[Senate Hearing 117-658]
[From the U.S. Government Publishing Office]
S. Hrg. 117-658
ENSURING VETERANS' TIMELY ACCESS TO
CARE IN VA AND THE COMMUNITY
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 21, 2022
__________
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
51-992 PDF WASHINGTON : 2023
___________________________________________________________________________
SENATE COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
Jon Towers, Republican Staff Director
C O N T E N T S
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September 21, 2022
SENATORS
Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............ 1
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire...... 5
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas...... 7
Tuberville, Hon. Tommy, U.S. Senator from Alabama................ 8
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 9
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 11
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 13
Boozman, Hon. John, U.S. Senator from Arkansas................... 15
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 17
Blackburn, Hon. Marsha, U.S. Senator from Tennessee.............. 20
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 22
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 26
Cassidy, Hon. Bill, U.S. Senator from Louisiana.................. 28
Sinema, Hon. Kyrsten, U.S. Senator from Arizona.................. 30
Cramer, Hon. Kevin, U.S. Senator from North Dakota............... 32
WITNESSES
Panel I
The Honorable Denis R. McDonough, Secretary of Veterans Affairs.. 3
Panel II
Carrie Farmer, PhD, Co-Director, Epstein Family Veterans Policy
Research Institute and Senior Policy Researcher, RAND
Corporation.................................................... 35
Joy Ilem, National Legislative Director, Disabled American
Veterans....................................................... 36
Darin Selnick, former Senior Advisor to the Secretary, Department
of Veterans Affairs............................................ 38
APPENDIX
Prepared Statements
The Honorable Denis R. McDonough, Secretary of Veterans Affairs.. 47
Carrie Farmer, PhD, Co-Director, Epstein Family Veterans Policy
Research Institute and Senior Policy Researcher, RAND
Corporation.................................................... 54
Joy Ilem, National Legislative Director, Disabled American
Veterans....................................................... 67
Darin Selnick, former Senior Advisor to the Secretary, Department
of Veterans Affairs............................................ 75
Attachment 1--Concerned Veterans for America (CVA) FOIA Key
Findings by the Americans for Prosperity (AFP) Foundation.... 83
Submission for the Record
FoxNews.com article dated September 13, 2022, titled ``Biden's VA
undermining law that gives veterans access to private health
care''......................................................... 89
Questions for the Record
Department of Veterans Affairs response to questions submitted
by:
Hon. Jerry Moran............................................... 95
Hon. Tommy Tuberville.......................................... 104
Hon. Margaret Wood Hassan...................................... 112
Hon. Mike Rounds............................................... 113
Hon. Marsha Blackburn.......................................... 115
Hon. Thom Tillis............................................... 116
Hon. Kevin Cramer.............................................. 119
Darin Selnick, former Senior Advisor response to questions
submitted by:
Hon. Tommy Tuberville.......................................... 121
Attachment for Question 1b response--VA Clinical Review
Process Flow Charts........................................ 124
ENSURING VETERANS' TIMELY ACCESS TO
CARE IN VA AND THE COMMUNITY
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WEDNESDAY, SEPTEMBER 21, 2022
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3 p.m., in Room
SR-418, Russell Senate Office Building, Hon. Jon Tester,
Chairman of the Committee, presiding.
Present: Senators Tester, Sanders, Brown, Blumenthal,
Hirono, Sinema, Hassan, Moran, Boozman, Cassidy, Rounds,
Sullivan, Blackburn, Cramer, and Tuberville.
OPENING STATEMENT OF CHAIRMAN TESTER
Chairman Tester. The Committee will come to order.
First of all, I just want to say thank you. This is a
really important hearing this afternoon and I want to thank the
Secretary for taking time out of his day to be here on the
first panel.
We have got a second panel up that we will talk about a
little later that is also going to be critically important for
us to listen to and get input from.
Studies have consistently shown the quality of care at VA
is often comparable to or better than care provided in the
private sector. I have said before, and I will say it again, VA
can outsource the work when it makes sense but it cannot
outsource the responsibility for taking care of our veterans.
Whether they receive care in the VA or care in the community,
they are responsible for both.
As we begin today's conversation on VA wait times, I want
to make sure we are continuing to emphasize that veterans
deserve top-notch care whether they are seen in a VA facility
or in the private sector. The Department is accountable for
making sure that is exactly what they receive, quality care.
Community are has always been a part of the VA and it is
time we treat both the Department and the private sector the
same on a lot of fronts, including ensuring veterans are
covered for medical injuries received when they go into the
community for services.
Right now, if a veteran is harmed while receiving services
through Community Care Program, they are not eligible to file
an 1151 claim through the VA, which would allow them to receive
compensation for a new disability or the worsening of an old
one because of medical mistakes. I think we can all agree that
is not right. Whether at VA or the community, vets need to be
treated the same.
If problems are occurring at the VA we have an Office of
Inspector General and Government Accountability Office to tell
us what is going wrong and how to fix it. We have none of those
protections for vets when they go in the community.
Another concern I have heard over and over is that private
sector providers are not giving medical records back to the VA
after appointments. The VA has a responsibility for
coordinating care which, in my book, includes getting a record
of care that takes place in the community. VA needs to do a
better job of getting those records back so the Department
providers are better informed about what treatments their
patients are getting in the community.
In this very room a few months ago we held a hearing on
quality measures and discussed holding community care providers
to the same quality standards that we hold the VA. We need to
have that same discussion today on wait time requirements.
Private sector providers who treat veterans in the community
should have to meet the same wait time rules as the VA. It
makes no sense to develop access standards VA is required to
meet and then give veterans the option for community care where
they may have to wait longer than if they had stayed with the
VA.
The VA must ensure veterans are receiving timely options
for private sector care and quickly connecting veterans with
community care when they need it. The Department must improve
its internal process for referrals so veterans receive faster
access to the community.
The bottom line is veterans deserve to know how long they
need to expect to wait for health care in the VA and in the
private sector.
We know challenges remain on how VA calculates wait times
and we know VA does not always get this right. But I hope that
after today's hearing, we can walk away with a better idea of
how to address these concerns. For care in the community, VA
does not have readily available data and that is a failure and
something that we need to help the VA fix.
On Friday, the Department released a congressionally
mandated report regarding access standards as required by the
VA Mission Act. I expect us to get into that a bit today but,
for now, I want to focus on one item in particular. That report
states that the VA is rapidly approaching a point where one-
half of all care available in both settings is provided through
community care. It also notes operational leaders are concerned
by the potential of a spiral effect in some areas where
workload and talent are shifting to outside of the VA.
Given that statement, I want to know what your plan is, Mr.
Secretary, for avoiding both those outcomes.
Finally, I am open to hearing recommendations for how to
improve community care. Look, we are all here working for the
veteran. Veterans deserve programs that work. But the only
solution cannot be just sending more folks into the community.
With that, is he close? Unclear.
Just so you guys know, we are in the middle of two votes.
And so, if people get up and leave, do not take that
personally.
With that, because Senator Moran is somewhere in transit, I
am going to turn it over to you, Secretary McDonough, a man
that I really do not have to introduce because he has been very
generous with his time to this Committee and we very much
appreciate that.
Secretary McDonough. Thank you.
Chairman Tester. And also, in a different hearing this
morning, I appreciate the staff that were sent over, Remy,
Elnahal, and others, because they did a very nice job at the
hearing, too.
So Mr. Secretary, I will turn it over to you.
PANEL I
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STATEMENT OF THE HONORABLE DENIS R. MCDONOUGH
Secretary McDonough. Chairman and members of the Committee,
thank you very much for your unwavering support of veterans and
thanks for this opportunity to testify today.
At VA, we come to work every day to ensure access to timely
world-class care for America's veterans, ensuring that they
receive, as you have just said, the best possible care wherever
they access that care, at the VA or in the community.
I am talking about veterans like Amanda Barbosa. I first
met Amanda at the U.S. Capitol earlier last month. One of those
tough vets who spent nights on the steps of the Capitol until
the PACT Act was passed. Amanda has been through a lot.
At what she remembers as the lowest point in her life, she
came to the VA clinic at Fort Benning, Georgia and, she said,
``VA saved my life and turned it around completely.''
Today, Amanda is thriving and she has devoted herself to
saving other veterans' lives. Veterans like her husband,
Raphael, a Marine vet and an Army vet exposed to toxins during
three deployments to Afghanistan, Iraq and Kuwait. Just two
years after he was honorably discharged, he was diagnosed with
cancer and Amanda, caring for him, helped him file his VA
claim. Three weeks later, they had a decision, 100 percent
service connection.
Amanda says that experience made her a stronger, better
advocate for others. As she sees it, it is her great privilege
to stand with other vets and their families to help save lives.
That is what we want to do at VA, stand with vets, be their
advocates, ensure they have access to the world-class care and
the timely benefits that they, their families' caregivers and
survivors have earned. And I know that that is what this
Committee also wants.
Since President Biden took office, VA has delivered more
care to more vets than at any other time in our Nation's
history. More care to more vets than at any other time in our
Nation's history. And when it comes to providing world-class
health care to veterans and their families, study after study
shows that we are delivering better health outcomes for
veterans than the private sector, which is why vets now have
trust scores for outpatient VA care averaging above 90 percent
during the past year.
Notably, in 2021, we had a record 33 million completed
appointments in the community. We are not where we need to be
on timely scheduling of those appointments, but as we have seen
this record volume we are making steady progress in reducing
wait times.
We have needed to fix the way we measure and publish wait
times for veterans since before I arrived at VA. So in July,
working with VSOs, with you and your staffs, and having
listened to the IG and GAO, we updated the website so that the
average wait times better align with what veterans experience
when they make their own appointments and give veterans
localized information that allows them to choose the care that
is best for them.
We also recently, and finally, completed the CMR, the
Congressionally Mandated Report, on access to care standards.
At the end of my last appearance in this room, I said to
Senator Moran that I was considering changing the access
criteria for community care. But on reflection, and after close
consultation with our new, excellent Under Secretary for Health
Dr. Shereef Elnahal, I have reconsidered.
VA is proposing no immediate changes to the current
designated access standards. However, we are planning to
propose incorporating VA telehealth availability into
determinations regarding eligibility. I know this will require
careful consideration and that is why we will welcome public
and congressional input on the proposal when we make it.
Telehealth is part of the evolving ways in which care is
delivered and it improves our ability to provide that care.
Ensuring veterans receive timely access to world-class
care, including each of those 33 million appointments in the
community, is influenced by many factors in addition to those
access standards including the enduring impact of COVID and the
pandemic on how health care is delivered; the state of VA
infrastructure, which I heard from our experts in Des Moines
last week, too often impacts their decision as to whether a
veteran can receive care at that VA facility; our sometimes too
slow internal handling of referrals to the community; and the
health care employee shortages that plague not just VA but all
of health care and thus, impact what care is available in the
community and in the VA direct care system.
We are overcoming each of these challenges, often with your
help, including through the passage of the PACT Act which gave
us new workforce authorities and important new infrastructure
opportunities to advance one of our top priorities, which is
getting more veterans into VA care because, as I have said,
study after study shows vets in VA care do better.
So with your help, we will continue to deliver for veterans
like Amanda and Raphael and millions of others and giving them
the very best because that is what they deserve, and nothing
less.
Again, thanks for this opportunity, Mr. Chairman, to
testify, members of the Committee. I look very much forward to
the questions.
[The prepared statement of Secretary McDonough appears on
page 47 of the Appendix.]
Chairman Tester. Thank you for your testimony, Secretary
McDonough. I will cede my time to Senator Hassan.
SENATOR MARGARET WOOD HASSAN
Senator Hassan. Thank you, very much, Mr. Chair. And thanks
to you and the Ranking Member for this hearing.
And Mr. Secretary, thank you for being here and please
extend my thanks to everybody who works at the VA, critical
work for people we all care about deeply.
I want to start with a question about mental health access.
Many veterans suffer from mental health crises and the VA needs
to provide appropriate and time sensitive care. The VA has
taken important steps, such as a nationwide crisis line that
helps connect veterans with the care that they need. However,
there are still problems with providing timely access to timely
mental health care.
According to the VA's website, the current wait time for a
new patient to get a mental health appointment at the VA
Medical Center in Manchester, New Hampshire is 22 days. This
delay in accessing care can put veterans at unnecessary risk
and discourage them from seeking help in the future. What is
the VA doing to lower mental health wait times and ensure that
veterans get the quality care that they need as soon as
possible?
