[Senate Hearing 116-482]
[From the U.S. Government Publishing Office]
S. Hrg. 116-482
VA MISSION ACT: ASSESSING PROGRESS
IMPLEMENTING TITLE I
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
OCTOBER 21, 2020
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Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
45-365 PDF WASHINGTON : 2021
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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
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Wednesday, October 21, 2020
SENATORS
Page
Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............ 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 3
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 16
Murray, Hon. Patty, U.S. Senator from Washington................. 17
Boozman, Hon. John, U.S. Senator from Arkansas................... 19
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 21
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 23
Blackburn, Hon. Marsha, U.S. Senator from Tennessee.............. 25
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 28
WITNESSES
Lt. Gen. Patricia D. Horoho, CEO, OptumServe..................... 5
Mr. David J. McIntyre, Jr., President and CEO, TriWest Health
Alliance....................................................... 6
Mr. Steve Schwab, CEO, Elizabeth Dole Foundation................. 8
Mrs. Jennie Beller, Pre-9/11 Veteran Caregiver and Fellow,
Elizabeth Dole Foundation Accompanied by; Ms. Molly Ramsey,
Manager of Policy and Programs, Elizabeth Dole Foundation...... 10
APPENDIX
Moran, Hon. Jerry, Chairman, prepared statement.................. 40
Sinema, Hon. Kyrsten, prepared statement......................... 42
Horoho, Lt. Gen. Patricia D. CEO, OptumServe, prepared statement. 43
McIntyre, David J. Jr., President and CEO, TriWest Health
Alliance, prepared statement................................... 51
Schwab, Steve CEO, Elizabeth Dole Foundation, prepared statement. 62
Beller, Jennie, Pre-9/11 Veteran Caregiver and Fellow, Elizabeth
Dole Foundation, prepared statement............................ 64
Joy J. Ilem, DAV National Legislative Director, prepared
statement...................................................... 66
Tish Hollingsworth, Vice President of Reimbursement, The Kansas
Hospital Association, prepared statement....................... 74
Thomas Bandzul, Esq., Legislative Counsel and Jack Krueger,
President, Veterans and Military Families for Progress,
prepared statement............................................. 76
Response to hearing questions submitted by:
Hon. Kevin Cramer.......................................... 80
Hon. Kelly Loeffler........................................ 83
Hon. Joe Manchin III....................................... 85
Hon. Patty Murray.......................................... 89
Hon. Kyrsten Sinema........................................ 92
VA MISSION ACT: ASSESSING PROGRESS IMPLEMENTING TITLE I
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WEDNESDAY, OCTOBER 21, 2020
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:33 a.m., in
room SD-106, Dirksen Senate Office Building, and via Webex,
Hon. Jerry Moran, Chairman of the Committee, presiding.
Present: Senators Moran, Boozman, Cassidy, Rounds, Tillis,
Blackburn, Loeffler, Tester, Murray, Brown, and Blumenthal and
Sinema.
OPENING STATEMENT OF CHAIRMAN MORAN
Chairman Moran. Good morning, everyone. The Committee will
come to order. I welcome our witnesses in person and those that
are appearing distantly. We look forward to their testimony and
getting a better understanding of where the Department of
Veterans Affairs and the third-party administrators are in
administering the MISSION Act. Also very interested in hearing
more today about the caregivers' implementation as well.
Almost every member of our Committee, though not physically
present at the moment, some are joining us in person and others
will be joining us. Almost every member of our Committee will
be participating, is expected at today's hearing.
The focus of today's hearing is the implementation of Title
I under the MISSION Act by the Department of Veterans Affairs
relating to veterans' Community Care programs and the program
of comprehensive assistance to family caregivers. I scheduled
this hearing because of my dissatisfaction with the pace of
MISSION implementation. While VA officials were invited to
participate in today's hearing to discuss the critical programs
they oversee, the Department chose to decline that invitation.
This Committee and the VA shared a common goal to pass the
MISSION Act in 2018 to better serve veterans and their
families, and we continue to work together to address important
issues for our Nation's veterans. I would expect them to be
here for this conversation, to share all they have accomplished
since the VA was transformed with this legislation, and to
discuss what needs to be done to make improvements.
The VA is an integral part of this dialog, which is why I
plan to hold subsequent engagements with the VA officials to
discussed Title I implementation.
I would be remiss not to recognized the unprecedented
challenges of this year due to the COVID-19 pandemic. The
dedicated staff on the VA's front lines deserve both our thanks
and recognition for their essential role in caring for veterans
and fulfilling the VA's fourth mission. However, at a time when
accessing health care is of utmost importance, the VA has
struggled to uphold the MISSION Act's requirements of providing
veterans access to community care.
My staff and I continue to hear complaints from veterans
and providers related to poor communications, lapses in
continuity of care, and network inadequacies. Third-party
administrators like TriWest and Optum, here with us today, are
valued and essential partners in the delivery of care to
veterans through the Community Care network. They play, you
play, an important role in building a robust and resilient
Community Care network that is able to provide veterans timely
access to care, and to make certain community providers receive
prompt payment for the care and services they provide.
When the VA released stringent access standards for
community care, I was encouraged to see more veterans would
finally be able to access timely quality care closer to home.
However, once again, my staff and I have since learned that the
VA's contracts with third-party administrators used a
completely different set of standards to determine how veterans
access care.
Under contract terms, rural and highly rural veterans could
be forced to drive up to 3 hours for care, which is completely,
totally unacceptable and contradicts the spirit of MISSION. I
have discussed this glaring inconsistency with the VA officials
for months, but despite VA's assurances, publicly and
privately, it is uncertain whether the VA has modified the
terms of the contract.
It appears to me that it is possible now for veterans to
have a different access for care, certainly than the law, the
MISSION Act requires, different than the regulations of the VA,
and perhaps different from VISN to VISN, based upon the
contract terms of the third-party administrators. As I said, we
hope to learn more about this today.
The Community Care network is central to the MISSION Act's
aim to transform the VA's health care into an innovative and
responsive 21st century health care system, capable of
addressing the challenges veterans face today and providing
access to the care veterans deserve under the law. As such, I
want to ensure that MISSION Act succeeds, and utilization of
Community Care Networks is accurately accounted for because
there are sufficient number of local providers in the network
for veterans to utilize.
Much has changed in our country since the Committee held a
hearing on implementation of the Community Care Network earlier
this year, but the intent and goal of the MISSION Act has not
changed. We remain committed to making certain that veterans
who qualify for care in the community are able to get that care
without unnecessary scheduling delays through a mature and
geographically dispersed network of community providers that
hold the VA's access standards, and that those providers are
paid in timely manners.
Congress has the responsibility to oversee VA's execution
of the laws that govern the agency's responsibility to serve
veterans, and I take, with the Committee, takes its
responsibilities seriously. I believe some of the VA's most
senior leaders might agree with me that while progress may be
underway, it must move faster to enable Community Care Networks
to serve veterans as we all envisioned. I want to know how the
VA is making progress in working with their third-party
administrators to transform the VA and offer veterans access to
the health care they deserve.
Another essential component of the MISSION Act is the
expansion and eligibility for program of comprehensive
assistance for family caregivers to all generations of
veterans. Many caregivers have been providing essential
services for their loved ones without support for years, and in
some cases, decades.
As veteran caregivers are often the main caretakers for
their loved ones, many can experience depression, anxiety, and
other mental health conditions attributed, in part or solely,
to their experience of caregiving. The stress associated with
caring for a spouse or family member with a set of complex
health care needs is a real and present concern for veteran
caregivers. It is essential that the VA support for caregivers
these mental health challenges be addressed effectively.
MISSION outlined a two-phased process to expand the
supportive resources with an anticipated start date of October
1, 2018, for Phase 1. Phase 1 implementation only just began
October 1 of this year, 2 years behind schedule. This delayed
rollout will result in caregivers needing to wait even longer
to be part of the vital support program.
I look forward to hearing the testimony from everyone who
will be taking part in today's hearing about the issues that
you face in your work to help care for and serve veterans, and
steps that the VA can take to make certain both of these
important programs are functional and able to deliver good
results and outcomes for veteran caregivers.
I apologize. My opening Statement is longer than my usual
practice, but I had sufficient desire to say a few things this
morning as we begin this hearing, and I now want to yield to
the Ranking Member and author, Senator Tester.
OPENING STATEMENT OF SENATOR TESTER
Senator Tester. Thank you, Mr. Chairman. I want to thank
you for holding today's hearing, and I am looking forward to
the discussion among our panelist witnesses. But I, like you,
am very disappointed the administration chose not to
participate in this dialog. I do not know why something as
important as implementation of the MISSION Act does not rise to
that importance in the VA. Hopefully it is not because they are
out campaigning across the country.
The fact is that this Committee has serious issues with the
administration on the implementation of the VA MISSION Act, and
it is unfortunate that VA could not be here to participate in
finding solutions to those problems.
When Congress creates programs to benefit veterans and
their families, the expectation is the administration will
implement those programs as Congress intended. You know, the
legislative branch is not here just as a nuisance. We actually
do things and have expectations. So the executive branch ought
to be sending folks here. With the creation of the VA MISSION
Act, Congress sought to provide veterans with greater options
for community care when the Department could not provide care
in a timely manner or when veterans were forced to travel long
distances to VA facilities.
The latest data we have from the VA shows that it made more
than 4.1 million referrals into the community from the
beginning of Fiscal Year 2020 to June. Nationally, it took VA
nearly 22 days to schedule health care services in the
community after a request was made. That is not acceptable. It
is a problem. Veterans should not have to wait for the VA to
navigate a bureaucratic process before their appointments are
scheduled. Then veterans wait an average of 20 days for their
appointments after they have been scheduled. That does not
work, man. That dog does not hunt. If the VA was here I would
tell them to find a way to reduce the red tape. The
administration needs to explain how it plans to bring down the
number of days it takes internally to get veterans to the point
where they get scheduled for care in the community. In the last
year there has not been much improvement in this timeline.
Rather than sticking with this broken process, the
administration needs to figure out a better path forward.
I have a bill, the Accountability and Department of
Veterans Affairs Scheduling and Consulting Management Act,
which passed out of Committee last August. It would help the VA
to do just that. It would require the VA to take a hard look at
its scheduling process and then report how long it takes to get
through that process. It would also require scheduling audits
and review of grading of positions involved in scheduling,
because too often personnel leave these important jobs for
better opportunities elsewhere in the VA.
My bill would also help veterans make better-informed
decisions on where they can get care, because they would have
the information they need to make those decisions. It would
also help Congress to exercise oversight of VA scheduling to
make sure the Community Care program is working as we intended.
Another area deserving scrutiny is the newly expanded
caregivers program. While it has the potential to vastly
improve the lives of veterans and their caregivers, many of
whom have waited years to receive the same stipends, training,
and mental health services that have been available to post-9/
11 veterans and their caregivers, I am concerned that the
administration too narrowly wrote the rules on eligibility.
Modifications that tighten eligibility for the current and
expanded program are not MISSION Act driven, and were
undertaken solely by the administration in an effort to limit
eligibility for this program and for the veterans that it
impacts.
I am also concerned that the administration is in a rush to
meet a new, self-composed deadline after missing the mark by a
year, spent little time preparing stakeholders for when the
program would actually go live, causing confusion when it
actually did it.
I do want to thank the Elizabeth Dole Foundation for being
here today, to shed light on these issues so that we can make
sure this program is functioning well for veterans and their
caregivers.
