[Senate Hearing 116-435]
[From the U.S. Government Publishing Office]



 
                                                        S. Hrg. 116-435
 
                     VA MISSION ACT: UPDATE ON THE
              IMPLEMENTATION OF THE COMMUNITY CARE NETWORK

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 5, 2020

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
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              U.S. GOVERNMENT PUBLISHING OFFICE 
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jerry Moran, Kansas, Chairman

John Boozman, Arkansas               Jon Tester, Montana, Ranking 
Bill Cassidy, Louisiana                  Member
Mike Rounds, South Dakota            Patty Murray, Washington
Thom Tillis, North Carolina          Bernard Sanders, (I) Vermont
Dan Sullivan, Alaska                 Sherrod Brown, Ohio
Marsha Blackburn, Tennessee          Richard Blumenthal, Connecticut
Kevin Cramer, North Dakota           Mazie K. Hirono, Hawaii
Kelly Loeffler, Georgia              Joe Manchin III, West Virginia
                                     Kyrsten Sinema, Arizona

            Caroline R. Canfield, Republican Staff Director
                Tony McClain, Democratic Staff Director

                            C O N T E N T S

                              ----------                              

                            February 5, 2020
                                SENATORS

                                                                   Page
Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     2
Rounds, Hon. Mike, U.S. Senator from South Dakota................    10
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    12
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    14
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    16
Murray, Hon. Patty, U.S. Senator from Washington.................    18
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    20
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    22
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    24
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    26
Loeffler, Hon. Kelly, U.S. Senator from Georgia..................    36
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    39

                               WITNESSES

PANEL I
Stone, Richard A., M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs; 
  Accompanied by Kameron Matthews, M.D., Assistant Under 
  Secretary for Health and Community Care, Veterans Health 
  Administration; and Jennifer MacDonald, M.D., VA MISSION Act 
  Lead, Veterans Health Administration...........................     4

PANEL II
Atizado, Adrian, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    28
Horoho, Lt. Gen. Patricia D. Chief Executive Officer, OptumServe.    30
McIntyre, David J., President and Chief Executive Officer, 
  TriWest Health Alliance........................................    31

                                APPENDIX

Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas, Prepared 
  Statement......................................................    48
Sanders, Hon. Bernard, U.S. Senator from Vermont, Prepared 
  Statement......................................................    49
Stone, Richard A., M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs, Prepared 
  Statement......................................................    51
U.S. Department of Veterans Affairs, Testimony Summary...........    58
Atizado, Adrian, Deputy National Legislative Director, Disabled 
  American Veterans, Prepared Statement..........................    59
Disabled American Veterans, Testimony Summary....................    66
Horoho, Lt. Gen. Patricia D. Chief Executive Officer, OptumServe, 
  Prepared Statement.............................................    67
OptumServe, Testimony Summary....................................    74
McIntyre, David J., President and Chief Executive Officer, 
  TriWest Health Alliance, Prepared Statement....................    75
TriWest, Testimony Summary.......................................    86

                         Questions and Reponses

Response by OptumServe to Questions of:
    Chairman Moran...............................................    87
    Senator Cramer...............................................    90
    Senator Sanders..............................................    91
    Senator Sinema...............................................    98
Response by U.S. Department of Veterans Affairs to Questions of:
    Senator Moran................................................   100
    Senator Tester...............................................   101
    Senator Boozman..............................................   104
    Senator Rounds...............................................   105
    Senator Cramer...............................................   107
    Senator Murray...............................................   108
    Senator Sanders..............................................   112
    Senator Brown................................................   116
    Senator Blumenthal...........................................   117
    Senator Hirono...............................................   121
    Senator Manchin..............................................   125
    Senator Sinema...............................................   130
Response by TriWest to Questions of:
    Chairman Moran...............................................   134
    Senator Hirono...............................................   138
    Senator Sinema...............................................   140


                     VA MISSION ACT: UPDATE ON THE

              IMPLEMENTATION OF THE COMMUNITY CARE NETWORK

                              ----------                              


                      WEDNESDAY, FEBRUARY 5, 2020

                              United States Senate,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 9:31 a.m., in 
Room 418, Russell Senate Office Building, Hon. Jerry Moran, 
Chairman of the Committee, presiding.
    Present: Senators Moran, Rounds, Tillis, Sullivan, 
Blackburn, Loeffler, Tester, Murray, Brown, Blumenthal, Hirono, 
Manchin, and Sinema.

              OPENING STATEMENT OF CHAIRMAN MORAN

    Chairman Moran. The Committee will come to order. Good 
morning, everyone. For our first hearing we are taking on the 
topic of the implementation of the MISSION Act, something that 
this Committee and Congress has spent a lot of time on over a 
long period of time on community Care. And I thank you, Dr. 
Stone, for you and your team joining us on today's first panel. 
I also thank the witnesses on our second panel for being here. 
I look forward to hearing their perspective as well.
    I certainly believe that the delivery of quality and timely 
health care to veterans has been a top priority for this 
Committee and for me. When our servicemembers leave the 
military it is our duty to make sure they receive the care that 
they have earned.
    Congress enacted the MISSION Act to transform VA health 
care into an innovation and responsive 21st century health care 
system capable of addressing the challenges with veterans 
today. And I think there is an important point to be made, that 
the MISSION Act, while we talk about it, and I just did a 
community care, care of the community, it is much more than 
just that.
    Our hearing today will focus on the efforts of the VA to 
deploy community care networks. The network is central to the 
MISSION's Community Care Program.
    When I was a Congressman I represented a congressional 
district size about the same as Illinois. No VA hospital in 
that congressional district, and so I bring a perspective of 
distance and travel time to my job in trying to care for 
veterans. So, in part, I always remain interested in how we 
care for veterans who live long distances from the VA's 
presence and how we can expand that presence to them.
    The VA recently completed Region 1 deployment of the 
network, and the first four regions, representing the lower 48 
states, are scheduled to be completed by the end of this year. 
The Committee has concerns about how the VA is building out the 
network and its ability to meet veteran demand.
    Under MISSION's expanded eligibility requirements, the 
number of patients seeking outside care is supposed to increase 
from 648,000 to 3.7 million. A recent VA OIG report predicts 
wait times could worsen once MISSION is in full effect. This is 
in addition to reports that the VA is still struggling with 
scheduling delays and paying community providers on time. We 
want to make sure this does not occur and look forward to 
working with you, Dr. Stone, and others at the VA, to ensure 
that.
    We must take the opportunity to learn what happens in 
Region 1 and have an honest conversation about the difficulties 
that could threaten the network well before it is fully 
deployed. We owe it to the veterans to get MISSION right the 
very first time.
    I now turn to my friend and Ranking Member, the Senator 
from Montana, Senator Tester, for his opening statement.

              OPENING STATEMENT OF SENATOR TESTER

    Senator Tester. Thank you, Chairman Moran, and I want to 
thank you for starting this meeting on time. I appreciate that 
very, very much. And I want to thank the three doctors for 
being here, especially you, Dr. Stone. I appreciate the meeting 
we had last week and the conversation you had with my staff and 
myself.
    In the 90 days following implementation of the new Veterans 
Community Care Program there were nearly 258,000 more referrals 
for the private sector than in the preceding 90 days. More 
concerning, there are 283,000 fewer referrals for appointments 
in the VA during that same period. So referrals for community 
care went up significantly and referrals for the VA went down 
significantly.
    I am concerned and I hope you are as well, and I need to 
understand what has happened, and if it is still going on, and 
if that is the intent. Congress did not create the new 
Community Care Program to simply supplant VA care with the 
private sector care, particularly when it takes less time for 
veterans to schedule appointments to be seen in VA facilities. 
It was set up to supplement VA care, in cases where the 
veteran, who is the driver of the situation, wanted to go into 
the community, for whatever reason that might be.
    If the VA is connecting veterans more quickly, why are so 
many veterans getting their care in the private sector. I am 
concerned that 43,000 vacancies in the VHA are one of the chief 
reasons, and we talked about that, but I remain frustrated that 
VHA is not making effective and aggressive use of the 
authorities Congress has provided to recruit and retain 
providers and support staff, particularly in areas that are 
rural.
    I am also concerned by reports that the decision support 
tool that was supposed to assist veterans and their providers 
in making decisions on where to get care is being underutilized 
because providers are choosing not to use it. My understanding 
is that the purpose of the DST was to review the criteria 
prescribed in the MISSION Act and determine whether a veteran 
is eligible and best served by utilizing private sector care, 
that it would document the decision rationale in the veteran's 
health record. However, I understand that the VA will use a new 
referral process that could complicate referrals even more. I 
do not understand how creating a team to coordinate a decision 
is quicker or makes more sense than a veteran and provider 
making that decision.
    I am also concerned that eight months into the program VA 
does not have a clear understanding of how many appointments 
have been completed in community care, and just as importantly, 
how much that costs, with the budget coming out next week. 
While I understand there is a lag time on medical bills coming 
in for completed appointments I do not understand how VA does 
not have an estimate of how much this is costing taxpayers, and 
with the President's budget coming in next week I do not see 
how that request will not be met with some skepticism.
    I can tell you this. If the request shows a sharp increase 
for community care and level funding for in-house care, VA 
needs to justify that and receipts to support that request.
    Dr. Stone, I know you are absolutely, unequivocally a 
straight shooter, and I have no doubt that the policies you 
advocate are in the best interest of the veterans, and I mean 
that. But as chief VA witness today, it will fall upon you to 
convince me, and others on this Committee, that the VA is not 
simply sending veterans into the community because it is 
easier.
    We also need your assurance that the IT program to support 
an expanded caregivers' program will be up and running by the 
end of the summer, which, as you know, is a full year after the 
VA was initially tasked with completing this project. This is 
an important project, and it is an important project to get 
moving. It is a project that Senator Murray and the previous 
chairman of this Committee wanted to get going, and I would 
tell you that the work on this is critically important for the 
veterans who have been waiting to be able to get assistance 
from the families and have not been able to afford to do that.
    So, Mr. Chairman, again I want to thank you for calling 
this meeting. This is an important meeting. The MISSION Act, I 
do not need to tell anybody around this table or anybody at 
that table or any of the veterans sitting in the crowd that it 
is a very, very, very important piece of legislation, that if 
implemented properly can be an incredible asset. If implemented 
improperly, can really take away veterans' care. Thank you.
    Chairman Moran. Senator Tester, thank you for your opening 
comments. I do not know whether it is a reflection on the 
United States Senate or a reflection on the fragility of our 
relationship, but only in this setting can you get a compliment 
for starting a meeting on time, the only compliment I got from 
you.
    [Laughter.]
    Senator Tester. Listen, I think your wife dressed you very 
well today.
    [Laughter.]
    Chairman Moran. I feel so much better now. I got two 
compliments from you.

                            PANEL I

    Dr. Stone, as I said earlier, welcome. This is Dr. Richard 
Stone. He is the Executive in Charge of the Veterans Health 
Administration. He is accompanied by the following: Dr. Kameron 
Matthews, Assistant Under Secretary for Health for Community 
Care, Veterans Health Administration; and Dr. Jennifer 
MacDonald, the VA MISSION Act Lead, also in Veterans Health 
Administration.
    Dr. Stone, we recognize you for your remarks.

