care provisions for these grandfathered Choice enrollees was 
evaluated separately.
     Group 2: 8% of enrollees, eligible for community care due 
to residing 30 minutes or more from primary care and 60 minutes or more 
from specialty care.
     Group 3: 7% of enrollees, eligible for community care due 
to residing 30 minutes or more from primary care but not 60 minutes or 
more from specialty care.
     Group 4: 18% of enrollees, eligible for community care due 
to residing 60 minutes or more from specialty care but not 30 minutes 
or more from primary care.
     Group 5: 60% of enrollees, who are not eligible for 
community care due to residing within 30 minutes of primary care and 
within 60 minutes of specialty care.

    Naturally, the eligible population increases as the drive time 
standards (or equivalent distance standards) are reduced. The eligible 
population was stratified in this manner to allow for estimation of 
community care utilization impacts in major service categories. For 
example, Group 2 is expected to increase their use of both primary and 
specialty care within the community, while Groups 3 and 4 will increase 
their utilization more intensively in just one of the two areas.
    Using Group 2 as an example of the evaluation process, FY 2017 
actual workload experience for these enrollees was analyzed to allocate 
workload into major categories of service, including primary care, 
specialty care, inpatient and residential care, institutional long-term 
services and supports (LTSS), home and community based services (HCBS), 
prescription drugs, and prosthetics. Group 2 will gain access to both 
primary and specialty care under the drive time standards, making their 
qualification for community care access similar to the grandfathered 
Choice enrollees under the 40-mile provision.
    At 7% of the enrollee population, the grandfathered Choice 
enrollees group also is of similar size to Group 2 and the benefits 
offered to Group 2 enrollees are essentially the same as the 40-mile 
benefit. Therefore, the utilization and expenditure experience of this 
population for community care services under the Choice Act is an 
appropriate reference point for anticipating the expenditures for Group 
2 enrollees under MISSION. VA's community care claims experience shows 
that the Choice 40-mile enrollees increased their overall ambulatory 
service utilization by 46% from FY 2015 (the onset of Choice) through 
FY 2018, with the vast majority of this care being provided in the 
community. However, it also is important to note that VA facility care 
utilization for this population has not declined over this time. In 
other words, these enrollees are not transferring VA facility services 
to the community under the Choice program; rather, VA is covering the 
claims for care they were already receiving in the community from other 
health insurers. Further, access to community care under MISSION is 
expected to be similar to Choice, in that use of community care will be 
authorized by VA for each episode of care and VA will continue to 
coordinate overall care for the veteran enrollee.
    Given Group 2's similarity to the 40-mile population in terms of 
community care access for both primary and specialty care, setting 
Group 2's expected ambulatory care expenditure impact at a 50% increase 
was deemed appropriate. For primary and secondary care, it is assumed 
that their current VA utilization, as represented by expenditures, 
would increase 50%, and that all of this increase would be serviced via 
community care. The increase in inpatient care expenditures (25%) was 
set equal to half of the increase in ambulatory specialty care and 
would also be serviced in the community. The lower increase in 
inpatient care is because approximately half of inpatient admissions 
begin as emergency room admissions, so they are not attributable to 
episodes of care referred to community care. The increase in 
prescription drug care was set equal to 20% of the increase in 
ambulatory specialty care. The relatively lower increase reflects the 
already high levels of reliance on VA for prescription drugs. 
Evaluation of Groups 3 and 4 were performed similarly, but with varying 
assumptions regarding the assumed increase in health care service 
expenditures. The resulting assumed percentage increase in expenditures 
by enrollee group are presented in the table in Figure 11.
        figure 11: assumed percentage increase in expenditures 
                  by enrollee eligibility and service
                  
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Workload increases in FY 2019 were set equal to one-sixth of the FY 
2021 percentage increases shown in Figure 11 to reflect that these 
provisions will only be in effect for four months in FY 2019 and 
assuming that not all enrollees will immediately use these provisions 
at their ultimate level. Workload increases in FY 2020 were set equal 
to one-half of the FY 2021 percentage increases to recognize that 
enrollee behavior patterns will not change immediately even if all 
processes have been fully implemented within VA. The estimated 
expenditure increases result in an expenditure impact of $3.0 billion 
in FY 2021 for the proposed drive time standard for Groups 2, 3, and 4 
(no expenditure impact was assumed for Group 5 enrollees, who do not 
qualify for community care under the proposed drive time standards).
    From a reliance perspective, these projected expenditure impacts 
are equivalent to increasing reliance to approximately 130% of starting 
levels. If the starting reliance for these enrollees matches the 
overall non-40-mile enrollee reliance of 36% in FY 2017 (exact measures 
of MISSION enrollee reliance have yet to become available), then this 
growth would lead to a projected reliance of 47% in FY 2021 (11% 
additive increase). Including projected enrollee demographic changes, 
reliance is expected to be approximately 48% in FY 2021. Further, the 
reliance growth for the populations eligible for just primary or just 
secondary care (Groups 3 and 4) is estimated to increase reliance to 
approximately 110% of starting levels by FY 2021. Again, assuming the 
starting reliance for these enrollees is also 36% in FY 2017, the 
expected reliance would be approximately 39% in FY 2019 due to the 
MISSION provisions. Including demographic changes would further 
increase this to approximately 40%.
                     limitations and considerations
    This analysis relies in part on data and other listings provided by 
various personnel at VA. That data has been reviewed for reasonableness 
and compared to past data submissions and other information, when 
possible. The information has not been audited by Milliman for 
accuracy. If the data or other listings are inaccurate or incomplete, 
this analysis may also be inaccurate or incomplete.
    Some of the information in this analysis is based on modeling 
assumptions and historical data. Estimates presented in this report 
will only be accurate if future experience exactly replicates those 
data and assumptions used in this analysis. Actual experience will 
likely vary from this analysis to a degree for a number of reasons. In 
addition, many of the modeling variables are assumed to be constant 
over time. Therefore, emerging experience should be continually 
monitored to detect whether expectations based on this analysis are 
appropriate over time.
    The results contained in these reports are projections. Actual 
results will differ from those projected here for many reasons. For 
example, it is impossible to determine how world events will unfold. 
Those events that impact the economy and the use of the Nation's 
military may have a profound impact on enrollment and expenditure 
projections into the future. It is important that actual enrollment and 
costs be monitored and the projections updated regularly based on this 
changing environment.
    This report and associated databases were prepared solely to 
provide assistance to the Department of Veterans Affairs. Neither the 
Department of Veterans Affairs nor Milliman assume any duty or 
liability to other parties who receive this work. Milliman recommends 
any recipient be aided by its own actuary or other qualified 
professional when reviewing the Milliman work product. Guidelines 
issued by the American Academy of Actuaries require actuaries to 
include their professional qualifications in all actuarial 
communications. I, Merideth Randles, am a member of the American 
Academy of Actuaries, and I meet the qualification standards for 
performing the analyses in this report.