With that, Mr. Chairman, I want to thank you again for
calling this very important hearing.
Chairman Moran. Senator Tester, thank you. Now let me
introduce our witnesses. Dave McIntyre is the CEO of TriWest.
Lt. General Patricia Horoho is the CEO of Optum. Steve Schwab
is the CEO of Elizabeth Dole Foundation, Molly Ramsey, Manager
of Policy and Programs for the Elizabeth Dole Foundation, and
Jennie Beller, Caregiver and Fellow, Elizabeth Dole Foundation.
Thank you all for being here with us today and for
providing testimony so that we can better understand the
circumstances by which we may help you accomplish your goals of
meeting the needs of veterans of our country.
We will now begin the hearing with our first witness, Lt.
General Horoho. You are now recognized for 5 minutes to
delivery your testimony, and thank you again for being here and
thank you for the conversation we had for nearly an hour on
Sunday evening.
STATEMENT OF LT. GEN. PATRICIA D. HOROHO
General Horoho. Good morning, Chairman Moran, Ranking
Member Tester, and members of the Committee. I am Patty Horoho,
CEO of OptumServe.
I am pleased to join Dave McIntyre and Steve Schwab and his
colleagues at the Elizabeth Dole Foundation today. On behalf of
the 325,000 employees of the UnitedHealth Group, we are honored
to support VA's mission to ensure that our Nation's heroes live
their healthiest lives.
Would you like me to start over?
Chairman Moran. I think it is fine.
General Horoho. Okay. Good. I had to dig deep into my
military voice there. Sorry.
After 33 years of uniformed service, the mission is
personal to me and our entire organization. We are veterans. My
leadership team has a total of 350 years of service in uniform.
Many of us, or our family members, receive care from the VA
health system or the community.
Since I last appeared before the Committee, OptumServe
completed our implementation across regions 1, 2, and 3. Our
responsibility is to build and manage a high-quality provider
network. We are managing a network of 830,000 providers across
1.6 million sites of care. We intentionally built a large
network so veterans could have their choice from a wide variety
of timely care options. To date, the VA has issued more than
1.5 million referrals for care to our network, connecting
individual veterans with a high-quality provider, one veteran
at a time.
One hundred percent of our contracted network is fully
accredited and credentialed. In addition, as compared to the 15
percent benchmark set by the VA, 54 percent of providers
assessed are designated as high-performing providers.
The success of our provider network goes beyond the data.
Underlying the data are hundreds of thousands of individual
connections made between care providers and veterans. We
understand that health care is local and the choice of a
provider is personal. Our network is dynamic, highly reliable,
and responds quickly to the needs on the ground.
Recently, the leadership of the Lexington VA Medical Center
expressed gratitude for our assistance in ensuring a veteran
who was battling cancer could be treated by the same provider
as his wife. We know that caring for our Nation's heroes is
more than signing a provider contract or paying a claim. It
means caring about the women and the men who have worn the
cloth of our Nation, and doing whatever it takes to help them
heal.
Every day we work side by side with VAMCs to advance
veteran care, review successes, develop action plans, address
challenges, and share best practices. These relationships are
critical when the unexpected happens. This occurred in August
when Hurricane Laura left 200,000 without water and a 1 million
without power in Louisiana. Many hospitals were forced to
close, and my team jumped into action, leveraging relationships
with the Louisiana Hospital Association. We ensured the VAMC
had up-to-date information on hospitals where they could safely
serve veterans.
Our network is not a national entity. It is a collection of
regional care ecosystems designed to be responsive and
convenient to veterans. Working with each VAMC, we have
prioritized the credentialing of high-quality providers with a
history of serving veterans in the community. As a result, we
have partnered with 92 percent of priority providers identified
by the VA and 93 percent of academic affiliates, including Duke
and the University of Kansas. And for the first time in the
VA's history of providing care in the community, Optum
partnered with the VA to bring the Mayo Clinic into the
Community Care Network.
While managing our network is a dynamic process, our
restlessness keeps the veteran at the center of everything we
do. This month we learned that a veteran was matched with a
life-saving heart, more quickly than expected. This evoked our
warrior ethos of never leaving a fallen comrade behind. Within
24 hours, this West Virginia veteran received a new heart. Over
the last few weeks we began facilitating dozens of life-saving
organ transplants. This is the power of one--one organization,
working one-on-one with VA staff, VSOs, Congress, caregivers,
and many others to advance the health and wellbeing of one
veteran at a time.
Mr. Chairman, Ranking Member Tester, and members of the
Committee, thank you for the opportunity to appear before you
today. As a veteran, former Army surgeon general, wife of a
veteran, daughter of a veteran, and the proud mother of an
airborne infantry lieutenant, ensuring veterans have a high-
quality, credentialed network that meets their needs is
important to me and our entire organization.
I look forward to your questions. Thank you.
Chairman Moran. General, thank you for your testimony, and
thank you to you and your family for your service to our
Nation. Mr. McIntyre, welcome.
STATEMENT OF DAVID McINTYRE, JR.
Mr. McIntyre. Mr. Chairman, Ranking Member Tester, and
distinguished members of the Senate Committee on Veterans'
Affairs, on behalf of all those associated with TriWest
Healthcare Alliance it is an honor to appear before you today,
and I am pleased to do so with Patty and the great folks from
the Bob and Elizabeth Dole Foundation.
We have been serving the military and veterans population
for nearly 25 years now. We are privileged to have partnered
with VA for the past 7 years in helping them respond to the
health care needs of veterans, from PC3 to the CHOICE Act, to
expansion and the replacing of Health Net, to the MISSION Act.
It has been quite a journey.
We have tried to remain nimble and focused on one
objective, to support, not compete with, the VA in providing
timely, quality care for veterans. Through the use of our
proven demand capacity process and leveraging the footprint of
our nonprofit owners, we have tailored high-quality networks in
collaboration with VA to match the unique demands of each VAMC
and their enrolled veterans.
Our network, which will soon contain all academic
affiliates for Region 4, has now delivered more than 32 million
medical appointments in support of VA to give them needed
elasticity. This has included everything from urgent care
within 30 minutes of a veteran's home to eye appointments, to
primary care, to urology, to women's services, to behavioral
health, and just this past weekend, a triple organ transplant
to save the life of a hero.
We and VA have collaborated in administering the IVF
benefit for hundreds of couples who cannot otherwise have
children because of their combat-related wounds. We have
customized the network for each one of the couples and their
unique circumstances, and lots of babies and proud and grateful
parents are the result.
I am pleased to report that due to the team effort between
us and VA, we are now processing and paying clean claims,
professional and institutional alike, within two weeks, to a
level of accuracy in excess of 98 percent. And it will please
you, I am sure, Mr. Chairman, to know that the VA is
reimbursing us on a timely basis as well.
Along with these successes have come some challenges,
especially in the delivery of timely appointments. As you know,
early in the year our Nation was hit with COVID, a challenge
unprecedented in our lifetimes. Community providers and VA
alike reduced the available services as they made changes to
keep their staffs and patients safe and preserve capacity for
those fighting the virus. It was a daunting situation.
But soon, and since July of this year, we have been
scheduling appointments within 5 days for 90 percent of all
veterans needing primary care appointments, and they are seen
within 26 days from the receipt of the referral, mental health
within 27, and specialty care within 28. All who are urgent and
emergent in their needs are seen within the MISSION Act
standards. There is still a bit of work to do, but we are
close, and only 1 percent of the care requests that we have
been given have been returned for no network provider.
Getting here has been challenging, but we are close and we
will not rest until we, and VA, in Region 4, are delivering on
our collective commitment to timely and convenient care. With
the implementation of CCN, VA takes over care coordination and
appointing. But at VA's request, we have begun supporting the
first six VAMCs in Region 4 with appointing services, and we
expect that elasticity soon to be spread to other VA Medical
Centers.
And with the recent award of the CCN contract for Region 5,
we look forward to doing the same in Alaska, not to replace VA
but to enhance it and provide the elasticity needed so that
they can serve veterans as you and they believe should be
served.
Veterans deserve no less. We applaud your continued
leadership, Mr. Chairman and members of the Committee, and
direction, as we work toward a common goal that we all are
united by-- providing timely, quality access to health care for
our Nation's veterans. Thank you.
Chairman Moran. Mr. McIntyre, thank you. I now recognize
Mr. Schwab for his testimony.
STATEMENT OF STEVE SCHWAB
Mr. Schwab. Chairman Moran, Ranking Member Tester, and
members of the Committee, the Elizabeth Dole Foundation is
pleased to testify today on the MISSION Act and the expansion
of the VA program of comprehensive assistance for family
caregivers. Hundreds of thousands of military caregivers are
counting on us to get this expansion right, as are the
generations of veterans who depend on their care.
The original legislation establishing this program unfairly
drew an artificial line between the caregivers of those who
served before September 11, 2001, and those who followed them.
Our nation must continue to swiftly act to end this disparity
in caregiver benefits.
Pre-9/11 caregivers provide a tremendous service on behalf
of our Nation, and it exacts an enormous toll on their lives.
They have been suffering in the shadows for decades, tending to
war wounds compounded by age, and now confronting additional
debilitating conditions such as ALS, Alzheimer's, cancer,
mobility issues, and so much more.
In 2014, the Elizabeth Dole Foundation released a landmark
study by the RAND corporation that found that 10 percent of
pre-9/11 caregivers spend more than 40 hours per week providing
care. A quarter have taken unpaid time off from work or
temporarily stopped working because of their caregiving. More
than 13 percent have dropped out of the work force entirely.
And the most common pre-9/11 caregivers is a grown child of the
veteran. Many of these caregivers fall in the sandwich
generation, who simultaneous care for their parent and their
children.
These hidden heroes are an unpaid work force contributing
nearly $15 billion in care every year, the vast majority of
which is provided by pre-9/11 caregivers. And experts agree
that a well-supported caregiver is the most important factor to
the well-being of a veteran.
Correcting the inequity of caregiving benefits was one of
our foundation's first and urgent priorities. We applaud
Congress for responding to our call, and we are grateful that
Secretary Robert Wilkie and the U.S. Department of Veterans
Affairs have carried out this legislation as part of the VA's
continued investment in caregivers.
Unfortunately, however, implementation of the expansion has
been married by ambiguities and delays that have led to
widespread frustration and confusion all across the caregiver
population. Our chief concern is the pace of implementation.
After more than a year of delays, the VA still intends to roll
out benefits in protracted phases, requiring those caring for
veterans who served before May 7, 1975, to wait two more years
for eligibility--that is 2 years. We understand that the phased
approach is specified by law, but these prolonged delays are
further straining caregivers.
The VA's Veterans' Families, Caregivers, and Survivors
Federal Advisory Committee, chaired by my boss, Senator
Elizabeth Dole, recently recommended that Congress provide
legislative relief to expedite this timeline. Mr. Chairman,
Senator Tester, members of the Committee, Senator Dole hopes
action is taken on this very important legislative reform. And
even more important, our pre-9/11 caregivers who are being
forced to wait even longer to receive their benefits, hope you
will take action immediately.
Our foundation also strongly urges the VA to standardize
the expansion's implementation. The largest source of caregiver
anxiety and dissatisfaction with the PCAFC has always been the
inconsistencies between VA centers. Among the areas open to
interpretation is the requirement for annual assessments. Some
medical centers choose to evaluate caregivers multiple times
each year. That causes undue stress among the caregivers over
the possibility that they will be dropped from the program.
