[Senate Hearing 116-482]
[From the U.S. Government Publishing Office]


                                                S. Hrg. 116-482

                    VA MISSION ACT: ASSESSING PROGRESS 
                          IMPLEMENTING TITLE I

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 21, 2020

                               __________

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

                              ----------                              

                      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

                              ----------                              


                      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

                              ----------                              


               Material Submitted for the Hearing Record

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
      

                                  [all]