    Senator Tester. Thank you for your testimony. I thank all 
of you for your testimony. I appreciate it very much.
    I think I am going to start with you, Ms. Randles, because 
actuaries are important.
    When you did your projections, our third-party 
administrator in Montana, and in many other States that had the 
same third-party administrator, was nothing short of a train 
wreck. If there would have been a better third-party 
administrator I think the utilization would have gone up.
    Did you allow for--that is my belief as a farmer, not as an 
actuary, all right? So, did you allow for any of that to impact 
your projections?
    Ms. Randles. I think we allowed for it in so much as, as I 
alluded to in my testimony, when we study the experience of the 
Choice 40-mile enrollees since fiscal year 2015----
    Senator Tester. Yeah.
    Ms. Randles [continuing]. Not only has their access in 
community care increased year over year, but it is not a 
situation where it increased the first year and plateaued. It 
is still on a pathway to increase, and we plan on that 
continuing into the future, during the next three fiscal years.
    So, what we think of as kind of enrollee response----
    Senator Tester. Yeah. Got it.
    Ms. Randles [continuing]. To the new program is continuing 
to have take-ups.
    Senator Tester. OK. Are you aware what the VA has requested 
for their Community Care portion of their budget?
    Ms. Randles. I am specifically aware with what I--the 
actual estimates that I provided to them.
    Senator Tester. So, that means you have got your estimates 
and they may be different from their budget.
    Ms. Randles. Correct.
    Senator Tester. Do we have your estimates?
    Ms. Randles. I believe my estimates were included in my 
written testimony.
    Senator Tester. OK. Good.
    Ms. Randles. One of the tables, yes, as well as in the RAA.
    Senator Tester. Perfect. That answers my question. You do 
not need to go any further. Thank you very much.
    Ms. Randles. You are welcome.
    Senator Tester. Mr. Atizado, we know that the VA cares 
pretty darn good by all the studies that are out there. It is a 
pretty decent quality, I would say higher than the private 
sector. Is the DAV concerned that the VA is holding itself 
accountable for meeting the proposed access standards, but yet 
the private sector not so much?
    Mr. Atizado. Certainly, Senator. You know, the thing we 
would like to avoid is not having this integrated network, 
which is really the foundation of the MISSION Act, right? If we 
do not have a network where VA and the community providers are 
actually working together, meaning working toward the same 
standard, what ends up happening is veterans may get better 
care in one place but not in the other, and that is not what we 
want. That is not what MISSION Act is all about. So, having a 
double standard is really--has so many adverse effects that can 
come of that which we would just like to avoid that altogether.
    Senator Tester. All right. Information is going to be 
critical on this. Are you concerned that many veterans may sign 
up for the Community Care and not understand that it may not be 
as timely or as good?
    Mr. Atizado. That depends on a couple of things, Senator, 
but yes, that is certainly a concern.
    I mentioned earlier, in my oral statement, about wanting to 
make sure all parties involved in this evolution are educated 
and trained and understand how things are supposed to happen. 
One of those things is with regards to coordination of care.
    Senator Tester. Yeah.
    Mr. Atizado. I think this Committee is well aware of the 
value of having coordinated care, but it is not regulated. In 
other words, VA did not propose how that is going to happen. It 
is such a critical piece of how VA delivers care that not to 
have it regulated, meaning to put in regulations to us, is, you 
know, an unfortunate oversight, and we would like to see VA 
correct that.
    Senator Tester. OK. I have got to scoot, but thank you 
guys. I have got to go vote, so thank you guys very, very much 
for your testimony. Ms. Silas, I did not get to you but we 
probably will later. Thank you.
    Ms. Silas. Thank you.
    Chairman Isakson [presiding]. I want to thank Senator 
Tester for burning more time than I intend to. We are not 
getting any cooperation out of our fellow members over there, 
and they are playing games, so we apologize for the delay. I 
appreciate the Ranking Member taking over as chairman for so 
long. Thank you very much--and you got all your questions 
answered?
    Senator Tester. We got them.
    Chairman Isakson. OK. Good. Thanks to all of you. I am so 
sorry that I missed your testimony and was not here when you 
made it. I appreciate your being here. Have you all been 
introduced appropriately?
    Ms. Silas. Yes.
    Mr. Atizado. Yes.
    Ms. Randles. Yes.
    Chairman Isakson. So, you are not upset about your 
introduction. You are all happy it was appropriate.
    Well, I have two quick things and then I want to close, if 
I can. Number 1, I want to thank Mr. Atizado and his 
organization for the amount of time they have put into the 
development of this program, the information that you have 
submitted before you testified today, and your testimony given 
today, which I did not hear because I was not here, but I have 
read, because it was provided to me earlier.
    The VSOs are critically important to our entire veteran 
services that we provide as a country. I am trying to make sure 
your voices are heard and your interest is heard as much as 
possible. I have changed some of the methods that we operated 
under. I have not had as many panels with all the VSOs 
operating at one time but I have tried to make sure the most 
appropriate VSOs for each hearing testified like you have 
today, and I want to thank you for what you have done.
    The other VSOs that are here, we are going to take their 
testimony in writing and submit it for the record, and be 
reviewed by all the Members of the Committee. Our veteran 
service organizations are a tremendous voice for the veteran 
first, and for the country, and we so much appreciate them 
doing it.
    Now, I am going to go to my two questions real quickly. One 
of them is a general question.
    In the cases of many medical treatments that are provided 
by the VA--hearing aids, dental surgery, replacements, 
prostheses--so many different things that are covered, and 
there are many different medical devices that serve the same 
need that are made by different manufacturers. When you provide 
a prosthetic leg or a prosthetic titanium tooth, for example, 
for implants or whatever it might be, do you mandate how many 
choices there must be for the product that is used or do you 
have one certain one that the VA approves? How do you go about 
that situation of making sure the veterans are exposed to the 
best possible equipment or device for the problem that they 
have, and whose choice is that, finally? Am I making good 
sense?
    Mr. Atizado, I will start with you.
    Mr. Atizado. Sure. Thank you for that question, Senator 
Isakson. As you know, when it comes to prosthetics items, let's 
just say for amputees, the prosthetic items that they end up 
selecting is quite individualized. There is a very intimate 
relationship between the prosthetist and the veteran patient.
    Chairman Isakson. Right.
    Mr. Atizado. They need to know both. They need to know 
where the veteran is having problems, what they like and what 
they do not like, what they would like to see more. The 
prosthetist has a responsibility to try and offer them the best 
solution or best prosthetic possible. And, it goes on from 
there. It tends to be quite a long relationship after that.
    Chairman Isakson. Right.
    Mr. Atizado. The decision really is a collaborative 
relationship between the clinician and the veteran, and that is 
critically important. Otherwise, we have got veterans going 
around having the wrong prosthetics can be quite--can have some 
quite terrible consequences for that amputated limb.
    Chairman Isakson. Does anybody else want to comment on that 
question?
    All right. Let me ask--yes, ma'am.
    Ms. Silas. Go ahead.
    Chairman Isakson. OK. Let me ask a second question. I am 74 
years old so I am in that age group where hearing aids are 
becoming a common need in a lot of cases. I have a 102-year-old 
mother-in-law, where my wife is today. My father-in-law passed 
away at 99 years and 11 months, was a World War II veteran. He 
had a hearing aid. I have had more horror stories to tell about 
hearing aids than you have got time to listen.
    However, unlike a prosthesis, where you understand the 
differences because of the anatomy, a hearing aid is a hearing 
aid. But, there are lots of different problems with hearing 
aids categorically. Some of them you cannot find. Some of them 
are too small to handle, all that type of thing. Are there any 
choices that you give the veterans to choose from or do they 
get the hearing aid that the VA recommends, or you recommend as 
a provider? I will ask any of you to address how we should do 
that, or how we do it.
    Ms. Silas, any comment?
    Ms. Silas. I was just going to defer to my fellow 
panelists, as I do not think I am in the best position to 
respond to the question.
    Ms. Randles. I am not in a position to respond to the 
choice that the veteran is given. From the perspective of the 
Enrollee Health Care Projection Model, both for hearing aids 
and in prosthetics, we actively engage with the program leads 
within VA, each year and on an ongoing basis, to find out what 
kind of devices and trends are emerging, so they can be built 
into the forecast to appropriately account for those within the 
budget formulation.
    Chairman Isakson. And that takes place periodically, as a 
function of the VA. Correct?
    Ms. Randles. Exactly. With every annual model update those 
conversations take place.
    Chairman Isakson. Well, thank you very much.
    Is there anything that you have not been asked or that you 
have not had the chance to say that you would like for us to 
know, from any one of these three panelists?
    Yes, sir.
    Mr. Atizado. If I could make one last comment, Senator. One 
of the things that I did not mention in my oral statement that 
I just noticed as I glanced over in my oral statement, but is 
in our written statement, is the idea that veterans in this new 
Community Care Program, the idea of them having an informed 
decision. One of the things that we were hoping VA would 
propose in its regulation is just that--what kind of 
information that veterans would like to see from this network 
so they can make the right choice, I think is what you are 
trying to drive at.
    Chairman Isakson. Precisely.
    Mr. Atizado. There are a couple of things that our members, 
generally, or veterans generally, ask for. For example, if an 
elder, aging veteran who has complex chronic conditions wants 
to be seen in the community, the first thing I would make sure 
the veteran would want to know is that you probably want to go 
see a geriatrician, not just a regular primary care physician, 
because of their conditions.
    So, if there is not this kind of a discussion between a 
doctor, at the very beginning, as far as what the veteran 
should probably look for, then we are really doing them a 
disservice.
    Now when they do find a specific doctor, there are a couple 
of things that patients like to see. I am sure everybody here 
would agree. They want to make sure that the doctor they are 
seeing is not only licensed but beyond that, that they have the 
training and competency standards to provide, say, for example, 
specific evidence-based advanced training that we know works 
for the condition that the veteran is going into the community 
for; that the patient knows the interpersonal skills of the 
clinician. Are they good with the patients? Do the patients 
like the doctors? Does the doctor have good communication 
skills? This basic information, as far as the patient or 
consumer would like to see, a sort of doctor scorecard.
    That is what we were hoping VA would provide our veterans 
when we wrote these provisions in the MISSION Act, about being 
able to compare and contrast between providers, not only in VA 
but comparing VA providers with private providers. 
Unfortunately, that is missing here in the proposed rule.
    Chairman Isakson. I appreciate your comment. I think what 
you are talking about is not only having a choice but making an 
informed choice. Is that correct?
    Mr. Atizado. Yes, sir.
    Chairman Isakson. Thank you very much for your testimony.
    Senator Moran has not asked questions of this panel yet. 
Senator Moran, you are recognized.
    Senator Moran. Chairman, thank you very much.
    Ms. Silas, there was a 2018 GAO report that found the VA 
could not systematically monitor the timeliness of veterans' 
access to care through Choice because it lacked the reliable 
data to do so.
    In a conversation in the appropriations process for 
Department of Defense, Vice Admiral Bono, who leads the 
Department of Defense Health Administration, said, ``The DHA 
believes that these military health system-wide access 
standards ensure a consistent experience of care and access for 
beneficiaries,'' and that ``different health systems must adapt 
standards that meet unique needs of the patients they serve. 
The specific standards we at DOD selected are perhaps not as 
important as the fact that the standards exist. We evaluate 
ourselves against the standards we set, and we share our 
performance with the people we serve.''
    My question is, do you believe that the MISSION Act's 
requirements for strategic planning for market assessments and 
new access standards would help put the VA on a system--help 
create a system that--of consistent experience of care and 
develop more reliable and available data?
    Ms. Silas. Thank you, Senator. I believe all of those 
efforts can make a difference, but I think based on the review 
that we did on the Choice Program, I think there are some 
additional actions that have to be taken to ensure that there 
is reliable data, including putting in processes that are not 
overly complex and putting out consistently comprehensive 
guidance and policies that the staff can be trained on, and 
communicating that information consistently throughout the 
program.
    Then, last, putting in information technology to support 
the program. In our recommendations from our reports on Choice 
last year, as I mentioned in my opening statement, that all of 
our recommendations remain open and they are reliant on two key 
actions from VA. One is awarding all six of the contracts. The 
other is implementing the information technologies to support 
the program. And the two key systems--the decision support tool 
and the health share referral manager system--are estimated to 
be implemented later this year, but I think we need to wait and 
see if they make the schedule for that.
    Senator Moran. Both of those recommendations, and the 
understanding that they are open, just as I--I mean, I assume 
you would agree that just as they are necessary to improve 
Choice they would be necessary and helpful in improving the 
implementation and supports of care for veterans in MISSION.
    Ms. Silas. Yes, sir. We conducted the work on the Choice 
Program, knowing that the program was temporary and would be 
ending and be followed by an implementation of a program--a 
permanent program. So, the audit work that we conducted for 
both of those reviews was doing that with that in mind. Our 
findings and recommendations were to provide opportunities, 
lessons learned, for VA so they could help inform the 
implementation of the new program.
    Senator Moran. One of the things--and I would have asked 
the question--I had prepared to ask a question of the VA 
witnesses, had we not had votes and I had been absent--about 
the implementation of MISSION and what kind of information is 
being provided to the VA in the field.
    Our case work certainly indicates that we get a certain 
direction from VA Central, but the folks who are implementing 
the decisions that have been made here, in Kansas, they do not 
know what the instructions are. We have been encouraging the VA 
to provide a handbook, a set of very straightforward kind of 
conversation, for their employees, for the staff at the VA 
around the country, to better help implement MISSION Act. There 
is more than just putting these regulations in place. How they 
are explained to veterans at home is a significant and critical 
piece.
    Let me just quickly ask Ms. Randles, your modeling is not 
only a project for veteran enrollment utilization for VA health 
care but helps to inform the VA in strategic planning. Is this 
interconnected process valuable for modeling projections to--
let me do this differently.
    Mr. Chairman, I am out of time. Do you want me to finish 
this, or----
    Ms. Randles, modeling for the MISSION Act. The cost impact 
of access standards is due to increased enrollee reliance, but 
I want to note what your statement says, and it was something--
I think this is pretty close--care is not being transferred 
from VA facilities to the community. The cost is due to care 
that was previously paid for by other payers that the VA is now 
paying for, which I believe tells us that the MISSION Act is 
increasing reliance on the VA for care, both in-house and in 
the community, as opposed to Medicare or private insurance.
    Is that something you were attempting to convey? And what I 
think the importance of that is--I mean, I saw this when we 
opened a CBOC, when the VA opened a CBOC in my hometown. The VA 
estimated that there would be 1,200 veterans who would access 
care at that CBOC. Within 6 months it was 2,400, double the 
amount. The difference was the VA estimated the number of 
veterans in that area of our State who would now, instead of 
going to Wichita, use the CBOC. What they never accounted for 
was the veterans who were not accessing care anywhere. I think 
that is part of the point that you are making is that there are 
people who are getting care outside the VA that we are now 
bringing home to the VA.
    Ms. Randles. Yes, that is correct. People who are getting 
care exclusively outside of VA but also part of their care, 
that over half of the veteran enrollees utilize the VA system 
in any given year, both VA and community care, as well as their 
other health insurance. And so the expansion of the MISSION Act 
estimates as an increase in reliance fulfilled through 
community care reflects an expectation that more of that care 
would come under the integration of VA in providing the care 
both within VA facilities in and in community care.
    Senator Moran. Is there another sentence that would follow 
that, that would answer the question, and that is good?
    Ms. Randles. Well, it certainly opens up access, in terms 
of more reliance indicates that VA is courting more of the care 
for the veteran.
    Senator Moran. Thank you. Thank you, Chairman.
    Chairman Isakson. Thank you.
    Senator Manchin.

     HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman. I appreciate you 
holding this hearing.
    Chairman Isakson. You are welcome.
    Senator Manchin. I have some concerns, and my concern 
[inaudible off microphone] want to. That is what is out there 
and that is what I face every day, where I really have a high 
population base per capita. There is no way in the world that I 
have any veteran that wants VA to be privatized. They like the 
care they get at the VA.
    Drive time--where is the song about West Virginia--Take Me 
Home, Country Roads. I can take you home 17 different ways, to 
your house, on a country road in West Virginia. One can take 35 
minutes; one can take 20; one can take 45. But, I will get you 
home. There is no standard set, and that is an $11 billion cost 
item, just to drive.
    We are rolling this out in less than 8 weeks, and they are 
saying here that some of the GAO recommendations you are 
implementing do not go into effect until later this year, but 
we are still rolling it out in 8 week. I do not know what the 
hurry is. I do not know why we are pushing this. We have got--
my goodness, we still have big issues with Choice and CareT and 
everything else.
    I mean, my main concern is how can I get the best care to 
my veterans? Anyway, I know that is in your heart too, or you 
would not be in these positions you are in. But, I do not know 
if we are forcing something on you and telling you to go down 
this path, but I can assure that the veterans and all the 
veteran representative groups are scared to death that this is 
basically the door opening to privatization, especially when 50 
percent of the people can be affected by drive time. It makes 
no sense at all.
    Anybody want to talk to that one? You can punt if you want 
to. I have got another one too.
    Mr. Atizado. Senator Manchin, I appreciate your comments. I 
can certainly agree that our veterans in West Virginia love the 
VA. We understand that it is a very different--they present as 
very complex patients compared to the other veterans in the 
region. So, your veterans in the State of West Virginia have 
very different needs, so applying a general standard to a very 
different population can have some very undesirable results.
    But, I think the thing that I want to key in on your 
comments, Senator Manchin, is that I think veterans who choose 
to go to VA should be allowed the opportunity to be seen by VA, 
not say, ``Well, I want to choose VA but since you cannot see 
me, well, you are going to send me outside.'' That is not 
really their first choice.
    So, that is what we are really trying to focus on, is that 
when they come to VA and want to be seen at the VA facility 
that they get seen at the VA facility, and not just say, 
``Well, since we are not meeting the standard that does not 
really apply anywhere else----''
    Senator Manchin. With all this technology today the private 
sector is going to prey on our veterans like you have never 
seen. I truly believe that in my heart. That is a whole `nother 
cash cow for them.
    Mr. Atizado. I cannot speak to that, Senator Manchin, but I 
can tell you this----
    Senator Manchin. Let me ask you this.
    Mr. Atizado [continuing]. If a veteran is to go to the 
private sector--I do not want to--I would like to make clear 
that DAV is not opposed to veterans going into the private 
sector.
    Senator Manchin. Oh, no. I know we are not. We are trying 
to make sure they get the best care wherever they need it.
    Mr. Atizado. That is exactly right, the best care, and that 
is what we are trying to focus on in this hearing, and in the 
regulations we proposed.
    Senator Manchin. I am trying to say if we keep our veteran 
hospitals and our CBOCs and our clinics up to snuff, doing 
their job, they are going to get the best care right there. And 
what happens, we have allowed a lot of things to fall below 
standards, showing that we cannot give them the care, and we 
have got to go outside into private care. That is what my 
concern is.
    And here is the other thing. To me, managed care--we should 
be managing some of our--you know, some of our more sickly and 
more critical illnesses, to where they are getting that best 
care, specialized care.
    I just--I am really worried about this, Mr. Chairman. I 
know that you have a tremendous population base also of 
veterans, and I do not know if you have heard it as much from 
yours, but I can tell you ours are very, very concerned, 
because now we are just starting to get some veteran CBOCs. We 
have got portable clinics. They are getting the care and they 
love it, and now they are going to say we are starting all over 
again. I do not know.
    Do you want to jump in?
    Ms. Randles. I would just reiterate, as I said before, from 
a data perspective, since the onset of the Choice Program, 
those enrollees who did become eligible for enhanced community 
access under Choice, the 40-milers, we have watched their 
utilization grow, both within the community but it has also 
been stable within the VA facility. So, over this 3 to 4-year 
period their use of the VA facilities has been stable and has 
not declined. It has actually had a slight increase over this 
period as well.
    The other thing I would say is when we sort veteran 
patients into VA facility or Community Care they do not fall 
into one bucket or the other. The vast majority of the 
enrollees are utilizing VA facility care and Community Care 
services, paid for by VA, and coordinated by VA, during the 
fiscal year. So, they are being served by both care delivery 
systems.
    Senator Manchin. The other thing I wanted to touch one, 
which just adds to the concerns that we have, I understand 
there are 40,000 vacancies in the VA--40,000? What effort are 
we trying to do to fill those, or are we basically taking this 
approach because we cannot fill them?
    Does anybody want to take that one?
    I will give you one part. I am going to help you a little 
bit here.
    Our CBOC in Parkersburg, WV, which is one of our larger 
little towns--beautiful, on the river, the Ohio River--they are 
having a lot of trouble hiring and retaining providers, and it 
is hard for them, and all of my VA facilities, really, to 
compete with the higher salaries in other States, which we have 
not made those adjustments.
    So, I mean, we are leaving--we are with a skeleton crew. We 
cannot give the services. We can justify they need to go to the 
private because they can get the better care, because we are 
not paying competent wages.
    Mr. Atizado. Senator Manchin, if I could tag onto that, I 
know your time is running. But first I want to----
    Senator Manchin. We are OK. Answer this and then----
    Chairman Isakson. I am actually enjoying what is going on 
with this. [Laughter.]
    I am going to take advantage of it in just a second. So, 
you all go ahead and finish your little exercise.
    Mr. Atizado. So, I want to thank this Committee for taking 
a very bold approach in rolling back one of the key components 
that VA uses to help attract and retain and recruit highly-
qualified candidates, and that is what Senator Sinema was 
referring to when she was here, at the hearing. It is the 
recruitment relocation retention bonus program that VA has. 
That is a very important tool that recruiters have, across the 
VA health care system, when they see a good candidate, a strong 
candidate, a compassionate candidate, that wants to work in a 
VA and take care of our veterans. We are so thankful this was 
passed and took that cap off. We are so glad this Committee 
gave the VA additional financial tools to help entice 
candidates to come in, whether it is debt reduction or 
scholarships.
    Senator Manchin. Let me ask you that, on debt reduction, 
because I have got an awful lot of medical schools--I have got 
three medical schools, and I asked them all, I said, ``Are they 
recruiting out with you all? Are they coming at you hard?'' I 
have got nursing schools. Are you recruiting in nursing 
schools? They do not see rapid or active recruitment going on.
    So, we might have put flyers out. We have might have done 
something but we have not actively gotten in and gone after--
because some of these people want to reduce their debt. They 
want to bet out of debt, and they just--they are looking for 
ways of public service. And who knows? We might find people 
that really love the care they are giving and stay right with 
us. It is something we should be--there is so much more we can 
do.
    Let me just say, about the Committee, though, our Chairman 
here. Our Chairman--this is going to be the best Committee you 
have got. It is the best Committee I serve on because it is 
bipartisan, truly bipartisan, because of our Chairman and our 
Ranking Member. All we care about--this is the one Committee 
that keeps us all together and bipartisan. It is the veterans.
    But, there are few that have a mindset that the private 
sector is always the way to go. That is except the type of care 
that a veteran deserves. It may be the private sector does not 
have really the resources, or they do not have the incentive 
for the return on investment that might come from a veteran 
that you might get in the private sector, so we have to be very 
care of that. So, we are very cautious. I have not found a 
veteran yet that wants to go to private care, but they will 
when they cannot get the care. I am concerned that we are not 
giving the care because it is kind of a back door, it forces 
them to go to private. That is the problem I am dealing with, 
which is hard.
    Mr. Chairman, thank you for indulging me. You and I have a 
passion. I appreciate it, man. You have been going at this and 
I appreciate it.
    Chairman Isakson. Well, I am glad you came and I am glad we 
closed with this exercise, and I want to comment on it. Is that 
all----
    Senator Manchin. They are, too.
    Chairman Isakson. Yeah. Everybody--you know, the mind can 
only absorb what the seat can endure, and I think all of us 
have had enough of that for a while.
    Anyway, I want to thank you for your comments and thank you 
all for being here. Let me make a couple of comments on the 
privatization deal.
    I have been here since this whole thing started. This is 
almost my 15th year in the U.S. Senate. John McCain really kind 
of kicked off the idea of veterans' Choice when he was coming 
to the Committee, to get us to address the subject, because 
veterans were having some problems. And, you know, we did not 
just create it out of the air because there was not a need. 
There was a need for more doctors to serve veterans. At the 
time maybe we did it by making Choice available. We came up 
with a 30-mile rule--I mean, the 30-day rule and 40-mile rule 
and these other thresholds, and now we are getting a new rule 
for access, which is a 20-day rule and the 28-day rule, or 
whatever they are.
    We tried to find those magic things to say, well, the 
veteran can go to the VA or if this happens, if they meet this 
criteria, we can let them go to the private sector. We have had 
some bad experiences, which you are going to have with any big 
program, but we also learned a lot.
    I think we learned two things. One, we learned that we are 
not giving our VA hospitals and doctors and directors and VISN 
directors the money and the access they need to go out and 
recruit in the private sector, and we were getting killed. I 
want to thank you for mentioning--you brought it up, Joe--what 
we did pass a couple of years ago, where they now have the 
ability in a lot of disciplines to go out and hire in a 
competitive manner, in the private sector, and that is great. 
We do have 40,000 vacancies in various places in the government 
because people do not want to work there.
    I would add, if we are always talking about privatizing 
something, I am not going to apply to work there if I do not 
know whether it is going to be public or private. So, we are 
our own worst enemies sometimes if we talk too much about 
alternative operations other than the one we have. That is not 
a criticism. That is just a point to make.
    The second thing is, I asked the question about hearing 
aids and other medical devices. I had a veteran who wanted to 
know if there is choice of somebody to provide the service they 
need medically but also provide what they need for their 
disease or their injury or their difficulty, to be better in 
the future than they are today. That depends o constantly 
looking at what is new to come, what is there, and what they 
can bring new to our veterans. You are never going to get the 
best of that unless you have some private participation as well 
as the VA.
    We are not going to privatize the VA. It is not my job to 
say we are or we are not. As Chairman of the Committee I cannot 
see any way you could privatize it, nor do I see any way you 
could treat our veterans by taking away the option of having a 
private sector choice. We have just got to make sure the 
private choice option they make is the best option for the 
veteran, and that we are doing the things we have to do in 
running that system, to be sure the doctors that are in that 
system get paid, and that we are demanding the best out of 
both--our employees as well as the private sector--without 
discrimination, without prejudice, or without anything else.
    I think we can do that. I think the system wants to do 
that, and I think the attitudes within the VA are better today 
toward making ourselves better than finding some reason to put 
off doing this Choice thing because we do not like the idea of 
what it may become.
    I hear loud and clear the fear that people have, and I know 
what some say in the private sector. I also know veterans who 
say they have had bad experiences in the VA, and Lord knows we 
have had some of those as well. But, I appreciate you bringing 
up the point, and thank you for complimenting us on what we did 
as a Committee. We are going to continue to try to do those 
things as a Committee to give tools to our VISNs, our hospital 
directors, and our other administrators, to figure out how to 
fill the vacancies we have got and hire the best people that we 
can.
    With that said, do you want to say something more, Joe?
    Senator Manchin. Yeah. I just wanted to follow up. You 
know, our affection for our dear, departed friend, John McCain, 
goes deep on both sides, very deep. The scandal that went on 
that caused all this to start, this dialog--you all remember 
that--and John was trying to react. We all reacted. We acted 
very quickly. We were embarrassed by it and wanted to fix it. 
Sometimes we are not the best at fixing; we will overfix. And, 
rather than getting rid of the bad apples and changing the 
system so you could not scam it and could not get bonuses and 
could not play the games they were playing, we went to a whole 
`nother area, which is where all this started.
    I am going to give you a perfect example. In the VA 
hospital in Clarksburg, WV, the Johnson Hospital, an 
autoclave--an autoclave is what sterilizes the operating 
equipment. You would think that someone would know that this 
one was on its last leg; we ought to get another one. It went 
down and they could not do any operations. Now you are asking 
me, how can that happen? How does that happen? And, they would 
start sending patients out to have the routine procedures done 
that we had been doing right there.
    We were doing another procedure for pulmonary exams. 
Private sector was charging us $700 to send them out and do 
pulmonary. We raised holy hell to get the equipment to do the 
exams in the VA. We were doing them for less than $100. We know 
we can do it, but for some reason--I do not know who is in 
charge of that--really, the audit and the equipment and the 
update and just the operation of these procedures, because that 
is what is happening to us, and that is the biggest fear they 
have. They said, ``Well, I need the care and I would like to 
get it at the VA, but they do not have it anymore'' or ``This 
is not working.''
    Does that make sense? That is what we are working with, Mr. 
Chairman. That is what we are afraid of. If we can keep that 
up, and they have the best of Choice, which is truly a choice, 
if I can get the same service at the Woody Williams VA Center 
in Huntington that I can get at CMC, Charleston Medical Center, 
I am fine with that. I am fine with that. We are not giving 
them that choice because we are not staying up to speed.
    That is my two cents. Thank you.
    Chairman Isakson. Well, I appreciate the input and I 
appreciate your testifying today. Our job here is to make sure 
the VA serves the veteran but also serves the taxpayer of the 
United States of America, that they are getting the best bang 
for their dollar as well. And, many taxpayers are also 
veterans, so we are in good shape--well, most of them are not 
veterans, but the 1 percent of them that are veterans deserve 
the very best choice, and this Committee is going to see to it 
that they get it.
    I appreciate the input we have had. We have got some 
challenges to go. I want to underwrite what Dr. Stone said. We 
are going to technically be ready by June 6, but practically, 
because we all know that because of the incumbent systems that 
are inherited, because of changes with technology that have to 
be made, there are lots of things we are going to have to do, 
to stumble before we walk.
    But, our goal is to walk and then run to do so 
successfully. This Committee is going to support the VA and 
support our veteran service organizations. We are going to be 
the Dumbos of the whole Congress. We are going to listen to the 
suggestions that we get and make sure we are doing the best 
thing we can do for our veterans.
    So, on behalf of all the veterans in America and the people 
of the United States of America who send us up here, thank you 
all for participating, and be reminded that everybody has got 5 
days--all Members have 5 days to submit additional questions or 
additional information they want to go for the record.
    Unless there is any other business before this Committee we 
stand adjourned.
    [Whereupon, at 4:34 p.m., the Committee was adjourned.]
                                ------                                