Additionally, key language about how caregivers are
evaluated lacks clarity. We are particularly concerned about
the reliance on activities of daily living as the market for
how much care a veteran requires. Mandating that caregivers
assist with ADLs on a daily basis, or each time they are
performed, will likely disqualify those caring for veterans
with post-traumatic stress and traumatic brain injury. The
abilities of veterans with cognitive injuries can vary over
time, even hour by hour. We cannot leave their caregivers
unsupported.
At the core of the implementation's challenges is a
critical lack of communication. Caregivers have largely learned
that the program was officially expanding benefits on October
1st secondhand, through social media or through word of mouth.
However, large percentages of the caregiver population do not
use social media or participate in online communities.
Furthermore, those who do participate in these communities are
vulnerable to inaccurate information. The VA must invest in a
proactive, comprehensive communications campaign, and
engagement with MSOs and VSOs like ourselves, to ensure that
all caregivers receive the benefits and communications that
they critically need and deserve.
Finally, our foundation calls on the VA to create a
permanent head of the VA support program and classify the
position as an SES. Currently the position is interim and that
is unacceptable. A program of such importance requires an
established position of senior leadership.
While we strongly encourage the VA to respond to the
recommendations we have presented today, we also praise the
Department for its commitment to implementing this historic
legislation. We know and we recognize a lot of hard work has
been done. It is a tremendous task. The Elizabeth Dole
Foundation and our coalition of partners are standing by and
ready to assist in promoting and implementing this program.
Thank you again, Mr. Chairman, Ranking Member Tester, and
Committee members for this opportunity to appear before you
today. We look forward to continuing our work together. We look
forward to your questions today and to supporting our Nation's
veteran caregivers.
Chairman Moran. Mr. Schwab, thank you for your presence
here today. Thank you for the work that the Dole Foundation
does and accomplishes. Please give our best wishes and
gratitude to the caregivers. And as a Kansan but as an
American, please give my regards to both Senator Doles for
their work in Congress and their retirement from Congress, the
work they have done since then on behalf of veterans and
America. Let me now turn to your colleague, Mrs. Beller.
STATEMENT OF JENNIE BELLER ACCOMPANIED BY; MOLLY RAMSEY,
ELIZABETH DOLE FOUNDATION
Ms. Beller. Chairman Moran, Ranking Member Tester, and
members of the Committee, thank you for inviting me to share my
story as you assess the expansion of caregiver benefits under
the VA MISSION Act of 2018.
I appear before you today as the caregiver of a veteran. At
the same time, I am also a national advocate for military
caregivers with the Elizabeth Dole Foundation, and a lawyer who
served as a Deputy Attorney General for the State of Indiana.
More than 45 years ago, my husband was exposed to Agent
Orange while deployed during the Vietnam War. The exposure
caused diabetes, and the diabetes triggered a major stroke. For
almost 10 years, Chuck has required 24-hour care. The stroke
caused paralysis on the right side of his body, so I assist him
with all activities of daily living. Every day begins with me
helping him out of bed, moving him into his chair, and getting
him dressed. I prepare breakfast, assist with eating, and
administer his insulin and other medications. And that's it
goes for the day.
Our biggest challenge is Chuck's inability to communicate.
His intelligence and memory are intact. However, he can no
longer read or write. He understands about 60 percent of what
is said, and his speech is completely garbled. As his
caregiver, it is my job to help him understand what is going on
in any given situation and to make sure that he feels he has
been heard, especially in medical appointments.
For my first 5 years as Chuck's caregiver, I did my best to
hold my own life together. I was entering some of the most
professionally fulfilling years of my life, not to mention the
highest earning years. I leaned on the Family Medical Leave Act
to help me stay employed, but even with that assistance, I
barely had time to sleep. Emotionally, I was devastated by the
never-ending cycle of work and caregiving.
Considering the sacrifices I was making as a caregiver, I
could not understand why VA benefits were denied to me and
millions of other pre-9/11 caregivers, just as I do not
understand, now, why we must endure continued delays and drawn-
out timelines.
The VA must find ways to streamline the evaluation process.
For example, the VA has a decade of medical files demonstrating
what my husband needs assistance with everyday and that I am
his primary caregiver. Yet to apply for benefits, a VA
representative is still required to interview me and my
husband, who can barely communicate, for two and a half hours.
This lengthy process can add stress and anxiety to both the
veteran and caregiver.
I understand that the VA is trying to gather as much
information as possible, but it is imperative that interviews
accommodate veterans who may not be communicative, like my
husband, or who may not be able to sit still for a full
interview. I am happy to say, however, that our Caregiver
Support Coordinator in Indianapolis was very accommodating for
Chuck, and the concern is that we cannot see that through the
rest of the VA system.
The VA should also enforce consistency in the evaluation
process. Caregivers sharing their application stories in online
communities are revealing significant variances between VA
locations and between the application instructions and how it
is applied. The most concerning of these inconsistencies is the
overreliance on activities of daily living as a measure of
required care. Caregivers assisting someone with invisible
wounds are struggling to prove the value of their care, and I
assure you, their care is saving their veterans' lives.
Resolving these issues is critical because caregivers are
counting on these benefits. The VA's financial assistance is
not insignificant to caregivers who have to choose between
caring for their veterans or paying the bills. I loved my
career, but I would have died if I continued working while
caregiving for Chuck, and then Chuck would have died shortly
thereafter.
However, it is not just about the financial assistance that
is invaluable. If allowed into this program, I will have
someone who is there to help me during my caregiver journey.
These benefits are lifelines to the caregivers, and without the
love and support from a family member or friend, a veteran may
not survive. This is how important caregivers are to their
veterans, and that is why allocating these benefits as quickly
as possible is so vital.
Despite the challenges I outlined today, I would like to
commend both Congress and the U.S. Department of Veterans
Affairs for remaining committed to correcting the inequity in
VA caregiver benefits. For many years, veteran caregivers have
felt voiceless. Today, we finally feel heard.
Chairman Moran. Thank you very much for your testimony and
thank you for your husband's service and your care and concern
for him and for other veterans and their caregivers.
I think now we are ready to begin the questions. Before I
do that I wanted to highlight something that I failed to say in
my opening remarks. Since we met last, the President has signed
in to law legislation passed by the House and passed by the
Senate, our own John Scott Hannon Veterans Mental Health Care
Improvement Act, and to my colleagues on the Committee, for
your help in accomplishing that goal, I wanted to express my
gratitude.
Let me begin with a couple of questions for both the
general and Mr. McIntyre. Has the VA reached out to your
companies to discuss modifications related to access standards?
Mr. McIntyre?
Mr. McIntyre. We have been implementing a series of changes
to our contracts since we started the implementation of Region
4. That follows the work that was done originally with Optum.
And to this point there is no modification currently being
negotiated formally as to the access standards.
Chairman Moran. General, I will come to you. Maybe it is
just easier if I ask a series of questions which are directed
to both of you. You are making progress in improving, I think
what you are saying, is the access, the timeliness, the access
standards. Why are you doing so if it is not included in your
contract?
Mr. McIntyre. We sought, from day one, to build a network
that was in keeping with the access standards that are
envisioned in the MISSION Act. And the award of Region 4 was
done in such a way that it predated the opportunity for the VA
to make an adjustment to the contract before award. So I
thought it made most sense for us to start on a trajectory line
with that in mind. The Region 5 contract that just got awarded
for Alaska to our company includes the MISSION Act standards.
When COVID hit we suspended a bit of our work to more
broadly build the network in favor of making sure that we
protected the base that needed to be built, and we are now
getting back to closing out the work on the MISSION Act
standards as well as refining the dental network, which has
been, as Senator Tester and others from Region 4 know, a little
bit more complicated than was initially anticipated.
Chairman Moran. It is my concern that veterans have
different access standards depending upon what third-party
administrators' contract says and what that third-party
administrator is doing. Now what you indicated is in the most
recent negotiations, the MISSION Act standards are included,
but in other contracts they are not. Therefore, depending upon
what VISN you live in, you are operating under a different
standard?
Mr. McIntyre. The MISSION Act standards were included in 5,
because that was most recently awarded. That gave the VA enough
time to modify that contract before award. That was not in the
case in Region 4, and so, therefore, we are stretching
ourselves voluntarily in the direction of the MISSION Act
standards for the network build for Region 4.
Chairman Moran. General, your response to those questions?
General Horoho. Thank you, Senator. So when we received our
contracts for Regions 1, 2, and 3, it was before the MISSION
Act went into law, and so 6 months after we had the awards it
went into law, so those standards were not part of the
contracts.
However, when we looked at the contracts we kind of looked
at it through three different lenses--one, to have a bigger
network, two, to have a bigger chance for availability, and
three, to have bigger veteran choice. So we intentionally went
and overbuilt the network. We realized that approximately
200,000 veterans leave the military every year, and so we did
not want to build the network just where veterans are today,
but we wanted to have a robust enough network that we have
capacity and providers in the right place at the right time for
the veterans for the future.
And so we are not in active conversations with the VA on
modification, but that has not stopped us from wanting to make
sure that we have the most robust network available.
So we kind of look at it through two lenses. One is a
retrospective lens, where we look at the referrals and through
the claims process, and we look to see how long it took for a
veteran to be able to get an appointment, and then we look
within that area to make sure that we are in access standards.
We then look prospectively and look at geo-mapping where the
veteran lives and where the providers are, to make sure that we
have really robust drive time as well as availability for care.
And so internally we have monitored ourselves on what
Secretary Wilkie had put out for the access standards of 30
minutes for primary care and behavioral health and then 60
minutes for specialty care. So internally we monitor that and
we are actually very close to meeting that standard across
primary care, behavioral health, and specialty, except for the
area of dental, where we have--we are probably about 79 percent
with dental. But everything else we are close to 90 percent or
higher.
Chairman Moran. Your contracts, the ones that were
negotiated before the MISSION Act took effect and therefore do
not include the MISSION Act standards, last for how long? The
contract length before they are renegotiated is how long?
General Horoho. Eight years.
Chairman Moran. And you have no indication that the VA--let
me ask a more neutral question. Do you have any indication, one
way or the other, whether the VA is interested in implanting a
contract, modifying your contracts, to meet those standards, to
include those standards?
General Horoho. Senator, we have given them all of our data
and information that they would need for them to make that
decision, and right now we are not in active discussions.
Chairman Moran. And now I may be editorializing, but
correct me if I am wrong. So if you both are working in the
direction, third-party administrators are working to meet the
standards of the MISSION Act, what is the reason for those not
to be included in the contract? And in the absence of contract,
the reason we have standards is so that a veteran, regardless
of where he or she lives, operates under the same rules. So in
VISN 5 there is a different standard for a veteran than a
veteran in Region or VISN 3. Is there any reason that makes any
sense?
General Horoho. Maybe if I can frame it in how we are
operating every single day. And so one of the things that we
have realized is health care is local. And so we work every
single day with each local VAMC on the ground to identify where
they have got gaps in care, where they are having access-to-
care issues, and ensuring that we have a robust enough network
to be able to support the demands of each one of those VAMCs.
And so consistency, from a veteran's perspective, I think
is very important, so I think I am in agreement with you. And
we believe that the intent is for veterans to be able to get
care where they need it, when they need it, which is part of
why we are driving to have the most robust network.
