[Senate Hearing 118-194]
[From the U.S. Government Publishing Office]


                                                         S. Hrg. 118-194

                     EXAMINING THE EFFECTIVENESS OF
                 THE OFFICE OF INTEGRATED VETERAN CARE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 21, 2023

                               __________

       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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                 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
Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
               David Shearman, Republican Staff Director
                           
                           C O N T E N T S

                              ----------                              

                             June 21, 2023

                                SENATORS

                                                                   Page
Hon. Jon Tester, Chairman, U.S. Senator from Montana.............     1
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas.......     5
Hon. Thom Tillis, U.S. Senator from North Carolina...............    11
Hon. John Boozman, U.S. Senator from Arkansas....................    13
Hon. Dan Sullivan, U.S. Senator from Alaska......................    16
Hon. Marsha Blackburn, U.S. Senator from Tennessee...............    17
Hon. Bill Cassidy, U.S. Senator from Louisiana...................    19

                               WITNESSES

The Honorable Shereef M. Elnahal, MD, Under Secretary for Health, 
  Department of Veterans Affairs; accompanied by Miguel H. LaPuz, 
  MD, MBA, Assistant Under Secretary for Health, Office of 
  Integrated Veteran Care, Veterans Health Administration; and 
  Hillary P. Peabody, MPH, Deputy Assistant Under Secretary of 
  Health for Integrated Veteran Care, Veterans Health 
  Administration.................................................     3

                                APPENDIX
                           Prepared Statement

The Honorable Shereef M. Elnahal, MD, Under Secretary for Health, 
  Department of Veterans Affairs.................................    27

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Mike Rounds...............................................    39
  Hon. Angus S. King, Jr.........................................    43
  Hon. Bill Cassidy..............................................    48

 
                   EXAMINING THE EFFECTIVENESS OF THE
                   OFFICE OF INTEGRATED VETERAN CARE

                              ----------                              


                        WEDNESDAY, JUNE 21, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:30 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.

    Present: Senators Tester, Brown, Blumenthal, Sinema, 
Hassan, Moran, Boozman, Cassidy, Tillis, Sullivan, and 
Blackburn.

            OPENING STATEMENT OF CHAIRMAN JON TESTER

    Chairman Tester. I am going to call this hearing to order. 
Senator Moran will be here shortly. I know he has got 
conflicts. As we do with almost every one of these meetings, we 
have people who have conflicts with other meetings. We will 
apologize ahead of time. It is always a busy time, and this is 
no exception.
    As we begin today's conversation on the ``Effectiveness of 
the Office of Integrated Veteran Care,'' our focus is a simple 
one, ensuring veterans receive the top-notch care they deserve 
and have earned, whether in the VA or in the private sector.
    As the largest integrated healthcare system in the country, 
VHA provided more than 115 million clinical encounters to more 
than 6.3 million veterans last year. That included 31 million 
telehealth appointments, 40 million in-person appointments, 38 
million community care appointments.
    Let me say that one more time: 31 million telehealth 
appointments, 40 million in-person appointments at VA 
facilities, and 38 million community care appointments.
    Are there often problems accessing care, particularly in 
rural America? Well, the answer to that is yes. When that 
happens, we hear from constituents, we hear from VSOs, and we 
often rely upon entities like the VA Office of Inspector 
General and the Government Accountability Office to tell us 
what is going wrong and how we fix it.
    Recently, a nationwide Medicare survey of patients showed 
VA outperformed non-VA hospitals on all 10 core patient 
satisfaction metrics. Those included overall hospital rating, 
communication with doctors, communication about medication, and 
willingness to recommend the hospital to another.
    Study after study, including findings recently published in 
the Journal of General Internal Medicine, shows VA health care 
is as good as, or superior to, what folks get outside the VA 
and veterans typically like their VA care more than their non-
veteran counterparts like in the private sector.
    But when veterans cannot be seen by the VA in a timely 
manner or they have to drive too far for the VA services, they 
need to be quickly connected with community care. Despite what 
some believe, the simple act of routing more veterans into 
community care is not the sole solution. The challenges of 
accessing care, particularly in rural and frontier America, are 
not specific to the VA. Communities in a state like Montana 
know that all too well.
    And as I said at last week's hearing, improving access to 
care for rural veterans by purchasing care from the community 
may have a limited effect, especially in rural areas that are 
already underserved. You cannot buy it if it is not there.
    So when veterans are sent into the community for care, VA 
certainly has room for improvement. There is no doubt about 
that. The Department must streamline its internal process for 
referrals so veterans receive faster access to care. That 
starts with establishing clear requirements for how long it 
should take for a veteran's appointment to be scheduled.
    And the VA also must place special emphasis on hiring non-
clinical support staff. VA cannot schedule if it does not have 
the medical support assistants it needs to facilitate those 
appointments. This is not news to any of you.
    VA and community providers must be able to more easily 
share information about a veteran's health care so the VA can 
better coordinate services and make sure nothing is slipping 
through the crack. Why? Because we can outsource the care, but 
we cannot outsource the responsibility.
    And to do that, the VA must adopt national interoperability 
standards for the electronic transfer of health information 
between the VA and community care providers. The Department 
must also reduce red tape in the community care program. When a 
patient and a provider jointly determine where the veteran 
should be best served, that decision needs to be final and not 
go through any extra layers of scrutiny.
    Moving forward, I look forward to hearing other 
recommendations as to how to improve community care because the 
veterans deserve programs that work and that work for them. 
That is why in the coming weeks I will be introducing the 
Making Community Care Work for Veterans Act of 2023. This is 
meant to improve the program Congress put into place five years 
ago. That bill will include the provisions that I have 
discussed this afternoon, among others.
    In the meantime, we have to keep working to bolster VA's 
internal capacity to provide care to veterans through the 
CAREERS Act and to give the VA the tools it needs to speed up 
the delivery of VA facilities through the BUILD Act. We have 
got to address the underlying causes of veterans opting for 
community care, and we cannot do that by focusing on community 
care alone.
    With that, I am going to introduce the panel. And by the 
way, when the Ranking Member gets here, Senator Moran, if one 
of you are done speaking, I will ask if he wants to do his 
opening statement. You know, it is going to be a little bit 
flexible here.
    I want to welcome Under Secretary for Health, the Honorable 
Shereef Elnahal. Dr. Elnahal is joined by the number one and 
number two from the Office of Integrated Veteran Care, Dr. 
Miguel LaPuz and Hillary Peabody. I want to welcome all of you 
to the Senate Veterans' Affairs Committee.
    Dr. Elnahal, you have the floor.