STATEMENT OF RICHARD A. STONE; ACCOMPANIED BY KAMERON MATTHEWS 
                     AND JENNIFER MACDONALD

    Dr. Stone. Good morning, Mr. Chairman, Ranking Member 
Tester, and members of the Committee. I appreciate the 
opportunity to discuss VA's continuing success in implementing 
the VA MISSION Act of 2018. This continues to be a time of 
transformative change at VA. The MISSION Act implementation is 
succeeding and has become part of our core business as we 
prepare to deploy additional benefits to support veterans and 
their families.
    Alongside our DoD and HHS partners we intend to lead the 
industry in quality health information exchange, opioid safety, 
and ultimately care coordination powered by our new joint 
electronic health record.
    Additionally, we will lead in providing services to 
veterans wherever they are, using the expanded reach of our new 
Community Care Program. We are building a strategy that will 
deliver health care excellence for veterans no matter where 
they choose to live or to seek care.
    On June 6th of last year, we successfully launched the new 
Veterans Community Care Program, a cornerstone of the MISSION 
Act. As the President promised, the MISSION Act has been good 
for veterans and good for the VA. Veterans now have enhanced 
care options and we are streamlining our processes and our 
technology to make their experience of care even better.
    I would like to dispel any misconceptions about 
privatization. The VA health care system is stable, and we are 
growing in the amount of care we are delivering, and we 
continue to approach care delivery as an integrated 
organization ensuring veterans receive the right care at the 
right time, whether that be through our direct care system or 
through our community partners.
    Since June 6th of last year, VA has authorized more than 
3.85 million episodes of care in the community. But in the 
first quarter of fiscal year 2020, we provided direct care 
services to over 315,000 individuals each and every business 
day. That is 2,100 more individuals receiving care each day 
than the same period last year. That is more than 3,000 
additional appointments every day in the direct care system.
    You have given us, through this act, the tools and 
resources to make us the most accessible health care system in 
the industry. Our network of 880,000 community-based providers 
provide an unprecedented range of options for veterans. VA 
remains committed to strengthening the VA health care system, 
expanding access, and pushing the boundaries of what is 
possible in serving our nation's veterans.
    I would like to highlight the satisfaction rate veterans 
are experiencing using this new benefit. Veterans' expression 
of trust in VHA has risen to 88 percent in the last fiscal 
year. Similarly, our home telehealth program has had trust 
scores reaching 91 percent. This indicates successful efforts 
to provide trusted convenience wherever care is delivered.
    Claims payment, timeliness to community providers remains a 
top priority as we modernize antiquated legacy payment systems. 
A new claim auto-adjudication system was implemented last 
month, and VA's third-party administrators under the community 
care contract, both TriWest and Optum, are paying the vast 
majority of claims in a timely manner. We are committed to 
being an excellent partner to the community providers who have 
expressed trust in us by signing contracts with our network.
    Other aspects of VA's modernization and advancement under 
the MISSION Act include telehealth, the new scholarship 
program, the education debt reduction program. These are tools 
that you have provided us, in telehealth especially, that has 
allows us to bring provider expertise across state lines. VA 
recently announced the delivery of telehealth services to more 
than 900,000 veterans and over 2.6 million episodes of care in 
the last fiscal year, an increase of 17 percent. The new 
scholarship program allows us to recruit by providing 
scholarship funding in exchange for a commitment to serve 
American veterans.
    We knew when we began implementing the VA MISSION Act that 
we had the potential to make an enormous positive impact for 
American veterans. Today we have begun to demonstrate that 
potential. We will continue to work to improve veterans' access 
to timely high-quality care in VA facilities both in person and 
virtually, and we will augment this, when appropriate, with 
excellent choices through our robust network of community 
partners.
    I am very proud of the future that we are building on 
behalf of America's veterans and their families, and sincerely 
appreciate this Committee's continued support.
    Mr. Chairman, this concludes my statement. My colleagues 
and I are prepared to answer any questions that you may have.
    Chairman Moran. Dr. Stone, thank you very much. Thanks for 
your opening statement and your presence here today.
    The VA worked hard to find the best practices in the 
private sector and other federal health care delivery systems 
to land on where we are and the best standards for veterans' 
access to primary care, mental health, and specialty care. I am 
frustrated when I discovered that the contracts for Regions 1 
to 4 do not incorporate the standards outlined in the MISSION 
Act.
    My view is--I do not think this is controversial or 
disputed--is that those contracts must reflect the law, and 
perhaps the VA, although I would be skeptical that you could, 
could convince me that those are not the right standards, but I 
do not think that is a discretionary call for the VA. And so I 
am disappointed that the standards in the contact for Regions 1 
and 4 do not reflect that.
    The consequence, I think, is longer wait times, drive times 
for veterans that I represent. It is an example of where a 
requirement by law, that this Committee worked diligently to 
determine what it should be, is not being complied with by the 
VA.
    I suppose, on one hand--let me say it this way. I am 
pleased to discover in the contracts with Region 5 the 
standards of the MISSION Act are incorporated in the contract. 
So my hope is that this means that the VA is going to now 
incorporate those standards in the contracts for the previous 
Regions 1 through 4.
    So Dr. Stone, can you and your colleagues tell me what I 
should know about my frustration?
    Dr. Stone. Senator, I appreciate this discussion because I 
think there is a difference in interpretation of the law, and I 
think we need to resolve that. I think we are getting closer. 
You know, when I was with DoD we went through multiple versions 
of TriCare before. Now we are on seven or eight, and we are 
getting it right.
    But I think that we have demonstrated in Region 5 that we 
need to place into the contracts access standards. 
Unfortunately, in highly rural areas, including in your own 
state, we are finding that even though our penetration of the 
market is higher than Medicare participation, in many counties, 
that we still would not meet either the 30- and 60-minute drive 
time or the 20- and 28-day standard. The American health care 
system is just not as robust as what we have committed 
ourselves to under the Secretary's leadership.
    I will defer to Dr. Matthews for additional discussion. I 
think we can resolve this. I think it is very clear, and you 
have been very clear on what you would like us to get to. I 
just do not think that the American commercial health care 
systems are prepared to comply in the manners that we would 
like to.
    Chairman Moran. I do not think, Dr. Stone, that there is a 
requirement that, for example, the region that Kansas is in had 
a different TPA prior to today. The network is different. The 
providers are--there are providers that were utilized in the 
previous network not being utilized or contacted today. I do 
not think the requirement is, although that creates some--I do 
not think--let me finish the sentence. I do not think the 
requirement is that the same providers have to be utilized, or 
even the same number of providers.
    But it does suggest to me that there is more outreach that 
could be done if the suggestion is that the private sector is 
not sufficient to meet the needs. The previous TPA was using 
additional providers than the current TPA, so that says 
something to me about expanding the network. And then the 
answer that we have received from the VA is that there is a 
study to be done, a utilization study, to determine what else 
needs to be done, and again, I worry that if you wait for a 
utilization statement, the veterans who are receiving care in 
the community will not be able to access that care and your 
utilization study will underestimate, undershow the demand for 
services and we will be shrinking the opportunities, not at 
least stabilizing them or increasing them.
    Dr. Matthews. Sir, we are definitely in agreement that this 
is an area that needs to be addressed with regard to providing 
the consistency between the regions. The background for Region 
5, we placed that solicitation publicly after the MISSION Act 
was passed, so we had the access standards. If you also read 
the RFP, however, there is a very large section about waiver of 
those access standards that we actually adopted from the 
Medicare program, such that when the TPA recognizes that there 
is not the availability of providers, that they cannot meet 
those access standards, there is a level of criteria that they 
need to provide data upon to set a level of access that they 
can then produce in the network. And between the TPA and VA, we 
would then agree that, particular to those counties, to those 
area, that indeed that would be the standard there.
    So the access standards, as Dr. Stone mentioned, would be 
our ultimate goal, but recognizing that contractually there is 
no way we could hold the network accountable to a level of 
adequacy that just does not exist in the industry.
    Chairman Moran. I appreciate that answer. In part, I was 
pleased to learn about the new standards, the current standards 
being utilized in Region 5, but you are telling me they could 
be something less.
    Dr. Matthews. Yes.
    Chairman Moran. So maybe a little disappointment, perhaps 
in the right direction.
    But I would conclude by saying that my expectation is that 
the TPAs in Regions 1 through 4 also have a provision that the 
standards can be increased or the demand upon them can be 
increased, and so it works both ways. And I understand that the 
standards were not in place when the first RFPs were proposed.
    Dr. Matthews. Exactly.
    Chairman Moran. We need to get us to the point, in my view, 
in which we are using the statutory requirements and they are 
uniform throughout the region. So thank you.
    Dr. MacDonald. Senator, if I may add, I had the privilege, 
sir, of seeing you stand next to the Secretary and witnessing 
in person your commitment to access for veterans in western 
Kansas, and that is a goal we share collectively here with you 
and with the Committee. We want to make sure that no matter 
where a veteran chooses to live that they have access to not 
only our system but to the right care, and we believe that this 
is a cross-functional strategy.
    That is what we are tackling now, that the network adequacy 
in community care is a piece of this. So is telehealth. So is 
deploying our providers with the mobile deployment teams that 
are set forth in the MISSION Act to bring providers to rural 
areas where they need to be and where they need to meet 
people's needs in person. We think this is a cross-functional 
strategy that will need our partners' input as well and your 
feedback, but we aim to be, as Dr. Stone said in his opening 
statement, the most accessible and convenient health care 
system in history. And to do that we need both that network 
adequacy and the other pieces and tools in the MISSION Act that 
you have given us.
    Chairman Moran. Thank you, Dr. MacDonald. Thank you, Dr. 
Matthews. Thank you. Yes, ma'am.
    Dr. Matthews. Do you mind if I just give one more 
clarifying point, because I definitely heard you. This 
transition between our networks is a critical time. We need to 
assure that veteran care, first and foremost, is not 
threatened, that continuity of care is in place, and that we 
have adequacy to meet those needs.
    I just wanted to also highlight, however, that under the 
Choice program, under PC3, the actual majority of care was not 
purchased through the network providers. It was purchased 
through what we called individual authorizations. A lot of 
times we were paying at higher rates. These were different sets 
of contractual agreements, if at all, between the VA and the 
providers directly.
    Moving to the CCN realm is a very different space for a lot 
of these providers, particularly our home health and dentistry 
providers, who were never networked with us previously. So we 
are really bringing on a different relationship than they had 
previously experienced and sometimes different reimbursement 
rates than they had previously experienced.
    So walking the path between what was formerly, particularly 
under the Choice network, now PC3, to CCN is not exactly one-
to-one.
    Chairman Moran. Thank you. I look forward to resolving 
this, what I think we all agree is an important issue.
    Senator, excuse me for going so long. It does not set a 
precedent. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman, and I appreciate 
your testimony, and I appreciate you talking about adequacy of 
care. I think we are talking about a different population than 
general population, and their challenges are greater because 
they often have multiple issues that they are dealing with. And 
so I think that is critically important.
    As I look at my little local hospital, and I live in a very 
rural area, it is a great little hospital but I am not sure it 
could meet the needs of the veteran, just to be flat honest 
with you, at least not to the level that the VA does. So thank 
you for that.
    Dr. Stone, it is always a challenge to forecast how much 
funding it is going to cost for community care. There is just 
no doubt about it. It is a problem forecasting that, because it 
is an unknown that we have not got the metrics behind it to 
find out.
    In 2017, as you well know, Congress stepped in three times 
to provide additional funding for the Department so it would 
not exhaust the Choice program funding. I am concerned that we 
may be headed down that path again.
    Eight months into the new Community Care Program, VA has 
not provided, or cannot provide, one or the other, the number 
of referrals that became appointments. I get the number of 
referrals but we do not know the number of referrals that 
became appointments. And thus, I do not see how we can figure 
out how many dollars are associated with those appointments and 
whether usage is in line with the projections that you and 
other smart people have developed when this program was set up.
    So Dr. Stone, do you have any concerns that the VA may be 
over budget with this program?
    Dr. Stone. Senator, I think you asked the key question that 
keeps me up at night, and that is that this is a brand new 
program. In the six months before June 6th we sent 2.7 million 
episodes of care out. In the six months after, we sent 3.8 
million episodes of care out. But we have seen the appointing 
and the authorizations not turn into bills coming back in. Now 
we have way better criteria in our regulations on how long a 
vendor has to bill us. We have followed the Medicare standard 
that you have got to have the bill in in 180 days, so we can 
follow this.
    Dr. Matthews briefs me on a weekly basis on the volume of 
referrals and authorizations, but we are still waiting for 
bills to come in. As we have seen this, it appears the 
authorizations are beginning to drop. We had predicted that 
there would be some kicking of the tires for community care and 
then it would drop off. That appears to be happening.
    Now our burn rate through dollars in community care is 
running just over $1 billion a month. It may reach $1.1 
billion. You gave us about $15 billion in the budget. I think 
we are safe, but part of this has to do with that timeliness of 
getting our bills paid, which is an absolute commitment that 
was in my opening statement. And we will keep you informed on a 
quarterly basis of our burn rate of dollars. But I am 
confident, at this point, that we are sufficiently funded, that 
we will not be up here asking for additional dollars.
    Senator Tester. So in a previous program called Choice, one 
of the problems that I had, and one of the reasons I, quite 
frankly, beat the third-party provider up, of which we have the 
two here sitting, that will be on the next panel, is because 
the providers were not being paid in a prompt time. One hundred 
80 days, by my math, is six months, and if the providers are 
not getting the bills in in six months--and I will bring this 
up to the next panel-- maybe the problem was not the third-
party providers.
    Dr. Stone. Well, let me say this. It can take a month for 
us to package a consult for routine care. That is something we 
are actively working on to fix and to get down to our three-day 
standard. That has actually been worked on in various 
sequesters for the last number of months. But at that point it 
is given to our third-party TPA, who then works to handle this, 
but it can take another month to get people in. If a provider 
does not get a--
    Senator Tester. Because you are getting two mics, Dr. 
Stone? What the heck?
    [Laughter.]
    Dr. Stone. No. This is me in stereo.
    Senator Tester. That is no problem.
    Dr. Stone. This is me in stereo, sir.
    Senator Tester. What is that?
    Dr. Stone. This is me in stereo.
    Senator Tester. Yeah, exactly. I get you in both ears.
    Dr. Stone. So we are working to get this right. I am as 
frustrated as you are, but I have to say to you that at this 
point our budget looks good and looks solid, but on a quarterly 
basis I think we need to be up here with leadership talking 
about our burn rate in dollars, and making sure we have got it 
right.
    Now, by the same token, it appears that our funding within 
the direct care system is correct. But I want to think about 
the disincentive to a medical center director who, if they are 
short of funds, or think they are short of funds, can just say, 
``Well, I am just going to send everything out to the community 
because it is going to go to Dr. Matthews.'' And it is one of 
the weaknesses in the way we bucket funds in the current 
budgeting process. It is way beyond where you want me to go in 
a five-minute answer, but I will tell you we struggle with 
creating the right incentives to get care correct in the way we 
currently bucket funds.
    Senator Tester. I will be very brief. The quarterly update 
is critically important and even more if necessary, in my 
opinion. And I will speak for myself on this, but I think 
working for flexibility in those dollars to make sure that the 
veteran is driving the bus, and they are going, that is really 
going to be critical. So that is all I have got. Thanks. I have 
got another round of questions but that is all I have got for 
now.
    Chairman Moran. Thank you, Senator Tester. Dr. Stone, I 
think it is an awfully important point about the buckets. I can 
see the incentive process, circumstance being very problematic 
for the future of this, how we handle this.
    Senator Rounds?

                         SENATOR ROUNDS

    Senator Rounds. Thank you, Mr. Chairman. Dr. Stone, thank 
you to you and your colleagues for being here today.
    In your written testimony, and then also in your visit with 
us earlier, you said that the MISSION Act implementation is 
succeeding and that VA is leading the health care industry 
forward. With all due respect, when it comes to paying provider 
claims, I would suggest that I have a very different opinion 
about what the definition of success should be.
    In South Dakota, and Dr. Matthews was kind enough to come 
to my office last week and we had a chance to visit, South 
Dakota has got 880,000 people in the entire state. We have got 
about 8 percent of our population, or thereabouts, is veterans. 
I have got two providers alone already that have between $5 and 
$6 million in unpaid bills, and these are through the direct 
care program.
    And I am just curious, these are the large providers. The 
small providers, the folks that really are part of that 
community care network that we want to be able to use, they are 
telling me that in some cases they have over $20,000 in unpaid 
bills. And when you suggested that you were not getting the 
bills in a timely fashion and so forth, I am not sure where the 
hang-up is, but it seems to me that they are billing but we are 
not paying.
    And right now we have got small providers out there that 
want to provide services to the veterans, and, in fact, they 
are, but at some point they are going to say, ``I cannot afford 
to do it anymore.'' The larger guys, they will keep doing it, 
at least for a period of time. They may be frustrated and they 
may get angry. But there is something wrong with this thing 
right now, and we need to nip it as quickly as possible.
    Dr. Matthews was in my office and indicated that she would 
do a short-term attempt to fix on the ones that we have got 
right now, but, look, this is not the way it is supposed to 
work. And I just want to disagree with you that this is a 
successful implementation at this stage of the game.
    I would like to know where, if you--in listening to my 
discussion with you right now, if you can give me your thoughts 
about where we may be having this disconnect between where my 
providers are not getting paid and your thoughts that--it 
almost sounded like you were saying they were not sending the 
bills in.
    Dr. Stone. Senator, I absolutely agree with you that we are 
not where we should be, and in my opening testimony I said that 
we are changing antiquated systems. What I want to reassure you 
is this is not our third-party administrators. This is not 
Optum and TriWest. This is internal to VA and this is exactly 
the work that Dr. Matthews is doing to correct our processes. 
Our processes do overwhelming oversight to every bill, and it 
slows the process down.
    Now when we came here a year and a half ago we were 
processing 100,000 claims a month. We are now processing over 
1.1 million claims a month, approximately the number that we 
are getting in each month. But we have got to correct this 
backlog. So if we get a million claims a month and I say to you 
we have got a 60- to 90-day backlog, it does not take you very 
long to figure out how many claims that we are sitting on. That 
is an inappropriate place to be as a partner to any size 
business.
    Senator Rounds. Dr. Stone, I think we are in agreement that 
it is inappropriate and that our goal should be to eliminate 
it. What I am looking for is the goal is admirable to eliminate 
the problem. What I am hoping to hear is what are the steps 
that are being taken to fix the problem?
    Dr. Stone. There are three. Number one, auto- adjudication 
of the claims, using the eCAMS system and setting up 
appropriate business rules to auto-adjudicate.
    Senator Rounds. How long is it going to take to get that 
done?
    Dr. Stone. My view is, and what Kam has reassured me, is 
that by this summer, within the next 90 days, we will be 
running really well with eCAMS.
    Senator Rounds. So that would be a good date for us to 
target and see whether or not we are making progress.
    Dr. Stone. Yes. Absolutely.
    Senator Rounds. What next?
    Dr. Stone. I think the second piece is to change our 
business rules on overwhelming audit, where we audit every 
claim, unlike Medicare that audits every 100th claim or every 
1,000th claim. I think we can get that. That is being 
instituted as we speak.
    Senator Rounds. What is it now and what is it going to, 
sir?
    Dr. Stone. Dr. Matthews?
    Dr. Matthews. We actually audit every claim prepayment at 
this point, just in order to avoid the fraud and waste of 
overpayment, the incorrect, underpayments. It is a significant 
amount of work that unfortunately is quite manual. We are 
trying to balance, of course, having accuracy of payment as 
opposed to--
    Senator Rounds. Well, let me just ask, Mr. Chairman, if you 
do not mind, then what you do, or what is your plan for when 
you are going to have that process changed, and what will it 
look like when you are done?
    Dr. Matthews. Sure. That actually will be tied in with the 
auto-adjudication rules that are going into the new--
    Senator Rounds. So within 90 days.
    Dr. Matthews. Yes.
    Dr. Stone. I think the third piece is enhanced contracts 
for outside vendors to pay bills. Even our third- party TPAs 
use outside companies to help pay bills. That, we just moved 
over 100 personnel against that contract contractually, to 
enhance this. I think all of this, you should see a very 
positive trend over the next 90 days with resolution as we go 
forward, and that resolution ought to be clear the next time we 
are talking about this.
    Senator Rounds. Thank you. Thank you, Mr. Chairman. I will 
just say this. As long as those third-party payers get paid by 
the VA, it will work. But if you are not paying the third-party 
payers on time, it will not work very long.
    Dr. Stone. And it is my understanding, and I am sure you 
will ask the TPAs sitting behind us, are we paying our bills on 
time, and it is my perception we are.
    Senator Rounds. I have already asked the question, sir.
    Dr. Stone. Thank you, sir.
    Senator Rounds. Thank you.
    Chairman Moran. Senator Rounds, thank you very much. 
Senator Manchin?