Chairman Moran. Thank you for that answer. I want Mr.
McIntyre to respond and then I need to move on. But I would say
that I agree with you, General, that care is local. I believe
that. But a 3-hour drive is a 3-hour drive wherever you live in
this country. Mr. McIntyre?
Mr. McIntyre. For the networks that we built, we have
sought to understand both what the footprint of the veteran is
and what the footprint of the VA Medical Center is--their
capacity, not just their capability. And then we seek to build
the elasticity that they are going to need.
With regard to your question about modifications, we have
done 100 modifications since we started in this space, and I
think there will probably be a day when it makes sense for VA
to modify our contracts, the ones we currently have, to layer
in the standards so that we can measure appropriately between
us how we are doing in meeting those standards.
I was refreshed to see that the MISSION Act standards are
layered into the Region 5 contract, and I think that is
probably an indication of where VA intends to go, but I have
not asked them that question.
Chairman Moran. Thank you very much. Thank you both. I
apologize to my colleagues for running over time significantly.
I will try to make up for it.
I do not know whether Senator Tester has returned from
another committee meeting. If so, I will recognize him. If not,
I recognize Senator Murray.
Senator Tester. I am here.
Chairman Moran. Senator Tester.
Senator Tester. Thank you, Mr. Chairman, and it's Okay if
you run over time once in a while. You have been very gracious.
So I want to thank everybody for testifying. I appreciate
your testimony. I am going to start with you, Mr. McIntyre,
because you are kind of a big deal in Montana, and I want to
talk a little bit about dental network rates and access to
preferred dental providers. It is a concern that I hear
consistently from veterans across the State.
So my State staff tells me that calls and emails from
veterans are concerned that regular dental providers not in the
TriWest network have eclipsed those about eligibility for
dental care through the VA. So the chief concern appears to be
the dentists believe the network rates are too low.
So what I would like to have you do, Dave, is walk me
through how you and the VA established dental rates in Region
4, and the adequacy of the dental network in Montana. In
particular, are the rates in Montana the same that you pay in
more urban areas where there might be more general dentists
than specialists, and does that make sense?
Mr. McIntyre. Great question, Senator Tester. It is good to
see you. We are building the network in Montana. As I said, it
has been a little more complicated than we initially expected.
The reason for that, in part, is there is no fee schedule that
is national for dental services for the VA. They were local fee
schedules. In some cases they varied substantially, market to
market. And what we were asked by VA to do in the dental space
was to attempt to put together a network that reflected the
market rates in those environments.
So what we have sought to do is to involve our dental
subcontractor, Delta Dental, which has a wide footprint across
the geographic expanse of Montana and the rest of Region 4, to
leverage their engagement in the marketplace and to convert
over to a fee schedule that is consistent and to build out that
network. In some cases, the market rate that they are paying
for dental services is different than what the VA was paying
historically, and that is where part of the rub has occurred.
And we and VA are collaborating, market by market, to make sure
that we are able to make appropriate adjustments and complete
the network.
Senator Tester. So I just want you to add on to that. In
what circumstances would you pay more than the rates are right
now?
Mr. McIntyre. More than the rates in the market, or more
than the rates----
Senator Tester. No, more than the rates--so let's assume
for a second that the problem is, in fact, that the network
rates are too low. Let's make that assumption. What
circumstances would cause you to raise those current rates?
Mr. McIntyre. If a higher rate was necessary to make sure
that we could build a complete dental network in your State.
This is----
Senator Tester. Okay. I appreciate that. So do you feel, at
this point in time, that the rates have not been a limiting
factor on you building that network?
Mr. McIntyre. I think that it has been a bit of a
challenge, but it is one that we and VA are working through to
attempt to respond to the local conditions in the market to
make sure that we can build a sufficient network that veterans
need to be able to rely on.
Senator Tester. Okay. General, Horoho, would you like to
add anything to this topic?
General Horoho. Yes, sir, I would. So when you look at
dental, the challenge is in a couple of areas. One,
approximately 12 percent of the veteran population is eligible
for dental, but that data is not readily available, and so you
really have to build the dental network to support the 6
million veterans that are there. And many of them, actually,
operate in a fee-for-service model and are not dependent on a
managed care model. So each dentist, there are different rates
for the subspecialty versus general dentistry.
And so what we have found is that we have had to pay up to
150 percent for some of our contracts to be able to ensure that
we can have a robust enough dental capability within that
marketplace. So when we look across our three regions for wait
times, Region 1 is about 27 days; Region 2, 21 days; and Region
3, about 13 days. And so it is a negotiation, market by market.
Senator Tester. I want to thank you both for your
explanation, and I want to point out to the Chairman that I
only went 25 seconds over.
I yield. Thank you, Mr. Chairman.
Chairman Moran. Thank you, Senator Tester. I now recognize
Senator Cassidy. Doctor?
SENATOR BILL CASSIDY
Senator Cassidy. You got me now.
Chairman Moran. Yes, sir.
Senator Cassidy. I think you do. Great. Thank you. Thank
you both.
You know, one of the issues that I am sure you have heard
of is the timely and accurate claims processing. And so there
is a system back home that says that from about June 2019 to
about June 2020 there is just a whole batch of claims that they
have not been compensated on.
Now, subsequent to that, it has gone Okay, but there are
these claims there. I say that because we are all aware of the
impact that COVID has had on hospital cash-flow, and so
obviously they are still in business but nonetheless part of
what keeps them in business is paying attention to stuff like
this.
And so can you give us some perspective on how TPAs are
going to handle this? And if you addressed this in your opening
remarks I apologize. I had to log off for just a little bit.
Mr. McIntyre. I will take that, Patty, if that is Okay,
because I filled the breach, our company did, before you
arrived in Louisiana. There is a requirement currently that
providers file claims within 180 days of delivery of service.
That is half the time given for Medicare and half the time
given for TRICARE and most other programs.
What has happened to them, unfortunately, is further
complicated because of the fact that sometimes VA ordered the
work, sometimes Health Net ordered the work, and sometimes we
ordered the work. And so there has been a complication on the
part of providers of where to file.
The VA and we have worked extensively over the last couple
of months to put a process in place that is going to allow
every provider that falls into the gap that you have so
articulately identified, Senator, that will allow them to
refile the claims, have them processed, and paid. And we have
the resources to do that, on the dollar side, and the VA will
reimburse us.
This just started at the beginning of October. There has
been common outreach between us and VA of that fact, and there
are now 1,367 claims that have been refiled that otherwise were
denied for timely filing in the last couple of weeks.
So we look forward to working with you, VA and ourselves,
to make sure that your constituents are aware of what to do and
how the process will work, so that they can get reimbursed for
the services that they have delivered.
Senator Cassidy. Okay. So we can followup directly with you
should there be a continued concern or a problem on their side,
because, of course, they think they filed directly.
Mr. Chairman, I cannot see the clock, so you tell me when I
am out of time.
Let me address this to Optum. The MISSION Act authorized
the new urgent care benefit for veterans, which I was strongly
supportive of, because it expanded options for care and made
sure that folks get urgent care where they needed it. TriCare
has established a nationwide network of 7,200 urgent care
providers, I am told serving 92 percent of enrolled veterans,
and I thank the VA and TriWest for establishing this.
Now Optum is the TPA for Region 3 and is in my State of
Louisiana. So I gather that Optum's urgent care network is not
as robust. And since obviously I care about this--I was the one
that sponsored the legislation--what steps is Optum taking to
ensure a robust network of urgent care providers, at least
comparable to TriWest?
General Horoho. Thank you, Senator. So we established
urgent care and we did that in the midst of COVID. We actually
have 6,600 urgent care centers across all three regions, and so
across those regions, in Region 1, 98 percent accessibility and
availability, 91 percent in Region 2, and 95 percent in Region
3. And we have seen where those have been utilized during
COVID, because we also had some of them that used tele-urgent
care, where those that wanted to access care were able to do
that remotely as well.
Senator Cassidy. Okay. So then what I have been informed is
that your network is as robust, and for whatever reason, as
Humphrey Bogart once said, ``I was misinformed.'' Okay. Well,
that is good news.
Just returning to the other, I will just emphasize that I
am told that providers are unaware of a process to resubmit
those claims. So the degree to which you all can publicize that
I think would benefit probably not just my folks but others.
But thank you for that, sir.
With that I yield back, Mr. Chair.
Mr. McIntyre. Mr. Chairman, if I might?
Chairman Moran. Mr. McIntyre.
Mr. McIntyre. I will commit that I will reach out to every
office that is on this Committee to inform you of the
communications that VA and we have put together, and to help
you understand the information that might be used to outreach
to providers in your State, and make Patty aware of the same
thing, because our commitment before we fully leave the areas
that she stood up is that all of the claims are paid, even
those that were not otherwise done on our watch but might have
been done in the HealthNet space.
General Horoho. And, Mr. Chairman, if I could just add to
that so we get a complete scenario on it, what we have done
internally as well. So we are paying claims on average in 11.9
days. But when we get claims that are actually either TriWest
or if it is HealthNet, at that time, we have got an internal
specific denial code. So we just do not deny them. What we do
is we put the code on it so that it gets routed back to the
provider. And we work closely with TriWest to make sure that
that works well, as well as working with the VA. So we try to
take away the friction from our providers.
Chairman Moran. Dr. Cassidy, thanks for raising these
topics.
I now recognize Senator Murray.
SENATOR PATTY MURRAY
Senator Murray. Mr. Chairman, thank you very much. I
appreciate it. And Mr. Schwab, thank you for your incredibly
important testimony and your recommendations today.
I really want to thank the Elizabeth Dole Foundation for
their dedication to our veteran caregivers. And Mrs. Beller,
thank you for all you do, both as an advocate and a caregiver.
I am so grateful to my colleagues for their support in passing
the caregivers legislation as part of the VA MISSION Act to
finally expand the program to veterans of all eras. But now we
have got to get this expansion right and make sure that current
participants are not getting unfairly pushed out of the
program.
Back in May, I joined Senator Tester in a public comment
letter to the VA regarding the agency's proposed changes to the
caregivers program, which would restrict the eligibility and
potentially remove some veterans from the programs. In the law,
we set the criteria to include eligibility for veterans who
need assistance with at least one activity of daily living, and
we included other eligibility criteria such as supervision,
protection, or instruction to make sure those with the
invisible wounds of war, who need assistance, can get it.
However, VA's new rule goes beyond Congress's intent to
further limit eligibility. So, Mr. Schwab, I wanted to ask you,
do you believe that the VA is defining eligibility too narrowly
when compared to the eligibility in the specifications outlined
in our law, and how will those new limitations on eligibility
to veterans rated at 70 percent service connected affect our
veterans?
Mr. Schwab. Senator Murray, thank you for the question and
thank you for your leadership going back years on advocating
for the expansion of this program. You were among the first
Members of Congress certainly to be with us at the Foundation
and calling for the expansion of the program, and you have
worked so hard on it. We appreciate that.
Your question is super important and something I
highlighted in my testimony. The program, even before expansion
was inconsistent, at best, in integrating, including, and
caring for folks who are caring for a veteran with mental and
emotional health care wounds and injuries.
Yes, we do believe that the VA has gone beyond the
interpretation in the ways that it is implementing eligibility
for folks who are caring for mental and emotional wounds. I
think that my colleague, Molly, if I could refer to her,
Senator, could expound on this point as well. Molly?