  Response to Posthearing Questions Submitted by Hon. Jerry Moran to 
    Sharon M. Silas, Acting Director, Health Care, U.S. Government 
                         Accountability Office
    Question 1. In June 2018, GAO published a report to assess access-
related challenges of VA care under the Veterans Choice Program. In 
that report, GAO stated that in spite of the requirement to receive 
care within 30 days under Choice, veteran patients could have to wait 
up to 70 days for care. The report stated that one of the primary 
factors leading to a delay in care is due to an insufficient number, 
mix, or geographic distribution of community providers. Is this true?
    Response. Yes, this is correct. According to VA medical center 
managers and third party administrator (TPA) officials we interviewed, 
the TPAs' inadequate networks of community providers affected both the 
timeliness with which veterans received Choice Program care and the 
extent to which veterans were able to access community providers 
located close to their homes. We found that establishing adequate 
networks of Choice Program providers in rural areas has been 
particularly difficult. In September 2015, about 11 months after the 
Choice Program was implemented, VA contracting officials sent 
corrective action letters to both TPAs, citing network adequacy (i.e., 
the number and mix of specialists and the geographic distribution of 
network providers) as a concern. The overall number of community 
providers participating in the TPAs' Choice Program networks nationwide 
grew dramatically over the following year-from almost 39,000 providers 
in September 2015 to more than 161,000 providers as of September 2016. 
However, at the time of our review, managers at five of the six 
selected VA medical centers told us that they still observed TPA 
network inadequacies that impeded veterans' access to Choice Program 
care. Similarly, managers at three VA medical centers in our sample 
said that key community providers-including large academic medical 
centers-have refused to join the TPAs' networks or dropped out of the 
networks after joining them, often because the TPAs had not paid them 
in a timely manner for the services they provided.