Secretary McDonough. Thanks very much, Senator.
Keep in mind that the wait times on the website, which we
updated in July with your help, do not include emergent or
emergency care. So importantly, things like the Veteran Crisis
Line, things like walk-in service at the vet centers, and even
walk-in service at our CBOCs or health care centers including
VA Medical Centers, means that especially during the pendency
of the pandemic, have met or exceeded the two-day requirement
that we seek, for example, for emergency care for Medicare.
Senator Hassan. Okay.
Secretary McDonough. So we are meeting emergency care and
urgent care requirements, one.
Two, it is true that first-time patients have a harder and
longer time getting into care. There is a certain degree of
that that is logic, meaning your first visit to your provider
in any system is going to be more and extra paperwork.
Senator Hassan. Right.
Secretary McDonough. So the fact is then that once you are
an established patient, you have a rapport and a relationship
with your provider, those subsequent appointments are much
easier.
Senator Hassan. Right.
Secretary McDonough. But the third thing is we, as I said
in my opening testimony, suffer from something that the rest of
the health care industry suffers from, which is a shortage of
mental health care providers.
So we are increasing our ability to smooth out the
providers we have in the country. So through telehealth we can
get a psychologist with extra time in his allotment to provide
care by telehealth into New Hampshire or into rural areas. So
national clinical resource hubs are critically important,
telehealth generally, and then training of additional
providers.
Lastly, we published on Monday of this week, grant support
to community providers and community organizations made
possible by this Committee, each of you, that allow us to
support organizations in local communities--including in New
Hampshire--where they know their veterans best, so they can
provide care and support to those vets.
Senator Hassan. Well, I appreciate that. And I think the
thing that I would like to follow up with you and your team on
is the statistics about emergent appointments versus less
urgent appointments. I think in the mental health space, that
can be a particularly hard judgment to make, for the veteran in
particular.
Secretary McDonough. Correct.
Senator Hassan. So it would be good if we could speed up
these times for first visits, just making sure that people know
that when they reach out with a mental health challenge they
can see somebody quickly, is going to be really important.
Secretary McDonough. Yes.
Senator Hassan. So I would look forward to following up
with you on that.
In the remaining time I have, let me turn to the Solid
Start Act.
Secretary McDonough. Yes.
Senator Hassan. The Senate recently passed my bipartisan
bill that strengthens the Solid Start Program through which, as
you know, the VA contacts every veteran after they leave active
duty to help connect them to the VA programs and benefits.
Solid Start supports newly separated veterans who are less
likely to know of and use the VA benefits that they have
earned. Do you support codifying the Solid Start Program to
ensure that the VA and Congress continue to support this
valuable program?
Secretary McDonough. We support your bill, yes.
Senator Hassan. Thank you.
And how does the VA use feedback that it gathers from the
Solid Start Program to better allocate resources and provide
newly separated veterans with timely health care.
Secretary McDonough. It gives us an opportunity to get a
relationship with those vets and obviously the feedback loop
for us is we identify where vets are and therefore where we
need additional resources to provide care.
And most importantly, it gives vets a better understanding
of what is available to them.
Senator Hassan. Well, I thank you for your support of the
bill and look forward to working with you on it.
Thank you again, Mr. Chairman.
Secretary McDonough. I think I missed the two most
important points in reaction to your first question.
One, if you are the best determiner of whether you are in
an urgent or an emergency situation is the veterans himself or
herself.
Senator Hassan. Yes.
Secretary McDonough. And so I urge any veteran or family
member who feels they are in an emergency situation to dial
988, press 1, and we will get them seen that day through the
Veteran Crisis Line. One.
Two, as I did in my opening comments, I commit to doing a
better job on reducing those wait times. I think we are making
progress but let nobody mistake me for saying that we are doing
enough. We will continue to do better on this.
Senator Hassan. I appreciate that and just a quick comment.
Every veteran I talk to in New Hampshire, this is their number
one concern for themselves and/or for their peers. I look
forward to continuing to work with you on it.
Thank you.
Secretary McDonough. Great, thank you.
Chairman Tester. Senator Moran for his opening statement,
and then we will go to Senator Tuberville.
OPENING STATEMENT OF SENATOR MORAN
Senator Moran. Chairman, thank you.
I was trying to cast the second vote to make this more
convenient for you, but I failed. The first vote is still
ongoing.
Mr. Secretary, I am sorry I missed what you had to say.
I thank the Chairman for this hearing today and I thank the
witnesses for being with us. This is a topic I care a lot
about, as are the topics of almost all of our hearings. But we
have been fully engaged in the Mission Act and the timing of
this determination is important to me because I think it is
important to veterans.
The Veterans Health Administration role is to make certain
that service-disabled veterans receive world-class health care
in a timely fashion. In most cases, that care is going to be
delivered, is delivered by the Department of Veterans Affairs
in VA facilities, by VA health care providers.
The Mission Act allows enrolled veterans the choice to
receive care from community network providers when (1) they are
or their doctors think it is in their best interest; (2) the VA
does not provide the service or does not provide it in
insufficient quality; or (3) when a veteran would have to wait
a long time or travel too far to receive care at a VA facility.
World-class health care, whether it is in the VA facility
or from a community network provider means nothing if a veteran
cannot have access to timely care. Measuring that access and
the number of days it takes to get a veteran into that care is
essential for the VHA to meet its mission, for veterans to know
when they qualify for health care outside the VA, and
ultimately is the way that our country meets its obligations to
veterans.
How the VA measures the number of days it takes is an
important component to meeting our obligations and it must be
done in a transparent way that takes each step into account,
from the veteran calling their provider to the scheduler
entering the appointment, to the veteran showing up at the VA
facility to actually receive the care.
The VA's decision to change how it reports average wait
times by using a different start date than the one used for
measuring wait times for community care eligibility is
concerning and leads to confusion and was not the intent of the
Mission Act. It is also a way for the VA to mislead on the
average wait time it takes for a veteran to see a doctor. This
is unacceptable.
My view is that a wait time begins when a veteran requests
care from the VA, not at any later point. I anticipate hearing
from our witnesses today on how the VA is measuring these wait
times. Perhaps there is something the Secretary or others will
say to dissuade me of my concerns, but it seems to me to be
very straightforward. Wait time is when you call and ask for an
appointment, you complain to the person on the phone saying
``these are my symptoms and I need to see a doctor.'' That is
when the time should begin. And I hope that turns out to be the
case.
Mr. Secretary, thank you for your presence today and I will
save my questions until others have had a chance to ask.
Chairman Tester. Senator Tuberville.
SENATOR TOMMY TUBERVILLE
Senator Tuberville. Thank you, Mr. Chairman. Thank you, Mr.
Secretary, for being here today and your hard work.
Those are great numbers, by the way, that you read off
earlier. That is encouraging. We have got a lot of people in my
State that need help but are getting help. So thank you for
that and I hope they continue.
As you know, many veterans suffer from sleep apnea due to
medical conditions they manage as a result of their service.
CPAP machines used to aid veterans' sleep apnea have been in
short supply since the pandemic--I think you know that--due to
chip shortage and a global recall on CPAPs.
I understand there are some devices that are available that
do not require a chip and could be available to veterans today.
We are having a huge problem in our State.
Would you consider it an ethical violation of the VA if the
VA provider was not provided the CPAP if they knew it was
available? And have you heard any problems with this?
Secretary McDonough. I have heard a lot of frustration,
especially with the recall and the complications that that is
creating for us. I have heard personally from a lot of vets and
then obviously I am getting updates on a regular basis on this.
So as to the question of an ethical concern, I am not sure
I understand the question precisely, but----
Senator Tuberville. Well, some of these do not need chips.
And we do have available devices that are available that are--
--
Secretary McDonough. Let me take and get that. I will be
happy to talk to your or your team afterwards and we will make
sure we dig into that. If there is a clinically proven
available option, then we will do it.
Senator Tuberville. Thank you, thank you.
On an unrelated topic of this hearing, I want to bring this
up. I want to take a minute to let you know I am strongly
opposed to the recent interim final rule that permits the VA to
provide abortion services in every State, even in those States
who have prohibited abortion.
For nearly two weeks now the VA has authorized medical
facilities to provide abortion services to enrolled veterans
and certain dependants. At this time, do you know, has a VA
medical facility performed an abortion since this has started
in the last two weeks? Do you know if there has been one?
Secretary McDonough. I am told that there has been one,
yes.
Senator Tuberville. The interim final rule is silent on
abortion restrictions after a certain point in pregnancy. Does
the VA have a plan on the abortion procedures up until the
birth of a child? How long do we go on this? What is the rules
and limitations that you know of?
Secretary McDonough. Thanks for the question, very much.
This is obviously an issue that we came to based on one
very simple principle which is the health and safety of our
veteran patients, of our pregnant veteran patients. We have
created an exception to the exclusion of providing either
abortion counseling or abortion services in four cases: rape,
incest, the life of the veteran, or the health of the veteran.
Those, it is spelled out in the interim final rule, how we
will come to those conclusions. As it relates to the health of
the mother, of the veteran, that will be determined in
consultation with the veteran's health care provider.
Senator Tuberville. How many are you considering, with all
of your facts and figures, how many abortions do you think we
will have in the first year? Is there any number that we came
up with?
Secretary McDonough. You know, I think the regular--as we
prepared the regulation, I think we had to make some estimates
for what that would result in terms of budget. I do not have
that at my fingertips.
My own view, we provide health care to 300,000 women
veterans of child-bearing age. My hope is that no one would
ever have to face the health or life-threatening, let alone
rape or incest, results to have this service. But because of
the importance of ensuring the health and safety of those
veteran patients, we have determined that we needed to do this.
Senator Tuberville. Do we have the proper equipment, that
you know of, in all facilities to perform abortions?
Secretary McDonough. We are going through those training
steps now and making sure that--obviously, these are all things
that we could not due prior to the interim final rule because
it was prohibited. So we are going through those steps now.
Senator Tuberville. Thank you, Mr. Secretary. Thank you,
Mr. Chairman.
Secretary McDonough. Thank you, Coach.
Senator Moran [presiding]. Senator Hirono, I am told that
Senator Brown was here first but you have a scheduling conflict
and the Chairman told me to recognize you and Senator Brown has
been reasonably polite.
Senator Brown. Reasonably.
SENATOR MAZIE HIRONO
Senator Hirono. Thank you very much, Senator Brown, and
thank you, Mr. Chairman.
I would like to follow up on the issue of your interim
final rule. The Supreme Court's decision in overturning Roe has
created fear and chaos throughout the country, including for
the 300,000 or so female veterans you just mentioned of child-
bearing age. Many of them live in States where abortion is no
longer available.
So the VA's decision to provide abortion services in the
instances of rape, incest, and the life or health of the mother
will save lives. There is absolutely no question that this
interim rule will save lives.
This is something that I called on the VA to do, to come up
with this interim rule.
So the Alabama Attorney General has already said that he
will prosecute any provider, anybody who provides these
services. And I would expect other Republican attorneys general
in the States where abortion is not provided to follow suit.
Mr. Secretary, what legal protections do Federal employees
of VA have under the interim final rule?
Secretary McDonough. Thank you for the question, Senator. I
just reiterate the principle that led us to take this step is
veteran patient safety. We take that very, very seriously.
Every health decision we make flows from that principle.
As it relates to your specific question, VA requested and
has received now, just in the last couple of hours, an opinion
from the Justice Department's Office of Legal Counsel
concluding that VA's interim final rule on access to
reproductive health services is a lawful exercise of VA's
authority.
The OLC opinion further concludes that States may not
impose criminal or civil liability on VA employees, including
doctors, nurses, administrative staff who provide or facilitate
abortions or related services in a manner authorized by Federal
law, including the IFR.
As that opinion, I am told, explains the Supremacy Clause
of the U.S. Constitution bars State officials from penalizing
VA employees from performing their Federal functions whether
through criminal prosecution, license revocation proceedings,
or civil litigation.
So I think this OLC opinion makes very clear the
protections that are afforded VA providers.
Senator Hirono. That is good to hear because there is no
question, as I mentioned, that the Supreme Court's decision has
created a lot of fear among doctors, and the professionals--
doctors, nurses, and others--as to what kind of reproductive
services they can provide. And it is really important that as
far as the VA is concerned, in terms of their legal posture,
that they are able to provide these kinds of services without
being dragged into court by State attorneys general.