Ms. Ramsey. Yes. Thank you so much, Steve, and thank you so
much, Senator Murray for everything for our caregivers and with
the Elizabeth Dole Foundation.
As Steve mentioned, we do believe that the VA has gone a
little further than the intention of what was put into the
initial caregiver bill and VA MISSION Act. We are hopeful that
they treat invisible wounds such as PTSD, TBIs, any other
neurological or emotional or mental illnesses or wounds as
equally as the physical need for ADLs, or physical assistance
with ADLs.
We have been told that the VA are weighing safety and
supervision as equally as the physical assistance with
activities of daily living each time. However, some caregivers
that we have in our network, that we are working with, have
expressed concerns of that.
You bring up a good point also of the 70 percent
requirement. That was something that we were surprised to see.
In the initial impact analysis that the VA provided, they did
try to assure the community that 95 percent of what they are
considering legacy participants, as well veterans who were
already receiving care under the VA health system would meet
that qualification. However, that is possibly the lower bar of
eligibility requirements. There are those functional assessment
needs, and then as Jennie Beller so eloquently put, the 2-hour
interview process. Those are the higher parts of the
eligibility requirements that are concerned with.
Senator Murray. Okay, well thank you. And, Mrs. Beller,
thank you for your testimony today. Let me just say we have got
to get this right and I am not going to give up. And thank you
for your recommendations. I look forward to working with you.
We have got to keep working on this, so I very much appreciate
it.
I just have a few seconds left and I wanted to ask about
IVF to Mr. McIntyre. This is really important to me that
veterans facing fertility challenges as a result of their
service have the smoothest experience possible in connecting
with the IVF provider that best matches their family's needs.
And I continue to have concerns about approvals from the VA
being delayed, and I am troubled by how it will affect the
scheduling process for these families.
To that end, I have heard that the VA will soon be assuming
full responsibility for scheduling appointments with community
providers as opposed to the network administrators scheduling
these. Mr. McIntyre, I just want to ask quickly, what have you
found to be most important in getting this done in a customized
way that fits each couple?
Mr. McIntyre. Senator, thank you for that question and your
leadership with this important topic. It is true that the VA is
going to be taking over the functions related to IVF. It, as
you say, has to be done very customized, and we anticipate that
they are ramping up to do that. We will continue to do the
network piece which is customized fully for the needs of the
couple when we come to understand what their authorization is
and what their circumstances are. And at this point the VA is
planning to do the scheduling of them, but Washington State is
one of the areas that we expect the VA to look to us for
elasticity on appointing, and if we can helpful with the
appointing on the IVF side to assist them, we certainly will do
so.
Senator Murray. Okay. Mr. Chairman, I have additional
questions that I want to submit for the record, and I
appreciate you allowing me to go over time.
SENATOR JOHN BOOZMAN
Senator Boozman. [Presiding.] Without objection. Thank you.
Senator Boozman. I want to thank Chairman Moran and Senator
Tester for having the hearing. I cannot imagine anything more
important than about increasing the quality of care and
maintaining the quality of care that we have, and again, going
forward, and then also access to care, which is really what
this is all about.
I know that we have had a really significant backlog
regarding reimbursement in the past. We have worked hard to--VA
has worked hard to get that down. General, recognizing that the
MISSION Act changed the reimbursement plan for providers,
placing a heavier burden on TPAs like OptumServe up front, can
you provide the Committee an update on how the VA is
reimbursing you for care to community care providers and your
network, and are there any challenges that you are facing that
we can be helpful with. I think that is really the bottom line.
Yes, you are not going lot have your providers if they do not
get paid in a timely fashion.
General Horoho. I could not agree more, and prior to
launching the three regions, one of the significant hurdles of
getting providers into the network was because of the
challenges of the past. I can report to you today that I think
we are in a very good place. We are paying providers first,
which is a change, and we are paying them on average in 11.9
days, almost 99 percent of the time. And then the VA is
actually reimbursing us around 7-9 days.
So that system is working right now, and we keep a very
close eye on it, because it is how we retain high-quality
providers.
Senator Boozman. Very good. Again, Optum now is in Arkansas
and has taken over, which is, again, great.
There is concern about people that are under other
providers that have had, you know, a long-term relationship
with them. For a veteran whose current provider is not in the
network, what does this transition look like? How can you--how
can we, how can you help provide continuous care for veterans
under these circumstances?
General Horoho. Thank you, Senator, for that question.
Continuity of care, which we both know is so very, very
important--and health care is a very personal relationship with
your provider--one of the things that we have done is we have
actually asked the VA to prospectively identify those
individuals that do have a relationship, that there are ongoing
authorizations, and then the analysis to see whether or not
there is a gap in the provider being in our network. And then
where there is, we can look to evaluate does that provider meet
the new standards of being a fully credentialed provider,
meeting all those standards. Then we are able to bring them
into the network.
When we meet every single month with 109 VAMCs we actually
talk about gaps in care. We talk about, you know, where they
need us. We talk about veterans' concerns. And so that is
another place where that can come in. And then actually the VA
has given us their priority providers as well, for us to bring
those into the network.
Senator Boozman. Very good. We understand that it takes
time to build community care networks, to best serve veterans.
Based on your testimony, General, it appears that OptumServe
has been able to quickly create a network that serves almost
all veterans in Region 3, and that is very commendable. You
Stated that for Region 3, 95 percent of veterans are able to
reach an in-network urgent care facility within a 30-minute
average drive time. This is partially a credit to OptumServe's
ability to efficiently accredit health care providers as part
of your network.
In terms of the process, what is the average timeline for a
health care provider to receive accreditation by OptumServe? Is
this something that can be improved on? Is there anything that
we can do as a committee to help in that regard?
General Horoho. So, thank you, Senator. Early on, when we
were first standing up Region 1, we had a challenge in that
area because we were bringing on hundreds of thousands of
providers, and so it really was a large volume going through
our system. We are now in much better shape, having fully
operationalized Regions 1, 2, and 3. So our average is 14 days.
Sometimes there is some specialty, like vision, that may take a
little bit, you know, currently averaging 45 days. But that
process is actually working extremely well right now. So I do
not think there is any assistance that we need from Congress.
Senator Boozman. Okay. Thank you very much. And now we will
go to Senator Blumenthal, I think.
[Pause.]
Senator Boozman. Well, we are going to go to Senator
Rounds.
SENATOR MIKE ROUNDS
Senator Rounds. Thank you, Mr. Chairman. Since Optum is
actually handling the processes within South Dakota, I would
like to address most of my questions to General Horoho. First
of all, I would like to thank you for your service to our
country.
General Horoho. Thank you.
Senator Rounds. And I appreciate your continued service as
your work with Optum.
There seems to be a little bit of a disconnect between what
you have shared with us today regarding the working environment
that you find yourself in with the VA, who have decided,
unfortunately, not to participate in this hearing, and also
with regard to what our folks on the ground in South Dakota
have been sharing with us about the availability of the
networks that you have been building and the networks that were
there prior to your participation. And I want to visit a little
bit about this disconnect I am hearing today.
I have heard from both large and small providers that they
literally have been extremely frustrated with the amount of
bureaucracy that it takes to actually get into the network, and
once in the network to actually get paid. On at least three
occasions, a veteran's local VA medical center has referred
them, unfortunately, to a TriWest network provider who had been
there with years of service but they are being denied then once
they have been there.
And it appears to be just simply administrative delays in
getting them moved into Optum's network. And in this particular
case, those veterans were denied access to care by those
providers because they were not in the network anymore, and
that most certainly is something, that as you have indicated
earlier, and just as we had a discussion here today, is
something not acceptable, and that continuity of care is
critical.
What I am going to ask is, I think we have got to have an
analysis of whether or not what we are seeing on the ground, in
terms of ground truth, versus having perhaps a 90 or a 90 or a
95 percent success rate, that is leaving out those critical
numbers in the middle that somehow suggest that there are
people that are getting left behind. And it appears to be a
bureaucracy problem, and what I would like to do is to discuss,
at least hear from you, what you are seeing in terms of what is
stopping, or perhaps is the most frustrating part for you. And
I am sure there are frustrating parts about your working with
the VA and then trying to get through with your team these
former providers, to get them in.
And finally, and I will let you answer, I would like to
know what it is that are the guidelines, and are they
published, for being an acceptable provider in your network
that might have excluded those from the previous network.
Thanks.
General Horoho. Yes. Thank you, Senator, and I will
absolutely, myself and the team, will come and meet with you
and kind of lay out the data for your area so that we can have
a further in-depth conversation on it.
But if I can kind of address some of the concerns that you
raised, I will address first what it takes to become in the
network. And so when we started to roll out Community Care,
what we went forward with is not trying to replicate the
network that was PC3 Choice, because Community Care changed the
standards and made it a mandate to ensure that the entire
network was fully credentialed.
So not only did they have to be licensed but we had to do
prime source verification on the national practitioner data
bank. We had to look at their education. We looked at their
licensing. We made sure that there were not any challenges and
issues, either from any agency that was out there. If they meet
those requirements and if there is a gap in care, absolutely we
attempt to bring them into the network. Or if it is a
continuity of care issue we attempt to bring them into the
network. And so that has been the standard and that is what it
takes to get into our network.
The other piece that I want to bring out to some of the
frustration that you have raised is we, in Regions 1, 2, and 3,
we actually do not do the scheduling. The scheduling is done by
the VA. And so when they go into the data bank the first
priority is to look at those practitioners that are part of
Regions 1, 2, and 3, to be able to schedule those appointments.
And so part of the transition, we just finished going live in
June of this year with all three of the regions, and so some of
that frustration may have been when there was the overlap,
which we did for all the right reasons for the veteran, is when
we went live we did a 30-day overlap with TriWest to ensure
that there was no gap in care during that transition. But that
also allowed the VA to look into a system and see the current
Optum providers as well as the TriWest, and they may have
scheduled one or the other, which then tied into claims being
put into the system that could have caused some of the
confusion.
But we can do a deep dive with you on all of your data that
is there.
Senator Rounds. Thank you, and look, I think what you are
pointing out here is that we do have a problem with this
transition, and I think the folks that are holding the bag on
this are veterans that very well may have been denied care. And
I do not think it has been a once-in-a-while issue. I think it
has happened on several different occasions. I think we are
going to have to go the extra step to cut through that
bureaucratic red tape, like another part of this that we are
going to have to talk about.
I like the idea that TriWest has come up with, where they
are going to go back in and allow for a revisit on those claims
that are over 180 days old. And I would like for your
commitment as well, that you will do the same thing. Because we
are going to have that problem. We have got folks out there
that have got claims that are over that time period. They
provided the services.
It looks to me like this transition has not been super
clean, and nor would we expect to necessarily be super clean,
but I do not want those providers holding the bag and I most
certainly do not want our veterans on the short end of being
able to get services with the individuals that have been
appropriately providing them with services in the past. I think
that means that as you transition into this I do think you are
going to have to go the extra mile, with focus on those
veterans.
I would sure like your commitment that you will look at
that 180-day rule, the same as TriWest, and that you will work
through to make sure these veterans have that continuity of
care where we have a problem. If you can give me that
commitment I think we can move forward.
General Horoho. Senator, I can already tell you we are
doing that right now. So every one of the claims that get
denied, we actually look to see what was the reason before it
goes back to the provider. We have been using an internal
specific denial code to make sure that it gets routed
appropriately. That did not happen at the very beginning. But
when we realized the confusion that was occurring with, just
like TriWest, realized the confusion that was occurring when
you had multiple third-party administrators in one market until
it was fully transitioned. So we have made that commitment, and
we are doing that. So you have got my commitment that it will
continue.