    Question 2. Do you agree that the MISSION Act access standards 
established by the VA will help to address this challenge?
    Response. VA's proposed access standards for the Veterans Community 
Care Program (VCCP) would allow veterans to receive care from community 
providers when the services needed are not available at a VA medical 
facility within allowable wait times or when veterans' average drive 
time from a VA medical facility exceeds 30 minutes for primary care, 
mental health, and non-institutional extended care or 60 minutes for 
specialty care. To help ensure the adequacy of provider networks under 
the VCCP, in our June 2018 report, we recommended that the Secretary of 
Veterans Affairs ensure that the contracts for the VCCP include 
performance metrics that will allow VA to monitor average driving times 
between veterans' homes and the practice locations of community 
providers that participate in the TPAs' networks. VA agreed with our 
recommendation and has taken steps to implement it. In April 2019, we 
reported that VA's Veterans Community Care Network contract request for 
proposals includes performance metrics that will allow VA to monitor 
average driving times between veterans' homes and the practice 
locations of community providers that participate in the TPAs' 
networks.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Jerry Moran to 
      Merideth Randles, Principal and Consulting Actuary, Milliman
    Question 1. On veteran reliance on VA care, can you please explain 
the difference you see and project in enrollee demographics?

    Question 1a. Do you see greater reliance on VA care from rural 
veterans or is it about the same as non-rural veterans?
    Response. Reliance is studied and modeled geographically by market 
areas defined by VA. These markets, which typically reflect catchment 
areas around VA medical centers, may contain both urban and rural 
enrollees. However, we can relay some reliance observations for the 
Choice 40-mile eligible population (Choice enrollees), which by means 
of their eligibility, represent a largely rural subset of the enrollee 
population. In FY 2017, the aggregate reliance (both VA facility and 
community care) for these Choice enrollees was slightly less than the 
average enrollee--within two percentage points, though the difference 
in reliance between 40-mile Choice enrollees and other enrollees was 
larger prior to the introduction of Choice.

    Question 1b. Is there a greater reliance on community care through 
the VA for rural veterans?
    Response. When considering reliance specifically for community 
care, the proportion of total reliance attributed to community care for 
these Choice enrollees was 27% while the outcome for all enrollees was 
17%. In other words, there was a greater reliance on community care 
through VA for Choice enrollees as compared to the average enrollee.

    Question 1c. How does geography and where a veteran resides play a 
role on reliance on VA care, within the VA or in the community?
    Response. A study of reliance and drive times conducted on FY 2008 
enrollee experience data indicated that as drive times to VA care are 
reduced, there was an increase on enrollee reliance. Further, the study 
indicated that changes in drive time to specialty secondary care 
generally had the largest impact on reliance while changes to primary 
care drive times generally had the least impact. This study did not 
discriminate between care provided at VA facilities versus community 
care obtained through VA.

    Question 2. What or who is the ``defined group of enrollees 
eligible under new drive-time standards and grandfathered Choice 40-
mile enrollee standards'' and what are your cost projections for this 
group?
    You have estimated that 39% of veteran enrollees--about 3.7 million 
veterans--are eligible for community care under either the 30 minute 
drive time access standard for Primary and Mental Health care or the 60 
minute drive time access standard for Specialty care. But, this 
percentage and figure also includes those veterans who are the 40-
miler's and grandfathered into MISSION. Breaking this down--for those 5 
states that were granted this grandfathering exemption where the new 
access standards will not apply to them, there are 685,000 veterans who 
will be eligible for care in the community regardless of the new drive 
time or wait time standards. Those 685,000 veterans account for almost 
19% of the total 3.7 million veterans eligible for care in the 
community, correct?
    Response. Yes, the 685,000 grandfathered 40-mile Choice enrollees 
are included in the 3.7 million veterans eligible for community care 
under MISSION. The remaining 3 million veterans are eligible for 
community care through the proposed drive time access standards of 30 
minute drive time for Primary and Mental Health care or the 60 minute 
drive time access standard for Specialty care. The MISSION Access 
standards Regulatory Impact Analysis (RIA) published by the Department 
of Veterans Affairs on February 15, 2019, also contains a table (below) 
detailing the enrollee groups associated with each MISSION eligibility 
provision.

         Table: Assumed Percentage Increase in Utilization by 
                Enrollee Eligibility Cohort and Service
                
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                            A P P E N D I X

                              ----------                              


Prepared Statement of American Federation of Government Employees, AFL-
                                  CIO
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, On behalf of the over 700,000 Federal and D.C. employees 
represented by the American Federation of Government Employees (AFGE), 
AFL-CIO, including the over 250,000 frontline employees of the 
Department of Veterans Affairs (VA) represented by AFGE, we write today 
to provide our comments on the state of the VA MISSION Act 
implementation as well as the harm expanded private sector intrusion 
will have on the VA's ability to deliver high quality, timely care to 
veterans. We want to take this opportunity to repeat our concerns about 
the VA MISSION Act, its proposed access standards, expansion of walk-in 
clinics, and the negative impact this law will have on the VA workforce 
and the veteran patient population across the country. Without taking 
substantially more time to analyze the large-scale impact of this law, 
including the proposed access standards and new walk-in clinic program, 
the VA MISSION Act will lead to an irreversible dismantling and 
weakening of VA's exemplary, uniquely veteran-centric health care 
system.
    While there are significant problems with the substance of the new 
law that must be considered, the first and most obvious problem is the 
secretive, unacceptable nature of the rule writing process. For 
example, the proposed access standards were created behind closed doors 
without any input from Congressional leadership, the veterans service 
organization (VSO) community, or representatives of the in-house 
frontline workforce. By writing this proposal without input from 
stakeholders the VA has made even more controversial an already 
controversial issue. Problems that are entirely foreseeable could have 
been mitigated if Congress, VSOs, and the VA workforce had been 
permitted to participate in the drafting process. That did not happen 
and, therefore the VA should withdraw the proposed rule and redraft the 
proposal in a more inclusive manner.
    One of the most serious shortcomings of the access standards 
created by the CHOICE program was the arbitrary 30 day/40-mile rule. 
Under this program if a veteran's VA had a 30 day wait, or if s/he 
lived 40 miles or more away from the nearest VA, that veteran was 
authorized to seek care in the private sector. Under the CHOICE 
standards, approximately 8 percent of veterans were eligible to go into 
the private sector.
    Unfortunately, the new proposed standards drastically increase the 
diversion of more VA care into the private sector. Under the proposed 
rule, if a veteran's nearest VA has a 20-day wait time for primary care 
(including mental health) or a 28-day wait time for specialty care the 
patient will be sent to the private sector. We also have strong 
concerns that if a veteran finds the wait time is too long outside of 
the VA, that veteran will have to go through an unnecessarily 
burdensome process to come back inside of the VA. This is not 
``choice'' or ``access;'' it is a one-way ticket to a fully outsourced 
VA. Similarly, if a veteran can certify that he or she has an average 
drivetime of 30-minutes for primary care and one-hour drivetime for 
specialty care, that also triggers a private sector referral. According 
to the VA's own Economic Regulatory Impact Analysis the total number of 
veterans eligible to receive private sector care is estimated to 
increase from 8 percent to 39 percent if this proposed rule goes into 
effect. The Committee must demand that the VA withdraw and re-write 
this proposed rule.
    Equally troubling is that if these new access standards are 
implemented, they will perpetuate the egregious double standard already 
inflicted upon VA providers (who have to meet stricter competency 
standards than private sector providers treating veterans). The private 
sector will not have to meet the same or even similar access standards. 
There is no metric in place that will guarantee that a veteran who 
qualifies for a private sector referral will not be sent out into the 
``community'' to wait 20 days or more for primary care or drive 30 
minutes or longer. Without providing an equal playing field the VA is 
setting itself up to fail and continues the push toward outright 
privatization.
    Another major aspect of this law that is problematic is the 
expanded access to walk-in clinics for a veteran to receive their care. 
It's important to look at the Department's past performance with walk-
in clinics to articulate our fears with this new proposal. For example, 
when then-Secretary Shulkin authorized the use of CVS Minute Clinics as 
a pilot program in 2017 the Department exercised virtually no oversight 
of the providers. It is premature to allow open access to walk-in 
clinics without studying the cost associated with these walk-in 
providers and the quality of care they provide. Since the CVS pilot has 
at least a year of data for examination, at a minimum, an estimate of 
how much this program will cost is needed, as well as information 
compiled on patient outcomes. Yet, unfortunately, no such study has 
been conducted prior to pushing implementation.
    The thought that veterans could use walk-in clinics for mental 
health services gives AFGE significant pause. We cannot conceive of any 
appropriate instance when mental health treatment would be suitably 
provided in a walk-in clinic. The VA is the national leader in 
integrating primary care and mental health; walk-in clinics will result 
in inferior, fragmented mental health care by providers with 
significantly less veteran centric training and accountability. This 
will most certainly lead to negative health outcomes for veterans. 
Instead of outsourcing this vital component of veteran care, the VA 
should be working to build internal mental health capacity.
    While it is encouraging to see the Department move toward placing a 
copayment on walk-in clinics after the third visit in a calendar year, 
more needs to be done to show this will be a deterrent. Currently there 
is no insight into how copayments will impact utilization or harm the 
veteran population. The underlying law also gives the Secretary full 
discretion to waive copayments. This poses a problem: if the Secretary 
routinely waives the copayments there will be no disincentive to using 
these clinics.
    Ultimately, none of this would be necessary if the VA would commit 
to building internal capacity and provide adequate money for staffing 
and internal resources. In order for the VA to be fully operational it 
must be fully staffed. In addition to creating a new, permanent private 
sector care program, the VA MISSION Act also requires the Department to 
publish data on vacancies and hiring. Since the first set of data was 
published on August 31, 2018, the number of vacant positions at the VA 
has steadily increased. As of the most recent reporting the total 
number of unfilled positions at the VA is nearly 49,000--with nearly 
43,000 of those positions located in VHA. Instead of finding ways to 
justify sending patients outside of the VA to receive their care, the 
VA should be laser focused on hiring more fulltime professionals who 
want to make a career out of serving the veterans.
    AFGE insists that the VA stop rushing to implement the MISSION Act 
and start over, with more provisions in place to ensure the integrity 
of the program and more oversight of cost and quality. The VA MISSION 
Act represents a truly massive change to the future of the VA, and its 
rollout should not be fast tracked, and implementation should not 
proceed before critical data on market capacity, provider quality and 
wait times are collected.
    Thank you for the opportunity to explain our concerns as it relates 
to implementing the VA MISSION Act and we look forward to working with 
the Committee to ensure that the VA workforce is able to grow, thrive, 
and continue providing world-class care and services to our Nation's 
heroes.
                                 ______
                                 