 STATEMENT OF HON. SHEREEF M. ELNAHAL ACCOMPANIED BY MIGUEL H. 
                  LAPUZ AND HILLARY P. PEABODY

    Dr. Elnahal. Thank you, Chairman Tester. I want to thank 
Ranking Member Moran as well and members of the Committee. 
Thank you for inviting us here today to discuss how VA is 
ensuring veterans have access to the best care in a timely 
manner, as they have earned.
    I am accompanied by Dr. LaPuz, Assistant Under Secretary 
for Health for the Office of Integrated Veteran Care, and Ms. 
Hillary Peabody, Deputy Assistant Under Secretary for Health 
for Integrated Veteran Care. We appreciate the opportunity to 
discuss the efforts IVC is leading to empower facilities to 
meet the challenges that Secretary McDonough set for this year, 
to provide more care and more benefits to more veterans than 
ever before.
    Meeting the increased demand for veterans in our system and 
fully implementing the PACT Act requires us to build capacity 
and improve access to care, whether that be through VA care or 
in the community. To ensure we are meeting veterans' needs for 
timely care, VA established measurable goals for all facilities 
based on feedback from veterans. These goals represent the most 
important areas we need to focus on systemwide. We refer to 
these as our North Star metrics, and they include direct care, 
wait times from the date of request for new patients, time to 
schedule community care appointments, and veteran satisfaction 
with the timeliness of care. VA has taken several steps toward 
improving these metrics.
    The most important way for us to build capacity is through 
hiring faster and more competitively. We set a goal of hiring 
52,000 new employees this year, including 30,000 positions in 
the occupations most needed to ensure access to high quality 
care: physicians, nurses, practical nurses, nursing assistants, 
medical support assistants, environmental service technicians, 
and food service workers.
    We have made significant progress on hiring, and with our 
concurrent progress on employee retention, we have already 
exceeded our goal for the year in increasing the total number 
of employees on board and we are still on track to meet our 
goal for external hires.
    Additionally, we are leading an effort aimed at optimizing 
the time our clinicians spend caring for veterans by 
implementing standards for bookable hours and appointment 
links. The bookable hour initiative will ensure clinicians are 
available for veteran care for 80 percent of their designated 
clinical time. Implementing this represents an opportunity to 
improve veterans' access to care and will ensure a more 
equitable workload across providers.
    Finally, we are leveraging every new modality we have to 
reach veterans with timely care. We continue to use telehealth, 
including VA Health Connect, our national network of call 
centers. Each year, VA Health Connect supports approximately 45 
million calls, serving as a virtual front door for veterans 
into VA. Through VA Health Connect, veterans can call 24-7 to 
talk to a nurse about a health concern, a medical support 
assistant to help with scheduling an appointment, a pharmacist 
to reorder a prescription when needed, and if needed, to meet a 
provider with a video appointment.
    So how are we doing? Already, we have seen progress in the 
North Star metrics from quarter one to quarter two of this 
fiscal year. Wait times for primary care for new patients 
improved in nearly 60 percent of our facilities. Further, more 
than half of our facilities met our first quarter goal for 
reducing wait times for primary care and 40 percent reached the 
same goal for mental health appointments.
    Primary care wait times are very important as we continue 
to implement the PACT Act because these appointments serve as 
the critical front door and coordinator for VA care, and 
importantly, we have seen these reductions in wait times even 
in the context of significant growth in the volume of new 
patient appointments. We provided 9.2 percent more of these 
appointments to veterans in our latest quarter of measurement.
    We are also making progress on community care scheduling. 
While the number of appointments scheduled across all these 
services in the community also increased, most sites still saw 
improvements in the time to schedule those appointments. But we 
do have a lot more work to do there, as you mentioned, 
Chairman.
    Candidly, we have seen fewer improvements in specialty care 
within our direct care system where salary constraints continue 
to make it difficult to recruit providers. I want to thank you, 
Chairman, as well as Senator Boozman, for introducing the VA 
CAREERS Act. This bill would eliminate the $400,000 cap on 
physician salaries and allow us to provide the market-based pay 
we need to compete for specialty providers in any market.
    And here is what we are doing next to further improve 
performance on the North Star metrics. We currently have three 
efforts underway to improve scheduling: enhancements to our 
internal scheduling system to allow schedulers better 
visibility into appointments, piloting of new technology to 
improve visibility into community providers' schedules, and the 
expansion of veteran self-scheduling.
    Veteran self-scheduling has already shown promise in 
reducing the time to schedule appointments in the community in 
our Bedford Medical Center, for example. One veteran in 
Bedford, who was referred to a community dental care 
appointment, explained to us that self-scheduling was the best 
option for him because he would often miss calls from community 
providers when he did not recognize the number. By simply 
providing this veteran with an authorization and the right 
number to call, VA empowered him to contact the provider on his 
schedule, which allowed him to secure his appointment in just 
two days.
    Work is well underway in our Community Care Network next 
generation contracts, where we are incorporating important 
lessons learned to best ensure that our community providers are 
providing timely and high quality care that veterans have 
earned.
    Chairman Tester, Ranking Member Moran, thank you again for 
the opportunity to appear before you today and for your 
continued support. We look forward to your questions.

    [The prepared statement of Dr. Elnahal appears on page 27 
of the Appendix.]

    Chairman Tester. I will now turn to Senator Moran for his 
opening statement.