Senator Rounds. I am assuming, has that change just
occurred in the last week or so?
General Horoho. No. We have been doing that, actually,
probably for the last several months.
Senator Boozman. Thank you, Senator Rounds. And again----
Senator Rounds. Thank you, Mr. Chairman.
Senator Boozman. Well, thank you, Senator Rounds, and
again, that really is an important point.
Senator Blumenthal?
SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Thank you, Mr. Chairman. Thanks for
being here, to all of you. I am disappointed, as Senator Moran
and Tester have expressed, that the VA is not here. I am also
disappointed that the VA has apparently declined to answer a
number of the questions that we have asked regarding the racial
disparity in the impact of COVID-19 on our veterans. Seven
months into this devastating pandemic, 3,667 VA patients have
died, which is a devastating average of about 17 veterans every
day.
Right now we are apparently at the beginning of another
surge. There has been a 50 percent increase in active cases at
the VA compared to last month. I will say that I am proud of
the VA facility in West Haven because they have done prompt
testing with rapid results, using the PCR process. It could be
a model for the whole country. And the infection rate at our VA
facility has been much lower than the national average. And I
want to point out that there is some good news, even amidst
some of the more discouraging facts.
But the results of a recent VA study have shown that Black
and Hispanic veterans are twice as likely as White veterans to
test positive for COVID at the VA. My guess is that not only
infection rates but also death rates show the same disparities.
The VA has refused to communicate with Congress about this
issue. Questions sent to the VA in June were completely
ignored, as was a followup letter sent by the Committee in
August. I joined my colleagues in expressing grave
dissatisfaction with this refusal to answer our questions. The
VA does a tremendous disservice to veterans when it refuses to
communicate with Members of Congress who represent them and
have a responsibility for oversight, and then refuse to come to
hearings, as it has done today.
So I would like to ask all of you, but particularly General
Horoho, how the COVID-19 pandemic has affected your operations.
In particular, at the facilities in your network had adequate
access to COVID-19 tests, reliable tests, and with prompt
results and personal protective equipment?
General Horoho. Thank you, Senator. If I could take 1
second before I answer that and just talk about health
disparities, because that has been so important. So one of the
things that OptumServe, my company is actually a data analytics
consulting health services and a logistics and technology
company. We developed a health disparity data analytical tool
that we have been using since COVID started, that we can go
down to the zip code level and identify those Americans that
are disadvantaged or at high risk for COVID-19 based on their
health disparities.
Then we have done ``Stop COVID'' where our company has done
philanthropic work of providing those testings for free, as
well as education wraparound packages to help them with that.
We have also reached out to the VA and offered that
capability, to be able to utilize that as well, because I agree
with you, it is a population that is extremely vulnerable.
And to answer your other question, a couple of things that
we did as an enterprise, when we looked at our network being so
tied to our enterprise network and making sure that providers
are, one, financially stable enough to keep their operations
going was important. And so we have accelerated nearly $2
billion in payments to doctors and hospitals that are also
serving veterans so that we made sure that financially they
were stable. We donated over $100 million to support COVID-19-
impacted, at-risk communities.
And then we worked in partnership with HHS to help disburse
over $100 billion of the CARES Act provider relief, and we did
that because we knew this robust network of 830,000
practitioners are not only providing care for veterans, but
they are providing care for Americans. And we wanted to make
sure that was stable.
What we are seeing is that we utilized a lot of, and
leveraged a lot of telehealth. Prior to COVID, only about 12,
well, 12 to 16 actually used telehealth as referrals, and then
now we are up to 12,000 a month. And so most of those were
behavioral health, about 31 percent, and we are starting to see
the systems really coming back to normal and being able to
improve access.
Senator Blumenthal. Thank you very much.
Senator Rounds [Presiding.] Thank you, Senator Blumenthal.
On behalf of the Chairman, Senator Blackburn. Senator
Blackburn?
SENATOR MARSHA BLACKBURN
Senator Blackburn. There we go. All right. Thank you all so
much. I appreciate your coming for the hearing, and I really
want to thank the Elizabeth Dole Foundation for their
leadership on caregiver advocacy. I will tell you, this is
something that from our veterans we hear a good bit about, so
we thank you for that.
OptumServe began managing the Community Care Network in
Tennessee earlier this year, and let me say right now, I really
agree with Chairman Moran's Statement that we are disappointed
the VA declined to participate in this, and look at the
progress that we have had with this network.
I will tell you, I am optimistic that we are going to be
able to expand here to our veterans, especially those in the
rural areas that are qualifying for care. And we are seeing an
increasing number of those that retire out from Fort Campbell.
They choose to stay in Tennessee because of its geographic
location, also because no State income tax. And the Community
Care is something that is vital for them.
And I want to focus today on the caregivers. We know, in
the past, and we have had some problems in Tennessee, with the
VA booting veterans and their caregivers from the program
without justification and without them knowing why they got
kicked off the program. Senator Peters and I have the TEAM
Caregivers Act that would put into law some guidelines and
bring some specificity to this program, to be sure it does not
continue to happen. We think those standards are going to be
vital. And it also takes steps to recognize the caregivers to a
veteran's--their access to the veterans' electronic health
record.
Mr. Schwab, in your testimony, you mentioned that
caregivers are hidden heroes. And we know that they are heroes,
but I will tell you they ought not to be hidden, certainly when
it comes to having access to that veteran's medical records.
Because this is one of the issues that we have in having that
precise, timely coverage. So let's work together and be sure
that they are not going to be hidden heroes.
Let me ask you a question, Mr. Schwab. In Tennessee, with
our caregiver program, what we see is we have many that are
there because of PTSD and traumatic brain injury, and really
what we term invisible wounds. And let's talk about the
activities of daily living criteria that have been set by the
VA, and talk to me about how that could negatively impact
veterans' eligibility for the caregiver program.
Mr. Schwab. Thank you for the question, Senator Blackburn,
and thank you for the work. Your recent legislative call for
consistency, access to health records is vital.
I will echo something I said in my testimony and that we
responded with in our answer earlier. The definitions that have
been established around ADLs with respect to mental and
emotional wounds, for caregivers care of those conditions
across veterans, it is causing inconsistency around
eligibility. I am going to ask my colleague, Molly, to expand
on this point, for your purposes as well. But standardization
of those conditions is really, really important. We are going
to continue to see people being booted in and out of the
program, as you have been seeing in Tennessee.
So, Molly, do you want to add a little bit to that?
Ms. Ramsey. Yes, absolutely. Thank you so much, Senator
Blackburn, for that wonderful question.
With the requirement of assistance with activities of daily
living, each time at least one activity of daily living is
performed, that definitely focuses more on the physical needs
of the veteran. However, the VA has worded ``as well as safety
and supervision on a daily basis.''
We know caregivers and veterans, and I even know one with
my father, who that assistance each time, daily basis, you
could go a couple of days of having great days where your
veteran is able to remember to not touch a warm mug of coffee
after being put into the microwave. They are able to do that
some days, but maybe not on a Wednesday, just because that is
how TBIs and PTSD can work. And also there are instances where
someone may be able to transfer themselves from their
wheelchair to, say, to use the rest room, or to the chair, or
to their bed. But there may be some times where they are not
able to do that.
Each time we understand can and will be limited, and I
think it would be great if the VA could help clarify,
especially to the caregivers, because to them that seems a
little bit of a gray area, especially with the fluctuation of
needs of assistance that they deal with every day. And then
especially for the PTSD and TBI, other neurological and
emotional caregivers, monitoring triggers every single day is
something that many of our caregivers do. And it is not the
safety and supervision necessarily, but it is just making sure
that they are able to function, be able to be home for
families, be able to be parents or grandparents, or just be
able to be a spouse or a friend.
So those are the things that we are hearing from caregivers
within our network. And again, we look forward to working with
your office. We wholeheartedly support the legislation with you
your members.
Senator Blackburn. Well, thank you. And I think you can see
Senator Murray has questioned the issue too, with her
questions, that lack of standardization and the lack of the
caregiver to understand why there are these ambiguous reasons
of them discharges. A veteran can be rated 100 percent disabled
and then still be moved out of the caregiver program, and it is
just--it is very frustrating. And it is going to be important
that we get these straightened out.
I know there are others to ask questions. Ms. Beller, first
of all, thank you for your husband's service and for your
dedication and service to our country. I appreciate how you
talked through the daily routine as you gave your testimony.
What I would like to hear from you, very quickly, is talk
to me about what has changed for you since you became a
caregiver, appropriately recognized, and then talk about the
uncertainties that exist with the program and your fear or
concerns with the program. And you have got about a minute.
Ms. Beller. Okay. For me, my life has drastically changed.
I left my career, and that changed a whole lot of just the way
our life operated. But Chuck's care required that.
In my situation, in attempting to enter the program, I have
applied, I have been interviews. Chuck's situation is such that
he is almost exclusively all the ADLs, and he needs a lot of
care. We are a very obvious situation. What is so concerning is
the people that, as you mentioned correctly, that have the
invisible wounds, that are literally, their protection of their
veteran and maintaining trigger levels and keeping things calm,
are keeping that veteran alive, in preventing the spirals that
can lead to suicide, and keeping that veteran safe.
What I am hearing on social media networks is exactly what
you said, that people are being dropped, they are not
communicating. It is as if their work is not valued, and that
is very concerning because their value is as great as what I do
for my husband, if not greater.
Senator Blackburn. Thank you. Thank you, Mr. Chairman.
Mr. Schwab. Senator Blackburn, if I could just add one
point, because you brought up a very important notion in your
earlier comment. A really large program that we are advocating
for across the VA is called the Campaign for Inclusive Care.
And one of the very fundamental issues that caregivers like
Jennie face is an inconsistent set of protocols that clinicians
use to interact with caregivers.
Molly mentioned when a veteran goes through a disability
rating interview, that veteran may be having a particularly
good day on that interview. The caregiver is not always let in
the room when those questions are being rendered, when those
answers are dependent upon the level of benefits that they are
going to receive.
Our campaign and our protocols call for caregivers always
being included in the room. That means that when a husband or a
wife feels like they are having a good day, their spouse is by
their side to say, ``But you know what, Jimmy?'' or ``You know
what, Susie, you've been having a couple of bad weeks before we
walked in today, and last week you had one of your mental or
emotional episodes, that it is really important for the VA to
be aware of.''
So that is why your bill, and legislation like the
legislation you have put forward, is so important, to create
fundamental levels of consistencies in the ways that the VA is
interacting with veterans and their caregivers, and we really
appreciate your continued leadership on this issue.
Senator Blackburn. Thank you. I appreciate that, and my
apologies for my time running over. Thank you, Mr. Chairman.
Chairman Moran [Presiding.] Senator Blackburn, thank you,
and the bill that you were discussing cleared on the hotline
just yesterday or today. So progress in that regard as well.
I think Senator Brown is next, and then that may be, other
than my ability to wrap up, the concluding questioning.
Senator Brown?
SENATOR SHERROD BROWN
Senator Brown. Thank you, Senator Moran, Chairman Moran,
and Ranking Member Tester. I appreciate you calling this
hearing. I have some important questions I would like to ask
the Department. It is too bad they declined to attend. It seems
to have been too much par for the course.