                        SENATOR MANCHIN

    Senator Manchin. Thank you. Thank you, Senator Moran. Thank 
you all of you for being here.
    I have got two questions. Dr. Stone, I think you know the 
first question, concerning the VA deaths. We have over 11 
murders at the VA hospital in Clarksburg, West Virginia. It has 
been a year and a half, and maybe you can update me a little 
bit. I get calls every day still yet from families. And I know 
you were kind enough to come in and we talked about it, and I 
appreciate that, but if you have any new, updated messages or 
information that I can give to the families in West Virginia I 
would appreciate it.
    Dr. Stone. Senator Manchin, you and I share our abhorrence 
of what occurred here, and I appreciate the time you gave me in 
your office to have a discussion of this. I cannot give you 
additional information.
    Senator Manchin. Timelines?
    Dr. Stone. I am subject to the same restrictions that you 
are. I meet with the IG every two weeks, and this is all in the 
hands of--
    Senator Manchin. I have that the U.S. attorney, the one who 
was on the case, has left and there is another?
    Dr. Stone. I am not aware of that.
    Senator Manchin. You are not sure?
    Dr. Stone. I am not aware of that. I can also tell you that 
I find out most through either the plaintiff's attorney or the 
media of what is going on here.
    Senator Manchin. Well, and I hope--
    Dr. Stone. And what I can assure you is that we believe 
that this is a safe site for veterans to receive care. You and 
I had that discussion.
    Senator Manchin. Right.
    Dr. Stone. We believe it is a safe site. We believe that we 
have discharged the employee that was involved in this, and we 
look forward to resolution. But the continuing pain in this 
community is intolerable.
    Senator Manchin. It is just unbelievable, for the families 
who might have lost a loved one during that period of time that 
is in question, and if that person has died they still believe 
it could be attributed to the care they were getting. It is 
just very hard. And a year and a half. You have to admit to 
yourself no family should go through that.
    So I am not here chastising. I am basically saying that the 
corrections that you tell me have been made, I have not had 
complaints since then from the patients and from our veterans, 
and I appreciate that. But I just do not have answers, and my 
heart bleeds for the families I just do not have answers for.
    Dr. Stone. Senator, I appreciate the leadership you have 
shown in this and the manner in which you have handled it, and 
I appreciate the time you have given me in discussing it 
honestly.
    Senator Manchin. Please, and we will talk further 
privately.
    Dr. Stone. Thank you, sir.
    Senator Manchin. Okay. As far as on the MISSION Act, sir, I 
had my doubts about MISSION Act. I have got to be honest with 
all of you. I thought it was a back door to privatizing VA and 
I am very, very much concerned about that. I am on high alert, 
if you will. I have got 112 jobs unfilled in the VA in West 
Virginia, in my four VA hospitals, and some of those are in the 
most critical care. And to outsource that would not assure, in 
rural areas, that they are going to get the care outside. A 
veteran wants to get care in a veteran hospital. They feel 
secure there. They feel good. People understand their concerns, 
their needs, and where they come from. So my concern has been 
basically of not staffing in the specialties that we need and 
also the care that we can give.
    I will give you an example. We did outside--there was 
outside immune work done, and we could do it inside if we had 
basically the necessary equipment that it took for the 
investment. I think you and I talked about that, that they were 
able to do it for about one-third of the price and do it much 
quicker.
    So I know the veterans hospitals in my area are capable of 
doing this work, and the veterans are much satisfied with it. 
But I also understand, and I appreciate the intent of MISSION 
was if you do not have it, shouldn't the veteran have the 
opportunity to have the best care? And I still feel very 
strongly. I am just concerned that we are abdicating our 
responsibility.
    Dr. Stone. Let us talk just then a little bit about what we 
are sending out. Ninety percent of the increase in 
consultations that are going out to the community are specialty 
care. We are not seeing an increase--
    Senator Manchin. I do not mean to interrupt you because I 
know our time is limited. But on that, do we have a good review 
process of the doctor who evaluates? Because I am 
understanding, if I am a veteran, I come in to the VA center, 
they evaluate me and decide where the best care would be. Is 
there anyone evaluating the evaluation doctor or that process 
is accurate?
    Dr. MacDonald. Yes, Senator, and actually this is an area 
of intense focus for us right now. As we have briefed Committee 
staff, we are pursuing what we are terming our referral 
coordination initiative. This is modernizing the way we process 
referrals, modernizing the experience the veteran has, and as 
clinicians sitting up here, I think we all understand walking 
out of a visit and waiting for the phone call about when that 
next step in care will have--will happen, the uncertainty of 
that.
    We are changing that and bringing ourselves in line with 
industry best practice, and instead having a referral 
coordination team take care of that veteran immediately, do 
today's work today, as is a best practice, pass on the 
uncertainty and instead give the veteran certainty about when 
that care will happen and what that next step will be.
    Senator Manchin. We would love to give you the input we are 
receiving, because we are not getting those same types of 
reports that you might, and we will give you the concerns that 
we have of how they have been evaluated and how they have been 
basically passed on.
    Dr. MacDonald. Glad to hear that, Senator.
    Senator Manchin. And it might be of help. I hope it does.
    Dr. MacDonald. We are confident and we are actually very 
encouraged to hear that when most veterans are interacting with 
the new initiative, our referral coordination teams, that they 
are telling us that they want to be with VA, that they want to 
stay with us and have that continuity.
    Senator Manchin. They tell me this all the time. I just 
wanted to reiterate to you all and make sure we are doing 
everything we can to get the service within the VA system.
    Dr. MacDonald. Absolutely.
    Senator Manchin. And this should not be a privatization 
move at all, in no way, shape, or form.
    Dr. MacDonald. Absolutely, and glad to discuss further, 
Senator.
    Senator Manchin. Thank you. Thank you.
    Chairman Moran. Senator Brown.

                         SENATOR BROWN

    Senator Brown. Thank you, Mr. Chairman. Dr. Stone, thank 
you for the work you have done with our office, especially in 
Cincinnati. Thank you.
    I want to build on Senator Manchin's questions with the 
same skepticism about sort of where this has all gone and the 
desire for some, many in the Administration and the Senate to 
privatize, as they want to privatize Social Security and the 
prison system and public education, all the things. I heard the 
President talk about failing government schools. That term 
just--I mean, I--most of us, certainly the three of you believe 
in public service as we all should.
    The two topics I want to more specifically address for Dr. 
Stone, the quality of care veterans receive in the community 
and ensuring VA medical centers have the resources they need to 
fulfill their missions. And similar to what Senator Manchin 
asked, but when we voted for the MISSION Act we never intended 
to have community care at the expense of VA care, especially 
when VA typically outperforms community health care facilities. 
And what Senator Manchin said about the comfort veterans feel 
when they are Wade Park, or they are at the Dayton VA, and the 
wonderful veterans hospitals around the country.
    But I have heard VA facilities in my state, and I am going 
to guess throughout the country, have a budget deficit, and 
because of that deficit employees are going to be let go. My 
question is, Dr. Stone, are VHA medical facilities operating 
with a budget deficit?
    Dr. Stone. Sir, they are not. There is no budget deficit. 
There is no hiring freeze.
    Senator Brown. Have you changed your patient care model?
    Dr. Stone. So here is what happened. When we stood up the 
new Community Care Program we loaded enough money, and we 
talked about this a little earlier, we loaded enough money into 
the Community Care Program that if I run short it will be a lot 
easier for me to come up and look at you and say, ``I have got 
to pull money out of the purchased care and put it into the 
direct care system.'' So we actually budgeted right on target, 
and we are performing right on target. In fact, last week we 
went into a budget burn sequester with all of our leaders of 
each of the regions. In 15 of the 18 VISNs we are right on 
target. In three we are burning a little hot, and I expect them 
to bring this----
    Senator Brown. So let me--sorry to interrupt you----
    Dr. Stone. And let me just finish this statement before you 
go ahead. We are about 1 percent off of where we need to be in 
those three regions.
    Senator Brown. So if you have not changed the patient model 
and you do not have a budget deficit, how does a facility let 
100 employees go over the course of three years and not see a 
degradation of services to veterans?
    Dr. Stone. I am not aware that there are 100 employees that 
have been let go. Now there are some openings and there is some 
strategic hiring. Let me talk to you about that. One of our 
biggest problems is very high-cost specialists exceed the 
reimbursement--the pay caps that we have.
    So a neurosurgeon or a gastroenterologist, a 
gastroenterologist can finish their residency and come out and 
command a $375,000 salary. We are capped at $400,000. So we 
have trouble recruiting in certain very high-cost specialties 
because of the pay caps, and it is something we are going to 
have to deal with.
    I have got over 300 specialists that are at their pay caps 
today, so there is no sense of us hiring a neurosurgeon nurse 
to support a neurosurgeon if I cannot hire the neurosurgeon.
    In California alone, one of the really high-cost markets 
for us, I have got over 400 nursing openings because we cannot 
compete. So we were just at UCLA and Los Angeles last week, 
working on the homeless issue. UCLA, across the highway from 
our campus, is picking off huge numbers of our nurses because 
we just cannot compete because of the pay caps.
    Senator Brown. I guess I am not entirely convinced.
    An unrelated topic. A year ago you told this Committee the 
Department was 90 days away from a recommendation on bladder 
cancer and hypertension and Parkinson's related to Agent Orange 
exposure. We have not forgotten. It has been over 300 days. We 
find the Department's response to reporting requirement by the 
end of the year appropriations package deficient. The science 
is there. Veterans deserve their benefits. You need to move on 
that.
    Dr. Stone. Senator, I think what I said was that I had 
reached my recommendation to the Secretary, and the Secretary 
would make a decision. I think he has worked his way through 
that. I think he has made some statements on the additional 
data that we are requiring, and I will defer to the Secretary 
to make the Department's definitive decision on that.
    Senator Brown. So why is it taking so long? Why is the 
Secretary so slow?
    Dr. Stone. I think specifically we are dealing with, 
especially in hypertension, a condition that affects 70 percent 
plus of over 65-year-old males in America. And so when you look 
at numbers on the Vietnam veteran population that exceed that 
by 5 to 6 percent, you really begin to wonder, what are we 
dealing with? Is it Agent Orange exposure or is it the fact 
that this may be a different demographic group? And I think we 
are struggling through that. So, therefore, the two studies 
that are still in motion and waiting for peer review and 
publication will either confirm this or not.
    Senator Brown. So an administration that wants to give--and 
I do not put you in this category because you are not sort of 
in that position, but an administration that is very willing to 
give tax cuts for the richest people in the country cannot find 
their way to slightly err on the side of taking care of people 
who served their country in Tet, in other times in Vietnam, 
apparently.
    Dr. Stone. Senator, I would say to you that what you should 
expect from me is me to base my decisions on good science.
    Senator Brown. And I think you have, so thank you.
    Dr. Stone. Thank you, sir.
    Chairman Moran. Senator Brown, thank you. Senator Tillis.