            OPENING STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Mr. Chairman, thank you. The Chairman has 
been kind enough to--we are working on cooperating with my new 
committee assignment, which is the Senate Committee on 
Intelligence that meets every Tuesday and Wednesday afternoons 
at 2:30, and after we had our schedule already determined what 
we were going to do here. So I apologize for my tardiness and 
pleased to be here.
    I only heard, Dr. Elnahal, about the good news. As you 
would expect, I have continued concerns about the capabilities 
and the support for community care, and mostly what I know is 
what veterans tell me as they experience the opportunities and 
disappointments that occur, both at the VA.
    We are also mostly here, I suppose, to review and see where 
the IVC is. It is a new office, combining previously two 
separate offices. The intent in combining those offices into a 
single entity was to streamline the efforts to improve access 
to both settings and make it easier for veterans to get the 
care they need. I do not see the evidence that that has been 
the case, but I am happy to hear the testimony that reassures 
me that it is.
    A couple of stories that I would tell just as you were 
telling yours as I came in the door. A veteran who lives here 
in the Washington, DC, area has conveyed to me, to my staff, 
despite being a long-term patient at a VA medical center here, 
he decided to request a primary care appointment for the first 
time in a little over two years. He was categorized, he did not 
know why, as a new patient of the VA. When he tried to make an 
appointment a couple of months ago, he was told that it would 
be 30 days before he would get a primary care appointment. He 
did not think that was right.
    He thought he was entitled to seek the option of community 
care, but when he asked the scheduler about community care, the 
scheduler quoted him access standard information that when 
shared with us was clearly not the right information, not the 
right standard. At one point, he was told he needed to see a VA 
primary care provider to make a referral to community care.
    Eventually, the same scheduler told him that, well, if he 
would call back the next day, she or he could offer him an 
appointment in just two weeks to a different provider. It seems 
that there is--it is reported that there is a local policy in 
place that directs schedulers only to look at the availability 
of certain providers instead of the availability of all 
providers for possible appointments.
    Closer to home, in Wichita, about a year ago, this veteran 
started to experience severe pain that was so bad he stopped 
eating and sleeping and could barely use the facilities. He 
contacted a VA doctor who advised that he should try Tylenol.
    Tylenol was not the cure. He went back to the VA and asked 
over and over again for help, with repeated requests that the 
VA order tests and scans and eventually a biopsy, but it took 
months for those appointments to occur, months in which that 
veteran continued to have debilitating pain that had nothing to 
do with being solved by Tylenol. He kept asking the VA to work 
faster, to get him in sooner, but nothing like that happened.
    Unlike this first veteran, he did not know about VA 
policies, was not familiar with the MISSION Act. He did not 
know that community care was something that he could ask for, 
little less know that he was entitled to. The VA referred him 
to the community for certain tests that his VA medical center 
could not perform in-house but never once offered him the 
option of seeing if a community care provider could get him the 
care he needed quicker.
    A few days before Christmas, this veteran was finally 
biopsied with--finally got the biopsy he had been waiting for, 
diagnosed with prostate cancer. At that point, the cancer had 
spread to several other parts of his body. Fortunately, the 
veteran is doing okay today. He is in treatment that appears to 
be working, and his spirits are high. He has good things to say 
about his VA doctors and thinks that they were just as 
frustrated as he was about how long it took him during this 
wait time.
    He describes the experience--and this sounds so much like 
veterans that I know. He just describes the VA care as an 
obstacle course that was extremely difficult to get through. He 
said that because it took the VA so long to get the care he 
needed, and he said that cancer got ahead of him. He will never 
get the months back and know whether his prognosis would be 
better if the cancer had been discovered sooner.
    I understand these are just two stories, but they are 
stories that I hear, and I would assume others hear, on a 
frequent basis. And so I am in my continual mission of trying 
to utilize the MISSION Act in a way that it was intended, to 
see that those veterans who need faster care, specialized care, 
care related to the distance in which they would have to travel 
is available and available in a way that there are fewer 
barriers and less frustrations and less delays.
    I do know that there are instances as you were describing, 
in which the VA in-house performs wonderful services and many 
veterans in Kansas, if not most, find the VA care very 
satisfactory and appropriate. I still am looking for the way to 
make sure that those who have a better option have no 
impediments toward getting that care, and I look forward to the 
conversations that tell me how the IVC is helping accomplish 
that.
    Chairman Tester. Thank you for your opening statement, 
Senator Moran.
    Recently, Medicare did a nationwide survey of patients. VA 
hospitals, by their survey, outperformed non-VA hospitals on 
all 10 core patient satisfaction metrics. This is good news for 
you. Congratulations. The fact that VA is performing well above 
the average on metrics regarding patient-doctor communication 
and care transition is really a testament to your hard work 
and, more importantly, the hard work of the folks who serve 
under you, the hardworking employees.
    So, Dr. Elnahal, what do you attribute VA's above average 
performance on that Medicare survey?
    Dr. Elnahal. Well, thank you, Chairman, for the question. I 
think you alluded to this in your question, that the most 
important reason I believe that veteran satisfaction far 
exceeds the private sector on average in our system is because 
of our people. Our people are squarely dedicated to the 
mission. A third of our employees are veterans themselves, so 
many more have a veteran in their lives, and take the mission 
personally.
    And so a lot of the questions on that standard survey 
issued to every hospital have to do with the respect that we 
offer patients in our medical institutions, responsiveness of 
hospital staff, the cleanliness of the environment, the 
quietness of the environment. All these are things that our 
employees pay attention to very closely because they know that 
every single veteran's experience matters.
    We are not there where we need to be on every facility. 
Seventy-two percent of our facilities are four or five stars 
compared to about 48 percent in the private sector, which is 
great, but we will not rest until 100 percent of our facilities 
are doing that because every veteran, no matter where they 
live, deserves that superior treatment.
    Chairman Tester. Internal patient satisfaction surveys 
reaffirm that VA services are top-notch. One metric in 
particular from this survey stood out to me: 93 percent of 
veterans surveyed stated that they have total trust in their VA 
facility to take care of their primary health care needs. That 
is something that cannot always be said for the folks receiving 
care at other facilities in the private sector.
    So, Dr. Elnahal, which metrics from this survey do you look 
at and say, this is a good indicator that the Department is 
meeting the needs of our veterans?
    Dr. Elnahal. So I think first is the overall hospital 
rating. It is a summative assessment of what veterans tell us 
their overall experience was. That is a very important metric 
to look at.
    And I think the next most important one is the willingness 
to recommend the hospital to other veterans. I often say that 
nobody cares more about veterans than other veterans, and that 
seal of approval for so many of our facilities really means a 
lot to us.
    So those are the two most important I would say.
    Chairman Tester. So you have a VA integrated care model 
within the VA, or I should say you have an integrated care 
model within the VA, not to be repetitive. How does that impact 
the results from a positive standpoint?
    Dr. Elnahal. I think that is the entire reason for the 
change we made to the way we organize ourselves here centrally. 
The fact is any veteran may need care in the community and may 