Mr. Schwab, I appreciate what you just said in response to
Senator Blackburn about caregivers being in the room. I had not
really thought that through the way you said it, and that is
kind of the point of hearings, to learn from witnesses. Thanks.
My first questions are for Mr. Schwab and Mrs. Beller.
Thank you. Thanks for your testimony. Expanding the caregiver
support program has been a Committee priority since, really for
a decade. During roundtable discussions and meetings throughout
Ohio, I do a number of roundtables with veterans. My staff does
even more than I do, where they just sit around the table and
listen to veterans who need this critical support. And wives
and children caring for aging family members know that this
kind of help is immensely helpful to them.
The program is already a year behind schedule, as we know.
Veterans who served after 1975, or before 9/11, will have to
wait another 2 years. This should not be the case. The VA
should be here to answer our questions about the delays in
implementation.
So a question for each of you, Mr. Schwab and Ms. Beller.
In your testimony, Mr. Schwab, you discussed the need for
greater communication between the VA and veterans community it
serves. My understanding is VA ignored input from that
community before finalizing the new rule to expand the
caregiver program. In addition to the ADL threshold, what is
the one thing that you wish VA had included in the final rule,
Mr. Schwab?
Mr. Schwab. Senator Brown, that is a great question, and
thank you for it, and thank you for the work that you have been
doing across your State to listen to veterans and their
caregivers. It is really appreciated.
I would suggest that evaluation and consistency around
evaluating eligibility is probably our No. 1 concern, and an
ongoing concern with the implementation of the MISSION Act. As
I addressed in my testimony, Senator--and we would love your
support on this--my boss, Senator Elizabeth Dole, your former
colleague, former member of the Senate, has put forward a
recommendation in her work chairing, in August, a group of
leaders at the VA to introduce legislation to speed up this
expansion. The MISSION Act called for a phased expansion of
caregiver benefits, and as you rightly noted, that expansion is
way behind, which means there are a lot of veterans being left
out right now.
We would love a legislative solution to knock out that
phased eligibility and just include everybody in the expansion
in the next phase.
Senator Brown. Thank you, Mr. Schwab. Ms. Beller, I just
really want to make a comment to you. First, thank you for your
years of service to our country and to Chuck. You have waited
far too long, as others have said, for the conditional
assistance and support. I appreciate your testimony where you
outlined the stress that caregivers and veterans go through
during the application process. Mr. Schwab's insight into that
also, the additional meetings and interviews, when the medical
records illustrates the support needed. So thank you for your
speaking out and the courage you have shown and the service you
have given, and we appreciate the testimony of all four of you.
Thanks so much.
Thank you, Mr. Chairman.
Chairman Moran. Senator Brown, thank you. There are no
other Senators?
I have a few questions for our witnesses. Let me start with
caregivers. Mr. Schwab, I have seen the RAND report that was
commissioned by the Elizabeth Dole Foundation, supporting
research studies in regard to caregiver mental health concerns.
It was published back in 2014. I also know that this topic was
discussed during the fifth annual national convention that you
held last week--maybe this week, earlier this week.
And I am just asking for a direction. What is it that you
would ask of this Committee in regard to the mental health and
wellbeing of caregivers? What more needs to be done? Is it just
related to implementation of the act, or is there something
that is missing? And I would highlight that this Committee has
indicated, and I think is attempting to fulfill, our stated
priority of mental health and suicide prevention for veterans.
And your testimony, your presence today is a reminder, to me,
at least, that we need to make certain that when we talk about
mental health, suicide prevention, certainly for veterans, we
also ought to include in our thought process, and policy
deliberations, the caregivers that are helpful to them.
What would you like for me to know?
Mr. Schwab. Mr. Chairman, thank you for that question. I
would say three things in response. First, I would ask the
Committee again to consider legislative removal of the phased
expansion of the MISSION Act so that all caregivers, all pre-9/
11 caregivers receive their benefits right away.
Around your question on mental health, as you noted we
commissioned and published a study in 2014, that is almost six,
7 years old by now, but the data still rings true. One of the
things the study called for was more robust longitudinal
studies, research, and data, on the situation facing
caregivers. We do not have a great deal of data. In fact, we
have really zero longitudinal data on the effects of caregiving
on military caregivers, the spouses, families, friends,
siblings, and other loved ones, who are providing this free,
at-home care. It is a new civic, and patriotic responsibility
that will be here forever. And we need to invest, this
Committee needs to invest, the VA and DoD need to invest in
understanding the implications of that care and service on
those loved ones.
Mr. Chairman, something you said that I want to put an
exclamation point on around suicide, is that caregivers are the
last line of defense in preventing veteran suicide. We believe,
at the Elizabeth Dole Foundation, that enough is not being done
to understand the unique roles that caregivers can play in
prevention. And so we would welcome wider dialog, perhaps a
roundtable with this Committee, and a number of caregivers and
other organizations, to talk about ways that the VA, that DoD
can more directly support the mental health needs of
caregivers.
One way to do that right away is to embrace and expand upon
the Campaign for Inclusive Care, that I mentioned earlier,
where we are working with VA to implement, now system-wide, a
series of trainings and protocols that will encourage
clinicians to engage with and support caregivers throughout the
care process, because right now it is a very disjoined
engagement. There are really no requirements for the ways that
clinicians and caregivers work with those providers.
So those are the three things, Mr. Chairman, that I would
suggest are really vital and important for the Committee to
consider.
Chairman Moran. I wasn't sure whose phone that was. I was
going to scowl at one of my colleagues, but if it is you it is
just fine. Thank you for your testimony. Thank you for your
three suggestions.
Let me ask Mrs. Beller a similar question about mental
health and suicide prevention in regard to caregivers. You
heard what Mr. Schwab said. One of the challenges I think we
face is lack of professionals, and the John Hannon Act attempts
to get resources to community providers, which I think is a--to
stand up new programs to help, particularly in rural or
isolated places. What would you ask of me to be of help in
regard to the mental health and wellbeing, suicide prevention,
not only of the veteran but also of the caregiver?
Ms. Beller. Well, I think what you said about providing
more resources for mental health issues. You know, candidly, I
have been to counseling a couple of times during this 10-year
journey, just to build resilience and to make sure that I am
capable and healthy of taking care of my veteran. And that is
so critical, because there are studies or indications that the
caregiver can develop secondary PTSD. That is especially in
situations dealing with TBI and PTSD in the veteran.
So these issues are very real. I know of caregivers who
have actually committed suicide, because it is very isolating
and a very lonely occupation. But fortunately with
organizations like the Elizabeth Dole Foundation, that is
helping to raise awareness and alleviate some of the struggles.
Chairman Moran. Thank you for that answer. You are a very
articulate and compelling witness, and I very much appreciate
your presence with us today. Thank you for doing an additional
task of testifying before our Committee.
Let me return, at least briefly, to the network issues.
Neither one of you indicate that you have any knowledge of
whether or not the VA is going to move in the effort to modify
their contract. If I misunderstood or you have additional
information than what you have told me I would like to know, if
you have any indication that the VA has decided not to modify
their contract.
I would then add this question, perhaps this argument. The
VA has testified to our Committee that they have sufficient
budget resources to modify the contracts. It is not a budget
issue. You both testified--I think this is a fair summary--that
your networks are expanding voluntarily to meet those
standards. So what could you say would be a justification for
not having a uniform standard as suggested by the MISSION Act?
What am I missing here? General?
General Horoho. Senator, just to share maybe some of the
conversations, I think not to speak for the VA but to share
conversations from the VA.
Chairman Moran. Okay.
General Horoho. Is I think some of their concerns are in,
when you look at the shortage of providers in some geographical
areas and you look at Veterans Choice, because some veterans
are willing to drive a distance to see either a particular
provider or one that is part of the VA or one that is part of
Community Care, that there is a perception that it would be
overbuilding by some of the stringent drive times in some
geographical areas. And I think that is part of their hesitancy
for moving in that direction.
We have looked at it through the lens of what we spoke
about, is wanting to ensure that we blanketed a geographical
area as much as we can, that we have utilized utilization data
to really tailor it to where we believe the veterans are
living, from, you know, geo-mapping them to providers in our
network. But I think that is part of the concerns that they
have raised, and I cannot speak to other concerns, but I can
share that one.
Chairman Moran. Mr. McIntyre?
Mr. McIntyre. I believe that a retrospective look at demand
prior to enabling enhanced access makes it very hard to
accurately predict what people like to do with their decisions,
if they are given the opportunity. And so as General Horoho
said, we are developing a network that is matched to what we
believe, based on our analytics and the 7-year journey with VA,
what likely is going to be sufficient to make sure there is
enhanced access and availability where it is needed.
You know, probably the best example of the collective
success that has been birthed between Congress, the VA, and the
community, rests in Harlingen, Texas, where you used to have to
drive 7 hours for care, beyond what a CBOC could do, or go
without. Today, four community hospitals and all the providers
in that community are at the side of that CBOC. The CBOC's
expanded and no one drives or goes without, and every kind of
care is available in that surrounding area, and more than
400,000 appointments have been done in the valley in Texas, in
that comprehensive network.
Chairman Moran. Thank you for outlining what the goal is
and indicating that it can be achieved.
You know, perhaps it appears that I am harping just on
insisting that the VA comply with the MISSION Act. And yet you
demonstrate--and that is not my point here. I think where the
concern is that if we do not build to those standards that
veterans will potentially--some veterans will become
discouraged, not able to get the care they need, and we are
back to--if we want to convince veterans that the MISSION Act,
the successor to the Choice Act, is here to stay and it is for
their benefit, then we have to build to a standard that does
not discourage anyone from using Choice, using MISSION.
And the fact that the two of you, your networks have
indicated you are going to build to those standards,
demonstrates to me why there is value of having standards. If
we did not have those words in the MISSION Act, I do not know
what you would be building to. I guess you would be building to
what the VA insists that you build to, under your contract. But
in my view you would be missing the opportunity to further
serve veterans who live rural or have a particular reason why
they need care closer to home.
So it is confusing to me, because the VA has indicated, in
their testimony and in their conversations with me, they are
pursuing this, but more recent stories indicate that the VA is
not interested in increasing the standards within the
contracts. And so while it is about the provisions of the
MISSION Act being utilized by the VA, it is much more about
caring for veterans and making certain that they have
confidence that the MISSION Act is fulfilling the needs of
those veterans when they did not see it with Choice, in some
circumstances.
So I want my veterans, in Kansas, and across the country, I
want veterans to know we have now got them in a position in
which they can access the care that they need, and is close to
home. And if we fail them one more time, in reality or in
image, we are doing a disservice, one more thing to distrust,
that while they say I got a benefit but I do not feel it or see
it.
So there is a real consequence to us not meeting the needs
of veterans now for a second iteration, maybe a third or fourth
iteration of community care. So it does matter, I think,
greatly, and we will continue to have this dialog.
Senator Tester has returned. I have one more question, I
think, but let me turn to Senator Tester and then I will try to
wrap up, as I indicated earlier. I talked too long and the
Ranking Member returned in time to have more conversation.
Senator Tester, I was told when I left the Commerce
Committee that you had asked every question about long-distance
passenger rail service that I asked. I was seen as an annoyance
because you and I had the same line of questioning. And then I
heard that you were filling in here in the Committee as
chairing today's hearing. That immediately caused me to lose
interest in being in the Commerce Committee and rushed back
just in case you were thinking this was a more long-term
circumstance than I am hoping.