                         SENATOR TILLIS

    Senator Tillis. Thank you, Mr. Chairman. Thank you all for 
being here. I was watching, Mr. Stone, and the Committee in my 
office before I came over, and in your opening statement you 
made a comment about very positive satisfaction levels. Would 
you repeat that again, where you are right now? I thought--did 
you say 80 percent?
    Dr. Stone. We are at 88 percent, 88 percent for our 
routine, direct, face-to-face care of do I trust VA with my 
care and the care that I am getting. It is at 88 percent. We 
are at 91 percent for home care.
    Senator Tillis. Yeah. So how does that compare against 
private sector benchmarks?
    Dr. Stone. It is above private sector benchmarks.
    Senator Tillis. Yeah. I think that is something that is 
always important to bring up here. Every once in a while I will 
go out in a public setting and I will hear someone say, ``We do 
not want our health care system to be like the VA.'' I said, 
"Hell, I wish it was.'' I wish that we were achieving the same 
levels of satisfaction. It does not mean that we do not have 
work to do. It does not mean you are not going to run into 
kinks in the implementation of MISSION. But you all have a very 
positive story to tell, and I am particularly proud of VISN 6 
and all the work that they are doing down in the Southeast and 
specifically in North Carolina.
    In fact, I am going to ask you some other questions about 
the implementation, but I think we just did a first- ever 
donation after a circulatory death surgery. It was a referral 
out of the VA for a veteran down at Duke University Hospital. 
Are you familiar with that case?
    Dr. Stone. I am, sir.
    Senator Tillis. Tell everybody else a little bit about it.
    Dr. Stone. Kam, do you want to talk about that? You got it?
    Dr. Matthews. Senator, with Ms. Seekins' leadership in that 
VISN----
    Senator Tillis. It was amazing.
    Dr. Matthews. ----as you said, this was an unprecedented 
occurrence. And this really goes in line with the way that the 
health of our transplant program has been prioritized. We are 
seeing additional access for veterans in the community but we 
are also seeing veterans continue to choose VA and continue to 
choose, as you highlighted with Duke, the partnerships and the 
academic affiliates that VA has as a part of our transplant 
program.
    Senator Tillis. Yeah. So I, for one, just want to let 
everybody know they are doing great work out there, and I like 
the way that you are going about making hiring decisions. You 
are right. It makes no sense to have support clinicians in 
place if the specialists cannot be hired. That is just good 
business sense. I am glad to see you are executing that way and 
I am proud of the Secretary and all of you all, incidentally, 
for the work that you have done on making the VA a preferred 
place to work in the Federal Government. It is great work, and 
that stems from leadership.
    I do want to echo, Senator Moran raised a question about 
provider networks as we do the implementation from TriWest to 
Optum. And I am not going to point to an immediate concern now, 
at least within my state, but I think it is something that we 
have got to watch very closely as we roll it out and make sure 
that our veterans have access to the providers they prefer. It 
has got to be within the components of the contract.
    But to the point Senator Moran made, it may mean that we 
need to look at it, and as you all said, provide some waivers, 
if necessary, to roll out and make sure we are primarily 
focused on the main thing. The main thing is satisfying the 
vet.
    Also, I wondered whether or not you all do any surveys on 
provider satisfaction. Do you all do that?
    Dr. Stone. Internal to our system or those providers that 
are under contract?
    Senator Tillis. Either one or both. It is just, you know, 
how happy are they working with the VA?
    Dr. Stone. In our all-employee survey providers are singled 
out, and we are actually exceeding the benchmarks in the 
private sector for most categories.
    Senator Tillis. I know you all have run into a few--I like 
the way you all have been proactive, particularly on 
reimbursements. When we have a problem, it looks like you are 
reaching out and really coaching the providers on how to submit 
the paperwork properly. That is good.
    One question that I had is it seems as though it generally 
a once-and-done with the provider once they understand the 
process, but what more could we do to maybe even avoid that 
first interaction through education, portal access, whatever 
kind of tools we can use to expedite the transition?
    Dr. Matthews. Senator, we are actually on our second 
generation portal for providers to be able to sign into and 
look at their claims and understand at what stage of the 
process they are in. We also have regular monthly webinars 
where our finance team is reaching out and working with 
different finance teams or even admin staff at different health 
systems, and then there is that one-on-one interaction. We 
really are increasing our provider engagement in that way.
    Ultimately, though, however, is also the larger 
transformation, not just automating how we process claims but 
to simplify the process, so there is not a confusion on where 
to send the claim. There is perhaps one clearing house. We are 
looking at that longer-term strategy as well.
    Senator Tillis. Well, thank you all for the great work. I 
am going to submit a number of questions for the record that 
are more technical in nature, and, Mr. Chairman, I appreciate 
you encouraging me and Senator Tester to continue the check-in 
on the electronic health record and some of the transformation. 
I know we will be reaching out to set up a meeting in our 
office so that we can just talk through the program office and 
see how you are doing at the implementation level. Thank you.
    Chairman Moran. Senator Tillis, thank you. Senator Murray.

                         SENATOR MURRAY

    Senator Murray. Thank you, Mr. Chairman. Dr. Stone, as you 
well know, it is really important to me to make sure that we 
are providing care for veterans who are facing fertility 
challenges as a result of their service. But I want you to know 
I am continuing to her about obstacles for veterans who are 
trying to access this care. I am hearing that providers and 
veterans are unaware if the care is available, I hear about 
long delays in processing and approving the requests, and I 
have even heard about providers who are putting their own 
opinions ahead of the veteran and actually refusing to give 
them access to treatment.
    It is really critically that after these veterans have 
sacrificed so much in their service they are fully supported, 
and fertility challenges are difficult enough without having to 
fight a bureaucracy to access care that they have earned and 
that they are entitled to. And as we all know, delays in this 
means sometimes they cannot access care and have kids.
    So I do not want to hear about this anymore and I want to 
know what the VA is doing to address those barriers and make 
sure veterans get the care when they need it.
    Dr. Matthews. Senator, this is such a critical point. We do 
have very structured guidelines, referral practices, so that 
the local staff, the local providers do have instruction on how 
to make these referrals, how to actually review fertility for 
service connection, because, of course, there are very strict 
rules on how we actually can provide fertility services.
    But as you are hearing of these individual cases, our 
office can definitely make moves to make sure that these 
individual veterans do receive the services that they deserve 
and are warranted to receive.
    Over the last year or so there has only been about 400 or 
so cases. There are very small numbers nationwide. So we do 
have the capability to really dig in on each and every one of 
those and make sure not only that they are evaluated 
appropriately but that we also have a provider in network that 
can actually provide those services.
    Senator Murray. Okay. Those are great words but I want to 
see them put into action, and I want you to know that we are 
hearing that that is not happening across the country.
    Dr. Stone. And Senator, with each and every one of those, 
if we could have direct contact we would appreciate it.
    Senator Murray. We do.
    Dr. Stone. Because when a patient comes to you it often can 
take a little bit of time. We need that direct contact and 
appreciate the relationship that we have, that you will bring 
that to us.
    Senator Murray. I will do that. All right.
    Dr. Stone, another topic. Implementing the expansion of the 
Caregiver Program, as you well know, is significantly behind 
schedule. We have talked about this before. I have significant 
concerns over any proposal that would cut eligibility or limit 
service to our veterans and their caregivers. And I do want to 
thank you for being transparent and up front with me about the 
VA's status when we met in December.
    But it is time to get this program moving. Our veterans are 
waiting. These services can make a tremendous difference in 
their quality of life. So I want to ask today, when will we see 
the proposed caregivers' regulations and will they propose any 
curtailing of services or eligibility?
    Dr. Stone. Dr. MacDonald has been working this actively, 
but let me say to you that it should be this month that you 
will see the regulations.
    Senator Murray. This month, as in February?
    Dr. Stone. As in February. Yes, ma'am.
    Dr. MacDonald. Senator, the expansion of this program, as 
you know, is something we have welcomed in VA for a long time. 
We are thrilled to be able to provide this benefit equitably 
across all areas of care, and especially to be expanding first 
to those pre-1975 veterans, those Vietnam- era veterans who we 
know have a significant need set, and who we know face a burden 
of illness that is often higher, on average, than the cohort 
that we have previously served in the post-9/11 generation, 
individual by individual. Certainly any burden of illness can 
be high, but we know that this cohort is significant, both in 
their own burden of illness and in the average age, as we 
anticipate, of the caregivers caring for them. Oftentimes this 
is a spouse who is delivering that care, day in and day out. 
Sometimes it is another family member.
    But we expect the average age of these caregivers to be 
over 70. And by design, this program will meet the needs of 
each of these eras equitably. You will see us expand in a way 
that is consistent and builds upon the more than 15 programs 
that serve this population now. The stipend program that is 
specifically expanding, we are hiring more than 680 staff 
across the nation, and have hired them at the regional level, 
at the VISN level. In every region they are already in place, 
ahead of the expansion, which we anticipate this summer.
    In addition, we have 50 percent, more than 50 percent now 
of the support staff on board, and we are in strong partnership 
with IT, stronger than ever before. And we anticipate that both 
the regulation, as it becomes final, as Dr. Stone said it will 
publish this month, but as it becomes final this summer that 
will come in line with the IT systems being delivered, and then 
this program will expand this summer.
    And we anticipate, also, reaching back to those veterans 
and caregiver pairs who have already reached out to us and 
expected this, as you said, on October 1st. We will be reaching 
back to all of those veterans who applied and guiding them 
through the process, if they still want to be part of the 
program when the expansion happens.
    Senator Murray. Okay. We will be watching for that, and 
stay in touch. I am out of time but I did want to just say that 
I am hearing a lot of concern about the Department's referral 
process to community care and quality and coordination. I will 
be submitting a question on that and I hope to get an answer as 
quickly as possible.
    Thank you, Mr. Chairman.
    Chairman Moran. Thank you, Senator Murray. Senator 
Sullivan.

                        SENATOR SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman, and Dr. Stone, I 
am glad that you are going to be making it up to Alaska 
sometime this spring. I appreciate that. I think you will be 
impressed with the VA operations in the state. Dr. Ballard is 
doing a great time. And you will get a good understanding for 
our need for new or expanded spaces that can accommodate not 
just the uptick in personnel but as a result of recruiting 
initial doctors and staff, which has been very positive, the 
increased traffic of veterans seeking services, I think 
Secretary Wilkie saw this on his recent visit. My hope is that 
your visit will also encourage you and your VHA leadership team 
for operations and management to reassess the way regional 
budget allocation models are setup to reflect booming growth.
    So let me ask Dr. Matthews, I know you are aware that 
Region 5--and the Chairman, I appreciate, just touched on 
this--is several months behind Regions 1 through 4 in terms of 
CCN deployment, though TriWest is bridging in the interim, and 
we appreciate that. And in fee for the contract was solicited 
back in October of last year. What is the current timeline for 
awarding the contract?
    Dr. Matthews. We are in the middle of the final stages of 
acquisition so we should be announcing in the coming month or 
two.
    Senator Sullivan. Can you just--again, the Chairman just 
touched on it--can you go into a little bit more detail of why 
Alaska was pulled into its own network in the first place?
    Dr. Matthews. Sure. So Region 4 was the original geography 
that we attempted to award, but VA did not find an offer of 
value. There was a lot built into that RFP that we then opted 
to amend. So we not only removed Alaska, when you look at the 
managed care industry there are not players that cover, from a 
network standpoint, Texas as well as Alaska. So that was a very 
large geography. Alaska tends to have actually just a couple of 
managed care players in that space, and they are solely in 
Alaska.
    So by removing Alaska we wanted to make sure we had a more 
focused offer that was really focused on the needs of your 
constituents. We also did the same with the Pacific 
territories. They were also bucketed into Region 6. So it was 
really just an idea to get better offers.
    Senator Sullivan. Well, look, we appreciate that, and I 
know you were taking input from a number of us on that issue. 
And when you are reexamining the Alaska market and drafting a 
new contract for the second RFP, how much input were you 
getting from the local VA leadership, which integrated into the 
final product?
    Dr. Matthews. Dr. Ballard, other members of his team, as 
well as the VISN staff, were all included in that integrated 
project team. We also had multiple consultations with several 
of the tribes.
    Senator Sullivan. Great.
    Dr. Matthews. Tribal leaders joined us at at least two 
different meetings, and I was able to join as well, to discuss 
just what this RFP looked like, what the critical nature of the 
relationships within Alaska, just because, again, they do 
differ from other states. So we did a great deal of input in 
order to build this final RFP.
    Senator Sullivan. Well, again, I appreciate that. You know, 
our Alaska Native veterans are a very, very high proportion, 
and we talked about that in the last hearing, and then Alaska 
native health care has a lot of reach into some of our more 
very remote communities. You know, we have over 200 communities 
that are not even connected by roads. That is a challenge that 
no other state faces.
    Dr. Matthews, how confident are you that the TPAs who have 
submitted bids for the Region 5 CCN contract will actually be 
able to meet the terms of it?
    Dr. Matthews. Unfortunately, I cannot speak to that, just 
because it is a confidential acquisition process that I am not 
a part of.
    Senator Sullivan. Okay. So anyone else? Dr. Stone, can you 
talk to that at all? I mean, I do not want to get into 
confidential info, but we want to make sure that all the work 
that you have done on the Region 5 issue is actually going to 
bear fruit. And if we do not think it will, what would be the 
alternative?
    Dr. Stone. We are optimistic, and we are in that very 
sensitive stage of acquisition, and we need to be very careful 
with our comments.
    Senator Sullivan. Okay.
    Dr. Stone. But I can say that the Secretary and I were over 
with the Secretary of Defense last week, talking about the 
uniqueness of the Alaskan delivery market, the role the DoD 
plays with us, the role of the Alaska Native health care 
system, and it was specifically an expression of our concern 
that as DoD evolves their health care system that we wanted to 
make sure there was no disruption with the very close 
relationship that our leader, Dr. Ballard, has had within the 
Alaskan delivery system.
    But it is unique. You have helped me understand how unique 
it is, and now on my third attempt to get up to Alaska I am 
hopeful that we will actually do it this spring.
    Senator Sullivan. Well, we look forward to welcoming you 
there, and I appreciate your comments on the uniqueness. But it 
does provide opportunities. We obviously have a big DoD 
presence there, which is growing quite significantly, more vets 
per capita than any state in the country, but also as you 
mentioned quite a solid and well-performing Alaska Native 
health system with reach, that the partnership with the VA we 
always see as a good opportunity to make the goal of what we 
all want, which is better health care for our vets.
    So thanks very much. I look forward to seeing you in 
Alaska.
    Dr. MacDonald. Senator, if I may very briefly follow on to 
what you just said about the uniqueness of Alaska, following 
onto our discussion earlier, in answer to the Chairman's 
question, this is where the tools in the MISSION Act need to 
come together with the other tools we have in VA. The Region 5 
network itself will be a step forward, and those partnerships, 
including the tribal entities, as you mentioned, will be 
critically important to access in that area.
    Additionally, VISN 20, of which Alaska is part, is leading 
in the telehealth space, and leading in deploying our health 
care providers into areas where veterans need to see them in 
person. We very much believe that the tools you have given us 
in the MISSION Act--telehealth, the network, the recruitment 
and retention tools that we now have--need to come together and 
synthesize in order to meet access for folks who choose to live 
further away and would not have access necessarily to a brick-
and-mortar facility. We need this to be cross-functional and 
meet them where they are, and your region is a primary example 
of how that strategy will come together.
    Senator Sullivan. Great. Thank you very much. Thank you, 
Mr. Chairman.
    Chairman Moran. Thank you, Senator Sullivan. Senator 
Blumenthal.