need care within our system, and if we take a holistic look at 
what is best for every single veteran who walks in the door, 
those processes should be coordinated. Veterans should not have 
to be ping-ponged back and forth from different departments.
    The two veterans' stories that Senator Moran mentioned 
could be examples of that. I think hearing those stories are 
not only important but necessary for us to make the right 
improvements.
    And what I can tell you is how this is working at our 
facilities so far is much better than our systemwide 
coordination of that integration. We still have some work to do 
on ensuring consistency of our processes, but I can tell you 
that excellence is really happening in a lot of our facilities 
and we are proud of it.
    Chairman Tester. So that is the positive side of the 
ledger. Let me tell you about the complaints that I hear, and 
the complaint that I hear from veterans in Montana, and Senator 
Moran referred to this, it is the length of time for an 
appointment to be scheduled. I mean, that is truthfully it. I 
mean, that is it. I mean, they really cannot complain about not 
having access if access is not there, but it is the amount of 
time it takes.
    So, Dr. Elnahal, or either one to your right or your left, 
walk us through the reasons that there are delays and what are 
you doing to fix that.
    Dr. Elnahal. So I think the most important reason we see 
delays in scheduling care in the community is that we do not 
yet have standardized, streamlined processes implemented across 
the system. That is one of the most important charges I have 
asked Integrated Veteran Care to focus on, to ensure that 
consistency and oversight. I will ask Dr. LaPuz to fill in some 
details there in a second.
    But I also think that many veterans have told us that they 
would rather just schedule the appointment themselves. That is 
how the care works for care that they get outside of the VA. 
Veterans feel empowered when you give them an authorization and 
you give them a community provider within our network. We have 
seen success on this in Bedford and in areas of VISN 19 as 
well. And so we want to expand that opportunity to more and 
more services over time, and I think if we do the evidence 
shows that we will reduce the time to schedule.
    I will also say that that is why this is one of our three 
most important metrics that we are tracking across the system. 
The time to schedule community care appointments is being 
tracked in every medical center with expectations for 
improvement throughout the fiscal year.
    If we have time, Dr. LaPuz?
    Dr. LaPuz. Yes, thank you very much, Senator, for that 
question. So the other thing, too, that we are improving is the 
technology that is available to schedule veterans in the 
community. So we have actually--we have a pilot in order to 
improve the efficiency of scheduling, and that pilot has shown 
to be beneficial. And that is the reason why now we are in the 
process of the acquisition in order for us to have the 
technology so then we can roll out the technology nationwide, 
and we expect that that is going to be happening probably 
before the end of the calendar year.
    The second thing that we are doing is we are--as Dr. 
Elnahal said, that we are improving the processes apart from 
veteran self-scheduling, that we are going to be rolling out 
and making sure that all of the facilities are employing 
veteran self-scheduling.
    The other thing, too, that we are doing is we are improving 
the utilization of what we call Consult Toolbox. This is a 
process to allow us to get the veteran's preference ahead of 
time so then we will be able to schedule the veterans much more 
smoothly.
    And then, finally, we thank Congress for the assistance 
that Congress has provided us so then we can hire the necessary 
staff because that is the other thing that we are having 
problems, particularly in the rural communities. That is hiring 
staff to actually be doing the scheduling. So we truly 
appreciate the assistance of Congress.
    Chairman Tester. Okay, Senator Moran.
    Senator Moran [presiding]. Well, Chairman, thank you. I 
appreciate what you said about length of time it takes. It is a 
significant problem. I recognize that the proposal to have 
veterans schedule themselves seems like, to me, perhaps a 
common-sense solution although we have invested a lot of effort 
at the VA getting schedulers and policies in place.
    And I appreciate what Dr. LaPuz said about--he added the 
thing that I was going to add to what the Chairman said, as my 
words, not his, but getting veterans to know they have the 
opportunity. In fact, they are entitled to have care in the 
community.
    And it seems to me there continues to be an unwillingness, 
a lack of information. I do not know what it is. A failure, we 
can say it that way, for the VA to tell veterans, well, here is 
an option.
    I do not want to do anything that undercuts the importance 
of the VA healthcare delivery system in-house, and it is why--
but we crafted the MISSION Act in a way that was designed to 
make certain that the VA did not have a restricted gatekeeping 
role in providing care to the community.
    And I have a mission myself of trying to make sure that 
that is still the opportunity for veterans who make the choice. 
If it is in their best interest, the criteria are met, that 
they have that access.
    So I would add to the Chairman's comments about the length 
of time it takes to get an appointment that also the confusion 
or lack of information that comes with both the person 
scheduling and the veteran who often does not know what the 
rules are.
    And it is often the case in my experience that what I 
learned from you, Dr. Elnahal, or anyone else in the VA 
leadership, this is our policy. It is not what the people in 
the VISN, in the local hospital know to be the policy. You said 
this earlier. I am just trying to confirm that what you said is 
still true. There is not a consistent application of the 
MISSION Act across the country and even across the VISN that I 
live in.
    I would be glad to have your response. Mostly, I was just--
that was my rant. That is the nature of--that is as bad as it 
gets.
    Dr. Elnahal. Senator, I think you are correct in saying 
that we do not see at all times consistent application of these 
processes, and what is most important in all of this is 
affording veterans of all options that they are entitled to, 
including options under the MISSION Act for community care.
    We articulate our priority on access by saying that 
veterans deserve the soonest and best care option available. 
Often, that is a VA care option. Often, it is a community care 
option. And veterans should be availed of that as we have 
discussed before.
    I do want to give Dr. LaPuz a chance to talk about the 
oversight work that IVC is doing to make sure we get to a more 
consistent application of these standards over time. This is a 
very important effort that the Integrated Veteran Care Office 
is undertaking.
    Dr. LaPuz?
    Senator Moran. Please do.
    Dr. LaPuz. Thank you, sir. We are aware, we are cognizant 
of the OIG findings that there is inconsistent application of 
policies that are happening in the field and that there is lack 
of awareness, like what you have said. And so what we are doing 
now is we are, first of all, reeducating and training all of 
the VISNs regarding our policies. So we are also reviewing our 
policies to ensure that the policies that we have are easily 
implementable.
    The second thing that we are doing is we are actually 
coming up with guidelines and checklists so then we can share 
those so then every policy will have a corresponding guideline 
and checklist that we share to the facilities and to the VISNs. 
So then the VISNs can actually do their oversight over the 
facilities, and we can actually partner with the VISNs to 
ensure that those oversight visits are being done.
    And then we are--finally, we are monitoring all of the 
oversight activities that are happening to ensure that again 
there is a consistent application of the policies and guidance 
that we have put out so then there is really a singular veteran 
experience.
    Senator Moran. I appreciate that answer. Let me tell you 
about a hearing we had last week in this Committee. The topic 
was substance use disorder. Suicide and substance use are often 
linked, overdose deaths have increased, and there is a 
nationwide fentanyl crisis.
    I am not telling you anything you do not know, but I am 
telling you about a hearing in which the testimony was the 
importance of timely connection in the circumstance of 
substance abuse and suicide prevention that there is no--there 
can be no delay in the contact between a provider and the 
veteran.