Senator Tester. Mr. Chairman, I would never think that, No.
1, and No. 2, it scares the hell out of me to think that you
and I are on the same page when it comes to asking questions.
But I do appreciate the opportunity to ask one more question. I
will try to make this as painless as possible, because I know
this has been a long hearing, and I do appreciate all the
witnesses for being here today.
This deals with COVID-19, and this goes to Mr. McIntyre and
General Horoho. My understanding is that referrals for
community care are on their way back up, and that is after a
dip in months after the start of this pandemic. Could you
either confirm that or is that right or wrong? Are referrals on
their way back up?
Mr. McIntyre. I can provide you with the stats for our
geographic territory in Region 4. Prior to COVID, we were
receiving about 7,300 authorizations for care a day. We, just
in the last week, pulled the data and we are now receiving over
7,800 authorization for care on a daily basis. There was,
during the height of, I will use ``Phase 1'' of COVID, some
tamping down on the requests, but for the most part the things
that we touched, minus about 10 percent, we were able to get
rescheduled and readjusted so the veterans ultimately got their
needs met for the work that we touched.
But it is starting to go up, and I think that is going to
be a permanent fixture.
Senator Tester. General?
General Horoho. Senator, we are seeing about 72,000
referrals a week.
Senator Tester. Okay. And so that leads me to my next
question, and that is how has the pandemic affected the
availability of providers in your networks to be able to see
veterans? And, Mr. McIntyre, talk about it generally within
your region, and if you could, talk about it specifically for
Montana.
Mr. McIntyre. Yes, Senator Tester, great question. You
know, providers have not been immune from the impact,
personally or with their staffs. We saw people struggling at
the start to figure out how to make sure that there was
sufficient supply of services to treat COVID patients directly,
and to protect their staffs they tamped down on most voluntary
services.
That has now changed. Most providers now opened back up for
business, and have been for months. A few providers have gone
under, as is true in the rest of the economy, but we are
finding, by and large, that people are wanting to see patients,
that they are willing to see patients, and that includes in
your great State of Montana.
Senator Tester. Okay. General?
General Horoho. Sir, very similar trends. One of the things
that we did see during COVID was an increased use of telehealth
capability. Thirty-one percent of that was for behavioral
health. And then I think a little surprising, the second was
for pain management, and then followed by physical therapy.
I think what we saw during COVID is the impact that it did
have across the health care system, but that it caused a rapid
change from face-to-face delivery of care to an accelerated use
of telehealth, which we rapidly transitioned to, and I think
that made a big difference. The other pieces I testified a
little bit earlier to was the large kind of influx of cash, so
accelerating payments that we did, to really support the
financial status of those providers so they could keep their
practice, because that was one of the big challenges as well.
Senator Tester. Last question, I promise, Mr. Chairman, and
we are going to stay on this, General, so I will stick with you
and we will let Dave answer second on this one, and it deals
with telehealth, and it deals with communities' capacity. If we
have learned one thing from this pandemic it is that telehealth
is critically important and that we need better broadband
service, quite frankly, across this country, but particularly
in a rural State like Montana and rural areas around this
country.
So, General, could you speak to the Community Care's
capacity to provide telehealth service and be able to avoid
those face-to-face instances, which is so critically important
in this pandemic, when it is not necessary for a veteran to be
seen in person, and that they can do it through telehealth? Is
that capacity there, generally speaking, or are you feeling
some limiting forces in your networks?
General Horoho. So, Senator, I appreciate the conversation
because I think tele capability is one of the things that I
would submit came out of this pandemic that has been a good
thing, and it really celebrated the use of it. One of my
concerns is that as we have been so reliant, as a Nation, on
the authorities that HHS and Congress gave to be able to
actually have transportability of licensing across State lines,
waiver for interState licensing, allowing practice at the top
of your license and then those authorities to be able to
leverage a network, that was not bound by State lines, made
such a huge difference in the ability, I think, of the health
care network being able to leverage tele capabilities.
That is one of the things that, if I was asked--you did not
specifically ask, but if I could put forth, I do think it is
something that if we could make those authorities permanent it
would make a big difference in the ability for communities to
be able to provide that.
Senator Tester. Thanks for that. I am sure the Chairman is
taking notes and crafting a bill in his mind right now.
Dave, would you want to respond to telehealth and its
availability and capacity with your network?
Mr. McIntyre. I would agree with Patty. Yes, at the same
time I think it is really important for certain types of
services where telehealth is leveraged, such as behavioral
health, to make sure that that service and the servicing
provider is as close to the veteran as possible. Because when
they need to go make a physical visit, it is important that
they see that person that they have been seeing on the screen.
And so we have really tried to put our focus on making sure
that we are enabling the existing providers in our network
within their own States to have that capacity.
We all remember, or we may remember, that telehealth really
was born out of Alaska and Hawaii, and your prior colleagues,
Senator Inouye and Senator Stevens, had a lot to do with that,
because it is how they brought access to the villages in Hawaii
and to the remote islands--I mean, the villages in Alaska and
the remote islands in Hawaii. And it is good to see that it is
expanding, but the challenge is access to broadband. And
hopefully one of the things that, as a Federal Government, is
going to be a focus is accelerating the access to broadband in
rural areas so that they can use telehealth as robustly as they
need to across a great State like Montana.
Senator Tester. Well, I would just close by saying I agree
with both of you and I agree we do need to increase capacity
across the board. And I also think that both of you and others
can be a tremendous help to Congress when we are talking about
allocating dollars for broadband by talking about the
challenges that you are facing in the community communities,
and particularly in rural areas--well, actually not just rural
areas. All areas.
So thank you all for being here, and I will turn it back to
you, Mr. Chairman.
Chairman Moran. Senator Tester, thank you. Let me see if I
can wrap up with just a few quick comments and a couple of
questions. Senator Tester went down the path of whether or not
the providers in your networks were ramping up their
capabilities, not post-COVID but latter-term COVID, or I hope
latter-term COVID, and I heard your answers. I would highlight
for you the indication by the VA in the beginning of COVID was
that a significant number of providers within your network were
no longer in business or were unwilling or uncapable of caring
for patients. It was not my experience in Kansas. Providers
could not understand why they were being denied referrals.
And I would just be interested in knowing if that was your
experience, that you could not find providers during COVID, or
the VA had made a decision to bring those appointments and
referrals--I guess that is not the right word--appointments in
house, which I think probably the best place we could have our
veteran patients is in their community, as compared to
traveling to a VA center during COVID. Was there a real
circumstance in which providers said, we are not, or will not,
or cannot provide service?
General Horoho. Senator, we found that our network remained
a viable network, and, you know, in the middle of this pandemic
we actually went live with two other regions and met the
accessibility standards in the high to low 90's. So we had
providers signing up. We had them available.
We also, as an enterprise, rolled out ProtectWell, which
was a mechanism to ensure, through an app, that our health care
providers front-lined were checking every single day on their
health, and if they had any symptoms they were not coming to
work.
So we had a very healthy network, both from the clinicians
being able to provide, and from the practices remaining open.
Chairman Moran. Thank you. Anything to add?
Mr. McIntyre. We, much the same. And we had the unique
opportunity to do appointing during that time in support of VA.
While a few of the providers were limiting their capacity or
were in furlough, we were able to find care for almost all of
the patients that were placed in our hands for the purpose of
care in the community.
Chairman Moran. I also would highlight, perhaps for you,
the interest there is, of course, veterans and their access to
care at a place of their choosing, but it is also detrimental
to our networks, or to you as providers, if you are not getting
referrals. Just the financial strain that can come from that,
we need to keep you viable yourselves.
Let me ask the General a question. It occurred to me, who
came with the 180-mile, highly rural standard? Is that
something that Optum created, or the Department of Veterans
Affairs?
General Horoho. Optum did not create that, and I will go
back to find out exactly who.
[Follow-up: VA created the 180-minute highly rural
standard; it is the requirement set forth by the BA in our VA
CCN contracts.]
Chairman Moran. Okay. Thank you very much.
In regard to Optum, which I am becoming more familiar with,
I just would highlight that please continue to pursue more
opportunities for specialized care, particularly chiropractic
care. We need more network providers closer to home than what
we have.
I also would compliment you both. I have had experience
with both companies, both third-party administrators in Kansas,
and you are very good about helping me and my staff in regard
to what we call casework--a veteran calls, writes, a family
member tells us there is a problem, and we have been able to
come to you and you have helped solve those problems.
The goal for all of us ought to be that it ought not be a
burden upon the veteran to bring a problem--I hate saying this
the way it may sound. We are not at all complaining about the
work that veterans provide us to try to meet their needs, but
we need a system that works in which it is not the
responsibility of the veteran to call a Member of Congress to
say, ``Something is not working here. Can you help me?''
So the ultimate goal--I want to again thank you for the
efforts that you have undertaken to meet the needs of veterans
as we bring those needs to you, and those concerns, those
complaints, those problems are what informs me and my staff to
know what we are supposed to be doing in advocating not just
for those veterans but for the system in which they are
beneficiaries of health care.
We look forward to working with both of you, your
colleagues at work, to try to make certain--and the Department
of Veterans Affairs--to try to make certain that it is not an
issue of who do I complain to because something is not
happening as it should. It is how do we make sure the system
makes certain that they are provided for to begin with.
So those are challenges that we all will face. Thanks for
helping us care for individual veterans. We just continue to
work to get the system to meet their needs as well.
Mr. McIntyre. Mr. Chairman, your focus in that space, and
that of the Ranking Member, and the other members of this
Committee is invaluable. And some people find that a nuisance.
The reality of what is present in each of those cases allows
us, if we choose in working the case, to find where the real
gaps are in making this work. And if we focus on that and we
adjust the processes and the tools to address those gaps,
pretty soon there are not any more gaps.
Chairman Moran. Well said, Mr. McIntyre. As you were
speaking I was thinking there is not usually a veteran who has
a unique issue. If a veteran has an issue with how things are
working, there are others who do as well, and they may not be
people who ever contract me or my staff for help. So we do not
let anybody slip through the cracks. We need to fix the problem
for the veteran that raises the issue, but we need to fix the
problem for everybody else who may not have said anything about
it.
I think I am done. I would give all of our witnesses the
chance, as is my practice, to say anything that they feel like
they need to correct or things they wish they were asked that
they did not get a chance to comment on. Is there anything that
anybody would like the Committee to know before I adjourn this
hearing?
[No response.]
Chairman Moran. Anyone online, on Zoom--WebEx, that is
interested in saying anything further?
Chairman Moran. Just a thank you to you, Mr. Chairman, and
the folks who testified today. I really appreciate their input.
Chairman Moran. Senator Tester, thank you.
Well, again, thank you for participating today. Thank you
to our Committee members and their interest in this, as we try
to make certain we implement Title I of the MISSION Act
appropriately. I appreciate hearing from each of you as third-
party administrators. I am very pleased to hear more about
caregivers, and the testimony I heard today is very useful and
I appreciate the challenge that was given us, here are the
things that need to be done.
I would now ask unanimous consent that members have five
legislative days to revise and extend their remarks and include
any extraneous material. If we submit any questions to you
please answer them as quickly as possible. There are a couple
of things that were said that you will get back with us with
information and we welcome that and encourage that.
With that the hearing is now adjourned.
[Whereupon, at 11:46 a.m., the Committee was adjourned.]
APPENDIX
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