                       SENATOR BLUMENTHAL

    Senator Blumenthal. Thank you, Mr. Chairman. I noted, 
unless I am mistaken, Dr. Stone, there is no mention in your 
testimony of mental health care. Yesterday in the State of the 
Union, actually during the day, I hosted a family whose son and 
nephew, Tyler Reeb, was a Marine Corps sniper, had three tours 
in Iraq and Afghanistan. He came back suffering from the 
invisible wounds of war and took his own life, all- too-common 
story.
    The fact that it is so common is really an indictment of 
our health care system, and I wonder if you could tell me 
whether you have seen any changes in the quality of care, 
whether there are new kinds of treatments and diagnoses, 
whether the community health care that is offered through the 
MISSION Act is improving the situation, and whether we can do 
better to help our veterans before they come out of the 
service, removing some of the stigma and seeking health care, 
mental health care so that it is integrated with community 
service once they are back in the civilian world?
    Dr. Stone. Senator, this is, I think, for all of us, one of 
the most frustrating things we deal with. You have given us a 
doubling of our mental health provider budget. We spend almost 
$10 billion a year. We now have over 25,000 providers in mental 
health within VA. Access to VA mental health services is same-
day access, across our entire delivery system, but yet we have 
not changed the trajectory and the number of suicides and self-
harm that is created.
    I talked extensively in previous testimonies about the fact 
that this is not simply a mental health problem. This is a 
problem of isolation and loneliness and hopelessness that 
really cries out to the rest of American society. It is why the 
President, in his Executive order, called for the development 
of the PREVENTS Task Force and why the PREVENTS Task Force will 
present a plan that will integrate a community response, not 
dissimilar to what you saw in homelessness, that has driven 
down veteran homelessness by 50 percent.
    VA cannot solve suicide alone, and if you gave us another 
$10 billion for mental health and we hired every single 
graduate of every single program it does not undo the intense 
loneliness that leads to this.
    Senator Blumenthal. You do not think the problem is one of 
more psychiatrists and more trained professionals?
    Dr. Stone. I do not. I do not, and I think we have 
demonstrated that. I think what this is----
    Senator Blumenthal. And do you think
    Dr. Stone. ----and I think we demonstrate that in the 
extraordinary difference in rates of suicide in areas like 
Montana, like Alaska, that have dramatically higher suicide 
rates than does New York City and Los Angeles. There is 
something about interpersonal contact that is protective, and 
it is why it is so important for us to maintain the mental 
health delivery system and the camaraderie that is developed in 
active duty that must continue when we leave. And it is why 
veterans choose us. You go into the lobbies of every one of our 
hospitals. Veterans stay there. There is a sense of community 
that is really important.
    I think it is also--and I know I am going on too long on 
this, but give me just one more second on this answer. There is 
a chance for us, in the transition program, to re-examine how 
we interrelate with the veteran. Right now it is up to the 
veteran, when they go through what we call our TAP program, 
whether they engage with us. We would like to consider an opt-
out program where every veteran is enrolled in VA health care, 
unless they choose to opt out. I think it would help us a lot.
    And the dramatic change, when I came off of active duty, 
from being in a cohesive community to what I experience now, I 
have talked about before, and I will not repeat. But I 
appreciate your tolerance of that prolonged answer.
    Senator Blumenthal. Well, I thank you for that answer, and 
my time has expired so I cannot pursue some of the questions it 
raises. But I agree completely that the VA is sought after and 
welcomed by the veterans' community because of that sense of 
camaraderie, whatever the ailment that is being treated. That 
is one of the reasons that they come to the VA. And so I 
welcome your approach and I would like to follow up on it, and 
particularly, if you are willing to do so, meet with the Reeb 
family, because they have some ideas about how Tyler Reeb could 
have been saved.
    Dr. Stone. I would, and I would welcome that meeting. Thank 
you. We will contact your office to schedule that.
    Senator Blumenthal. Thank you. Thanks very much. Thank you, 
Mr. Chairman.
    Chairman Moran. Thank you, Senator Blumenthal. Senator 
Hirono.

                         SENATOR HIRONO

    Senator Hirono. Thank you very much. I appreciate this 
discussion on suicide prevention because it has been a concern 
for many of us for, well, for all of us, I would say. So you 
mentioned, Dr. Stone, the prevention--PREVENTS Task Force? 
PREVENTS Task Force--what is that? They are supposed to be 
coming up with an integrated community plan for addressing----
    Dr. Stone. This is part, Senator, of the President's 
Executive order, as we look towards the community approach.
    Senator Hirono. I think that is a great idea, so I would 
like to have more information about who is leading this task 
force and when are they coming up with their recommendations.
    Dr. Stone. This is, yeah, Dr. Barbara Van Dahlen, and this 
is an all-of-government approach to a different view, using a 
public health approach to suicide. And it really goes back to 
my previous comments, that this is not about really hiring more 
mental health professionals. This is really about an all-of-
society approach, just like we did with the homeless problem.
    Senator Hirono. I understand and I applaud that much, much 
more of a whole-person approach to suicide prevention, knowing 
also that most of the suicides of veterans who take their own 
lives are not part of the VA. They have not engaged with the 
VA. So I really like your opt-out approach. So are you going to 
be implementing that?
    Dr. Stone. So we just yesterday had additional discussions 
of that. This will require some help, and we will work our way 
through, from your level, how to actually implement that.
    In addition, we have been talking about some pilot programs 
and expanding access through our Class 7 and Class 8 veterans 
that would not normally have accessibility at the same level to 
enhance that accessibility. And we are working on a pilot in 
VISN 8 on that, which is our Florida/South Georgia region.
    Senator Hirono. So anything you can do to pretty much 
enroll all veterans in the VA rather than expecting them to 
show up, and doing that, I am all for, and if we need to change 
the legislation I hope you have something in mind.
    The Director of the VA Pacific Islands Health Care System 
recently departed her position, and in the last six years, five 
to six years, you have had three different directors. And 
usually it takes quite a while for a new person to be hired, 
and clearly we need somebody in that position who can connect 
with the community, including, of course, engaging with our 
neighbor island veteran populations, because, as you know, 
Hawaii is comprised of seven inhabited islands.
    So I would like to know from you what is the status of the 
search for a new director for Hawaii? When can we expect a new 
person to come on board?
    Dr. Stone. I would be happy to take that one for the 
record, and let me tell you only why. I have had a number of 
discussions with potential candidates who are interested in 
that. It is a very attractive site for a number of our leaders 
to go to. It is a bit of a dance when it comes to making sure 
that we are covering all areas properly and do not leave 
another area short.
    But a number of our leaders within the system are 
interested in that job, and I will take that, if you do not 
mind, for the record, and get you the exact details of how 
close we are.
    Senator Hirono. Yes, because the director in Hawaii also 
takes care of the veterans in Guam, right? I mean, this is a 
big job and we need somebody in there. And, of course, you 
mentioned before that recruitment and retention is an issue for 
the VA and you cannot compete with the private sector. But if 
there are things that we have to do to enable you to better 
compete. Although one would think that working for the VA, you 
know, you can appeal to a sense of community, of being part of 
providing care for people who have sacrificed for us. I mean, 
there are these non- financial aspects one would think that 
would, I hope, be part of your recruitment effort.
    Dr. Stone. I think it is. I think it is what has drawn all 
three of us to this job, these jobs, this sense of being part 
of something greater than ourselves.
    Senator Hirono. So you do put that out as part of your----
    Dr. Stone. Well, we do, but we also need to recognize that 
a young resident coming out of their training does not always 
have the same connection that we would like to the mission of 
selfless service. And I am not demeaning in any way, but----
    Senator Hirono. Yes. More is the pity.
    I just have--my time is running out so I wanted to ask you 
one more question, Dr. Stone. Mr. Atizado--he is on the next 
panel--mentioned that Disabled Veterans of America has heard 
from veterans that they are being offered access to community 
care network providers without being fully informed of their 
options to receive care in the VA.
    So are you making sure that the veterans know that they can 
actually get care in the VA without having to go out into the 
community?
    Dr. MacDonald. Senator, thank you so much for raising this, 
and we are so grateful for our veteran service organization 
partners and feedback on this. We have heard this from actually 
several veteran service organizations.
    As you heard me mention earlier about our referral 
coordination initiative, we want to make sure that veterans are 
empowered with their options. That has been at the center of 
our approach to the MISSION Act from the beginning. And I think 
we can safely say we have empowered people with their community 
care options. They are aware that that is an option.
    What we are hearing from veterans, proudly so, is that they 
want to know more about what additional VA options they have. 
Can they use telehealth? Can they use an e-consult? What 
additional options do they have in the VA, even if they have to 
drive a little further?
    That is beautiful news to our ears. We are proud that 
veterans want to stay with us, and that is why we are 
implementing that new initiative. That will get us down to 
three business days in scheduling people for care, empower them 
to schedule where they want to schedule, including if it is 
with us, and guide veterans through that process and really 
give them a list of options, which may be beyond their 
facility--that may be in their region and that may be 
nationally, via telehealth. We are taking this very seriously 
and taking that feedback to heart from our veteran service 
organizations, partners, and what we are hearing directly from 
veterans themselves in our facilities.
    Senator Hirono. Yeah. So what we are hearing is that they 
are not receiving the full range of options, and when you talk 
about empowerment, a lot of empowerment has to do with having 
the information necessary for them to make a decision.
    I do have some other questions for the record, which I will 
submit. Thank you, Mr. Chairman.
    Chairman Moran. Senator Blackburn.

                       SENATOR BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and I want to 
thank you all for being here. This is an issue that, in 
Tennessee, we talk a lot about, to our state director and our 
veteran facility directors. And we recently had a pretty 
poignant telephone call about some of this, because the wait 
times in Tennessee are exceeding the national average. Mountain 
Home facility, which is the best, the most highly rated 
facility in Tennessee, the wait times have increased since the 
implementation of community care.
    So you get that push and pull from veterans and from the 
providers there within the VA system that they feel like they 
do not want you leaving the VA system and going to the 
community because they are making it difficult. The VA is 
making it difficult for you to have your choice and have your 
options. And I know that you all have had some discussion 
before I got in here, from the Chairman, about this.
    And one of the things that we talked about with RCTs, and 
this movement, is this going to be done from existing staff or 
is it going to be done from new hires, and what is the training 
process so that the veteran is the first consideration, not a 
byproduct but the first consideration?
    Dr. MacDonald. Thank you so much for that question, 
Senator. You raise a critical issue about referral timeliness. 
It is first critically important to understanding that over the 
past several years VA has become extremely adept in delivering 
urgent care, and by urgent care I mean when a referral is 
urgent, when the care is needed now, and we need to get that 
veteran to care we deliver that in less than two days. 
Actually, it is continuing to go down and we are at 1.4 days. 
We deliver that internally and in the community right away, and 
we get those needs met.
    Where we have work to do is in our routine referrals, as 
you mentioned, and we have that work to do across the system.
    Senator Blackburn. And let me interrupt you right there 
please, and ask you, when we discuss this with our center 
directors, what they will say is, ``Well, it is because of the 
contract and because of the MISSION access, MISSION Act 
standards.'' So are you modifying those contracts, or where is 
the flexibility in that so that you are moving these forward 
and getting those wait times down?
    Dr. MacDonald. Senator, this is two-fold, and it is about 
process. It is about our internal process. In the past, 
processes were fragmented between our internal traditional care 
system and community care. We are solving that by putting, as 
you said, the veteran is the priority. The veteran is at the 
center. They are empowered, as we were talking about earlier 
with their options.
    When they have that range of options presented to them, 
immediately, again, doing today's work today, we are driving 
that wait time down to the three business days to process that 
scheduling.
    Senator Blackburn. What is your timeline for getting it 
down to within a day?
    Dr. MacDonald. Already, on Monday, all of our facilities 
conducted a stand-down, and----
    Senator Blackburn. What is your timeline?
    Dr. MacDonald. By July, ma'am.
    Senator Blackburn. By July.
    Dr. MacDonald. Yes.
    Senator Blackburn. Okay. Let me move on in my minute and a 
half left, and I know Senator Rounds talked to you about 
reimbursement. And we hear from people in small practices, not 
the big providers but the small practices, that they are not 
being reimbursed properly and there is a tremendous amount of 
delinquent payments that are there.
    So how many community care reimbursement claims are 
backlogged, what is causing that backlog, and what is your 
timeline for clearing that backlog?
    Dr. Matthews. Thank you, Senator, for that question. 
Currently, nationwide, our backlog, meaning aged claims beyond 
30 or 45 days, depending on the population of claims, is 2.5 
million claims. Our inventory as a whole is about 3.4 million, 
so there is always going to be some inventory because they have 
not aged yet. But that backlog is about 2.5 million. I do have 
a breakdown and can share it with each of you what your 
particular state backlog is, both by numbers as well as billed 
charged.
    But yes, this has been an ongoing legacy issue for the 
claims submitted to the VA.
    Senator Blackburn. What is your timeline for clearing the 
backlog?
    Dr. Matthews. By the end of this fiscal year.
    Senator Blackburn. The end of this fiscal year. And then 
your turnaround time per payment is expected to be what--15 
days? 30 days?
    Dr. Matthews. No. Our goal is definitely short of 30 days.
    Senator Blackburn. Short of 30 days.
    Dr. Matthews. Yes.
    Senator Blackburn. Okay. Thank you. I yield back.
    Chairman Moran. Thank you, Senator Blackburn. There is some 
interest in additional questions but we have a second panel 
that we think is also very important. Dr. Stone and Dr. 
MacDonald and Dr. Matthews, you have been very helpful to us. I 
appreciate the directness of your answers. We are going to turn 
to the second panel. I would guess that there would be, 
including from me, several questions for the record that we 
will submit to you. Thank you for your service.
    Dr. Stone. Mr. Chairman, thank you very much. Ranking 
Member Tester, thank you. I appreciate the courtesy shown to 
us.
    Chairman Moran. You are welcome.

                            PANEL II

    We will call that second panel, which consists of Adrian 
Atizado, the Deputy National Legislative Director for the 
Disabled American Veterans; Lieutenant General Patricia D. 
Horoho, CEO of OptumServe; and David J. McIntyre, President and 
CEO of TriWest Health Alliance.
    [Pause.]
    Chairman Moran. Welcome to the three of you. I thank you 
very much for agreeing to testify. We are grateful for your 
presence. I think it is particularly valuable that you were 
here to hear the testimony of Dr. Stone and his colleagues, and 
with that I would turn to Mr. Atizado for your opening 
statement.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Chairman Moran, Ranking Member Tester, 
distinguished members of the Committee, first of all I would 
like to congratulate you, Senator Moran, for your confirmation 
as the 12th Chair of this illustrious Committee. We look 
forward to working with you and your staff, sir, over your 
tenure here, to collaboratively work over the issues and make 
the lives of our ill and injured veterans better.
    Chairman Moran. I look forward to that too, as well. Thank 
you.
    Mr. Atizado. I want to thank you again for inviting DAV to 
testify at this hearing to examine the implementation of the 
new urgent care benefit and Veteran Community Care Program as 
envisioned by the VA MISSION Act that was passed a couple of 
years ago. Comprised of more than 1 million wartime service-
disabled veterans, DAV is a congressionally chartered nonprofit 
veteran service organization. We are dedicated to a single 
purpose which is to empower veterans to lead high-quality lives 
with respect and dignity.
    DAV is grateful for the support that this Committee and VA 
led to veterans, that led to veterans having access to urgent 
care furnished by the Department. Section 105 of the VA MISSION 
Act can be tracked to a 2016 resolution that was adopted by our 
members, asking for urgent care to be included in VA's medical 
benefits package. And today the need for this benefit is 
abundantly clear, with over 170,000 urgent care visits made by 
veterans across the country.
    Much of the success can be attributed to TriWest's efforts 
to build a network of over 6,400 urgent care providers as well 
as training them to understand the process and the procedures. 
And we are pleased to report that DAV members who have used 
this benefit express positive comments about their experiences, 
from the eligibility determination of the point of sight to 
actually the care that they receive, and not having been billed 
by it, which is extraordinary, I must say.
    We are hopeful the transition of the urgent care in Region 
1 from TriWest to Optum will be as robust a network and a 
process that is as seamless as veterans have experienced thus 
far.
    Mr. Chairman, it should come as no surprise, though, the 
DAV vehemently opposes VA's decision to charge copayments to 
service-connected veterans for urgent care. This is a 
discretionary authority given to the Secretary, which he then 
exercised. In DAV's view, service-connected veterans have 
already paid any such costs for their service and sacrifice, 
yet VA breached this principle without attempting other means 
to achieve their desired ends.
    I would like to turn now, at this point, to Section 101 of 
the VA MISSION Act. According to VA, the Veteran Community Care 
Program, which is embodied in Section 1 of the law, will be 
administered through a Community Care Network contract across 
five of six regions by the end of this year, and DAV recognizes 
the implementation of this program as a tremendous effort, and 
recognizes it is a massive undertaking, and its TPA partners, 
with TriWest and Optum, will really be needed. This partnership 
is critical for this program to work.
    To help bridge this transition, as mentioned in this 
hearing earlier, VA has leveraged the PC3 through a contract 
and the Choice contract with TriWest helped bridge this 
transition. This is critically important. While DAV is unable 
to fully assess the progress to implement a high- performing 
integrated network, which is what the law envisions, we 
continue to hear, as was mentioned by Senator Hirono, issues--
as well as the other Senators--from both veterans, VA providers 
themselves across the country, as well as community providers.
    Mr. Chairman, we bring these issues to light so that VA and 
its partners can work together to systematically and 
holistically improve this critical program, and not treat it as 
one-off issues that they need to tackle as it comes up. VA is 
learning institution. Its partners should be, as well, and this 
program should reflect that. They should not only measure but 
they should also be able to manage and identify them in the 
system.
    To this end, we remain concerned about implementation of 
the required care coordination and competency standards of non-
VA health care providers as required in Sections 101 and 133 of 
the VA MISSION Act. To carry out the care coordination piece, 
VA medical centers are assuming all responsibility in 
appointment and scheduling all eligible veterans, and I respect 
Senator Hirono's comments about the staffing requirements for 
these.
    We also have not received fully sufficient information to 
assess the status of implementing the competency standards, in 
other words, the quality of care that veterans receive both 
inside and outside the VA health care system. Ignoring these 
standards shortchanges veterans and taxpayers of what otherwise 
should be high-quality and high-value care. It could also 
fragment veterans' care. This is something that should not be 
happening in a high-performance health care network.
    Mr. Chairman, this is my time, and I appreciate the 
opportunity. I will take any questions from this Committee. 
Thank you.
    Chairman Moran. I thank you so very much. Lieutenant 
General, welcome. Thank you very much. I look forward to your 
testimony.