    As I understand it, the VA does not hold inpatient or 
residential substance use services to the same access standards 
that the VA uses for other mental health and suicide prevention 
services. Those are minimum coverage insurance policies under 
the Affordable Care Act to have basic access--the policies have 
access to inpatient mental health and substance use treatment. 
Shouldn't that change, and the criteria, the standards be the 
same?
    Dr. Elnahal. I think it should change, Senator, and in fact 
we have charged a group to look into exactly what the policy 
change should be for our timeliness standards, for residential 
treatment for mental health issues, to include substance use 
disorder, and that group is going to be coming out with 
recommendations very soon that we will share when they are 
ready.
    But I will tell you that prioritizing access to this 
critical therapy in light of the epidemiologic trends you were 
just mentioning around substance use disorder and overdose 
deaths, we are seeing similar trends, unfortunately, in the 
veteran population. So timeliness of care for this service is 
extremely important. We will be addressing not only our 
timeliness standards for internal care but when and how we 
refer care to the community.
    Senator Moran. One of the reasons that CHOICE ultimately 
became MISSION, was enacted by Congress, signed by the 
President into law, was the lack of providers, adequate number 
of providers within the VA, and this clearly has to be an area 
in which that is the case as there are not enough providers any 
place when we get to mental health and substance uses. And so 
it is again seemingly--it seems to me that it is one of the 
areas in which the MISSION Act has a significant role to play 
as we try to bring in all the available providers to meet this 
growing demand.
    Thank you, Dr. Elnahal. You have offered to come to Kansas 
and spend time with me on numerous occasions, and I look 
forward to me--it is my court, not yours, and I look forward to 
being able to tell you, yes, I would love to do that.
    Dr. Elnahal. Thanks, Senator. Appreciate that.
    Senator Moran. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. You looked around the table, hoping you 
could recognize somebody else.
    Senator Moran. Well, you know the bipartisan nature of this 
Committee. I was looking for the Democrat.
    Senator Tillis. Thank you all for being here and for the 
work you do on behalf of veterans. I got a couple of questions. 
I mentioned in last week's hearing about the Patient's Bill of 
Rights. I know that we spoke on veterans--or we have spoken 
with Veterans Affairs since then, but I just want to make sure 
people understand what I am trying to do here.
    My motive is at a time when millions of dollars are being 
spent to advertise, those Camp Lejeune toxics ads, which the 
bill was supported by and in large part written by my office, 
looks like a great opportunity to get veterans connected that 
have never been connected to the VA before.
    So my first question, let us say a veteran who is connected 
to the VA already sees one of those ads and decides to call 1-
800-VA, and they say I want to file a claim for Camp Lejeune 
toxics. What script do they read off to that veteran?
    Dr. Elnahal. So we have a one-stop shop, essentially, for 
any veteran interested in getting PACT Act benefits. They can 
call 1-800-MyVA411 or www.va.gov/pact. We, in fact, screen for 
toxic exposures to include contaminated water at Camp Lejeune 
during the affected period, and what happens after that is that 
it is a warm handoff to VBA after that screening, to be able to 
send that veteran a letter encouraging them to apply for 
additional benefits. So we encourage that no matter where the 
veteran is coming from, whether internal or external.
    Senator Tillis. What about the touch point that they have 
to make with the Department of Navy as a part of the 
registration for Camp Lejeune relief? Have you talked about 
that?
    Dr. Elnahal. I believe, Senator, that the PACT Act does 
offer the opportunity to veterans to essentially sue the 
Federal Government for conditions related to the contaminated 
water----
    Senator Tillis. Yes.
    Dr. Elnahal [continuing]. At Camp Lejeune.
    Senator Tillis. Well, what I am trying to get at is there 
are--the majority of suicides that occur every day are 
nonconnected veterans, not connected to the VA. We always talk 
about--we had a substance abuse discussion last week. Same 
thing, fair to assume that a lot of the people that are 
succumbing to overdoses and dying are likely not connected.
    And it just seemed to me to be a perfect time to get two 
things accomplished. Number one, let these veterans who are not 
connected know we want them connected to the VA and also let 
them know they may not have to spend a dime to get the benefits 
that they are entitled to if they call a congressional office 
or if they call a VSO.
    And so we are trying to put a bill together. We want to get 
the technical aspects of it right, but we are just simply 
saying: Before you sign a retainer for an attorney who is going 
to take some of the benefits that you would otherwise be 
eligible, have you at least contacted your Senators? Have you 
contacted your Congressmen? Have you taken--have you contacted 
a VSO that is focusing on this?
    Do they understand all the resources that we want to give 
them that will not cost them a dime that could remedy it. For 
complex situations, go get an attorney.
    But I am just trying to figure out--it seems fairly simple. 
It does not cost a whole lot. Probably will not make trial 
lawyers very happy. But it puts us in a position while this 
subject--and it will be through next year or summer of next 
year. It is going to be running through the ads. It just looks 
like a great opportunity to engage more people, I mean.
    Philosophically, do you see any holes in what we are trying 
to propose here?
    Dr. Elnahal. Absolutely not, Senator. I completely agree 
with you that we think the best outcomes for veterans are more 
possible if a veteran files a claim for their exposure to 
contaminated water.
    Senator Tillis. I just want them fully informed. It amazes 
me how people thank me for doing my job in constituent service, 
and I want them to know that that is what I get paid to do here 
and that is one of the primary reasons that I am here. So we 
are going to continue to work with you all and hopefully get 
your support for the bill.
    I am not going to have time to go through some other 
questions, but I do have one on wait times. I have also got--I 
always say I do not do constituent service here. I am going to 
break my rule.
    I know that the Salisbury VA currently does not have CAT 
scan capabilities on premise. Is that a violation of VHA 
directive?
    Dr. Elnahal. They should have CT scan operations online, 
and we did look into this issue. The medical center is 
understaffed in the CT imaging department right now, which is 
why at certain periods of the week they do have to refer to a 
community provider to get that imaging.
    We really should have that imaging up 24-7. CT scan is a 
fairly basic imaging modality that should be available at all 
times for a lot of reasons. And so rest assured the facility is 
doing everything it can, especially with the new PACT Act 
hiring, retention, and salary authorities, to make those CT 
tech jobs more attractive, and we hope they will be able to 
staff up soon.
    Senator Tillis. Well, we are watching that. You know, that 
particular center is a big catch basin, so I think it is 
something that we will be tracking.
    And, Chair, can I ask one other question?
    Chairman Tester [presiding]. You bet you can.
    Senator Tillis. Since you have no alternative.
    Chairman Tester. Unless Senator Boozman has a fuss.
    Senator Tillis. Oh, I forgot. Senator Boozman, I will be 
real quick.
    On the wait times, I know that we are getting the high 
level numbers, but how granular can we get? Can I go to a VISN 
level? Can I go to a geographic area so that we are all 
drilling down at the atomic level for me to know where--I have 
not seen that. I have seen the high level numbers and the 
trending, but is that something that you all can just submit 
back for the record?
    Dr. Elnahal. We can, Senator. You can also go to 
www.accesstocare.va.gov. All of that information is 
transparently available to the public, wait times by medical 
center, wait times by VISN, across multiple services, but we 
are happy to take----
    Senator Tillis. Does it drill down beyond VISN?
    Dr. Elnahal. Absolutely, by medical center.
    Senator Tillis. Okay. Then we will do the homework there. 
Thank you all.
    Chairman Tester. Senator Tillis, I have not heard the word 