Thank you very much for your--I really appreciate the VA,
in the context of this environment of chaos and fear as a
result of the Roe decision, that you have stepped forward to
provide these services for the hundreds of thousands of
veterans who are of child-bearing age.
I also appreciate your comments about the Department's
plans to focus on challenges veterans are facing in different
parts of the country, including Hawaii. Hawaii's unique
geography creates significant challenges for veterans when it
comes to accessing care through both the VA and in the
community, especially given Hawaii's current shortage of health
care workers.
So veterans living in a more rural community, neighbor
island veterans, not those living on Oahu, still sometimes have
to wait months to get treated in the community on the island in
which they live when traveling to a VA facility on Oahu, for
example, could significant reduce their wait times.
If a veteran referred to community care can be treated much
sooner at a VA facility, does the Department provide
reimbursement for travel to get such treatment?
Secretary McDonough. We do have beneficiary travel. This is
an issue of particular importance, I know, to you in your
State, to Senator Moran in his, Senator Tester in his, Senator
Rounds in his, given those big geographic expanses. The rules
on that are governed by established practice and, in some
cases, statute.
But yes, we do provide reimbursement for travel. Not in
every case, but in many cases.
Senator Hirono. So are these individual case-by-case
determinations? Because I would think that if there is an
emergency then it is more likely that you would pay for such
travel. But if it is not an emergency but let us say it is to
alleviate pain, would that be considered reimbursable travel?
Secretary McDonough. I think what would be useful, and I
know Senator Sullivan in particular on this question of
emergent transportation reimbursement is also obviously--given
the situation similar to yours geographically.
We have certain authorities now, emergency authorities,
that allow us to cover certain emergency proceedings and
procedures related to the fact of the pandemic. When those
emergency authorities go away, we will have to look at those
and establish that.
But as it relates--rather than me trying to go through the
individual aegis here, I know we will be spending some time
together and we will figure out----
Senator Hirono. I appreciate that very much.
Secretary McDonough. We will be happy to dig into those
questions with you.
Senator Hirono. By the way, Mr. Chairman, I am really glad
that--thank you for agreeing to let the Secretary come to
Hawaii, but it is not just because we have a lovely State,
because when the Secretary comes he will be working every
moment. He will not be lying around in the sun, right?
Secretary McDonough. I arrive in the morning and I leave in
the afternoon, I am told.
Senator Moran. I am only curious at what season the
Secretary is visiting.
Senator Hirono. Well, he is coming. We are glad.
Thank you.
Senator Moran. Senator Rounds.
SENATOR MIKE ROUNDS
Senator Rounds. Thank you, Mr. Chairman.
Secretary McDonough, first of all, let me begin by saying
thank you for the amount of time that you have taken to work on
the challenges we found at the Sioux Falls VA facility. I can
tell you that there have been improvements there, but your
interest in helping the veterans there was greatly appreciated
and noticed. And my team there has made it very clear that they
appreciated the opportunity to participate with you in those
meetings.
I hope you found it interesting and perhaps----
Secretary McDonough. Very much so. Very much so.
Senator Rounds. The challenges that are there, you helped
to alleviate some of them.
I would like to share with you, and as you know, I have had
real concerns about the implementation of care in the
community, in part because I really do not believe that the VA,
by itself, has the resources to take care of all of the needs
of all of our veterans, and in some cases the needs of the
veterans would be better served closer to home, using the
physician of their choice, or in some cases simply because the
VA does not have all the resources necessary on a timely basis
to meet that.
What I would like to share with you, with regard to care in
the community, from one of my team members who has been working
with veterans since you were there, this is his message, and I
think it is self-explanatory, but then we can kind of discuss
where we go from here.
``In the past six months, care in the community at the
Sioux Falls VA has hired approximately seven additional
employees to assist in the call center. This solved the problem
of call wait times and call drops. Now veterans wait only
minutes or seconds to have their calls answered, a huge
improvement over the one-hour-plus wait times many had been
experiencing.
``But this seems to be where the process comes to another
halt. The call center verifies the veteran's demographics and
notes the veteran's preference for care providers. After this
has been accomplished, the veteran will be transferred to a
scheduler in order to schedule that appointment with an in-
network provider of their choice.
``In many cases, if not the majority of cases, there is not
a scheduler available to take that next step to schedule the
appointment. When that happens, the veteran is told that his or
her preference for care is listed and that he or she will be
contacted by a scheduler when they are available. Currently it
can take up to two months for the veteran to receive a callback
to schedule that appointment, unless it is an urgent or STAT
situation.
``The issue of timely and appropriate care has not been
resolved, and the actual scheduling wait times have not
improved and are simply not acceptable. The veteran is not
receiving the same standard of care as civilians in the
community.''
And based upon that message, I guess what I am asking is, I
recognize that you are trying to work through the issues within
the VA to get a clear and concise measurement, but the bottom
line is care in the community should be available, and right
now it appears there is still a huge amount of pressure within
the VA itself to keep as many veterans as possible within the
VA system, and that even if their preference is to go to the
care in the community program they are really being restricted.
And I am just curious, are you finding that still to be the
case within the VA?
Secretary McDonough. Yes. Senator, thanks very much, and I
was thrilled to be in Sioux Falls. I really appreciated the
time there. Your team was great, and I am glad to hear there is
some progress.
What I hear when I listen to what you are reading there is
I hear, one, the waiting two months to get a call back from a
scheduler is unacceptable, one. Two is we submitted in a report
last Friday, I said in my opening comments, that these periods
during which we spend as much time talking to ourselves about
scheduling a veteran in the community as it actually ends up
taking to schedule the appointment in the community is not
acceptable. And so we are working through what we call our work
flows on that, and we will get those right.
Third, what I also hear in there is--well, I could be
wrong. Your team knows it better than anything--but there is
still a shortage of people, the MSAs, we call them, the
schedulers. This is one of the hardest jobs to fill right now
in the system. It has to do with wage grade and a lot of other
things. But that is part of the issue, which brings me to the
fourth thing to respond to your question.
I do not think anybody--look, the good news is that the IG
is looking at this too. You and I have had a back-and-forth on
the Referral Coordination Initiative. They are looking at that,
and we will see what they come back with, and I am eager to
find out what they come back with.
Are there individuals who are refusing to move people into
the community? Maybe. That is not what I experience. But let me
just say this, because the evidence I have on this, I was with
Rob McDivitt last week in Des Moines. He told me fiscal year
2018 he spent, in VISN 23, we spent, on you all's behalf, $700
million in care in the community. This year, fiscal year 2022,
which ends in two weeks, VISN 22 will spend $1.3 billion.
Senator Rounds. Mr. Secretary, I think that points out the
veterans really do want to use care in the community, and I
think your message, in your opening statement, your written
statement, that the use of VA direct care is growing, but use
of community care is growing faster. Third, the growing use of
VA care is not uniform across the country. It is clear. I think
in rural areas, where it is closer to home, you may very well
find out that the care in the community is perhaps growing
faster. I just simply want to point out, long term----
Secretary McDonough. I think that is fair, and I think that
is probably a good thing.
Senator Rounds [continuing]. We should focus on what the
veteran wants, and if I could--and I am over time--if there is
any possibility that once a veteran has been cleared rather
than having the VA schedule it, why not give them an
authorization, tell them who the providers are that are
accepted, and allow that veteran to access their provider
directly, and save that whole 30 to 60 additional days?
Secretary McDonough. So we have a couple of pilots where we
are testing different scheduling options, and we will be happy
to brief you on those.
Senator Rounds. Thank you. Thank you very much, and thank
you, Mr. Chairman.
Senator Moran. Senator Brown.
SENATOR SHERROD BROWN
Senator Brown. Thank you, Senator Moran. I echo Chair
Tester's opening statements about your accessibility and your
reasonableness and your responsiveness, and thank you both for
what you have done for all of us and what you have done for
veterans in Ohio.
Before I turn to the hearing topic I want to reiterate my
concerns. We have talked about it before and I want to do it
publicly, about the Oracle-Cerner electronic health record.
Your team in Columbus is doing amazing work. I have been there.
I have talked to them.
Yet the concerns keep mounting and employees are stretched
thin. You know all that. We need to find answers to the
pharmacy and scheduling concerns in the system. Latency issues
all could affect patient safety and veteran satisfaction. I
implore you and Deputy Remy and the whole team to stop the
rollout until all the concerns are addressed.
Secretary McDonough. I know you and Dr. Elnahal had a good
conversation after he was in Columbus. I think he was shocked
to find the challenges there to be even starker than he had
feared, notwithstanding the conversations that we have had with
you and others on the ground.
Deputy Secretary Remy said again this morning, in the
Appropriations Committee, that we are committed to not moving
forward until we have clarity on the deployment checklist and
confidence that this is not going to negatively impact veteran
safety. And so we will stay on top of that. But the frustration
I hear from you, that we Shereef heard directly from the
providers when he was in Columbus two Fridays ago, we are very
worried.
Senator Brown. We will continue this.
In the congressionally mandated report released on Friday,
VA said if the balance of care provided in the community
continues on its current upward trajectory we anticipate that
certain VA medical facilities, particularly those in rural
areas, including one you visited in Ohio, may not be able to
sustain sufficient workload to operate at the current capacity.
Obviously, that includes the PACT Act.
Joy Ilem highlighted that concern in her testimony, and I
appreciate that, and I have done a number, as many on this
Committee have, I have personally a number of roundtables with
veterans in all parts of the State, and so has Anna, Andrew,
and my staff. We must focus on strengthening VA and attracting
medical and administrative personnel especially to rural parts,
to care for our veterans. Section 901 of the PACT Act requires
a national rural recruitment and hiring plan.
I urge you to consult with local VSOs and community
stakeholders and union representatives, local veterans, and
those who support them, who provide valuable insight into how
to best address that. Will you ensure--just a simple yes, I
think, will be fine--will you ensure that rural voices are
heard during this process and commit to regular updating us?
Secretary McDonough. Simply yes.
Senator Brown. Thank you. Increasing staff in rural areas
will help bring down wait times within VA. We know that.
My last question, Mr. Chair, a consistent refrain at
veterans roundtables we hear about is VA doctors. Veterans will
often say--and you know this, and I want particularly people on
the other side of the aisle to hear this--``VA doctors
understand me in a way that community doctors do not.'' ``VA
doctors understand me,'' veterans tell me all the time, ``in
ways that community doctors do not. They know what I am going
through. They know how to provide me with the care I need.''
That is what I hear. I think that is what you hear.
Veterans rely on VA for consistent care by well-trained
professionals. Many of the providers are veterans themselves.
Getting that care in the community is much less likely. And
this is especially true with respect to mental health. I think
we are going to hear that more and more as patients come in
through the PACT Act.
When this Committee drafted the MISSION Act, Senator
Blumenthal and I worked with the veterans community,
specifically DAV, to draft Section 133. It stipulates that VA
establish competency standards for community care clinicians
treating PTSD, MST, and TBI. I want to again emphasize how
important that is, as there are people on this Committee that
want to privatize far too many VA services. Senator Sanders,
when he was chair, fought back against that, as Senator Tester
has. A lot of us have.
My question about this is what steps are you taking to
ensure community care providers meet the same rigorous training
that VA clinicians receive?
Secretary McDonough. Yes, well thank you very much. We
obviously have the quality standards that we also have to meet.
We reported on those earlier this summer. So we have not only
the access standards but the quality standards, and we take
those very seriously and we report to you on those. That is one
step we take.
Second is you have given us additional authorities and
training requirements to make sure that we are training the
network providers, to ensure that they have best available data
and best available practice as it relates to interacting with
vets, that they are providing culturally competent care.
And third is, this is not anecdotal, right. I mean, we have
had study after study, I referenced several in my opening
statement, that show vets in our care do better in terms of
outcomes, and that is a real driving force for us. There are
times when we do not have the care, when it takes too long,
that we obviously facilitate that care in the community.
The thing we really need from our community providers is
their help, as the CBO reported last October, their help in
making this care much more integrated, by getting those records
back to us, by working with us in a more coordinated fashion so
that our providers, who do know vets best, can help integrate
that care.
Chairman Tester [presiding]. Senator Boozman, I want to
thank Senator Boozman for the great hearing this morning on
electronic health records.
