[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

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

                                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
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                          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

                              ----------                              

                           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

                              ----------                              


                     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

                              ----------                              


         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.]

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