``granular'' since we used to meet with Bob McDonald.
    Senator Tillis. I miss him.
    Chairman Tester. Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Okay. Thank you, Mr. Chairman. Thank you 
and Senator Moran for holding this hearing. Taking care of our 
veterans has always been, and still is, our highest priority. 
Access to quality care, especially in rural communities, is 
essential regardless if they receive the care at the VA or in 
the community, and we do appreciate you all's hard work in 
trying to make that happen.
    Dr. Elnahal, I am interested in knowing what the average 
time is for a veteran to receive an appointment, what is being 
referred to Community Care Referral Coordination Team for 
scheduling.
    Dr. Elnahal. So, Senator, where we started this fiscal year 
was an inexcusably long interval of time. It was an average of 
about 28 days to be able to--for the veteran to get their 
confirmed appointment, which is not excusable, and it is also 
why we have put the time to schedule as one of the three main 
metrics we are tracking across the system.
    I want to ask my colleagues if they have the latest average 
for time to scheduling for the Senator. If not, we can take it 
for the record.
    Dr. LaPuz. Well, just to be accurate, we will take that for 
the record, but I would like to actually add to the response 
that in fact since we have started looking into this, you know, 
the average time to schedule, community care, what we have seen 
is an improvement by 60 percent of the facilities, by over 60 
percent of the facilities. So from first quarter of this fiscal 
year to the second quarter, over 60 percent have improved in 
three categories. That is primary care, mental health, as well 
as in specialty. Specialty not so much, but in primary care and 
mental health, we are showing around 60 percent of the 
facilities are improving.
    Senator Boozman. No, that is good. And again, I am not 
being critical yet and just really trying to understand. I know 
how difficult it is to schedule patients, you know, outside of 
the VA. Just within the community to other community members, 
it is difficult.
    Do you break it down? If you have got somebody that maybe 
came in with really significant neurological conditions, 
somebody that you felt like, you know, was in a situation that 
really acutely needed care then, do you break it down how much 
time it takes to get to that specialist versus just kind of 
lumping it all together?
    Dr. Elnahal. Absolutely, Senator. So if the referring 
provider classifies a consult as urgent, we have a standard for 
that veteran to be seen within two days, and thankfully, we are 
meeting that standard for urgent appointments.
    Senator Boozman. Good, very good. Veterans in a rural 
state, like my State of Arkansas, face unique challenges to 
care. I say, unique. You know, this is something that happens 
all over the country, but some of these challenges include lack 
of access to broadband and long driving distances to access 
quality of care.
    According to the GAO, about one-third of veterans enrolled 
in the VHA live in rural areas. Additionally, GAO found that 17 
percent of people living in rural areas lack broadband access. 
Given these challenges that rural veterans face to receiving 
care, can you speak to what the VA is doing to ensure rural 
veterans are receiving access to community care?
    Dr. Elnahal. Absolutely, Senator. First, on your point with 
broadband, and I will pass the community care part of the 
answer to Ms. Peabody in a second. But we have a program with 
the FCC that actually does allow for support in the form of 
financial support for veterans to be able to get broadband, and 
we also do have a program that offers devices to veterans to be 
able to receive telehealth appointments. And there has been 
some significant uptake in that program, especially in rural 
areas.
    I have also charged our Office of Rural Health to look into 
other options to potentially offer broadband within our current 
authority, and we will come back to you with ideas on that if 
we do not have the authority to do so.
    Ms. Peabody?
    Ms. Peabody. Thanks for the question. Two things I would 
like to mention, Senator. One is our VA Health Connect, which 
Dr. Elnahal mentioned in his opening testimony. That is already 
taking about 45 million calls a year. That really serves as 
VA's front door. So we want to be able to expand some of those 
capabilities with VA Health Connect, expanding what we are 
doing in the several VISNs where it exists today so that a 
veteran just call.
    We are looking at doing tele-emergency care through VA 
Health Connect as well. So I think that is one way that we 
should be able to reach more rural veterans.
    With respect to our community care program, we are 
currently in the thick of some pretty heavy market research for 
our community care next gen contract, and so one of the things 
we are looking at is getting some industry feedback on how we 
can do that better, what are some unique industry ways we can 
do that in rural areas. Thank you.
    Senator Boozman. Can I ask one more question, Mr. Chairman?
    Chairman Tester. You bet.
    Senator Boozman. What is your biggest obstacle? You are in 
situations where people need to get into the community for 
various reasons. You know, you do not have the ability to take 
care of them. What is your biggest hindrance to that?
    I said earlier I understand. You know, I was a former 
provider. I understand how difficult it is and referral 
patterns are anyway. Is it that? Is it lack of access to 
specialists, or is it are we not paying enough? Is that a 
factor where perhaps providers are limited their access to VA 
care that way?
    What is the biggest handicap that you have as far as 
getting people in the hands of these folks?
    Dr. Elnahal. So candidly, Senator, I think the biggest 
bottleneck now is our scheduling process. I takes much too 
long. It requires our currently, in many places, understaffed 
offices of community care throughout the field to go back and 
forth between community providers and veterans themselves.
    I mentioned an example in my opening about a veteran out of 
Bedford who was able to schedule his own appointment in two 
days because at that medical center they have veteran self-
scheduling across all of their community provider appointments. 
Because the veteran knows their own schedule, give them an 
authorization and providers within our network; they can do it 
themselves, which is another reason--which is the major reason 
why we are doing self-scheduling across more and more 
specialties, to include optometry, by the way, your field. And 
so as we continue to try to increase that option, we hope to 
see that process get better.
    Senator Boozman. So your schedulers do not seem to have 
that much flexibility. Is that correct? I mean, is it more 
rigid than in private practice?
    Dr. Elnahal. I think they are understaffed. That is one of 
the major issues. The workload is significant. And I also think 
the systems that they are using are not meeting the needs for 
an efficient workflow, which is why Dr. LaPuz highlighted 
earlier our acquisition effort for a community care scheduling 
system whereby we can work directly with our community 
providers, see directly into their grid should they agree, and 
make that process a lot easier.
    Senator Boozman. Good. That is helpful. Thank you all very 
much.
    Thank you, Mr. Chairman.
    Chairman Tester. Just a quick follow-up, I think Senator 
Blackburn is going to be coming in, in a second. So we have had 
many hearings on electronic health records. Does the electronic 
health record potentially fix the scheduling issue?
    Dr. Elnahal. It----
    Chairman Tester. As a community care component.
    Dr. Elnahal. It does not in and of itself, Senator. So we 
are actually in the market for a scheduling system that would 
meet the need for community provider scheduling.
    We do have the option to use that scheduling module. It is 
in use in one place, in Columbus VA, and it is part of a number 
of things that we are going to try to improve across the five 
sites during the reset period for the electronic health record. 
But that is not the system we have committed to using because, 
you know, again a lot of these improvements need to be made.
    Chairman Tester. Okay, Senator Sullivan.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman, and appreciate 
the witnesses here today. I have kind of a really important 
issue and have kind of been here before, but we really need 
your help on it, and it is with regard to call centers.
    So when I first got elected in 2015, I think it was the 
MISSION Act; they had removed the local call centers that were 
based in Alaska I think down to Louisiana or something. So we 