SENATOR JOHN BOOZMAN
Senator Boozman. We did have a really good hearing this
morning. Thank you for participating and being such a big part
of it. Your team did a great job, Mr. Secretary. I get my
dates--we are so busy running around here that I thought the
hearing was--I had forgotten that the hearing was today. I told
them that if you got hurt in the ballgame tonight it was not an
excuse for you not showing up tomorrow, but here you are this
afternoon. Good luck. When I see the Capitol Police I tell them
to be nice to you and not to hurt you too bad.
Secretary McDonough. I appreciate that very much.
Senator Boozman. That is good.
I want to talk to you about, you know, scheduling, because
it really is a real consideration. As you know, we had an
incident in Fayetteville, and that was really more of a
leadership problem than a scheduling problem, but it was a
scheduling problem too. We had a veteran that developed cancer,
recommended to have surgery. That was in March. There were two
or three referrals back and forth. Again, it was just a total
mess and did not wind up getting the surgery until September
29th, which was not good, okay, and everybody agrees it was not
good and just a complete failure.
But the problem is we have not had a head of the hospital
for 18 months, and it really does make a difference. The staff
in Fayetteville does a very, very good job. They are very
talented. As I talk to veterans they are very pleased with
everything that goes on. This, to me, it is a leadership
problem. So what I need is for you to work hard to get us
somebody on board, somebody good.
The other part of that is I know that these are big jobs,
and when you compare the job there compared to what they do in
the private sector there is no comparison pay. I mean, they do
it because they are called to do this, and we have got to deal
with that. But regardless, I would like for you to commit to
helping us out there.
And the other thing, too, is to put in place, to make sure
that this same thing does not happen someplace else with this
system, within the safeguard that if somebody is not getting
scheduled. It is one thing to not be scheduled for an elective
procedure or something like that, but something like this, that
truly is a life-and-death situation, we have got to have the
safeguards in place where it just simply cannot happen.
Secretary McDonough. Senator, I agree 100 percent, one.
Two, my heart breaks for that veteran's family and for his
loved ones.
I talked, just this afternoon, and talked to her last night
and talked to her again this afternoon, with Skye McDougall,
who is our network director. I know she is in touch with your
team on a regular basis. She also briefed all the legislative
staff in and around the Fayetteville region last week about two
changes we have made. One is daily administrative review of
cases, weekly clinical review of these cases, and then--three
changes--regular discussions with those veterans who are
awaiting those procedures. This, I think, is going to end up
being a best practice, so we will keep working that across the
system.
But you are also right that it is a leadership challenge.
Skye McDougall briefed your team last week that she had
narrowed the director job down to two people. She told me a
couple of hours ago that she has made a selection for who that
person will be, the permanent director of Fayetteville. We now
have to run through some traps in OPM and otherwise, but I will
stay on top of that and make sure that gets done.
Senator Boozman. Very good. We appreciate that very much.
One thing, in order to solve a problem you really have to
understand it, and I know that there has been some problems
with calculating wait time calculations. The IG was critical of
how we were doing that. I would like for you to comment on
that. But again, that is so important, not to be critical but
if we do not know exactly what the wait times are, you know,
how do you deal with it?
The other thing, and I know it is a problem because I am
out and about as much as anybody, as are the rest of the
Committee here, but we hear that from so many people. One of
the problems that we have got, and VA needs to help us with
this, is that the VA compensation is based on Medicare.
Medicare is scheduled to get a 4 percent cut this year. You
know, every year for the last few years we are dealing with
this, and as a result it is really difficult.
I have been in offices of friends where they are on the
phone. You know, these are very respected people in the
community. They are in the private sector and they need to find
somebody that will accept a new Medicare patient because they
are starting to limit there.
So it all goes together and it is something that we have
got to work on, as a whole. Can you comment on that real
quickly before the Chairman gavels me down?
Secretary McDonough. I know how tough he is.
Two things. One is I hear you on reimbursement rates, and I
will obviously take and work that. I do want to say that I am
proud of the fact that we have made great improvements over the
course of the last 18 months on timeliness of our payment. That
does not mean that there are not Arkansas doctors who----
Senator Boozman. I agree, and I am not really hearing that
like I used to.
Secretary McDonough. So we are working on timeliness. We
will work on rate of reimbursement. So I hear you on that.
On the time, this has been a burr in our collective saddle
since I got in this job. We updated the website, which average
time across the whole system, which we want to make more usable
for veterans so that it is more representative of their
experience. Individual determinations of eligibility are going
to continue to be made on a case-by-case basis. But we want to
get the most accurate, illustrative data available to veterans
through the website. We did that in consultation with the IG,
the GAO, with your staffs, with VSOs. It is not perfect but it
is getting better.
And I guess I would just say this, one proof point, which
is uniformly the numbers went up on the wait times. So again,
in response to an earlier question, if we are trying to stop
community care we are doing a bad job, and if we are trying to
hide wait times we are doing a bad job, because our updated
website just made them look longer, not shorter.
So I have no interest in hiding the facts from you. Most
importantly, I have no interest in hiding the facts from the
vets. We will continue to work with your teams on this. If
there is a better way to do this with the data, we are all
ears. It is a nettlesome problem. It is not impossible. But the
bottom line is let us also not mistake the averages on the
website for the individual referrals and the individual
eligibility determinations, which will continue to be made on a
case-by-case basis.
Senator Boozman. Thank you very much. Good luck tonight.
Secretary McDonough. Thank you.
Chairman Tester. Senator Sanders.
SENATOR BERNARD SANDERS
Senator Sanders. Thank you, Mr. Chairman, and my apologies,
Mr. Secretary, for missing your opening remarks. I will read
them. And thanks very much for coming to Vermont. I hope you
enjoyed your day there.
Throughout the pandemic VA has been offering more and more
telehealth appointments, and my understanding is that veterans
feel pretty good about that. However, these appointments do not
count toward VA access standards, which is what we are
discussing today. Clearly if a veteran is able to receive the
care they need via telehealth there is no reason that should
not count toward VA meeting those requirements. My
understanding, Mr. Secretary, is you have the authority to make
this change. Will you commit to implement this regulatory
change by the end of the year?
Secretary McDonough. I want to be careful on how I say this
because I am told by the lawyers that the verbs I use here are
really important. I intend to carefully consider and propose
such a change, and I will make sure that we work with everybody
on this Committee to make sure that they have an opportunity to
comment on it and that the public has an opportunity to comment
on it.
Senator Sanders. Do I hear you saying, though, you intend
to go forward to make this change?
Secretary McDonough. I intend to propose a change.
Senator Sanders. You intend to propose.
Secretary McDonough. Right.
Senator Sanders. All right. I am not a lawyer. I do not
know exactly what that means.
Secretary McDonough. As I said in my opening statement, we
are providing more and more care by telehealth. A lot of vets
like it. Some do not. We want to be able to update the access
standards in this way. We are going to do it consistent with
the law and consistent with getting good public input on it,
which, by the way is not--well, so, that is surely my
intention.
Senator Sanders. Okay. In a VA report on access to care
issued last Friday, VA stated, I quote, ``VA should allow both
telehealth and in-person care to satisfy the wait time standard
for VA access to care,'' end quote. It went on to say, quote,
``Only when VA cannot meet demand to include using telehealth
should it use community providers,'' end quote.
How are you prioritizing in-house care over private sector
care?
Secretary McDonough. Well, the bottom line, as I have said
now a couple of different times, is we believe, and studies
show, that vets in the direct care system do better. And so as
a general matter, you know, Senator Rounds said it earlier that
33 million have completed appointments in 2021, speaks to
veteran demand, partially. They also speak to provider vacancy.
They also speak to aging facilities. They also speak to, as you
and I have discussed, to stringent eligibility priority
groupings. They also speak to limited access in rural areas.
And so by using the authorities you have given us in the
PACT Act to hire and to keep professionals, by using the
authority you gave us to get these 31 new leases done, we are
continuing to make VA the most attractive option. But there are
going to be places where a veteran wants to choose otherwise,
and telehealth is a good example of that. If a vet says, ``You
know what? I prefer to wait an extra six weeks to get direct
care in the direct care system, in person, rather than get
telehealth,'' well, we are going to make that happen.
Senator Sanders. That makes sense.
All right. Let me ask you a question, and I do not know if
you have the information on this. You know, a lot of the
debate, there is a lot of agreement in this Committee, and
there is some disagreement. It is my view that the private
health care system in this country is the most expensive in the
entire world, that the outcomes are not necessarily all that
great compared to other countries.
Do you have numbers--and I know it is hard to come up with
this stuff, but everything being equal, the same procedure
being done within the VA as opposed to being done in the
private sector, which is more expensive? My assumption is the
private sector health care is more expensive. Is that correct
or not?
Secretary McDonough. We have a section in the
congressionally mandated report on this issue. I have had a
back-and-forth extended with Senator Moran on this question. I
think that when you take into account all of the requirements
that VA meets in terms of the provision of care, I think that
we are very, very competitive. But I will be more than happy to
give you----
Senator Sanders. But do we have anything more than just--
look, the United States----
Secretary McDonough. We do. We do, but I do not----
Senator Sanders [continuing]. The United States spends
twice as much as almost any other country on health care. One
would assume that if we do not have a UnitedHealth making, I
would assume, billions of dollars administering the program,
and all the other things that take place in the private sector,
VA would provide less expensive health care. But do we have
numbers on that, or is that just an assumption?
Secretary McDonough. I think it is an assumption, one, but
I also know that there are numbers on this, and I would be
happy to get you those. I just do not have them at my
fingertips.
Senator Sanders. Okay. When we talk about, you know,
sometimes people think, well, it takes me a while to get into
the VA but gee, I just get on the phone and I go into the
community health care and in five minutes I have an appointment
with a doctor. Clearly that is not the case. Do we have any
information as to how long it takes veterans to get an
appointment in the private sector?
Secretary McDonough. It is very difficult to get that
information because nobody else maintains information like
that. And so we have tried that. We have had this ongoing back-
and-forth with the Chairman, with the Ranking Member, on this
question, to try to get some apples-to-apples so that veterans
are best informed. But it is hard enough for us to do that with
the data in our own system. We have not yet figured out how to
do that in the private system.
Senator Sanders. All right. I believe that when we spend
health care dollars they should go to doctors and medicine and
the provision of health care, not to bureaucracy. As I
understand it, and correct me if I am wrong, UnitedHealth is
the major administrator in getting veterans to community health
care. Is that correct?
Secretary McDonough. We have two----
Senator Sanders. Two, right. Optum is the other one.
Secretary McDonough. Yes, Optum and TriWest. Optum is
related to UnitedHealthcare--third-party administrator.
Senator Sanders. How much do we spend----
Senator Sullivan. Are we going to have a debate on health
care or are we going to go to the other Senators?
Senator Sanders. Let me just finish up.
Senator Sullivan. We are going kind of long.
Senator Sanders. No, we are not. This is not any longer
than other people have gone.
Just a question. Do we know how much money we spend to
those two companies in administering health care?
Secretary McDonough. It is knowable. I do not have it with
me.
Senator Sanders. Could you get me that as well?
Secretary McDonough. Yes.
Senator Sanders. Okay. Thank you.
Chairman Tester. Senator Sullivan.
Senator Sullivan. Mr. Chairman, I am going to pass my time
right now to Senator Blackburn.
SENATOR MARSHA BLACKBURN
Senator Blackburn. Thank you, Mr. Chairman, and thank you
to Senator Sullivan for this, and thanks for coming back to us.
We appreciate.
Secretary McDonough. Thank you for having me.
Senator Blackburn. You know, one of the things that Senator
Tuberville and I have worked on is legislation we have
introduced with a three-year pilot program that would allow
veterans to go directly into facilities in their community and
really kind of take the referral process from VA out of this.
It is frustrating to people. There are so many frustrations
with how the VA is working and running the Community Care
Program.
And in June you indicated to us that the VA might propose
changes to the current access standards, because Community Care
was costing too much. And in your recent report, which was
late, about three months late----
Secretary McDonough. Yes, ma'am.
Senator Blackburn [continuing]. You stated that you would
not propose immediate changes to the current access standards.
So that is good, but however, what concerns me is that you go
on to state that you are planning to incorporate VA telehealth
into the access standard eligibility criteria. And the concern
is this might be a way that the VA would manipulate the numbers
and prevent veterans from seeking care outside the VA.
So if a veteran wants an in-person visit but the VA can
provide a telehealth visit within the wait time eligibility
category, will that veteran be allowed access to an in-person
visit in the community?