       STATEMENT OF LIEUTENANT GENERAL PATRICIA D. HOROHO

    Lieutenant General Horoho. Thank you. Good morning, 
Chairman Moran, Ranking Member Tester, and members of the 
Committee. I am Patty Horoho, CEO of OptumServe. On behalf of 
the more than 325,000 men and women of UnitedHealth Group, we 
are honored to be part of this mission. We have a long history 
of serving our nation's military and veterans, and we are 
deeply committed to standing up the community care network that 
honors the sacrifices made by our nation's heroes.
    Half of Optum serves community care program staff, our 
veterans, and most of us have family members who are veterans. 
This experience is enhanced through extensive quantitative and 
qualitative research we perform to better understand veterans 
and their lives and their experience with navigating the health 
care system.
    We met with 125 veterans in their homes over five states. 
We completed a national survey of 5,500 veterans, and then we 
mapped veterans' experience and steps in getting care, called 
the journey mapping. This research uncovered valuable insights 
and informed us on how the process would work better for 
veterans, for the VA, and community providers.
    Taking in these insights that places the veteran at the 
center of our planning, we are equally dedicated to excellence 
in execution. Center to our responsibilities and community care 
is delivering a network of high-quality health providers from 
which the VA medical staff and veterans can choose. We began by 
leveraging the 1.3 million providers in the National 
UnitedHealthcare and Optum provider networks, but our network 
strategy did not end there. We worked with the VA to identify 
quality providers. We have a history and a desire to care for 
our veterans.
    Six months ago, we began health care delivery at two sites 
in Region 1. Today, in Region 1, our company has built a 
network that includes more than 178,000 unique health systems 
and providers across more than 309,000 care sites. And since we 
completed Region 1 implementation activities in December, the 
network has grown by more than 10 percent, which includes more 
than 18,000 unique providers, over 44,000 sites of care.
    Taking a data-driven approach, we will continue to 
implement and evolve the network as we assess the needs of our 
veterans in Regions 1, 2, and 3.
    We also care deeply about delivering a seamless experience 
for community care providers, including paying community care 
providers for care that they have delivered. This is a critical 
element to the success of our network. It demonstrates that 
Optum is a reliable partner and increases provider confidence 
in continuing to participate in our network. As of today, we 
have processed more than 150,000 claims and paid claims in an 
average of 11.9 days.
    Another critical element to the success of our network is 
resolving provider issues as soon as possible. As of today, we 
have received 35,000 calls to our customer service center from 
VA staff and providers, with an average speed to answer of 3.6 
seconds, and our customer service staff have resolved more than 
99 percent of the issues, first time, first call.
    Throughout the entire provider experience we are providing 
them information that they need to take action. It begins with 
letters, calls, in-person meetings. After they have joined we 
provide training on how this new network operates. This occurs 
through webinars, in-person trainings, virtual town halls, and 
provider expos. We also provide regular updates, education 
materials, and on-demand videos to providers, either directly 
or through our online portal. We are restless in our desire to 
do more and learning, and leaning far forward to identify new 
ways and new methods to communicate.
    In conclusion, what is important six months into health 
care delivery is that veterans are getting care from our 
network, providers are promptly getting paid, and we continue 
to adapt and build our networks across all three regions, 
continuing our strong partnership with the VA and TriWest.
    I am committed to continue to deepen our partnership with 
veterans, with Congress, veteran service organizations, and 
other important stakeholders. We understand your interest in 
ensuring the community care networks meet our veterans' needs 
and we share this interest. I am equally committed to 
continuing our open lines of communications and regular 
engagements with the VSO community, including Adrian's 
wonderful organization, and I am very proud to serve alongside 
you.
    As a veteran, former Army sergeant general, and commanding 
general of the U.S. Army Medical Command, wife of a veteran, 
daughter of a veteran, and now the proud mother of an airborne 
infantry officer, getting this implementation right is 
important to us. We understand firsthand the compassion the VA 
medical staff bring to veterans, and the importance of 
coordinated care across the health system. This mission is 
personal and important to us. We understand why getting this 
right is so vital.
    Mr. Chairman, congratulations on your new role leading this 
Committee. Thank you for what you and the entire Committee do 
every day to support our veterans, and thank you for this 
opportunity to testify.
    Chairman Moran. Thank you for your testimony, and thank 
you, General, for your and your family's service.
    Mr. McIntyre?

                 STATEMENT OF DAVID J. McINTYRE

    Mr. McIntyre. Good morning, Chairman Moran, Ranking Member 
Tester, and members of the Committee. I am Dave McIntyre. I am 
the President and CEO of TriWest Healthcare Alliance. Thanks 
for the invitation to appear today. I ask that my written 
testimony be submitted for the record.
    Chairman Moran. Without objection.
    Mr. McIntyre. Our company stands at the doorstep of 
implementing the new CCN contract in Region 4, which begins on 
April 7th in Montana and eastern Colorado, and will continue 
through the summer. Lots of work is underway between us and VA, 
at the local level and at the national level, to make sure that 
we are ready to execute in our areas of responsibility, 
including making sure that the provider network is set for CCN.
    But as most of you know, we at TriWest Healthcare Alliance 
have been on quite a journey the last six years, because you, 
we, and VA have traveled much of it together. The earliest days 
of this privileged work were extremely challenging, but our 
north star was two fully engaged members of the Arizona 
congressional delegation, one of whom for which the MISSION Act 
is partially named, and the other one who now serves on this 
Committee. From moment one they were fully and completely 
engaged, seeking an understanding of what was going on and 
pragmatic solutions to what needed to be done to make sure that 
Phoenicians who served their country were going to get what 
they were owed.
    But the focus was not unique to Arizona. It was true across 
the nation. And it was true between branches of government and 
the veterans' community, including the great organization that 
Adrian is from. By working together, we brought things to a 
place of reasonable stability in the half of the country for 
which our company had the privilege of serving alongside VA, in 
terms of community care. We paid our claims, we assisted with 
appointing, we made sure that networks were available, and we 
performed other administrative functions, while you and VA 
worked at crafting the long-term blueprint for the future of 
VA, which is embodied in the MISSION Act.
    Then we all found ourselves in a position where a company 
walked away from its commitments, leaving VA, veterans, and 
community providers in the other half of the country without 
the support that they were to have had. Senator Tester, I will 
always remember your graciousness in taking a meeting request 
from me when I was trying to decide whether we were going to 
accept the request of Dr. Stone to lean forward and plug the 
gap and build the bridge in the other part of the country. It 
was a rather intense conversation. It was very frank. Frankly, 
it is the roadmap on which all of us at TriWest, in full 
partnership with VA, have adhered.
    Not only that, I was impressed that when I said yes to Dr. 
Stone, you, in turn, said, ``I am going to lean forward and I 
am going to be your partner, as is my staff in this process.'' 
You leaned out vulnerably and told the providers in your state 
that this would all work and that they could trust and have 
confidence that at the end of the day we were going to get it 
right.
    In fact, three weeks ago I found myself in Montana, as I am 
often, but I was there at the side of my 85-year-old veteran 
father as he decided to take on the role of secret shopper in 
one of Montana's fine cardiac units, and they did one heck of a 
job, just as they have been doing for veterans ever since we 
went live in Montana on December 7, 2018, 90 days after we said 
we would assault that cliff.
    As a proud American humbled to be of service to our 
nation's heroes in support of VA, along with all who are 
associated with TriWest, I tell you this story because it is a 
story that all of you are a part of, minus the flame that has 
at times been trained on my backside. But it is repeated for 
every member on this Committee, because we built that bridge 
together in the other half of the country.
    It was done to strengthen, not weaken, VA. And great 
providers from across this country, some 685,000 on our watch, 
with 1.3 million care sites of access, leaned forward. They 
have delivered care. They have delivered more than 20 million 
appointments in support of VA. In fact, because of them, we 
have returned less than 2 percent of care requests for no 
network provider.
    We paid claims--18 days on average, 10 days in the area of 
expansion--to an accuracy rate greater than 96 percent. With 
the exception of the last couple of months, because of a fee 
hold issue tied to an update in the payment rates, we have 
delivered on what we said we would do. We are almost out of the 
back end of that challenge.
    As Adrian said, we stood up the urgent care benefit--
175,000 encounters have now occurred.
    So we are getting ready for the implementation of the CCN 
contract. We are proudly leaning forward. We are working at the 
side of the VA. We have sat market by market by market over the 
last month and a half to two months, and reviewed what the 
demand profile is going to look like for the care needs in the 
community in each market, with our colleagues in VA. We have 
now factored that into the setting of our network, and the 
deployment of that network construction is underway with 
Montana and Denver being first. And we will be up and 
operational on April 7th.
    Thanks for your leadership. Thanks for your partnership. 
Thanks for your fully engaged involvement in support of 
veterans. It has been our privilege to serve at your side the 
last six years. Thank you.
    Chairman Moran. Mr. McIntyre, thank you very much. Let me 
start where I started with the first panel, dealing with access 
standards under the MISSION Act. I realize that the Optum 
contract was entered into before the MISSION Act standards were 
in place. I was pleased that the contract that was negotiated 
for Region 5 included those MISSION Act standards. I learned 
from Dr. Stone and his colleagues that while that seemingly is 
good news I also learned that that may be something that can be 
waived.
    My question is, what is your reaction to what I have been 
told this morning, and how insistent should I be in that the 
MISSION Act standards, access standards, be included in your 
contract, either by amendment or by Optum voluntarily meeting 
those standards, and how concerned should I be that there may 
be a waiver in Region 5 of those standards? And what does this 
ultimately mean to the ability for veterans across the country, 
particularly those who live in very rural areas, what does it 
mean for them?
    Let me start with Mr. McIntyre, because you have been 
through both Choice and now MISSION.
    Mr. McIntyre. Yes, sir. Thank you for the question. I will 
answer it with regard to Montana, where we are in the process 
of constructing the network that will exist for CCN Region 4, 
and Montana leads the deployment of that.
    We have gone through a demand capacity process to seek to 
understand the demand for care that will be going into the 
community. We used a rather extensive set of tools--and they 
are very complex--that we use for urgent care. We are going to 
be mapping to what those standards are that are contained in 
the MISSION Act, and it is up to the VA, along with veterans, 
to decide when they will place care in the community.
    Our objective is to make sure that we--to the degree that 
there are providers available to contract with, because they 
actually exist in the market--we will be seeking to make sure 
that there is sufficient supply of all the specialties that are 
required to be able to comply with the MISSION Act standards.
    Chairman Moran. Thank you. Lieutenant General?
    Lieutenant General Horoho. Thank you, Senator. The intent 
of the MISSION Act is really to make sure you have a robust 
network that is available for our veterans to be able to 
receive care, and it is near where they live. And so with that 
intent we have been aggressively building a network. When I 
talked about, in my opening statement, where we have gone live 
and met the standards of the contract, we actually continue to 
build our network to make sure that we are close. And I will 
give a good example.
    So we are getting ready to go live in Georgia, which has 
about 159 counties that are rural, and 150 of those--excuse me, 
150 counties that are rural, out of 159. We have met the drive 
time. We will meet the drive time of 60 minutes versus what 
would have been in the contract of 100 minutes.
    So we are trying very, very hard to continually adapt and 
build a network and build it upon referral data that we are 
starting to look at since November time frame.
    Chairman Moran. General, we have had this conversation, my 
team and your team, as well as us. Is my concern that the 
failure to utilize the previous network of TriWest in Kansas, 
and awaiting a utilization study, those two things combined I 
am worried will find veterans once again experiencing the 
circumstance in which, one, they had care provided with a 
particular provider, now no longer available, and, two, the 
network is, at this point, not as large as it was, regardless 
of which providers are included in that network. And the end 
result of that is that--could be that there is a 
disappointment, again, in the ability to access care. I think, 
in many instances, veterans were discouraged in their 
utilization of Choice by experiences that caused them to throw 
up their arms and say ``this is not working.''
    A significant goal of the VA and this Committee needs to 
be--and the TPAs--needs to be that there is no immediate 
dissatisfaction with this program so we do not disappoint our 
veterans once again. What would you tell me that assures me 
that that is not going to be the case?
    Lieutenant General Horoho. Senator, thank you for the 
question. I would say first is that we looked at rolling out 
community care very different than I think in the past of any 
other TPA. One is with our partner with TriWest, with the VA 
and ourselves, we made a commitment to put the veteran in the 
very center. We also stood up, where we have regular meetings, 
to be able to share and understand lessons learned, which we 
have applied. We make sure that in addition to leveraging our 
high-quality network we have gotten over 1,700 preferred 
providers that the VA wants us to put into that network.
    In particular, we are also talking with TriWest and finding 
out who are those preferred providers, so that we can reach out 
to them. And then we have prioritized making sure that when we 
now look at the referral data we can see who those high-volume 
providers are and where the veterans are used to going, and we 
are then prioritizing and reaching out to them to make sure 
that we get them in our network.
    Chairman Moran. Is your answer is that my concerns are 
unfounded?
    Lieutenant General Horoho. I think, sir, when I look at 
your area in particular, we are going into your area with over 
a 97 percent accessibility, and we have not even gone live yet. 
And so you have my commitment, and all of the leaders on the 
Committee have my commitment that we are going to do everything 
possible to build the most robust network to care for our 
veterans.
    Chairman Moran. Thank you. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I want to thank 
all three of you for your testimony. I think it was very, very 
good. And I also want to thank Dr. Matthews and Dr. MacDonald 
for being here. I think it is really important that folks stick 
around. I know you can see it on TV, but it is good you are 
here so you can answer any questions, or they can ask you 
questions after the fact.
    Adrian, I am going to start with you. You heard Senator 
Hirono ask about whether--ask Dr. Stone whether veterans are 
getting all the information that they need to make an informed 
choice on where to get care. What are the factors that are most 
important for the VA to cover with veterans when making health 
care choices, and do you believe that the VA has that 
information to assist veterans in order to make--in using it to 
make decisions?
    Mr. Atizado. Thank you for that question, Senator Tester. 
So I think I will first start to answer that question by really 
making sure we understand which veteran we are talking about. 
If we are talking about a relatively healthy veteran, 
empowering them to make a choice would be a relatively easy 
lift. But if we are talking about a population which is 
prevalent, in the population that VA treats, is older, aging, 
has a lot of complex conditions, they have life-long 
conditions, the kind of information they are looking for is 
more meaningful. It would have to be a little bit more 
information than one that is relatively healthy.
    So, for example, if you are suffering from multiple 
sclerosis, which is a prevalent condition in the veteran 
patient population, you are looking at information that would 
be able to tell you, as a patient, would you want to have a 
life-long relationship with this doctor? Would I rather drive, 
can I drive, do I have the capability to drive to them if they 
were far, if they were of that value to me and my life, and how 
this would affect my ability to be an active member of society?
    Now having said that, I understand the previous panel, Dr. 
MacDonald had talked about the RCT, which really is a kind of 
care coordination approach in making sure, as she has said, 
veterans are empowered. I find it curious, though, that what 
that effort entails is still unknown to me, to DAV. We do not 
know what that is other than what was mentioned in this 
hearing. It has been mentioned in passing, almost, but 
certainly not in full briefing. So I could not possibly comment 
on that, although I do understand that this new responsibility 
that VA is taking on, under the community care contract, as far 
as scheduling and coordinating this care, is going to be quite 
different than what VA is doing today. And so I question what 
that effort is going to be.
    So those are the two things I would say about that aspect, 
about what kind of information a veteran would want and need--
it depends on what that veteran is facing in terms of health 
care needs--and whether VA is going to be able to achieve that 
kind of coordination.
    Senator Tester. Okay. Thank you. As you know, the VA is 
undertaking market assessments across the country. As 
indicated, its teams are meeting with veterans and other 
stakeholders on the ground in different regions of the country. 
Can you describe your organization, DAV's involvement in these 
market assessments, and whether it is locally or whether it is 
here in D.C., and have you received any briefings on them?
    Mr. Atizado. Sure. So with regards to the market 
assessments, Senator, I am not really sure which assessment you 
are referring to. There are actually two different assessments 
outlined in the MISSION Act.
    Senator Tester. Pick the one you want. It is for the 
marketplace, though. Go ahead.
    Mr. Atizado. So I want to be clear. Both assessments have 
to be done separately. It appears that VA is trying to do one 
assessment, which is supposed to serve two different purposes. 
We believe that is the wrong way to go about it, but 
nonetheless, to describe our engagement with a market 
assessment it is probably best described as scarce.
    Senator Tester. As what?
    Mr. Atizado. Scarce. We have had scarce engagement on the 
market assessment. We know----
    Senator Tester. That is not a good sign, especially for 
disabled veterans.
    Mr. Atizado. No, sir, and especially that the law really 
intimates a consultative process that we would be more engaged 
than we are today. We are trying to bring this up to VA as a 
matter of course. We know they have a lot of things on their 
plate, but we would really like to have a little bit more 
engagement.
    Senator Tester. Yeah, and I think it is absolutely 
necessary, and that is why it is good that the two VA folks are 
here. You can take that back.
    I have--we will pass on them. I am out of time for now.
    Chairman Moran. Senator Tester, thank you. Mr. Adrian, the 
RCT catches my attention too. I think there is a lot to be 
learned about what this involves, and I would be happy to work 
with you as we work with the VA to learn more about it.
    Mr. Atizado. Yes, sir.
    Chairman Moran. Senator Loeffler.