had the VA call centers that were really good and effective in 
Alaska, and then they were moved, and then you had people in 
the lower 48 who were making appointments for veterans based in 
Alaska who had no idea about Alaska.
    You know, it is a very big state, and you would have--let 
me give you one example. You would have someone from Ketchikan, 
and they would call, and these guys would say, oh, you can just 
drive to Anchorage. Well, you cannot drive to Anchorage from 
Ketchikan, right? So it was this basic stuff, and it really in 
many ways collapsed the system.
    So the new incoming Under Secretary, Dr. Shulkin, who later 
became Secretary, he came up to Alaska, saw this chaos, and 
committed to me to fixing it, which he did, brought the call 
centers back.
    Well, we are having the same problem again. As you probably 
know, VISN-level call centers are to ensure a consistent 
experience for veterans. Alaska is part of VISN 20, which 
includes Washington, Oregon, and West Idaho, which of course, 
would make it the biggest region by far. And we once again have 
call centers that have been moved out of the state, and so the 
number of veterans--so we have nobody who understands the 
geography just making the basic appointments.
    And so I am trying to get you guys to commit to supporting 
a new VISN call center--this is kind of going back to 2015--
that would be based in Alaska to support the consistent 
experience for veterans, which is what you testified to. It 
just makes sense.
    The number one issue I am hearing from our veterans right 
now is this issue, call centers. They do not understand that 
the wait times are long again, but--the VA does a great job in 
my state when they are local, but when they are outsourced to 
other places--you know. I mean, it is not their fault really, 
but they just do not understand the geography and what it 
takes.
    So you know, we do not have a full-service hospital, the 
VA, in the whole State of Alaska. We have more vets per capita 
than any state in the country.
    I am just hopeful that you guys can bring back call centers 
to have better service, so I would like to get your view on 
this. I have raised it with the Secretary. I think he is 
amenable, but this would give--again, to your testimony, it 
would ensure a consistent experience for veterans regardless of 
where they live.
    Dr. Elnahal. I am also amenable, Senator, and I appreciate 
you making me aware of those concerns for your constituents. 
This may have been a function of the transition to VA Health 
Connect, which is the centralized VISN-level call centers----
    Senator Sullivan. It was.
    Dr. Elnahal [continuing]. As you were mentioning. And so I 
understand that Alaska is a unique environment. I do hope to 
visit at some point.
    Senator Sullivan. Yes, we would love to have you out.
    Dr. Elnahal. Perhaps, I can travel----
    Senator Sullivan. This summer.
    Dr. Elnahal. Yes.
    Senator Sullivan. When the salmon are running.
    Dr. Elnahal. But absolutely something we have to look into 
because we need to serve vets in Alaska to the best extent we 
can.
    Senator Sullivan. Okay. And again, I appreciate the 
commitment. My staff and I will work with all of you. It is 
just deja vu all over again. It got fixed last time by Dr. 
Shulkin, and we are in the same spot, and we are hearing the 
same challenges. And so if we can work with all of you on 
dealing with this issue for community care, especially care, it 
would be really helpful.
    So, thank you for that approach. I think the Secretary is, 
like I said, amenable. And we all share the same goal, which is 
getting our vets the care they have earned, and this is an 
important way to do it in my state. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
all for coming in. Let me give you an example of some of the 
problems Tennesseans are having with implementation on 
community care, which is something they really want.
    And I had one veteran from Chattanooga, recently was giving 
me her story of trying to get community care for mental health 
services, and she was telling me how frustrating this was. And 
she likened it to going to the DMV and having a really bad 
experience and having to jump through all the hoops that were 
there. And finally, after meeting everything the VA made her do 
on community care, eight months later, eight months, she was 
able to see a mental health specialist in Chattanooga.
    This is so totally unacceptable, and it is as if the VA is 
trying to stonewall people and not let them into the community 
care program. Some of these individuals do not have someone 
that can take a day off work and drive them to a VA facility, 
and when they call they are needing help then.
    Likewise, right now--and we check regularly to see how long 
the wait times are--if you wanted, in Clarksville, to go to a 
primary care physician, let us say you are sick and you call 
today and say you need to see someone in primary care at the 
VA, 28 days. In other places in the state, it is 74 days, 100 
days, to see somebody. So we have got to do something about 
allowing veterans to get to the care they need at a place where 
they are able to get the care, and that is the whole purpose of 
community care.
    And I have got a Veterans Health Care Freedom Act that 
would create a pilot program that removes these requirements 
that a veteran has to get all this preauthorization and jump 
through these referrals.
    Dr. Elnahal, do you think that veterans can make these 
decisions on their own? Do you all trust them to make these 
decisions?
    Why are we getting these continual roadblocks? Is it the 
employee's union that does not want this to work? What is the 
issue?
    Dr. Elnahal. Well, Senator, the first thing I will say is 
if the veteran is amenable and your office is amenable, we are 
happy to do everything we can for the veteran you just 
mentioned. You know, that is an inexcusably long wait time, I 
agree, and we have to do better.
    Senator Blackburn. We have a long list of those.
    Dr. Elnahal. Yes.
    Senator Blackburn. That is just one.
    Dr. Elnahal. And again, we are happy to review every single 
one and meet their needs. We have a patient advocacy office 
that can help us with that.
    More broadly, it is why--the problems you are mentioning 
are exactly why I have identified the time to schedule veteran 
appointments in the community as one of the most important 
metrics we are tracking across the system. And where we are 
seeing deficiencies and inexcusably long wait times, we are 
honing in on trying to improve them and standardize those 
processes.
    We are also trying to expand the program that allows us to 
simply hand a veteran an authorization and a list of providers 
in the community that are in our network and empower that 
veteran to schedule the appointment themselves. Where we have 
tried this in certain areas of the country, Bedford, 
Massachusetts, VISN 19, we have seen success. We have seen that 
care coordinate sooner.
    Senator Blackburn. That is what veterans want. Well, let me 
ask you this: If that is your goal, is to say, here you go, 
here is a list, you know, if they call the VA, they can e-mail 
that list back to them right then so they call through, then 
why did the VA take down the MISSION Act website?
    Dr. Elnahal. So I think, Senator, the website has the 
content that it has always had. The purpose of the update to 
the website was to offer a one-stop shop to veterans online to 
understand all our programming, both internally within the VA 
and in the community.
    I am squarely focused, in addition to improving access to 
our direct care system, on making sure that the veteran 
experience through our community care program gets better and 
better. And again, we have identified that time to schedule, 
the coordination of care in the community as the most important 
things we have to improve, and you can be assured that I am 
very focused on that.
    Senator Blackburn. Well, I would encourage you to try one 
of your pilot projects in Tennessee because we could give you a 
list of stories like this, a list of people that are waiting, 
as I said, 30, 70, 100 days to see a primary care physician, a 
list of people that are waiting for oncology and they are 
waiting months. So we would invite you to try one of these 
pilot projects in Tennessee.
    Thank you so much for being here today.
    Dr. Elnahal. Thanks, Senator.
    Chairman Tester. The good Senator, Dr. Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Thank you, Chairman Tester. I am going to 
probably ask some questions that are kind of 101 just to try 
and understand, and I apologize if others have asked.
    So somebody is referred to a cardiologist. Now the 
cardiologist has a whole list of things that the cardiologist 