Secretary McDonough. Yes, thanks, Senator. I am not aware
of anybody who wants to manipulate the data or obfuscate
anything. When we make a proposal on the inclusion of
telehealth we will make sure that we do this with plenty of
time and transparency for public comment, obviously from you,
from veterans in Tennessee, from veterans across the country,
and we will obviously carefully consider those.
Senator Blackburn. Telehealth can be a wonderful tool, but
we do have veterans that prefer----
Secretary McDonough. Definitely.
Senator Blackburn [continuing]. An in-person.
Secretary McDonough. Definitely.
Senator Blackburn. So that is of concern.
Let us talk about the PACT Act because we are very
concerned about that. Now one of the questions that has come to
us is veterans have been receiving treatment from a provider in
community care, outside the VA. Will the VA force that veteran
to then come into the VA to receive care if they are covered in
that PACT Act addition, or are they going to allow them to stay
with the provider where they have established that
relationship?
Secretary McDonough. There is nothing in the PACT Act that
would force any changes in existing referrals and existing
relationships with doctors.
Senator Blackburn. Okay.
Secretary McDonough. I am not sure I understand the
question precisely, but----
Senator Blackburn. Well, we have got some veterans who have
chosen community care and they are there, but they are also
going to be given additional services because of the PACT Act.
And what they are wanting to do is stay with what they have.
Let me ask you something.
Secretary McDonough. Well, they would obviously continue to
work that out with their primary care provider and the VA, and
they would work that through their referral process and their
relationship with their doc.
Senator Blackburn. Let us talk about wait times because why
has the VA chosen not to calculate wait times based on the date
of request as required by the Veterans Community Care Program
regulation?
Secretary McDonough. We have not made that choice, so I am
not sure what you are referring to.
Senator Blackburn. Okay. Well, you all are----
Secretary McDonough. For new patient appointments with a
referral the average wait time is calculated starting when the
consult is entered by the provider to the date that the
appointment is completed.
Senator Blackburn. Okay. All right.
Secretary McDonough. For a new patient without a referral,
the average wait time starts with the earliest recorded date in
the process of receiving care.
Senator Blackburn. Okay.
Secretary McDonough. For established patients, the
calculation is made from the moment that that veteran, with his
provider, determine, hey, I would like to have you come back in
six months, or I would like to have you come back in three
months.
So that is the way we do it. I think you might be referring
to the way the calculations were made on the website, which I
have committed to the Senator from Kansas the first time I
appeared here, I would change, because that happened before I
got here.
So if that is what you are referring to, that has changed
as of July.
Senator Blackburn. As of July. Okay. Thank you, and I will
submit one to you for the record.
Secretary McDonough. Thank you very much.
Senator Blackburn. Thank you.
Chairman Tester. Thank you. Senator Blumenthal.
SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Thanks, Mr. Chairman. Thanks for having
the hearing, and thank you for being here, Mr. Secretary, and
your impressive work on all of these issues----
Secretary McDonough. Thanks.
Senator Blumenthal [continuing]. At the VA. I would just
like to join your comments at the outset of your testimony on
the performance of the VA staff, employees, docs, nurses. As
you said, they have deferred time off as well as retirement,
out of their sense of dedication. This has been an
extraordinarily demanding time as I have seen in Connecticut,
but it has also brought forth the very best in the VA health
care system. They have performed with tremendous courage and
skill and strength, so thank you.
In that connection, is the VA continuing to provide
vaccinations and boosters to veterans who want them----
Secretary McDonough. Yep.
Senator Blumenthal [continuing]. And I hope encouraging
them to seek them.
Secretary McDonough. Yes, and encouraging vets, so when
they come in to get both the bivalent, the new, updated
vaccine, along with flu, while we are very worried about flu
this season. So yes, we are doing that.
Senator Blumenthal. And the VA folks themselves, are they
getting boosters?
Secretary McDonough. Yes. Yes. So same thing, that we
continue to offer boosters, including the new bivalent, updated
booster to the workforce.
Senator Blumenthal. On the PACT Act, thank you to you for
your support for it. Obviously, the champions, Senator Tester,
deserves a ton of credit, along with Senator Moran, and I have
been proud to help in that effort.
I am concerned about getting the word out, telling veterans
about the availability of this care, the changes in policy. As
much as we like to think that the world is riveted on what we
do in this building, there are a lot of folks who, frankly, do
not know about it. And I am concerned that they may not be
availing themselves of the care that they could get.
So I have been doing the best I can to hold meetings and
forums around the State of Connecticut, but obviously that is a
limited effort. I wonder if the VA has planned outreach in that
regard.
Secretary McDonough. We do. Importantly, I think you all,
in the PACT Act, gave us additional authority and additional
funding to increase communications around the PACT Act.
I agree with you, by the way. I think applications or
claims filed are up about 20 percent since the President signed
the bill into law.
Senator Blumenthal. That is great news.
Secretary McDonough. That is good news, but I had kind of
hoped it might even be higher. So we are trying to ascertain
whether there is any confusion about the PACT Act and the
claims process. We are constantly looking at that.
We are also working right now with the appropriators to get
clearance on the $500 million toxic exposure fund to allow us
to begin the effort on implementing this act. That is a fund
expressly for toxic exposure and not for anything else. So we
are working to make sure that the appropriators understand our
plan on that. That will then unlock the comm's effort.
Importantly, I hope our veterans understand that the
effective date of August 10, 2022, which is the date the
President signed the bill into law, that is the effective date
for all 23 conditions in the bill, but vets have to file within
the first year to make that effective date available to them.
So we are really urging them to file so that they get that
August 10, 2022, effective date, meaning that benefits paid out
will be paid out starting that date.
Senator Blumenthal. That is very important, very important.
And likewise, on Agent Orange, the coverage of hypertension----
Secretary McDonough. Correct.
Senator Blumenthal [continuing]. That is the effective date
as well.
Secretary McDonough. Exactly. So Agent Orange does not wait
until fiscal year 2027, which was an option under the law. The
President urged us to move that up to August 10, 2022, which we
have now done. So the Agent Orange-exposed Vietnam vets now
suffering from hypertension should also make their claims
filed.
Senator Blumenthal. I am just about out of time, you will
be happy to know, because my next questions were going to be
about the New Haven hospital. But I will follow up, if it is
okay with you.
Secretary McDonough. I know we are going to spend time
there together here in the next couple months, so I am looking
forward to that.
Senator Blumenthal. Great. Thank you very much, Mr.
Secretary.
Chairman Tester. Senator Moran has not asked his questions
yet, and since he has got a commitment here we are going to go
to Senator Moran.
Secretary McDonough. Is that commitment still that there
will be easy questions?
Senator Moran. You handle them all so adeptly, Secretary.
I walked in from voting as you were concluding your answers
to Senator Blackburn, and I wanted to follow up a bit because
it is the second topic at least that you were talking about
then that I am interested in.
The website has said this. ``Measuring wait times from the
date the appointment was requested until the date the
appointment is completed is the most accurate measure for
veterans because it is the actual average number of days
veterans have waited for an appointment,'' end quote.
The answer that I heard is we have changed our words on our
website to reflect what we now do, which makes sense. You would
want to say what you do. But I do not understand the
justification for not using what I have to think is the common
meaning of ``wait time.''
If I call the doctor and I want an appointment, my wait
time starts from the moment I ask the receptionist to schedule
me an appointment, not the moment that the decision is made,
well, we will schedule Jerry for August 31st.
Secretary McDonough. Yes.
Senator Moran. And this is a bit in response to Senator
Rounds' questions. A reason that I worry about this is for the
same reason he suggested he is worried. I worry that there is a
bias. I lived with this with Choice, which there is a bias
against Community Care. And so every time you do something, the
VA does something, it sends me another message that I am
worried. We were so intentful in the MISSION language to try to
overcome the capabilities of the Department of Veterans Affairs
to undo Community Care. And so you get me on these questions
because I see them as an effort to undermine the plan.
Secretary McDonough. And look, that comes through, and it
has come through in every one of our interactions in this room
and every one of our interactions on the phone and every one of
our interactions in person, and I get that. And I will keep
arguing that nobody is trying to limit a veteran's access to
best available care.
I will tell you, my view is I want all the vets we can keep
in the system to stay in the system, but that is not my call.
But let me just say the following. Let me just give you one
data point, which was in my opening statement. In 2021, 33
million completed appointments in the Community Care system.
That is a big number. Now, you are automatically thinking of,
yes, well, relative to what, and all that stuff, and I get
that. But this is a function of a lot of things, not just
veteran preference, although veteran preference is one of them.
We do not have enough nurses and docs. We have talked about
this in both of your States. We have pent-up demand for care,
so we cannot schedule appointments because we still have a lot
of care that is getting worked. We do not have enough MSAs,
which is exactly what Senator Rounds talked about.
So let me just give you three examples of how we calculate
wait times and make sure that we are talking about the same
thing, at least.
New patient appointments with a referral, the average wait
time is calculated starting when the consult is entered by the
provider to the date that the appointment is completed. This
calculation is new on the website, and the starting point now
includes a date that is earlier than previously measured. Okay?
The date that the provider puts the referral into the system to
the date that the care is provided.
For new patient appointments without a referral, that
average wait time starts with the earliest recorded date in the
process of receiving care, usually the date that the scheduler
talks to the veteran.
Senator Moran. The scheduler is not the first point of
contact with the veteran. Is that true?
Secretary McDonough. No, because we do not have a referral,
right?
Senator Moran. Right.
Secretary McDonough. So that is the second calculation.
This did not change between the old system developed by the
team before I got there and our new system, because it is
really hard for us to figure out when else to press start on
the gun.
Senator Moran. And is there no ability, Mr. Secretary, to
press start on the gun when the veteran asks for an
appointment, walks in the door----
Secretary McDonough. I asked the same question----
Senator Moran [continuing]. Sends an email.
Secretary McDonough [continuing]. Yes, I asked the same
question today and I have asked the same question each time
after I talk to you, and we are looking for that, and where we
can establish that we use it. But oftentimes the clearest
indication of the start, without a referral, is that moment.
Senator Moran. Let me see if I can summarize. You will be
pleased to know that I have to leave here before I get a chance
to continue this conversation. But let me sum up what I think
you are telling me is, in your view, there is no or little bias
against Community Care. We are not trying to game the system by
the point in which we determine ``wait times.'' It is only that
we do not have the data. We do not have the information when
someone calls, walks in the door, or sends an email saying, ``I
need help from the VA.'' Is that a summary of what you are
telling me?
Secretary McDonough. That is a summary of what I am telling
you. I would add to the summary the following. We are also
constantly looking at how we measure this. You know, we spent
18 months to get this update in July. We will keep updating it.
We update it with new data every day, and we will keep doing
that.
But I also want to not mistake the average wait time on the
website, which is meant to explain to the veteran, here is what
you should expect, generally speaking. Let us not mistake that
from the individual determination as to whether that veteran
qualifies for the referral. He works that out with his
provider.
And so the third thing I would say is the IG is looking at
this, which I am really glad about. I want everybody to look at
this because I am not like the world's most effective manager,
but if I am trying to stop guys from going into the community
and we have set a new record the last two years for completed
appointments in the community, then I am really a bad manager.
Senator Moran. I will conclude. I just would highlight I do
not want there to be false information provided to Congress to
the veteran----
Secretary McDonough. You and me both.
Senator Moran [continuing]. For either the setting in
Community Care or the wait times for an appointment or a
procedure at the VA. They are the same to me.
Secretary McDonough. Yes.
Senator Moran. And I just want to be able to compare those
wait times, and I certainly do not want the wait time to be
shortened as a method by which it reduces the availability of
the usage of Community Care. I want there to be a fair
understanding of the facts, and the shot being not based upon--
this just seems so out of character. A beginning point time is
when I ask for an appointment, and we cannot get there, and it
must be the VA does not have the--at least that is what you are
telling me is the VA does not have the capability to do what I
think is just the straightforward way of answering this
question.
Secretary McDonough. I wish I had a better answer for you
than that, but that is the answer. And if somebody has a better
way for us to do that then I am all ears.
Senator Moran. We will be calling the Inspector General.
Chairman Tester. Senator Sullivan.
SENATOR DAN SULLIVAN
Senator Sullivan. Thank you, Mr. Chairman, and I know
Senator Moran has to leave, but maybe a quick follow-up. I do
not want to see bias in Community Care either. Congress passed
the MISSION Act to increase access to community care where wait
times were too long.