                        SENATOR LOEFFLER

    Senator Loeffler. I want to thank you for your testimony 
today, for this panel. Lieutenant General Horoho, as Optum 
prepares for the rollout of the community care network in 
Georgia in two weeks. Can you share what outreach has been done 
with veterans to talk about this transition and to prepare 
them?
    Lieutenant General Horoho. Thank you, Senator. Our outreach 
primarily is with the providers and building the network, and 
then the VA actually is reaching out to the veterans. And so 
from our outreach with the providers is we reach out to them, 
we explain what the network--the responsibilities of the 
network.
    We have online training so that they understand that 
training, they understand the culture of the veteran. We have 
online training in a portal that they can access that will show 
them about Psych Hub, because of the high suicide rates, so we 
try to address that right up front. And we have many other 
trainings that are there.
    And then we do in person, meeting with the contractors and 
the providers that are coming in, and then we have the call 
center in which they can call into as well. We are looking 
forward to actually serving your veterans in your area.
    Senator Loeffler. Right. Thank you.
    Lieutenant General Horoho. Thank you.
    Chairman Moran. Anything further, Senator Loeffler?
    Senator Loeffler. Nothing further. Thank you.
    Chairman Moran. Senator Tillis.
    Senator Tillis. Thank you, Mr. Chairman. Thank you all for 
being here. Mr. Atizado, I want to ask you a question. I know 
you said in your opening statement you were vehemently opposed 
to the copay for urgent care.
    And I guess the question, in North Carolina, since the 
MISSION Act was implemented, I think we are ahead of every 
other state, adjusted for population. We are at nearly 10,000 
urgent care visits since it was implemented back in June. And I 
understand it is a $30 copay after the first three--is that 
correct?--the first three urgent care visits in a given 
calendar year?
    Mr. Atizado. So yes, sir. The copayment schedule includes 
that. There are some veterans that have to pay on their first 
visit.
    Senator Tillis. Disability and other factors come into 
play. Is that correct?
    Mr. Atizado. Yes, sir.
    Senator Tillis. Service related or not?
    Mr. Atizado. Yes, sir.
    Senator Tillis. So is the concern with the copay, is it 
more where that could lead to other policy decisions, or just 
on its face you think it is inappropriate?
    Mr. Atizado. Sir, so on its face we think it is 
inappropriate, and there are a number of reasons, a couple of 
which I will bring to your attention now. When a veteran is 
trying to engage a complex health care system, the more 
standard it is for that patient, the better. So they start 
having to engage a different part of their health care benefit 
and having to determine whether or not they have to pay 
copayments, that adds to a little bit of that confusion, for 
one. And really the more important one is the principal nature 
of that.
    Senator Tillis. Yeah. Well, that is what I was wondering. I 
am just trying to figure out, on the one hand you want to 
provide that benefit. On the other hand you also want to make 
sure the lowest cost, high quality provider that can provide 
whatever care is in plan. I am assuming that was some of the 
rationale behind it, but that is something I will look into a 
little bit later.
    Tell me a little bit about what you are doing. You guys do 
great work and you have helped a lot of veterans through 
several transitions--PC3, VA Choice, and now MISSION. What are 
you all doing engaging--in your VSO, what are you doing and 
what can we learn, what other VSOs could do to help with these 
transitions?
    Mr. Atizado. So I think what we are getting ready to do is 
do a survey of our members. That is going to be a point in 
time, and I think we are going to do this in a recurring event.
    But I think the first thing that should be done is for us 
to do some inreach with our members to find out, in a general 
sense, how they are experiencing this program. I can tell you 
that there are some parts, as mentioned in my testimony, where 
they are feeling some disruptions. We feel some of them are 
quite unnecessary.
    And once we get the sense of how it is operating, how they 
are experiencing, then we will take this to VA and see whether 
or not they are, in fact, identifying and measuring these 
issues, and then fixing them, in a systematic way. Because 
doing one-offs, this is an evolution that is going to be going 
for years. I think that would be a little bit better approach.
    If I can just go back real quick to the urgent care 
benefit, we were very instrumental. We worked with Senator 
Cramer and this Committee on that provision in the bill. Our 
proposal at the time was to mimic what DoD's Defense Health 
Agency was doing with regards to the urgent care benefit, 
because it would reduce their overall cost in other areas.
    How the Defense Health Agency did this was they used a 
nurse advice line to help manage that need. They would direct 
the patient to the appropriate venue, preferably the least 
costly and one that is most responsive to the need, but that is 
not the approach the VA took on this.
    Senator Tillis. That is something we should talk more 
about. In my remaining minute, it is less of a question. 
TriWest has a larger network in Region 1, but larger does not 
necessarily mean that Optum needs to get to that point. What we 
will be tracking, as you go through the implementation, are any 
unserved or underserved areas within North Carolina. It sounds 
like the analytical approach you are using to figure out where 
to go to get additional providers should stay ahead of that, 
but, you know, expect us to continue to reach out and see any 
areas that may be one-offs. But I hope that in response to the 
Chairman's question, that you are going to stay ahead of it.
    I will also tell you that I make an offering several times 
a year to any provider whose bills are not getting paid on time 
in North Carolina. They are a constituent and we treat it like 
casework. So I am glad to hear that you are doing a good job on 
reimbursements. That is critically important.
    And I am over, but take rate, when you do your analytics 
you identify another provider that you need to get into the 
system. What is your success generally in getting that on 
board?
    Lieutenant General Horoho. Actually, we are having a very 
high success rate. There are some academic affiliates that it 
takes a longer process to get them in, and that is probably 
where we see the longer timeline. When we see individual ones, 
they tend to come into our network a little bit easier.
    Senator Tillis. Well, in any instance where you are looking 
at a provider in North Carolina and we can help, let me know.
    Thank you, Mr. Chair.
    Lieutenant General Horoho. Thank you, Senator.
    Chairman Moran. Thank you, Senator Tillis. Senator Sinema.