could order. Does that authorization to the cardiologist's 
office include a preauthorization for whatever test the 
patient--for whichever test the doctor would order?
    Dr. Elnahal. I will ask Ms. Peabody to help with that 
question, Senator. Thank you.
    Ms. Peabody. Senator, yes, that is correct.
    Senator Cassidy. So now I am going to approach this from 
the other side. There are some providers who are overutilizers, 
and if you overutilize you obviously have an increased risk of 
complications. So if somebody goes with chest pain, you get an 
EKG, you get an echo, you get a treadmill, you get a 
radionuclide study, and other tests. I am a little rusty on my 
health care. Could they go all the way to a cardiac 
catheterization on that same authorization?
    Ms. Peabody. Senator, one of the things that Dr. Elnahal 
has actually charged our office with is taking on looking at 
appropriateness of care. As we look at our future CCN 
contracts, we know that we have got to find unique ways to 
better address making sure our veterans get the right quality 
of care. So as part of that, we are in the process of 
developing a strategic plan and roadmap for how we will be 
looking at that.
    Senator Cassidy. Can I stop you a second?
    Ms. Peabody. Yes, sir.
    Senator Cassidy. But now--I am just speaking now, not as 
developing a roadmap--if I had that preauthorization for that 
doctor's office, could that doctor take me all the way to a 
cardiac catheterization with no review of whether or not that 
cardiac catheterization would be appropriate or not?
    Ms. Peabody. Dr. LaPuz, do you want to add?
    Dr. LaPuz. For outpatient, not necessarily. So cardiac 
catheterization is not authorized for outpatient care. Now on 
the other hand, if the veteran went to the emergency room, that 
cardiac catheterization would be part of the SEOC for that 
emergency room visit.
    Senator Cassidy. Now, are you doing--because we also want 
to make sure that the veteran gets the care the veteran needs, 
but we also want to be protective of taxpayer resources. And we 
know that--I am a physician, so I will just say that there is a 
subset of physicians that will greatly overutilize if there is 
no check on what they order. So has there been any ongoing 
evaluation of the people to whom the VA refers or has in their 
provider network as to the amount of testing they order and, by 
extension, the appropriateness of that testing?
    Dr. Elnahal. So, Senator, I will say that you are 
highlighting one of the major risks that we see right now. The 
good news is that in my charge, as Hillary mentioned, to 
Integrated Veteran Care on doing more work on appropriateness 
of care, a lot of this data is already public vis-a-vis 
Medicare. So we have ways----
    Senator Cassidy. I am with you on that. So I know; believe 
me, I understand. You can understand if somebody is ordering 
this test, you know, two standard deviations more than 
everybody.
    Dr. Elnahal. Yes.
    Senator Cassidy. And there are guidelines for the 
cardiologist that say, no, you should only be ordering to here.
    Dr. Elnahal. Yes.
    Senator Cassidy. Is the VA looking at that and looking at 
the--okay, this is how much I am being charged? Are you looking 
at a frequency distribution to make sure that we are only 
putting people as providers who are ordering tests 
appropriately, knowing that they could appeal, there can be a 
review, there may be some extenuating circumstances, but also 
knowing that some people will order too many tests?
    Dr. Elnahal. So, Senator, we do not consistently look at 
that right now when we do authorizations, and I have identified 
that as a risk to veterans, most importantly, because 
overutilization is not just a cost issue.
    Senator Cassidy. Now let me ask because I think it was a 
couple of years ago that I asked this same question.
    Dr. Elnahal. Okay.
    Senator Cassidy. And so is there--and I cannot blame you 
all. I mean, Ms. Peabody is from Tulane, and I will forgive 
that. I am an LSU graduate. But I am just teasing. You are an 
LSU--you are a Louisiana person. I like that.
    But I guess my point is having raised this issue before and 
finding that there is not a program in place, but like every 
insurance company in the nation has a program like this.
    Dr. Elnahal. Yes.
    Senator Cassidy. This is not new territory. And in the 
MISSION Act, the VA is effectively an insurance company.
    So is there any thought of contracting with a third-party 
administrator, using off-the-shelf tools to allow them to 
immediately apply a system as opposed to the VA developing 
their own? I just say that because I do not want two years from 
now to be asking the same questions and finding the same 
answer.
    Dr. Elnahal. I think you have the right focus, Senator. I 
think there are things not only--and I will ask Ms. Peabody to 
talk about what we are thinking for the next generation 
community care contracts with the TPAs. But there are also 
operational things we can do on just data visibility, if we 
execute it right, that will show which providers are high 
quality, meeting our standards for veteran care and where 
appropriateness of care measures are deviated----
    Senator Cassidy. I am totally with you on that.
    Dr. Elnahal. Yes.
    Senator Cassidy. But I would like to move from the 
theoretical to the operational.
    Dr. Elnahal. Me, too, Senator. Absolutely.
    Senator Cassidy. And can you give us a timeline of when you 
think you would either contract with a third-party 
administrator or be able to use this kind of transparency 
because ultimately I do not care what you do? You are either 
spending money--but even minor tests can have complications.
    Dr. Elnahal. Yes.
    Senator Cassidy. I mean, I can just tell you. You know, you 
do procedures. Sooner or later, you have something going on. So 
I am just sensitive to this.
    Ms. Peabody. Senator, there is one thing that gets at what 
you are asking I think that we have put in place. We just have 
not implemented it universally, and that is our High Performing 
Provider program. So we are using from both of our TPAs, from 
TriWest and from Optum. They are already, you know, normal 
insurance industry-recognized standards, and they have done 
some customization for VA.
    And you can see within PPMS, which is our internal provider 
directory that the schedulers use to find a provider for our 
veterans when they are scheduling, they can see if the provider 
has that HPP designation. What we have not done is mandated 
that you must schedule to that or that you have to tell the 
veteran. So we are working on figuring out how we can better 
optimize that.
    And then as part of that CCN next gen contract, getting to 
your question about timeline, I think we will most likely put 
some additional requirements in place under that contract, 
which will be in place in the next couple of years.
    Senator Cassidy. I am not a cardiologist, but I also say, 
going back to Dr. LaPuz's point, just because someone goes to 
the ER with chest pain does not mean they should be cathed. 
There is a lot of other reasons for chest pain that can be 
evaluated before cath.
    It also seems like that is sort of--and every now and then 
somebody dies from a catheterization. So it does seem as if you 
could do a frequency distribution there.
    I am just asking that and would ask you all to implement it 
ASAP for the variety of reasons that we discussed. So, thank 
you.
    Chairman Tester. Senator Cassidy, I want to thank you for 
that line of questions because I think it is spot-on. I mean, 
if you take a look at the growth in money that we are putting 
out for community care, it is exponential, predicted to be $2 
billion a year for the next three or four years, additional to 
the 23.5 we are at right now. And I think that point is a point 
you talked about, spending taxpayers' dollars appropriately.
    And so I am willing to work with you. I am willing to work 
with you guys to make sure that people are doing the right 
thing, basically. So, thank you.
    I want to thank you guys for being here today. Appreciate 
it very much. I look forward to continuing to work with you to 
ensure veterans receive timely, quality care in the VA and in 
the community.
    And we will keep the record open for a week, and as long as 
there are some questions you have already taken for the record, 
I would like you to get those answered as soon as possible. 
With that, this hearing is adjourned.
    [Whereupon, at 4:36 p.m., the hearing was adjourned.]

                            A P P E N D I X

                           Prepared Statement

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                        Questions for the Record

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