There was a recent article. I would like you to comment.
Maybe Senator Moran wants to hear this too, that the VA
recently removed the MISSION Act website and is redirecting
veterans toward a page called ``Choose VA.''
Mr. Chairman, I would like to submit this for the record.
Chairman Tester. Without objection.
[The article submitted by Senator Sullivan appears on page
89 of the Appendix.]
Senator Sullivan. ``Biden's VA undermining the law that
gives veterans access to private health.'' So is that true, and
then why did you do it, if it is true? And we are doing wait
times and everything--that seems like blatant bias if you did
that. So is that true, and why did you do it?
Secretary McDonough. We have an Office of Integrated
Veteran Care now, so veterans----
Senator Sullivan. But you removed MISSION Act, which talks
about Community Care, completely off your website, and now it
just says ``Choose VA.'' That is the replacement? What is that?
Maybe it is not true. Maybe the Fox News----
Secretary McDonough. Should I answer the question or not?
Senator Sullivan. Yes, try to answer it.
Secretary McDonough. We have an Office of Integrated
Veteran Care. It used to be we had an Office of Community Care
and an Office of Access to Care, where we would force veterans
to decide which one they should choose. You know what I want
them to have? Access to care, timely access to world-class
care, so they should go to one office. And it used to be that
people on your side of the aisle----
Senator Sullivan. No, no. Do not do ``your side of the
aisle.'' I am getting ready to ask you some questions on your
side of the aisle. You know, look, I used to be a big fan of
yours. The way you worked the PACT Act stuff, you are starting
to become partisan, and this agency should not be partisan.
Secretary McDonough. We just----
Senator Sullivan. And I have been on this Committee way
longer than you have. I have been focused on veterans' issues
way longer than you have, and I do not want ``your side of the
aisle'' stuff. That is not the way this Committee works. You
started doing that during the PACT Act, your CNN appearance,
your misinformation about the Toomey Amendment. You need to
tone it down, Mr. Secretary. That is not going to help
veterans.
So take the ``your side of the aisle'' back. We all want
care for our veterans.
Secretary McDonough. I take it back.
Senator Sullivan. And I have enjoyed working with you, but
you are the one who is starting to get partisan, and I am not
appreciating it.
Secretary McDonough. I take it back. We are trying to
reduce the overhead of having two offices that provide the same
service, which is access to care. So rather than make vets have
to choose which of those offices they go to, we have been
working for the last 18 months on a plan that was put in place
by the clinicians before I arrived at VA to have one place that
those decisions are made.
And we have been talking to you guys about this since I
arrived on the job, and we will continue to talk to you about
it.
Senator Sullivan. Well, if there is oversight on this
Committee, which you are seeing it--we all care about our
veterans. My State has got more veterans per capita than any
State in the country, and if certain members are starting to
think that there is a bias with regard to Community Care, which
was a bipartisan bill on the MISSION Act, I think you need to
listen to it.
Secretary McDonough. I am listening to you and that is why
I am coming to your State. That is why I am spending time on
this question. That is why I am here today. That is why I will
continue to listen to you.
Senator Sullivan. Okay. Let me turn to--I was going to go
into all the details of the PACT Act, the Toomey Amendment, but
I just think your statement on CNN after you and I talked over
the weekend, I tried to connect you with Senator Toomey so we
could have a good, bipartisan understanding, and the fact that
you went on national TV and said this is an artificial cap on
spending, on veterans, it is risk rationing care.
Look, I can submit a million things for the record. That
just was not accurate, and I do not think it was helpful. It
was more partisan talking points from the White House. I think
you are better than that. I have appreciated working with you
on that. So just take that as a point. At least one Senator
that was not impressed, and to be honest, was disappointed.
Let me turn to one final issue. I just met with a recent
group of Alaska Natives. They mentioned that the Native
American Direct Loan Program, which is about Native veteran
housing, there has been no Alaska Native who has qualified for
a loan since the program started in 1992.
Now, this relates to the issues of trust land, but the
point of the program is to get Native American veterans help on
housing through the VA, and my constituents, for almost 40
years, having gotten one loan. They are some of the most
patriotic Americans. The GAO came out, as you probably know,
with a report saying, hey, this is wrong. You cannot exclude
Alaska Natives from a really important program.
So can I get your commitment to work with me, like the GAO
said, to fix this? There is nobody on this Committee that wants
to discriminate against an entire set of Native Americans who,
by the way, Alaska Natives and Lower 48 Indians serve at higher
rates in the military than any other ethnic group in the
country. This might be an oversight, but we need to fix this.
My Alaska Native veterans do not need to be treated like this.
Can I get your commitment on that, Mr. Secretary?
Secretary McDonough. You have my commitment on this. I have
worked closely with Senator Rounds on this.
Senator Sullivan. No, I am aware of what you are working
on.
Secretary McDonough. Yes. I am frustrated to hear that. He
has had the same experience, and obviously South Dakota has a
major Native population. You know, it is in the ones, the
numbers of mortgages that we have gotten done through this
program. So yes, it is something that we can do much, much
better.
Senator Sullivan. Thank you. Thank you, Mr. Chairman.
Chairman Tester. Senator Cassidy.
SENATOR BILL CASSIDY
Senator Cassidy. Hello, Mr. Secretary.
Secretary McDonough. Senator.
Senator Cassidy. Mr. Secretary, I will also echo some
disappointments. When we first met I expressed to you how, in
previous administrations, not of presidents but of secretaries,
it had been very difficult to have transparency with the VA,
and you assured me that was not going to be the case under your
watch. And as a physician I have, you know, at least a little
bit of an ability to look at productivity numbers to get a
sense of what those productivity numbers are. I just know how a
well-run clinic goes.
So my staff requested information regarding veterans health
care in the Community Care center, and we were told to submit a
Freedom of Information Act. This is Congress. This is the VA
Committee, which is supposed to be providing oversight, and we
were told to submit a FOIA.
It kind of took things to a new level because I once told
you of an episode where we had requested something and we got
it six months later and it was off point. We requested it and
it came back six months later and it was off point. And it was
just a rope-a-dope in terms of getting this information. That
actually looks good relative to being asked to get a FOIA. I do
not know how to say that is such disrespect for the institution
of Congress.
Secretary McDonough. I will take it and I will dig into it.
Senator Cassidy. It just blows my mind. And I am sorry to
be so frustrated, but I am representing people, and when those
people feel as if the VA is doing nothing but hiding, it is not
me. It is the people I represent, the veterans I represent, who
are really being offended.
So just to say that. And if we could have a point person
that we could contact, and that is accountable to you, and I
can call you up and say, ``Denis, we had a great meeting, man.
What is going on?'' and you could ride herd over this person--
because I suspect you did not know about this. But it is being
made by somebody who does not want to give us information.
So if we could have that, and your staff could relate to
Christian--raise your hand, man--then I would appreciate that
sort of workaround on something which is wrong.
Secretary McDonough. Fair enough.
Senator Cassidy. Secondly, kind of related to the same. On
April 12th, our office sent a letter to you regarding the
ineffectiveness of the VA's Opioid Safety Initiative and asked
what barriers Congress should remove in order to better public-
private partnerships to increase veterans' access to testing
and treatment. There was an August 21 report in Washington
Post, which kind of motivated this, which showed that after the
introduction of the Opioid Safety Initiative suicides among
veterans in rural areas increased by 75 percent and increased
in the urban area by 30 percent.
We have not heard back from a letter that we sent on April
12th about a program which the Washington Post is reporting was
at least associated, temporally--we do not know causally--with
a 75 percent increase in veteran suicide in rural areas. I do
not know. Any comment?
Secretary McDonough. No. I will get to the bottom of it.
Senator Cassidy. Okay. And again, I am sorry to seem as
agitated as Senator Sullivan, but you can imagine when I come
to my staff and I say, hey, man, I am all excited about this.
We put something together, worked really hard on it, we send it
off, and we have a FOIA request.
The next issue is--and again, I have always enjoyed our
interactions so I am sorry for the unpleasantness of this.
Again, I am a physician, and I know there are certain
productivity measures. They are just a way a well-functioning
outfit should work. It is my concern that in some places that
there are a lot of folks employed but not as many patients
being seen. Frankly, I think there are some facilities the VA
would choose to close because of lack of adequate patient
volume. I actually see that as important and you have my
support, depending on where it is.
But the point being is that we should expect a certain
amount of patients seen per provider in order to just have a
well-functioning clinic, even to keep up clinical skills.
This is the GAO report, and I am sure you are familiar with
it, reported in 2017, that VA did not maintain an accurate
count of physicians providing care in the VA, hindering the
ability to ensure the appropriate number of the clinical
workforce--I would say the appropriate number of people being
seen per physician--and also lacked data on the number of
contract physicians providing care in the VA because its
personnel databases and workforce planning tools did not
include contractors.
Now I do not know how many contractors you are, but
contractors are a pretty important part. Have you all corrected
that? Because one thing I want to know is patient volume per
provider. And so has that been updated, and what is going on?
Secretary McDonough. It sounds like a--I heard you say
2017, the GAO report. Is that right? So I assume it has been
updated, but let me take and find that out. But what we do is
we track average daily census in our facilities, which
obviously helps us make sure that we are tracking, most
importantly, patient safety, which is obviously derivative of
whether our docs, our nurses, our specialists are getting
adequate rounds, adequate time on target. And so I would be
happy to work through that with you.
But I assuming, from a 2017 GAO report, we have done that,
but let me take that.
Senator Cassidy. Well, I will finish by saying the reason I
asked is one thing we have asked for is datasets so that we can
actually look at this data ourselves, and, of course, we have
not heard back. But on the other hand, if what we are receiving
does not take into account contractors it would unfairly
portray. And I am absolutely not doing this to go after the VA.
I am doing this to gain understanding. But if I have to be
aware of the limitations of the data, which we would hope to
receive before we do that.
Secretary McDonough. Okay.
Senator Cassidy. So if they could have that codicil or that
addendum to that, I would appreciate it.
Secretary McDonough. Got it.
Senator Cassidy. Thank you.
Chairman Tester. Thank you, Senator Cassidy. Before I go to
Senator Sinema I just want to say that I would be just as
frustrated as you with a FOIA request back. I would hope that,
because I have done this with everybody from Wilkie to this
Secretary, that if there was something that came up like that
you guys could get hold of them immediately and say, ``Hey,
this is unacceptable.''
I do not know what the rules around FOIA are, but I get
your point, and when we ask questions we need to get answers.
Senator Sinema.
SENATOR KYRSTEN SINEMA
Senator Sinema. Thank you, Mr. Chairman, and thank you to
Ranking Member Moran for holding this hearing.
Wait times are of particular concern to me, given the
Phoenix VA's history, as you are aware, Secretary. Veterans in
Arizona and around the Nation deserve access to timely care
without a loss of quality. But with more veterans entering the
VA health care system every day we need to ensure we have a
plan in place to take care of them. No one should slip through
the system and no one should be left behind. You and I have
spoken about this numerous times, and thanks again for being
here today. I appreciate it.
So Secretary McDonough, during the COVID-19 pandemic the
use of telehealth increased nationwide. What lessons did we
learn that we could use from that timeframe to improve both the
quality and accessibility of health care and decrease wait
times for veterans?
Secretary McDonough. Yes. Let me say two things. One is
that I was recently in Boise, Idaho, where I visited the
Clinical Resource Hub. What we do in Clinical Resource Hubs,
which we have within VISNs, so within your VISN, within your
region in Arizona, but then we also have across the country,
allows us to smooth out providers. We have a lot of providers
in different places. We have too few in other places.
So by using these Clinical Resource Hubs we can connect
providers to veterans who are not getting timely access,
irrespective of where they are.
I have told the story before about meeting a veteran in
Kansas who was getting coverage from a psychiatrist in New York
City. In Boise, that Clinical Resource Hub is giving coverage
to veterans throughout that VISN, so into the Upper Northwest.
That is a really important capability we have, and we find that
veterans--not every veteran but a lot of veterans--have really
appreciated it. That is point one.
Point two. That requires us to be able to, for example,
prescribe controlled substances across borders. So one thing
that we are really worried about is when the national emergency
related to the pandemic ends, whenever that may be, the
emergency authority our clinicians now have to prescribe across
State lines goes away. So we need some statutory relief there,
because this ability to provide care through Clinical Resource
Hubs into lightly populated areas where we have a lot of vets
but we do not have enough providers, that prescribing authority
goes away with the pandemic national emergency.