        Prepared Statement of Dan Caldwell, Executive Director, 
                     Concerned Veterans for America
                               testimony
    Five years ago to the day, we learned that dozens of veterans died 
on secret wait lists waiting to receive health care appointments at the 
Phoenix VA Medical Center.
    In the weeks that followed, the media reported alarming details 
about how the Phoenix VA and other VA facilities across the United 
States used secret wait lists to game the system and hide the number of 
veterans left waiting weeks and months to receive medical care.
    That summer, Concerned Veterans for America along with dozens of 
other veterans organizations agreed an alternative option for veterans 
to access care in the community was necessary.
    This led to the passage of the Veterans Access, Choice, and 
Accountability Act of 2014 which created the Veterans Choice Program. 
The temporary new program was intended to give veterans more choice and 
reduce wait times, however, it faced significant challenges and 
limitations.
    Four years later, Congress passed the landmark VA MISSION Act of 
2018 to consolidate the VA's community care programs into one permanent 
program.
    Instead of repeating the mistakes of the Veterans Choice Program 
and using arbitrary eligibility criteria for non-VA care, the VA 
MISSION Act directs the VA to structure the new Veterans Community Care 
Program and eligibility standards to reflect best practices used in the 
private sector and other government-run health care programs with the 
goal of delivering the best medical outcomes.
    In February, the VA released the Proposed Rule (PR) for the new 
Veterans Community Care Program access standards. CVA believes these 
access standards mark significant progress toward modernizing the VA's 
delivery of health care.
Proposed Designated Access Standards
    The VA's interpretation of ``designated access standard'' to 
include all types of care delivered through the Veterans Health 
Administration rightly reflects the flexibility given to the VA in the 
law. The VA is clearly given discretion to determine the clinical 
services eligible for community care in the VA's access standards in 
Section 1703B(a) of the VA MISSION Act.
TRICARE Prime-type Access Standards
    Last summer CVA responded to the VA's Request for Information and 
expressed our support for TRICARE Prime-type access standards based on 
drive time, wait time, and the type of care needed.\1\
---------------------------------------------------------------------------
    \1\ Concerned Veterans for America, ``Comment on Requests for 
Information: Health Care Access Standards,'' July 27, 2018,https://
www.regulations.gov/document?D=VA-2018-VACO-0001-1183
---------------------------------------------------------------------------
    As a managed care option for military families, TRICARE Prime 
allows individuals access to military health system facilities while 
also offering the ability to refer patients to community providers if 
the established access to care standards cannot be met in-network. This 
style of network closely mirrors the current VA health care system and 
how the VA has utilized various community care authorization 
authorities over the years, including before the Choice Program even 
existed.
    The TRICARE Prime-style standards CVA supports reflect how access 
standards are applied across other Federal programs and industry 
practice.
    According to the August 2014 Military Health System Review report, 
there are no national benchmarks or scientific evidence to recommend 
specific access standards. Based on their review of over a dozen major 
health care providers in Appendix 3.6 \2\ of the report, the current 
TRICARE Prime access to care standards closely align with industry 
standards for urgent, routine, and specialty care. Additionally, data 
collected by the Department of Health and Human Services in a 2014 
report\3\ found over 30 states have drive time or mileage requirements 
for primary care under Medicaid.
---------------------------------------------------------------------------
    \2\ Military Health System Review Report, August 2014. Appendix 3.6 
http://archive.defense.gov/pubs/
140930_MHS_Review_Final_Report_Appendices.pdf#page=198
    \3\ Office of the Inspector General, Department of Health and Human 
Services, ``State Standards for Access to Care in Medicaid Managed 
Care,'' September 25, 2014. https://oig.hhs.gov/oei/reports/oei-02-11-
00320.pdf
---------------------------------------------------------------------------
    From the very beginning, the Choice Program's mileage criteria for 
eligibility was arbitrary, poorly calculated, and difficult to fairly 
implement. In the PR, the VA outlines how shifting from mileage to 
drive time reflects standard industry practice. CVA agrees using drive 
time as a standard for eligibility will improve access to outside care 
for both rural and urban veterans.
    Many of today's veterans who are entering the VA health care system 
are accustomed to the TRICARE Prime system and understand its access to 
care standards. Integrating those same standards into the Veterans 
Health Administration (VHA) is an opportunity to streamline care for 
our veterans. By utilizing standards that account for the differences 
between routine care, specialty, and urgent care while also using drive 
time as a measurement tool, much-needed clarity can be brought into 
VHA.
Application of Access Standards to Community Care
    In our comment to the PR in the Federal Register,\4\ CVA noted the 
application of access standards in the private sector is inherently 
different from how Federal and state agencies utilize access standards.
---------------------------------------------------------------------------
    \4\ Concerned Veterans for America, ``Comment on Proposed Rule: 
Veterans Community Care Program,'' March 25, 2019, https://
www.regulations.gov/document?D=VA-2019-VHA-0008-22815
---------------------------------------------------------------------------
    For the VHA, access standards are the mechanism to provide the 
option of choice in the community if the VA cannot meet those 
standards. In the private sector, patients already have full choice and 
access standards are a mechanism to measure performance and network 
capacity, not eligibility. We agree with the VA's assessment in their 
PR and in the Economic Regulatory Impact Analysis that measuring access 
standards used by Federal and state agencies is a better comparison 
tool.
    Additionally, recognizing private health care providers are not 
comparable to Federal entities, a broad application of the proposed 
access standards onto all community care providers would lead to 
unintended consequences. Under the VA MISSION Act, non-VA providers are 
required to comply with the established access standards, however, CVA 
believes the strict disqualification of community care providers based 
on access standards would be unwise.
    For example, in areas where there is a shortage of medical 
providers, a primary care provider that is a 45-minute drive is still a 
more attractive option for a veteran who might otherwise face a 60-
minute drive to a VA clinic.
    The VA should make every effort to apply the access standards in a 
reasonable manner that provides flexibility to non-VA providers and 
ultimately puts the needs of veterans first.
Misinformation Regarding Implementation
    Significant incorrect claims have been circulated about the VA 
MISSION Act that do not accurately reflect the actual text of the law 
or the PR.
    Neither the PR nor the VA MISSION Act dismantle the VHA. The VA 
will continue to serve as the primary location where eligible veterans 
receive health care services. However, in the 21st Century with an 
increasingly diverse and geographically scattered veteran population, 
the VA is not always the best option for every veteran. Providing a 
permanent program to coordinate non-VA care will ensure the VA 
continues to provide the best medical care to our veterans.
    The PR will not divert funding from VA facilities to community care 
needs. The VA MISSION Act does require the VA to conduct market 
assessments and examine the VA's current infrastructure and adjust and 
realign as necessary, however, the VA does not have the authority to 
reprogram Federal dollars without the explicit authorization of 
Congress.
Delaying Implementation
    Concerns have arisen from Members of Congress regarding the VA's 
readiness for implementing the necessary IT systems to manage the new 
VA Community Care Program.
    Since passage of the VA MISSION Act, CVA has tirelessly advocated 
for robust congressional oversight to ensure the VA is meeting internal 
deadlines to develop and test systems prior to implementation. The VA 
should be held to the deadlines established by Congress in the VA 
MISSION Act, however, if modifications to the rollout need to be made, 
that is a conversation for Congress and the VA to engage in and come to 
a mutually agreed upon decision.
    One thing is clear, the rollout should not be delayed as a 
political ploy to undermine the VA MISSION Act. Congress should act in 
good faith to assist the VA and support the successful implementation 
of the VA MISSION Act.
                               conclusion
    The VA's proposed access standards mark significant progress toward 
modernizing the VA's delivery of health care.
    If a veteran is eligible under the VA MISSION Act for community 
care, the final decision will always be left up to the veteran. Nothing 
in the VA MISSION Act mandates a veteran receive care in the community. 
Protecting the VA bureaucracy and VA bureaucrats is nowhere in the VA's 
mission statement and the chief responsibility of the VA health care 
system is to deliver quality care to our Nation's veterans.
    Veterans who choose to serve their country in uniform should be 
able to choose their doctor when they take off their uniform, 
especially if their local VA facility cannot deliver quality care in a 
timely or accessible manner. When veterans do not have choice, you get 
the Phoenix VA in 2014.
    What happened at the Phoenix VA hospital is inexcusable and five 
years later, Congress and the VA must get implementation of the VA 
MISSION Act right.
                                 ______
                                 