                         SENATOR SINEMA

    Senator Sinema. Thank you, Mr. Chairman, and thank you to 
our witnesses for being here today, especially to my friend 
David McIntyre, CEO of TriWest, and of course a proud Arizonan.
    We are, in large part, here today because in 2014, the 
Phoenix VA Medical Center was at the center of a national 
scandal in which veterans experienced dangerously long wait 
times for medical care. That crisis led to the Choice program 
and now the community care network established under the 
MISSION Act.
    The VA has made steady progress improving transparency, 
wait times, and access to care, but much more work needs to be 
done. I am extremely concerned about the time it takes for an 
appointment to be scheduled after a VA clinician has referred a 
veteran for community care and the processes that contribute to 
that delay. According to VA data provided to the Committee in 
December, the national average is 27 days between a VA 
clinician referring a veteran for community care to the 
scheduling of a veteran's appointment. The average in Arizona 
is about 25 days across our three VA health systems, and that 
is unacceptable.
    So those data do not account for the wait time between 
making the appointment to actually seeing the community care 
provider. These delays have serious consequences for the 
quality of care and experience that veterans and their 
caregivers have when engaging with the VA.
    For example, Sharon Grassi is an Arizonan, an Elizabeth 
Dole Foundation fellow, and a caregiver to her son, Derek, an 
Army veteran who served from 2006 to 2015. He returned home 
with spine injuries, post-traumatic stress disorder, traumatic 
brain injuries, and more. Sharon worked closely with my staff 
outlining the challenges she has had moving in and out of the 
Choice program, and now the community care network.
    In one of her more recent challenges, Derek's VA provider 
referred him to community care because the VA did not have a 
specialist he required. But when the order was reviewed within 
the VA, it was modified without consulting the original 
clinician and Derek was not assigned to the specialist. This 
created confusion, delays, and deep frustration for Sharon and 
her family.
    In Sharon's words to me, ``The order had been modified 
without talking to Derek's doctor, without researching his 
case, understanding the diagnosis, or determining the 
capability of the facility. In the VA system a doctor's order 
is transferred to a purchased care team, forwarded to a 
department head, and given to a voucher examiner before being 
approved for care, and during this process clinically necessary 
care is delayed, modified, dropped, or lost. When community 
care is authorized, communication between providers is stunted, 
record management is horrible, and record-sharing a 
dysfunctional mess.''
    Sharon praised the Phoenix VA and so many of the providers 
who have supported Derek, but voiced frustration with the 
process. She ended her letter to me with relief, because their 
petition to the Army to change Derek's discharge to medical was 
granted. He will now use Tricare services moving forward and 
not the VA.
    The VA has a real problem when a caregiver or a veteran are 
excited to be out of the system and receiving care somewhere 
else.
    So I have got several questions now for our panel. My first 
is for Mr. Atizado. What is your understanding of the VA's 
process when a VA clinician refers a veteran into the community 
care network, and what are you hearing from your members about 
that process?
    Mr. Atizado. So, Senator Sinema, thank you for that 
question. It is disappointing to hear that situation you just 
described. Unfortunately in our casework it is not an isolated 
incident. It is absolutely--it is infuriating to hear that a 
veteran who has agreed on a treatment plan with their provider 
is changed by some faceless individual. That should not happen. 
I am sure if you were to ask VA that they would say that that 
should not happen as well, but the problem is that it does.
    I will be honest with you. I do not know what the process 
is now, because of how community care has changed over the last 
several years, not to mention there are still a couple of 
authorities out there which has different processes in place, 
and now we are talking about another change in how VA does 
their business, when referring veterans out in the community.
    But that should not be the case. That expectation should be 
preserved. Senator Tester asked about what information veterans 
would need, and I think that really comes down to that first 
question, is that VA provider needs to sit with that veteran 
and know what they want and what they need. You want to talk 
about veteran-centric? That is it. When they agree on that 
treatment plan the veteran is not only encouraged to comply 
with that plan but somehow VA, in this particular instance and 
in others, does not. I do not understand it.
    Anyway, I apologize. Thank you.
    Senator Sinema. No apology is needed. I think we all share 
this frustration.
    Mr. Chairman, my time has expired. I do have further 
questions for members of the panel. I will just submit those.
    Chairman Moran. Thank you very much.
    Senator Sinema. Thank you.
    Chairman Moran. We are going to do a second, hopefully 
relatively quick round. Let me--in regard to Senator Sinema's 
question, and particularly again while the doctors from the VA 
are here, I think an issue on the wait time is that the VA 
considers the wait time not to start--in other words, do they 
comply with the number of days--it does not start until they 
schedule the appointment. And the issue in my view should be 
the wait time begins when they make the decision for the 
referral. So we need to make certain that there is not a 
significant gap between the decision to refer and then the 
scheduling of the appointment, which then perhaps, under 
somebody's theory, extends the amount of time in which you are 
either in compliance or not.
    I have a question, which causes me to pull up my iPhone. I 
looked something up because I have tried for a decade. The 
conversation about mental health--maybe this was Senator 
Blumenthal--we have, in Kansas, and perhaps it is true in other 
states, we have something called community mental health 
centers, and they are created by statute. They are the 
gatekeeper for our state hospitals, but most importantly they 
provide mental health services in the community.
    According to their website, the way they are defined is ``a 
community mental health center are charged by statute with 
providing community-based, public mental health services safety 
net. In addition to providing the full range of outpatient 
clinical services, Kansas' 26 community mental health centers 
provide comprehensive mental health rehabilitation services 
such as psychosocial rehabilitation, community psychiatric 
support and treatment, peer support, case management, and 
attendant care.''
    I have tried for a decade, in fact, before Choice and then 
under Choice, and now under MISSION, to make certain that a 
community mental health center qualifies for a referral from 
the VA for mental health services. I ran out of time to ask the 
VA this question, but are those community mental health centers 
being contacted? Are they being offered the opportunity to be a 
provider in the network? And, I guess finally, the reason this 
is so important is timing for all health care is critical, but 
in today's efforts to reduce suicide requires providing mental 
health services quickly, and I assume where a person lives.
    I heard what Dr. Stone said about wrapping people in other 
people, and it is not always about the mental health 
professional. It is about being surrounded by people who are 
going to care for you. Our community mental health centers do 
that every day for Kansans and they do it in the most rural 
settings of our state. Can I be assured that they are being 
included in this network and can provide services under MISSION 
for veterans?
    Mr. McIntyre. So Mr. Chairman, if you look at the network 
that we constructed over the last number of years, many of them 
are in the network that we have, and as we set for CCN the next 
network in the states that we will be responsible for, we will 
be porting them over. Many of them, though, had direct 
contracts at one point with VA, because some of this care used 
to move directly. Now it is moving through a consolidated 
network.
    In fact, in the state of Montana, Senator Tester's staff, 
myself personally, and the VA team on the ground are going to 
meet together in Montana with the four facilities that fall 
under that definition, because their direct contract is aging 
out, and we will be bringing them together into the footprint 
of the network for Montana as we map demand against supply.
    The last thing I would say is you are right. The other 
Senators that have articulated this were right. It is about 
human connection. And the bottom line, at the end of the day, 
is what people say who did not commit the act of suicide but 
thought about it, I did not do it because I saw someone or I 
heard someone or I felt like I needed to be there for someone 
that was on the other side.
    We do a lot of mental health appointing in this space for 
VA. We also run a stress program that we built for the Marine 
Corps years ago. We have never lost a Marine through that 
program. We are in the process, as our contribution to suicide 
prevention, of marrying those two pieces together so that 
appointing will not just be appointing, it will also be a place 
that people can go to have lifelines. And we are going to build 
a 24/7 apparatus against that, just like what we operate for 
the Marine Corps.
    Chairman Moran. Yes, ma'am.
    Lieutenant General Horoho. Senator, if I could just share, 
actually, a story. You know, we have our call center and our 
call center is actually for providers and the VA staff, for any 
questions that they have got. Well, we had a veteran that 
called the call center, and one of our techs that answered the 
phone was talking and realized that he seemed very, very 
stressed, and started engaging him in conversation. During that 
conversation, he actually shared that he had a plan to kill 
himself and had the intent to do that. She was able to be 
decisively engaged with him, got him care, and actually saved a 
life.
    So when we talk about trying to prevent suicides, it truly 
is a comprehensive touch point. It is that personal connection. 
It is making sure that everybody that is serving our veterans, 
or part of community care, understands the personal engagement 
and understands warning signs of someone who either has mental, 
physical, spiritual, emotional, or financial stressors, because 
all of that plays into someone when they start feeling 
hopeless.
    Chairman Moran. Thank you. In regard to--I appreciate that 
story and it is--I mean, humans, as we are, we need somebody 
who loves and cares for us, and it is important. I would ask 
you to follow up with me about the issue of community mental 
health centers in Kansas and being in the network.
    Finally, and my time has expired as well, but I want to say 
that our experience--there are 125 hospitals in Kansas. I 
visited all of them. I do it on an ongoing, continual basis. 
And I am always touting the Choice program as an option for 
particularly those rural hospitals to help meet the needs of 
their veterans. It does not appear to me that many of them know 
about the MISSION Act. They have had experiences with Choice. 
Some of them decided not to participate--continue to 
participate in Choice because of lack of payment, inability.
    Mr. McIntyre was very helpful in making sure our hospitals 
were reimbursed at a Medicare rate sufficient to cover the cost 
of providing the service, as they are under Medicare, because 
of the nature and size of their hospital.
    But I would encourage greater efforts, by both the VA and 
the TPAs, to have outreach and convince the provider that it is 
something that they can afford to do, because they want to do 
it.
    And then, finally, we have discovered, and we need to take 
this up because I think with our VISN, because VA's outreach is 
occurring at the state and local level, the local level as 
compared to the central office, we have lots of veterans who 
have little information or understanding of MISSION, and it is 
always the surprising thing. It is a significant role that VSOs 
play in trying to get information and opportunities 
understanding to veterans.
    This change is something that I still think that many 
veterans do not know what their options are, within the VA or 
the VA's referral to the community.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman, and then what 
further complicates that situation are the veterans out there 
that do not use the VA and are not apprised of those services, 
and, quite frankly, it turns out bad.
    I would say this, generally. The person, the employee that 
did what that employee did needs to be commended, because a lot 
of folks would have said, ``Gee, this is not in my job 
description, so what the heck.'' And so I just--when you get 
people like that, they need to know that they have done a good 
job, and in a job that oftentimes many of us would not have 
done. And so I just think that is important.
    Dave, I want to talk about providers getting paid. We both 
know it is a key component. If you are going to have folks in 
the network they need to get paid in a timely manner. We have 
both heard concerns in Montana about late payments. Could you 
explain to me the process for paying ER claims and non-ER 
claims? Are they the same? And if they are not the same, what 
is the difference?
    Mr. McIntyre. Yeah, you bet. Great question, and there is 
no question about the fact that when you order care from 
somebody you are supposed to pay for it, right, and on time, 
and accurately.
    We have some challenges between us and VA at the moment 
around emergency room care and the claims related to that. The 
claims for emergency room care were directed to come to us as a 
corporation for the purpose of paying the providers that we 
have in network, which is a large network across the country, 
for emergency room care. You can't pay those claims without the 
actual authorization itself from VA.
    And so we and VA are in the process of discussing right now 
what do we do about this? How do we make sure that those things 
are going to be properly processed? Those discussions are 
underway. They are very accelerated. There was a very late-
night conversation two nights ago between myself and the COO 
for that part of the system in VA for an hour. We were looking 
at options that were viable. What I told VA is I am not sending 
those back. I am not denying them. We will go red on 
performance before we will send things back and put the 
providers in a do--loop on the other side.
    So it is important that this ER stuff is getting handled 
differently than it was historically. I think people were very 
well intentioned about what they were thinking might make 
sense, but it is a process piece that needs to catch up so that 
we can make sure that we get this right.
    Senator Tester. Okay. Thank you. And are you getting 
everything that you need from the VA, and can you tell me what 
the problem is and whether the providers--what kind of timeline 
for improvement?
    Mr. McIntyre. So in terms of ER?
    Senator Tester. Yeah.
    Mr. McIntyre. I was very gratified to get a call two nights 
ago from the senior leadership to say, ``Are you available?'' 
And we were on the phone from 9:30 to 10:30 at night. I know 
those people personally because we have done a lot of work in 
the claims processing space over the last couple of years. Dr. 
Matthews has been directly engaged, as has Dr. Stone, and I am 
confident, based on our collective track record, that we will 
figure out the right answer. We will get this line unkinked, 
and it will not get kinked again.
    Senator Tester. Good, and thank you, and I once again want 
to thank you, as I did the first panel, about being here. I 
appreciate you guys' input. As you know, and as we all know, 
quite frankly, good communication is the key. And if we have 
good communication and we know what the problems are I think 
this Committee will work to try to solve them.
    Adrian, I appreciate your testimony and I appreciate the 
fact that we can do better, and I am talking about we, the VA, 
can do better, with talking to the veteran service 
organizations to make sure they are meeting the needs. I have 
said it many times. We take our direction from the veterans, 
and, quite frankly, we need to pay attention to what they are 
saying if we are going to meet their needs. And I thank you for 
being on the panel.
    Chairman Moran. Senator Tester, thank you. We are just 
about to wrap up. So that Senator Tester does not have the last 
word I have something more to say. But his comment is the 
precipitating factor for saying this about veterans who are not 
in the system.
    So our first effort at trying to provide for Kansans who 
live long distances from a VA hospital, again, a congressional 
district the size of Illinois, that had no VA hospital, was 
outpatient clinics. And we were successful in getting these 
outpatient clinics in lots of places, in a significant number 
of places, across Kansas.
    In my hometown of Hays, the VA opened an outpatient clinic. 
The VA estimated that 1,200 veterans would access care at that 
clinic. Within six months, the number was 2,400. And what the 
difference was is the VA estimated how many veterans in 
northwest Kansas are driving to Wichita to access care, who 
will now stop in Hays, which is 2 + hours closer than Wichita, 
to where many of them live, and access care through the 
outpatient clinic.
    What was not taken into account were the veterans who were 
accessing care nowhere. And so the VA--we, as a committee, you, 
as third-party administrators--have a significant--I would add 
the VSOs have a significant opportunity here to make sure that 
fewer and fewer people are in that category of getting care 
nowhere. And so I offer to you and to the VA and to all the 
VSOs our help in trying to make sure we get the opportunity 
available to people who otherwise receive no service from the 
VA, but are entitled, are eligible.
    So it is a constant effort. And again, I have been 
surprised my entire time in dealing, in having relationships 
with veterans, how many of them do not know what they are 
eligible and entitled to do.
    Mr. McIntyre. Sir, as you work the question of education, 
and everybody else works that at your side, what I would say is 
the way we collectively approached urgent care and the 
construction of that is exactly the way you need to construct 
the network backbone, whether it is direct system or whether it 
is purchased on the outside.
    And what we did is we took a set of mapping tools, and we 
looked at demand ratios. We looked at the actual address of a 
veteran, and we looked at the footprint of where the locations 
were for providers. And then by ratio we developed what we felt 
like the network footprint needed to look like for urgent care.
    Today, more than 90 percent of veterans have access to 
urgent care within 30 minutes of their house. That was the 
requirement. And so that is the same approach we have taken to 
refine the current network, and the approach that we are going 
to be taking to the core network.
    And I believe, listening to General Horoho talk about the 
approach that they are taking to try and assess and figure out 
what the need ultimately is going to look like in the territory 
that they are walking into, that she will arrive at a place 
that is similar to where we are. We have a little bit of an 
advance run because we have been at this the hard way for the 
last six years, and we and VA, have assessed what that demand 
profile looks like, where the locations are, what kinds of gaps 
there are, and we are going to have that at the core of how we 
are doing network construction for Region 4.
    Chairman Moran. General Horoho, just like I cannot let 
Senator Tester have the last word, I give you the opportunity 
to make sure that Mr. McIntyre does not either.
    Lieutenant General Horoho. Thank you, Mr. Chairman. 
Probably the happiest I have been all day.
    [Laughter.]
    Lieutenant General Horoho. What you raise is such a 
critical issue, and I just want to raise it up a little bit to 
a higher level.
    So about a year and a half ago we looked at doing an 
executive development program, and one of the ideas that we 
looked at was individuals that are dual eligible for insurance, 
right, that are getting commercial insurance but are also 
eligible for VA and disabilities, and they do not even know 
they are.
    And so we actually put together a program and looked at it, 
and one of the things that we found is we fail within the 
commercial sector to ask someone, ``Are you a veteran? Have you 
served?'' Because when you do that it changes the conversation 
in how you provide care.
    The second thing, and probably one of the most powerful 
stories that we shared across our company, is one individual, 
an Air Force veteran, in his 70s, had never ever applied for 
disability, did not even know what his opportunities were. We 
talked with him. They connected him with the VA. He went 
through the process. He ended up being able to get medication 
that he could not afford when he did not have his disability, 
and actually him and his wife made a decision who was going to 
get medication. He got the medication that went from $400-
something a month down to about $4 a month, and he realized 
that he had the eligibility for burial and insurance.
    It completely changed their lives at the age of 70, and I 
think that is an example, when we talk of this shadow 
population that has given so much to our country, and they have 
not tapped into all that they are eligible for.
    Chairman Moran. General Horoho, thank you very much for 
that example. It is something that I do not know that I had 
thought about, is the relationship that we--too often we 
separate disability and health care into two separate 
components, and the two are, in my mind, in people's minds, 
unrelated. But there is a huge connection between your 
disability and your health care well being. So I appreciate 
that.
    Mr. Atizado, one of the things that I take from this 
hearing is in this outreach the importance of making certain 
that veterans understand this is not just promoting community 
care. This is about promoting what is in the best interest of 
the veteran, that he or she, a decision he or she and their 
health care provider at the VA make, and the idea that we are 
not talking about that you are eligible. If we are not talking 
about that you are eligible for care to continue within the VA, 
without a referral outside that is a significant error on our 
part.
    And I will work on my communication skills so that we make 
certain that the options are available, not to be decided by 
the person who is providing the information but by the veteran 
and his health care provider determining what is in their best 
interest, as the MISSION Act requires.
    Senator Tester. Not to let you get the last word in, but 
part of this--I mean, it is really a good point, and once again 
thanks for being here, the folks from the VA, because you could 
have a person that is scheduling these appointments, that says 
it is a hell of a lot easier to throw them in the community and 
then I really do not have to worry about them anymore. So this 
is really an important point to be addressing here today.
    And so I just wanted, once again, Mr. Chairman, thank you 
for your good looks and your leadership.
    Chairman Moran. You are using credibility.
    [Laughter.]
    Chairman Moran. And a point to follow that is Dr. Stone 
talking about incentives about referrals. That is, again, 
something I think is very important, the idea that budgetarily 
there may be an incentive to send somebody so that it is 
somebody else's problem, not how it gets paid.
    I will conclude. I would ask the witnesses, is there 
anything that you want to make sure that is on the record? Do 
you want to say anything, correct anything, something that we 
failed to ask that would be of value to this hearing?
    If not, we are going to conclude the hearing. Members have 
five days in which to submit additional statements or questions 
for the record, and we would appreciate your prompt response to 
those questions.
    With that, the hearing is adjourned.
    [Whereupon, at 11:59 a.m., the Committee was adjourned.]

                                APPENDIX

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                Material Submitted for the Hearing Record
                        
                        
                        
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