So those are two things, the good and the bad, that are
lessons learned from this experience, that I hope we can get
you guys' help. We have been talking with the Committee now on
this for a while, in the House and the Senate, so I think we
are just about there. But that is something that we could use
as a very clear lesson learned from the pandemic, that I would
like to see continue apace here, because it gets to this big
question of access, wait times, and then the full suite of
care, including, where necessary, pharmaceutical prescriptions.
Senator Sinema. I appreciate that answer. Mr. Chair, I just
want to say that I would be more than happy to work on this
issue. In particular the ability to have psychiatrists
prescribe psychotropic medication for veterans who live in
underserved areas where they cannot get access to the mental
health services they need in a physical setting would be very
important. So I would be very interested in helping solve that
issue.
I know that in Arizona, for sure, we have got veterans who
sometimes have trouble getting access to timely care for the
mental health services they need, and of course, a loss or an
interruption of psychotropic medication can be deadly for
veterans.
Secretary McDonough. Deadly. Yes.
Senator Sinema. Thank you. So my next question, Secretary,
is I have heard that Community Care referrals to rural areas
may not be able to sustain the anticipated trajectory of need
as it increases upwards. What do you feel is the most important
aspect to focus on to alleviate this issue and ensure timely
access to quality care?
Secretary McDonough. I think two things. One is we have to
use the authorities that you have given us in the PACT Act to
hire and keep the clinicians that we have, and hire the
clinicians that we need. But that is in the direct care system,
so that is the first thing we have to do.
The second thing we have to do is really focus on network
adequacy. And this is where I have had this conversation with
folks in this room, including with Senator Moran. We are a
better payer now in the Community Care networks than we have
been. I am proud of that fact. We should now expect better
performance from our third-party administrators too on
maintaining a healthy, high-quality network, so that we are not
in a position, in certain rural areas, where we do not have
access to high-quality providers.
So this is a rub for us, but this is highly doable, and we
are surely investing enough in the Community Care Program to
make that happen.
Senator Sinema. Mr. Chair, I see my time has expired. Might
I ask one follow-up question?
Chairman Tester. Yes. Senator Cramer is going to be very
patient. Go ahead. Go ahead. Ask one more.
Senator Sinema. I owe you one, Kevin.
Thank you, Secretary. Telehealth, including ATLAS pods,
have been discussed as a potential solution, but we are not
seeing high utilization rates at many ATLAS pods----
Secretary McDonough. We are not.
Senator Sinema [continuing]. Including the one at
Wickenburg, Arizona, which we fought so hard to get.
Secretary McDonough. I know.
Senator Sinema. What can be done to improve the ATLAS
program so that we are meeting the need and increasing
utilization of these pods?
Secretary McDonough. It is a good question, and, you know,
I have had this conversation with other members of the
Committee too, and we are talking through our Office of Mental
Health with our partners in this program, to see what more we
could do. So I do not have a specific brief with me on that but
I would be happy to follow up with you on that. I know this is
a conversation you and I have been having on the ATLAS program
itself. So let me follow up with you and give you a sense of
where those conversations are with our partners.
Senator Sinema. I appreciate that. Thank you, Mr. Chair,
and Senator Cramer, thank you for your patience.
Chairman Tester. Senator Cramer.
SENATOR KEVIN CRAMER
Senator Cramer. It is my pleasure to wait. I like to hear.
Thank you, Mr. Secretary, for being here.
Secretary McDonough. Nice to see you, Senator.
Senator Cramer. Nice to see you. I am going to highlight a
specific situation to illustrate the point, and then hopefully
we can have maybe an early discussion of solutions. Let us put
it that way.
Secretary McDonough. Okay.
Senator Cramer. So I have a staff person who actually is
stuck in one of these ruts between the VA and Community Care.
Roughly four months ago, she was told that it would take five
months to get an appointment for the particular specific
service she needed. Of course, obviously, well outside the 28
days to qualify.
Secretary McDonough. Right.
Senator Cramer. So in hopes of not having to wait five
months, which, by the way, in and of itself is a ridiculous
proposition, but believe me, I know the challenges the VA and
all of health care is having, pretty much every industry is
having these days. So without passing judgment from me on that.
She, of course, then sought third-party care, or community
care.
She got approval from the VA, of course, to pursue the
community care, but what she got caught up in is the
authorization system, the movement of information from the VA
to the third-party administrator, back and forth, back and
forth, which became very frustrating. As I said, this was four
months ago.
And one of the more concerning issues for me is there is
this pointing of the finger back and forth between the two
entities. We sent it, we did not receive it. We faxed it, we
did not get it. We faxed it, we did not get it. Now I suppose
they could both be right, but right now I have a staff person
who is neither getting the care and at the same time sort of
anxious about, where is all my personal health care information
that keeps getting faxed?
Now I would like to say this is the only one that I have
had to deal with, but I have constituents that have had very
similar situations where days turned into weeks, turned into
months.
And just sort of listening to what I have listened to
today, I am afraid the VA, like every bureaucracy around here,
if we do not prescribe, in law, precisely what they have to do,
and write into law precisely what they are prohibited from
doing, they will do whatever they want to do. And I do not
think that is necessarily your fault. In fact, largely I think
it is more likely a reaction from the bureaucracy itself as
opposed to the leadership, the political leadership itself.
I do not see a lot of incentive for you to be part of any
of these problems, but at the same time I have told some
people, actually, some of the other politicos in your agency
before--I voted for them--I know you mean what you say and I
guarantee you, you will find it harder to do than you think.
``Oh, no, no. I am going to fight like hell.'' No, you are
going to, and they are going to win.
So I want to be part of the solution. First of all, I do
worry about the personal information going back and forth on a
fax machine.
Secretary McDonough. Yes.
Senator Cramer. But a lot of us are from rural States. You
are hearing a lot of the rural issues. The access issue is
particularly relevant to them.
I am thinking out loud with you a little bit here now.
Would it be possible that in a State like Montana, Alaska,
North Dakota, where we have a lot of critical access hospitals,
which are critical access because they are so far from other
places, they are hospitals that run on very small margins, have
very small populations but they are still necessary, you know,
is there a way that we could work on something where at least
we could simplify it for those people in those very remote,
rural places and maybe just make a critical access hospital an
extension of the VA?
I know it has got to be more complicated than that. I tend
to simplify complicated things, because I am a simple person,
but I just want to find a solution.
Secretary McDonough. Look, I visited a facility like that
with Senator Moran in Kansas, and we do a lot of business in
that facility for veterans in Kansas. And so I think there is a
way to make this work. So I am open to having that
conversation. Maybe it is because I understand your accent, but
it seems like something that we could do some work on, one.
Two is I also worry about your staff member, and I am
confident, if she is comfortable talking to our Office of
Community Care, I am confident we can get that worked out.
Senator Cramer. I am sure she would be, and I would
appreciate that.
Secretary McDonough. So we will track that down.
Senator Cramer. Well, I appreciate that and we will follow
up on that. And I have had other people that have helped in
similar situations, where when I make the inquiry it gets
solved. But every time I do that it bothers me because I think
of how many people do not know me? You know, most people know
me in North Dakota, just like everyone knows Senator Tester in
Montana. But there are some people who do not think to call
their Senator to get help.
Secretary McDonough. That is right and you do not want to
have to have that special pleading.
Senator Cramer. That is right. Thank you. Thank you, Mr.
Chairman.
Chairman Tester. Thank you, Senator Cramer.
Look, you have been at this for an hour and 45 minutes. I
put my questions in for the record to save the pain, and then
you can answer them in a timely manner. But I just want to say
thank you very much for being here.
Secretary McDonough. Thank you.
Chairman Tester. Thank you for fielding the questions. I
will tell you that I think it is important that people are
passionate, but I apologize. It kind of got out of control here
for a bit.
Secretary McDonough. I am sure----
Chairman Tester. No, that is my call. I should have handled
it, and I am sorry.
Secretary McDonough. It is my fault. I will follow up with
Senator Sullivan. It was inappropriate what I said.
Chairman Tester. But thank you. I will release you now, and
we will get to our second panel.
Secretary McDonough. Thank you, Mr. Chairman.
Chairman Tester. Yes. And, look, one of the problems with
being on a second panel after an hour and a half with the
Secretary is that everybody burns out and goes home. They will
be watching this and reading this verbally. But I do want to
introduce the second panel, and I do want to very much thank
them for being here.
First, I want to introduce Dr. Carrie Farmer, who is Co-
Director of the Epstein Family Veterans Policy Research
Institute, which is a mouthful, and Senior Policy Researcher
for the RAND Corporation.
Thank you for being here, Carrie.
Joy Ilem, who is no stranger to this Committee, she is
National Legislative Director of the Disabled American
Veterans.
Welcome back, Joy.
And finally, Darin Selnick, who was Senior Advisor to the
Secretary of Veterans Affairs during the Trump administration.
Thank you for being here, Darin.
So, Dr. Farmer, we will go with your testimony, and look,
we like you to keep within five minutes but know your whole
testimony will be a part of the record.
PANEL II
----------
STATEMENT OF CARRIE FARMER
Ms. Farmer. Great. Thank you. Good afternoon, Chairman
Tester and members of the Committee that may be listening to
this later. Thank you for your invitation to testify today.
I am a senior policy researcher at the nonprofit,
nonpartisan RAND Corporation where I co-direct the RAND Epstein
Family Veterans Policy Research Institute. I am a health
services researcher by training, and my research is focused on
military and veteran health care, including health care
provided by the U.S. Department of Veterans Affairs.
VA provides health care to nearly 7 million veterans every
year, both through care delivered in VA facilities and through
the Community Care Program, where care is paid for by VA and
delivered by the private sector. Since 2014, over 3 million
veterans have used VA Community Care, but whether this has
resulted in more timely, high-quality care for veterans is not
well understood. There is no single, accepted measure of timely
care, nor are there any national standards for how long is too
long for a patient to wait for a health care appointment. By
and large, no U.S. health care system other than VA publically
reports their data on wait times, so making comparisons is
difficult.
VA publically reports wait time information at the facility
level on its Access to Care website. VA updates this data
daily, so any veteran looking for information about care local
to them has up-to-date information about how long they should
expect to wait for an appointment. Using my own location as an
example, I was able to find out that the average wait time for
a new mental health care appointment at my closest VA medical
center was 34 days, but there was no wait for an appointment at
a local VA clinic. This kind of information simply does not
exist outside VA.
There is little available data about how VA wait times
compare to non-VA wait times, but what does exist suggests that
VA's wait times may be comparable or shorter. A study just
released last month by Merritt Hawkins examined physician wait
times in 15 major metropolitan areas. I estimated average VA
wait times in these metropolitan areas using the data from the
Access to Care website and compared them to the Merritt Hawkins
data. I found that in many parts of the country and for some
types of care veterans may face a shorter wait time for care
from VA than an average person getting care from the private
sector.
Data also suggests that veterans have shorter wait times
for care from a VA facility than from Community Care. Though VA
provides detailed information on how long veterans should
expect to wait for an appointment at a VA facility, VA does not
publically report wait times for VA Community Care.
In a recent analysis, VA researchers examined referrals for
new patient appointments for VA-delivered care and VA Community
Care. The analysis included over 22 million appointments for
primary care, mental health care, and specialty care. For each
type of care, wait times for VA-delivered care were shorter
than VA Community Care, and these findings persisted in
different parts of the country.
It is critical that discussions about veterans' access to
care always consider care quality. An appointment available
tomorrow that provides poor care could be worse than waiting
for good care. As prior RAND research has demonstrated, VA
typically provides care that is equal to, or better than, the
private sector. While VA tracks and reports on dozens of
quality measures and makes much of these data publically
available, equivalent data are not available for VA Community
Care. VA does not publically report or, to my knowledge, assess
quality measures for VA Community Care.
Better data about the timeliness and quality of VA
Community Care is needed. I have three recommendations for how
Congress and VA could improve available data.
First, VA should publically report average wait times for
VA Community Care appointments using the same data and
methodology used to report average wait times for VA-delivered
care.
Second, VA should make use of existing data to
systematically monitor and publically report the quality of
community care. For example, VA could use community care
claims-type data to construct quality measures for veterans
receiving care in the community.