          Prepared Statement from the Defense Health Agency, 
                         Department of Defense
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, I am pleased to represent the Defense Health Agency (DHA) 
and share our approach to improving the patient experience in the 
Department of Defense (DOD), to include establishing and monitoring 
access to care standards for military beneficiaries. We have been 
fortunate to work closely with our colleagues in the Department of 
Veterans Affairs (VA) over the past year as they develop standards in 
support of the VA Maintaining Internal Systems and Strengthening 
Integrated Outside Networks Act (MISSION Act) of 2018.
    While our core access standards have been in place for 25 years, we 
have continuously learned and adapted our approach as beneficiary 
expectations and needs have changed. While I recognize that the VA 
population is less concentrated around military installations than our 
own, we share some similarities in serving a dispersed beneficiary 
population with a mixture of medical facilities we operate, 
complemented by a network of contracted medical services to support 
locations where facilities have limited scope of services for our 
beneficiaries. I will provide a brief history on how we established 
these standards, and our experience in managing compliance with these 
standards both for our military hospitals and clinics and for providers 
in our TRICARE network.
    When TRICARE was first established in 1993, patients were provided 
with choices in health care plans--TRICARE Prime, TRICARE Extra, and 
TRICARE Standard. The TRICARE Prime option functioned similar to a 
health maintenance organization (HMO) model. Patients were provided 
with a primary care manager, responsible for all of the patient's 
primary care needs, and would manage referrals to specialists. In 1994, 
DOD established access to care standards as an important incentive to 
attract beneficiaries to select TRICARE Prime as their health plan 
choice. Although the TRICARE choices were redefined to just two options 
in the National Defense Authorization Act for Fiscal Year 2017--TRICARE 
Prime and TRICARE Select--the core access standards are focused on 
TRICARE Prime. The TRICARE Select health option is similar to a 
Preferred Provider/Fee-for-Service (PPO/FFS) option in the civilian 
market. Beneficiaries who select this option have much greater freedom-
of-choice to select any authorized provider with higher out-of-pocket 
expenses associated with that episode of care.
    Also in 2017, with our new T-2017 next generation of TRICARE 
contracts, we transitioned from three net-work regions, to two regions 
consisting of HealthNet (West) and Humana Military (East). This 
provides for a simpler and more streamlined net-work of managed care 
providers.
    The Military Health System (MHS) model is unique. The MHS is 
comprised of a direct care system--military-operated hospitals and 
clinics, staffed by uniformed or government civilian employees, and a 
purchased care system--civilian outpatient and inpatient, private 
sector providers. The purchased care system both augments the direct 
care system around military installations, and serves as the primary 
choice for care in those locations where there is no military medical 
presence. MHS access standards for TRICARE Prime enrollees apply in 
either setting. The access standards are also the same for all 
beneficiary categories, i.e. active duty, active duty family member and 
retirees.
    Access standards for our beneficiares are based on both distance--
the travel time to reach both primary care and specialty providers--and 
timeliness of appointments. A primary care network provider should be 
reachable within 30 minutes drive time from an enrollee's residence, 
and specialty care network providers should be reachable within 60 
minutes drive time from an enrollee's residence. Appointing timeliness 
standards are as follows: urgent care appointments must be available 
within 24 hours; routine primary and behavioral health care within 
seven days; well-patients within 28 days; and specialty care visits 
within 28 days (or sooner as directed by the provider).
    The premise of these access standards is simple. If our military 
treatment facilities (MTF) or our civilian network providers cannot 
provide an appointment to our TRICARE Prime enrollees within the 
allotted standards, our patients have the freedom to request a referral 
to another network provider, or a non-network provider when a network 
provider is unavailable.
    If a provider is not available within 100 miles of patient's 
residence, TRICARE will cover the travel costs for the patient. TRICARE 
will reimburse for mileage expenses in a privately-owned vehicle 
according to government mileage rates, rental car coverage (if needed), 
and overnight lodging and meal expenses that are covered up to the 
approved local per diem rates. The DHA believes that these MHS-wide 
access standards ensure a consistent experience of care and access for 
beneficiaries. These standards are embedded both within our DOD 
regulatory and policymaking documents, and included in our TRICARE 
contracts.
    The MHS has taken a number of steps over the last several years to 
further enhance the patient experience and improve access to care 
throughout the system. We expanded hours of operation in many military 
clinics to better accommodate families. We introduced a 24/7 global 
nurse advice line that is integrated with appointing so that patients 
needing a follow-on health care appointment can be accommodated during 
their original call. We improved access to urgent care by allowing 
enrollees to use urgent care centers in the TRICARE network without 
requiring a referral from their primary care managers. Furthermore, we 
established enrollment capacity and provider productivity standards, 
with appropriate adjustments for readiness and other training demands 
in our MTFs, to optimize internal clinical operations, and better 
support our patient care needs.
    The DHA has invested resources to create a performance management 
system that provides leaders and staff at all levels of the MHS with 
insight into access, quality, satisfaction, and cost measures. 
Information can be viewed at the MHS, Military Department, Medical 
Market, MTF, and Provider level. While less granular, we also monitor 
performance of our civilian TRICARE network providers, largely through 
patient surveys that assess satisfaction with timeliness and other care 
delivery measures. These measures are transparent to MTF commanders and 
staff at other military hospitals and clinics, allowing leaders to 
compare their performance with their peers. Key performance measures 
are also shared with the public at the enterprise level through 
www.health.mil, and at the local level through individual MTF websites. 
We also provide an annual ``Evaluation of the TRICARE Program'' report 
to Congress. Going forward, we intend to further integrate these 
performance measures between our direct and purchased care systems to 
provide our beneficiaries with an even more transparent and seamless 
integrated health care delivery system.
    To ensure transparency with other key stakeholders, the DHA meets 
monthly with representatives from our military and veterans service 
organizations to review a wide range of policy and performance matters. 
Often, representatives from each of our Managed Care Support Contract 
(MCSC) are in attendance at these meetings to receive feedback from our 
beneficiaries and share efforts they have made to respond to 
beneficiary concerns. We review our performance on issues such as 
network adequacy, access to care, and satisfaction. These meetings 
provide another opportunity for review and information that help us 
adjust policies and programs to meet the needs of our beneficiaries.
    We recognize that population size, individual health status, family 
circumstances, geographic location (to include residing in medically 
underserved communities), and cost considerations vary across the 
country--for health systems and for patients. Different health systems 
must adapt standards that meet the unique needs of the patients they 
serve. The specific standards we selected are perhaps not as important 
as the fact that the standards exist. We evaluate ourselves against the 
standards we set. And we share our performance with the people we 
serve.
    I hope this brief overview of our approach to patient experience 
and access to care is helpful to your deliberations. Our DHA staff is 
committed to sharing our lessons learned and performance management 
approaches with our VA partners, and continue to meet regularly with 
them to assist in any manner that is helpful. I welcome the opportunity 
to provide any additional detail the Committee may require. Thank you 
for allowing me to share this information with you.
                                 ______
                                 