Third, the third-party administrators responsible for
managing the Community Care network routinely collect
information about network providers that is not shared with VA
because it is not required by contract. VA should explore
contract changes that would facilitate additional information
sharing and new data collection about network providers and the
quality of care they provide.
In conclusion, concerns about veterans' access to timely,
high-quality care have been longstanding. To truly improve
veterans' care, however, additional data and analysis on the
timeliness and quality of VA Community Care and how that
compares to VA-delivered care are required.
Thank you for inviting me to speak with you today on this
important topic, and I look forward to any questions you may
have.
[The prepared statement of Ms. Farmer appears on page 54 of
the Appendix.]
Chairman Tester. Thank you for your testimony.
Joy?
STATEMENT OF JOY ILEM
Ms. Ilem. Thank you, Chairman Tester. I am pleased to be
here this afternoon on behalf of DAV to present our testimony
on VA health care wait times, access standards, and ways to
improve the quality of care veterans receive.
Assuring timely access to high-quality, veteran-focused
medical care has been, and will remain, a top priority for DAV
and our members. However, any discussion of timeliness must be
linked directly to the quality of that care because timely
access to low-quality care is no more acceptable than delayed
access to high-quality care.
While access to community care to meeting the needs of our
Nation's ill and injured veterans, one consequence of VA's
current access standards is an increased shift of veterans and
funding from VA to community providers. According to a recent
RAND report, since 2014, the number of veterans authorized to
receive community care and the cost to provide that care has
doubled.
VA's recent report on access to care standards noted, ``If
the balance of care provided in the community continues on its
current upward trajectory, certain VA medical facilities,
particularly those in rural areas, may not be able to sustain a
sufficient workload to operate in their current capacity.''
VA also warned of a potential for this spiral effect in
some areas where workload and talent are shifting externally
and, thus, threaten to harm VA's training, research, and
emergency preparedness missions.
Mr. Chairman, maintaining a comprehensive system of care
for service-disabled veterans is essential, and new research
confirms that VA health care outperforms the private sector for
quality, cost, and timeliness. The Journal of the American
Medical Association, or JAMA, just published a study which
found that VA wait times were lower than community care
providers for primary care, mental health, and specialty care.
Importantly, according to the JAMA study, areas with high
wait times for community care are not expected to benefit from
liberalized access and, instead, suggested it would take more
creative policies ``such as physician relocation incentives,
telehealth, or mobile deployment units,'' to expand access and
reduce wait times for veterans in underserved areas. This is
critical in rural areas, particularly those with longer wait
times--with longer VA wait times, such as VISN 15, which
includes Kansas. VA and Congress must work with the Office of
Rural Health on developing unique solutions for these areas.
In terms of cost, RAND found indications community care may
be more expensive than VHA-delivered care and that VHA-
delivered care costs less than comparable care from Medicaid
providers and produced better outcomes.
Research also continues to confirm that the quality of care
provided by VA is equal to, or better than, the private sector.
One reason for that, RAND reported, was VA clinicians are well
versed in veteran culture and the conditions that are prevalent
among veterans and only a small portion of community providers
ever complete training offered by VA.
Mr. Chairman, to improve timeliness and quality, DAV
recommends that VA continue a full continuum of care in as many
locations as possible and remain the primary provider and
coordinator of veterans care. Community care providers must
meet the same quality, competency, and training requirements as
VA providers. VA must develop a scheduling system that shows
real-time available appointments in both the VA and community
as well as comparable timeliness and quality metrics, and VA
needs to increase funding and develop innovative models to
expand access for rural veterans.
Mr. Chairman, VA has struggled for decades to expand its
capacity to meet the ever rising demand for care, often
resulting in these excess wait times for veterans. While the
use of wait time standards to allow veterans to use community
care can help address some of the access problems, research
indicates that the best way to reduce wait times is by
investing in the VA system that millions choose and rely on.
With its world-class, evidenced care, cutting-edge
research, medical education, national emergency roles, VA is an
irreplaceable system that we must continue to strengthen and
sustain for our ill and injured veterans now and in the future.
Mr. Chairman, that concludes my statement, and I am happy
to answer any questions you may have.
[The prepared statement of Ms. Ilem appears on page 67 of
the Appendix.]
Chairman Tester. Thank you for your statement.
Darin?
STATEMENT OF DARIN SELNICK
Mr. Selnick. Chairman Tester, I appreciate the opportunity
to testify in today's hearing on addressing health care wait
times at the Department of Veterans Affairs and in the
community. My testimony today reflects my own personal
expertise as former Senior Advisor to both VA Secretaries
Shulkin and Wilkie and as Veterans Affairs Advisor at the White
House Domestic Policy Council.
The VA facility wait times are inaccurate and misleading
and can lead to delayed care for veterans, causing negative
health consequences or even death as happened in the Phoenix VA
Medical scandal in 2014. The VA MISSION Act was a promise that
this would never happen again, but that promise is being
broken.
First, VA announced in October '21, they were
decommissioning and closing the Office of Community Care. Plus,
VA shut down the MISSION Act website, making it harder for
veterans to access information regarding their health care
options and community care eligibility.
Last June, the VA Secretary implied that he wanted to roll
back VA access standards. He said demand for health care has
increased more intensely for care in the community than for
care in the direct system and told Senators, ``My hunch is that
we should change access standards.''
Why would VA want to restrict community care? The answer
came from Acting Deputy Under Secretary for Health LaPuz in his
HVAC testimony: If care provided in the community continues on
its current upward trajectory, certain VA medical facilities
may not be able to sustain sufficient workload to operate in
their current capacity.
VA's problems with providing accurate wait times came to
light with the AFP Foundation FOIA documents. Key findings
included, one, denying community care referrals based on
clinical appropriateness, two, waiving wait time access
standards without veterans' consent, three, overriding
providers and veterans on deciding ``best medical interest,''
four, using ``patient indicated date'' to misrepresent wait
times, and five, neglecting to advise veterans of their
community care eligibility.
The problem with VA's calculation of average wait times is
they do not follow the VCCP regulation, which states, VA cannot
schedule an appointment within 20 to 28 days of the date of
request, unless a later date has been agreed to by the veteran.
Inaccurate wait times deny veterans their eligibility for
community care. This includes a new wait time method submitted
to the Federal Register on July 25th which has two main
problems.
First, VA is incorrectly dividing veteran patients into new
patient and established patient categories and using different
types of start dates. All patients should have their wait times
calculated the same way to ensure consistent and accurate wait
times.
Here are two examples:
Billings, Montana. Mental health. New patient, 76 days.
Existing patient, 10 days.
Eisenhower Medical Center, Kansas. Mental health. New
patient, 51 days. Existing patient, 14 days.
Second, the start date and end date measures are inaccurate
and should not be used as they artificially shorten wait times.
Here is why:
Earliest recorded date in the scheduling system to the date
it is scheduled to occur. There is often a delay in recording
the date, and a scheduled appointment may be canceled and
rescheduled by the VA.
Second, from the date agreed upon between the veteran and
provider for future care. Date agreed upon is only to be used
for follow-up appointments after it is agreed by the veteran
that the date of request does not work.
And, Third Next Available Appointment. The problem with
using TNAA is that is a theoretical appointment, not a real
appointment with a start and end date.
The correct way to calculate average wait times is to start
with the date of request and end with the date the appointment
is completed.
For community care wait times, VA is not following the 2019
Community Care policy of processing requests in two business
days and, instead, is adding additional steps through the
referral coordination initiative. The solution is to go back to
following the 2019 policy.
VA's review of access standards. Although VA says it is not
changing access standards, it is instead proposing a ``Trojan
horse,'' incorporating telehealth availability into
determinations regarding eligibility based on the designated
access standards. VA rejected this in 2019 because it can be
used to game the system and is a way to gut access standards
and reduce community care eligibility.
Here are three recommendations to improve VA wait times:
First, pass the GHAPS Act with the existing access
standards included. This will provide veterans with a guarantee
and certainty on their ability to choose community care when
facility wait times are too long.
Second, follow the VCCP regulation for average wait times.
Start at date of request and end on the date care is received.
VA should withdraw its Federal Register submission on
calculation of average wait times.
Third, educate all veterans and staff on the requirements
of the MISSION Act and VCCP regulation per Section 121.
In conclusion, as VA goes forward, it must change its
culture and become veteran-centric. As General Omar Bradley
said, ``We are dealing with veterans, not procedures; with
their problems, not ours.''
I look forward to working with the Chairman and Ranking
Member and all members of this Committee to achieving what is
best for veterans. I am happy to answer any questions. Thank
you.
[The prepared statement of Mr. Selnick appears on page 75
of the Appendix.]
Chairman Tester. Thank you for your statement, and I want
to thank you all for your statements.
I am going to start with you, Ms. Ilem. You heard my
earlier statement on the Department rapidly approaching the
point where one-half of all care available in both settings is
provided through community care. What is your take on that? Are
you concerned by that statistic?
Ms. Ilem. I think it is concerning. You know, I think the
Secretary well stated, you know, that we are really seeing this
increase in community care, and while veterans may need access
to community care, that has always been part of what, you know,
VA has provided. You know, they are trying to look at a good
balance across the system in terms of, you know, maintaining
the ability to provide veterans the best-quality, high-quality,
you know, care available. They know that the outcomes are
better in VA care. You know, they should be resourced and the
vacancies filled and having the ability, to the best of their
ability, to provide that care whenever veterans--you know,
whenever they can.
And I think I noted in my statement, you know, particularly
in rural areas it is a concern, you know, if it is going to be
negatively impacted for VA to have the ability to provide that
care, especially for service-disabled veterans.
Chairman Tester. I think in your statement--correct me if I
am wrong--you talked about that while timeliness is important
quality of care is really important also.
Ms. Ilem. Absolutely.
Chairman Tester. So in addition to quality of care and
timeliness, what are other factors that Congress should be
considering when evaluating VA's versus community health care's
performances?
Ms. Ilem. So I think the virtues of VA health care are its
integrated health care system, you know, its focus on the
veteran, especially those with service-related disabilities,
you know, the special disabilities for blindness, spinal cord
injury, mental health services. Having a system that is focused
on them, research is focused on them, I think is critical,
especially for those veterans who are going to need the system
for the long term, for the remainder of their lives, and
expect--you know, they are satisfied with that care. They tell
us they like that care because the ability of providers to
really focus on their needs, spend the time with them that they
need. They have complex health conditions that require unique
attention.
And while we need access to care in the community when VA
cannot provide that care, we do not know as much about the
quality of care. That has been noted several times here today.
The research shows, you know, VA is providing good, high-
quality care. So their ability to continue to do that in every
place that they can is important for service-disabled veterans
and to have a system that meets their unique needs for the long
run.
Chairman Tester. Thank you.
Dr. Farmer, you work for the RAND Corporation. I read and
listened to your testimony. As you could tell, there is a bit
of a scrap here on community care versus VA care. Do you have a
dog in this fight?
Ms. Farmer. Absolutely not. We are not affiliated with VA
in any way. We are a nonpartisan organization that just
believes in the research and the data.
Chairman Tester. Okay. You hit on a point in your testimony
that I think is pretty key, actually, and that is getting down
to the information we need to make an honest evaluation. I
think the VA is the only medical system in the country that
reports wait time, and it does so daily, and it also does it at
the facility level.
Your comparison using Merritt Hawkins survey data is the
sort of information that veterans should be presented with when
they are making choices about where they need to get care or
where they should--you know, so it is their choice, so they are
making it with reasonable information.
So what should VA keep in mind if it moves forward with
comparing in-house and community care timeliness numbers so
that veterans would know?
Ms. Farmer. Well, first, there is just not data on the
timeliness of community care, so I really encourage VA to
identify how that might be possible, to publically report the
data in the same way that the data is currently available for
care delivered by VA facilities.
I acknowledge that there is nuance to that. It may be
difficult in certain parts of the country. The number of visits
may not make sense to add together, and so it may have to
happen at the VISN level or some--but I do believe there is
some way to report this information in a way that can help
dispel what I think is a myth, that getting care in the
community is going to be faster than getting care from a VA
facility.
Chairman Tester. Okay. Well, look, I just want to thank you
all. I want to thank all the witnesses for being here. I
appreciate your patience waiting.
This Committee is going to continue to work so that
veterans receive quality care in a timely manner.
We will keep the record open for a week, and with that,
this hearing is adjourned. Thank you.
[Whereupon, at 5:08 p.m., the Committee was adjourned.]
A P P E N D I X
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