     Prepared Statement of Nurses Organization of Veterans Affairs
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, On behalf of the Nurses Organization of Veterans Affairs 
(NOVA) we thank you for allowing us to submit our views on today's 
important hearing.
    As nurses who provide the coordination and care for millions of 
Veterans throughout the VA Health Care System, we believe we have a 
unique voice and ground level view of how VA care should look and 
perform in the future.
    Since the passage of the VA MISSION Act in June 2018, NOVA has 
voiced its concerns about how the Veterans Community Care Program 
(VCCP), to include new access standards, would change internal VA 
systems, but more importantly, if it continues to provide the ``right'' 
care for our Veteran patients.
    The rollout of access standards for the VCCP, did little to 
alleviate our concerns. The new standards set arbitrary wait times and 
drive-times that do not take into consideration ``quality of care'' and 
access to providers who would be subject to the same high standards as 
VA demands. This creates a double standard under which ``community 
care'' is held to a lower standard while seemingly offering Veterans 
``choice,'' but at what cost?
    We believe all care provided the Veteran patient must demonstrate 
and meet access and quality standards whether they choose to receive 
care in the community, under the VCCP or remain at a VA Medical Center, 
or other VA facility.
    The credentials, training, competency and performance standards 
that VHA requires of its own clinicians should be the benchmark for 
providers in the VCCP. Yet, the proposed standards for the program 
indicate that the minimal qualification and quality standards used to 
contract providers for the Veterans Choice Program will remain 
unchanged. Choice was nothing if not a lesson in contract negotiations 
gone terribly wrong.
    NOVA members who coordinate care for non-VA care/Choice programs 
reported a myriad of problems being made by outside providers that led 
to delays in care, the wrong care given, or in many cases, the Veteran 
not being seen by an outside provider at all. Failure to ask the 
question ``access to what kind of care?'' can compromise the health and 
well-being of Veterans.
    One of the core justifications for the MISSION Act was to give 
Veterans comparative information on the quality of VHA and non-VA 
provider care in order to make health care decisions. While robust 
metrics exist for a limited number of inpatient process measures, there 
are very few accurate ones for outcome measures. Almost no measures 
exist that compare the quality of individual providers or clinics in 
the private sector to those within VHA.
    The regulations state that provider quality ratings will be 
published, but most of the relevant comparative information that 
Veterans need to make health care decisions will not be available.
    How can Veterans make an educated choice on their health care if 
this information is not available?
    We are also troubled by the lack of attention to internal VHA 
staffing needs with respect to implementing the VCCP. It is widely 
known, that VHA has over 45,000 vacancies--nurses are among many of 
those positions unfilled.
    For the VCCP to be implemented properly, staff within VHA will be 
responsible for making appointments, coordinating care, obtaining 
documentation, collecting Veteran copayments, discussing options with 
Veterans, etc. But there is no assessment of, or accommodation made for 
extra staff needed to perform this huge expansion of workload. No 
consideration has been made as to how the VA is going to case manage 
all the Veterans that will be going out into the community. Those 
coordinating outside care are struggling with enough staff to keep up 
and balance changes in contracts, IT solutions and other workforce 
issues within VCCP.
    NOVA asks that given this, how can new duties be effectively 
undertaken without significant numbers of additional staff? If these 
duties are executed by diverting staff from other clinical care needs--
it has been mentioned that Patient Aligned Care Teams (PACT) would 
carry out some of these functions--remaining staff will become 
overburdened with more appointments in shorter periods of time, which 
could sacrifice timely access to quality care. VA's own report to 
Congress (required by the MISSION Act) on quality standards, recognized 
fragmentation of care is at risk. Shouldn't some of the burden in fact 
be borne by non-VA providers who are being paid to care for Veterans? 
VA can, and should make this a condition of contracting with non-VA 
primary care providers.
    VA's own Impact Analysis recognizes that meeting the wait time 
regulation would require significant increase in staffing, but never 
considers adding FTEs to VHA to meet those standards. Is there 
consideration to provide grants or funding to hire more nurses and 
support staff to satisfy increases assessed under VCCP?
    The Impact Analysis predicted that the new access standards would 
significantly increase the number of Veterans who receive VCCP care, 
all of which must be reimbursed by VA. The Independent Budget (IB), 
which NOVA has endorsed, notes that the Administration's budget 
proposal falls far short of covering associated VCCP costs.\1\
---------------------------------------------------------------------------
    \1\ The Independent Budget Statement on VA's FY 2020 Budget Request 
at www.independentbudget.org
---------------------------------------------------------------------------
    The IB is asking for $18.1billion in medical community care for FY 
2020 which includes current services, estimated spending (not including 
full cost of wait time and drive time access standards which VA 
estimates will increase by 29% for PCP and 14% for Mental Health) under 
Choice and VA MISSION Act.
    The importance of VA properly estimating community care costs is 
critical and we would remind the Committee that Congress had to twice 
provide ``emergency funding'' for Choice due to improper forecasting 
the demand for care among Veterans. We are confident that Congress does 
not want to repeat past mistakes and put VHA funding in jeopardy in the 
coming fiscal years. We stand by the IB estimates and ask that funding 
for community care be allocated separately and adequately to not 
deplete VHA funds.
    NOVA recognizes and understands that community providers are a 
crucial part of an integrated network designed to provide care where 
there are shortages. Providers should be used to supplant VA care, not 
replace it, and be held accountable for performance, quality, and 
timeliness of care and services. Most importantly, VA must remain the 
first point of access and coordinator of all care.
    VA provides high quality care to millions of Veterans across the 
country, many of whom have indicated through surveys* that they prefer 
to use VA because they believe the quality of care is higher and that 
VA's ability to treat service-connected conditions is unmatched by any 
care in the private sector.
---------------------------------------------------------------------------
    * VFW 2015, 2017, 2018 surveys relayed in its ``Our Care Report'' 
at https://www.vfw.org/advocacy/va-health-care-watch shows large 
numbers of Veterans prefer VA care.
---------------------------------------------------------------------------
    As Congress and VA move toward final implementation of the VCCP, we 
ask that they consider a delay until such time that access and quality 
standards for the program are equal for both internal and external 
care. Care that is fair, accountable and of the highest quality is what 
Veterans deserve now and into the future.

    Thank you for allowing us to submit our comments and 
recommendations.
                                 ______
                                 
          Prepared Statement of Paralyzed Veterans of America
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for this opportunity to offer our views on the Department of Veterans 
Affairs' (VA) proposed access standards for community care as required 
by the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA 
Maintaining Internal Systems and Strengthening Integrated Outside 
Networks (VA MISSION) Act of 2018.
    On June 6, 2018, President Trump signed into law the VA MISSION 
Act, one of the most significant pieces of legislation in recent 
decades impacting veterans health care. If implemented correctly, the 
VA MISSION Act could drastically improve how VA delivers health care to 
our Nation's veterans. However, if implemented poorly, it could result 
in veterans, community providers, and Congress, losing confidence in 
the VA health care system and its ability to deliver timely quality 
health care to veterans.
    The VA MISSION Act consolidated VA's authority to provide community 
care, including through the Choice Program, into a new program, the 
Veterans Community Care Program (VCCP). As part of the process of 
implementing the VCCP, the law required VA to develop access standards 
for furnishing hospital care, medical services, or extended care 
services to covered veterans in the community. The law also required VA 
to craft these access standards in a manner that provides relevant, 
comparative information that is clear, useful, and timely, so that 
covered veterans can make informed decisions regarding their health 
care.
    On July 30, 2018, PVA submitted comments to VA in response to its 
request for information regarding the development of access standards 
for the VCCP. In our comments, we expressed the importance of VA 
avoiding the problems in implementing the VA MISSION Act that plagued 
the roll out of the Veterans Choice Program. In addition, we requested 
that VA require that a spinal cord injured veteran's primary care 
provider be the informed coordinator of the veteran's care.
    At the end of January 2019, VA announced the proposed access 
standards for VCCP. The standards for accessing community care were 
based on average drive times and appointment wait times. For primary 
care, mental health, and non-institutional extended care services, VA 
proposed a 30-minute average drive time standard. For specialty care, 
VA proposed a 60-minute average drive time standard. VA's proposed 
appointment wait-time standard is 20 days for primary care, mental 
health care, and non-institutional extended care services, and 28 days 
for specialty care from the date of request with certain exceptions.
    In PVA's comments to VA's proposed rule on implementation of the 
VCCP, we noted that the proposed rule's detail explaining eligibility 
and access standards would be useless if the new decision support tool 
was not ready on June 6. We also noted that the proposed access 
standards based on average drive times and appointment wait times are 
just as arbitrary as the 30 day/40 mile rule under the Choice program. 
In addition, VA's proposed regulations were short on specifics about 
how drive times would be determined. We also requested that VA resist 
calls to reduce proposed wait times to 14 days and instead focus on 
meeting its proposed 20-day standard.
    At this time, we remain quite concerned that the decision support 
tool needed to efficiently and effectively determine eligibility will 
not be ready for deployment by VCCP's implementation on June 6. On 
March 1, the U.S. Digital Service (USDS) issued a report entitled, 
``MISSION Act: Community Care.'' The report voiced serious concerns 
about VA's proposed access standards and the status of VA's decision 
support tool for eligibility determinations. According to USDS, ``Much 
of the data necessary to determine eligibility is currently housed 
across several legacy VA systems that don't interoperate, creating an 
inefficient and highly manual determination process.'' \1\ USDS further 
stated that the decision support tool ``could streamline the 
eligibility determination by connecting to these legacy VA systems to 
gather data on the Veteran and produce a determination.'' \2\ 
Unfortunately, USDS found ``significant risks surrounding software 
development timing, integration dependencies, and usability.'' \3\
---------------------------------------------------------------------------
    \1\ Chris Eldredge, Lauryn Fantano, Natalie Kates, Rick Lee, Sheri 
Trivedi, & Aaron Wieczorek, USDS Discovery Sprint Report, MISSION Act: 
Community Care 6 (2019), available at https://www.documentcloud.org/
documents/5766330-USDS-Mission-Act-Report.html (last visited March 26, 
2019).
    \2\ Id.
    \3\ Id.
---------------------------------------------------------------------------
    We believe that there is significant potential for confusion among 
VA personnel and veterans regarding eligibility for community care. VA 
has responded to these concerns by noting that they are working on 
implementing the rollout process which includes training, policies, and 
tools that will ensure there is consistency for veterans, their 
families, and support teams. We concur that these requirements are 
essential, however, due to time constraints, there may not be 
sufficient time to rollout this information to all stakeholders.
    PVA believes VA has failed in its mission to ensure VA's proposed 
access standards are clear and allow covered veterans to make informed 
decisions about their health care. As the final implementation of VCCP 
moves closer, we are very concerned about VA's reliance on modernized 
health care IT to successfully execute it. Considering the VA's past 
and current failures with IT programs, it is a very risky assumption 
that VA can get this right, particularly with the target implementation 
date less than two months away. We want to make sure that the VCCP is 
successful and believe that moving forward with untested IT would be 
unhelpful to veterans needing access to care.
    As a result, we believe that VA should delay implementation of the 
new access standards based on drive times and wait times until VA can 
certify that the requisite IT solutions have been properly implemented 
and that VA can successfully roll out eligibility determinations based 
on these standards. In the meantime, VA should maintain the access 
standards of the Choice program. The remainder of the VA MISSION Act's 
eligibility standards and requirements should move forward as laid out 
in the law.
    Finally, VA's proposed rule also invited comments on the 
possibility of VA considering the development of access standards for 
the care provided by Centers of Excellence or foundational services for 
possible inclusion in the VCCP. PVA would vigorously oppose any effort 
to move Spinal Cord Injury/Disorder (SCI/D) care into the VCCP. VA's 
health care system is the world leader in the treatment of spinal cord 
injuries and disorders. Through regular assessment, we know this level 
of care is unmatched in the civilian sector; thus, opening this line of 
service via the VCCP would result in the provision of lesser quality 
care when compared to that which is received at VA's SCI/D centers.
    PVA is committed to working with VA and Congress for the successful 
implementation of the VA MISSION Act and its many provisions like the 
VCCP. Congress and VA must work together to ensure the longevity of the 
VA health care system for our members, and all veterans with 
catastrophic disabilities, who depend on that system. The proper 
balance of access to community care, coordinated by VA, is an important 
part of ensuring the long-term success of VA's system of care.
                                 ______
                                 
      Prepared Statement of Carrie M. Farmer and Terri Tanielian, 
                          The RAND Corporation
                          
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