[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]
COMMUNITY CARE NETWORK NEXT
GENERATION: ONE TRILLION
DOLLARS OF OVERSIGHT
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED NINETEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, JANUARY 22, 2026
__________
Serial No. 119-45
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
64-341 WASHINGTON : 2026
=======================================================================
COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa SHEILA CHERFILUS-MCCORMICK,
GREGORY F. MURPHY, North Carolina Florida
DERRICK VAN ORDEN, Wisconsin MORGAN MCGARVEY, Kentucky
MORGAN LUTTRELL, Texas DELIA RAMIREZ, Illinois
JUAN CISCOMANI, Arizona NIKKI BUDZINSKI, Illinois
KEITH SELF, Texas TIMOTHY M. KENNEDY, New York
JEN KIGGANS, Virginia MAXINE DEXTER, Oregon
ABE HAMADEH, Arizona HERB CONAWAY, New Jersey
KIMBERLYN KING-HINDS, Northern KELLY MORRISON, Minnesota
Mariana Islands
TOM BARRETT, Michigan
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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THURSDAY, JANUARY 22, 2026
Page
OPENING STATEMENTS
The Honorable Mike Bost, Chairman................................ 1
The Honorable Mark Takano, Ranking Member........................ 4
WITNESSES
Panel I
Mr. Richard F. Topping, Assistant Secretary for Management and
Chief Financial Officer, U.S. Department of Veterans Affairs... 8
Accompanied by:
Ms. Alicia Skolrood, Executive Director, Integrated External
Networks, Office of Integrated Veteran Care, Veterans
Health Administration, U.S. Department of Veterans
Affairs
Panel II
Mr. John Vick, Executive Director, Concerned Veterans for America 41
Dr. Rachel Madley, Ph.D., Executive Director, Center for Health
and Democracy.................................................. 43
APPENDIX
Prepared Statements Of Witnesses
Mr. Richard F. Topping Prepared Statement........................ 55
Mr. John Vick Prepared Statement................................. 58
Dr. Rachel Madley, Ph.D. Prepared Statement...................... 65
Statements For The Record
Letter to The Honorable Douglas A. Collins from The Honorable
Maxine Dexter, U.S. House of Representatives, (OR-03).......... 77
Questions for the Record Submitted by The Honorable Abe Hamadeh,
U.S. House of Representatives, (AZ-08)......................... 79
COMMUNITY CARE NETWORK NEXT
GENERATION: ONE TRILLION
DOLLARS OF OVERSIGHT
----------
THURSDAY, JANUARY 22, 2026
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, DC.
The committee met, pursuant to notice, at 10:17 a.m., in
room 360, Cannon House Office Building, Hon. Mike Bost
(chairman of the committee) presiding.
Present: Representatives Bost, Radewagen, Bergman, Miller-
Meeks, Van Orden, Luttrell, Self, Barrett, Takano, Brownley,
Pappas, Cherfilus-McCormick, McGarvey, Ramirez, Budzinski,
Kennedy, Dexter, and Morrison.
OPENING STATEMENT OF MIKE BOST, CHAIRMAN
Mr. Chairman. Good morning. Without objection, the chair
may declare a recess at any time. We are expecting votes about
10:30, so odds are we will have to do that.
Before I proceed, I would like to clarify the purpose of
this hearing. Article 1 of the Constitution grants Congress the
authority over financial matters and the powers to create law
governing the executive branch and the responsibilities to
oversee the executive--execution of those laws. The committee
is neither a stakeholder in this contract, a bidder, nor a
regulator. We are the constitutional body responsible for
authorizing funding and overseeing the Department of Veterans'
Affairs. Our duty does not dismiss--diminish simply because a
contract is large, complex, or currently active.
I also want to raise the issue of timelines and timeliness
with the testimony for today's hearing. This is the second time
this week that we have not received the testimony from U.S.
Department of Veterans Affairs (VA) in a timely manner. It is
incredibly frustrating for staff and members to try to prepare
for a hearing without having testimony to review prior to the
hearing. If this were not such an incredibly important hearing,
I would consider preventing VA from testifying today. However,
given the importance of this hearing and the need for this
committee to conduct critical oversight over this contract, I
plan to proceed for the hearing, but rest assured that I will
not be forgiving in the future.
Now, I want to thank Mr. Richard Topping for being here
today. Mr. Topping is a VA assistant secretary for Management
and chief financial officer (CFO). Before VA has--before he
has--was chief legal officer for CareSource, which is a
Medicaid management care organization. He was also president of
CareSource Military and Veterans, which is a piloting
competitive health plan for TRICARE. More importantly, Mr.
Topping is also a veteran, an Army veteran, but we will have to
excuse him for that. This is the whole jarhead thing. I cannot
help it. I believe the background makes him a good fit to lead
the Trump administration's effort to manage VA's Community Care
Next Generation contract.
However, this contract is going to cost the American
taxpayer an estimated $1 trillion. I want to make sure this
money goes where it needs to go, improving health care access
for veterans nationwide, no matter who at the VA is in charge.
This hearing is the beginning of the conversation between VA
and Congress to ensure this contract will maximize health care
access and choice for veterans.
The Community Care Next Generation contract, or CCN Next
Gen, is one of the largest government contracts in the Nation's
history. It is also a unique type of Indefinite Delivery,
Indefinite Quantity (IDIQ) contract being used to purchase
health care. I am sure that Mr. Topping will explain that in
detail in his testimony. Long story short, this is a
revolutionary idea. If done properly, this contract would allow
unprecedented flexibility for VA to award contracts and task
orders that would leverage competition for the benefit of our
veterans. It is an ambitious idea. If it works, it may be one
of the most important innovations in government-run health care
programs.
Unlike the first generation, CCN Next Gen would all--would
award multiple contracts at the outset. Rather than being stuck
with just one contractor, this will allow different contractors
to compete for new task orders. As I understand it, the idea
that the VA would be able to leverage new ideas and innovation
for the benefit of the veterans. This contract structure would
also provide a way to off-ramp poor-performing contractors.
CCN Next Gen will also feature Value-Based Care, or VBC, at
a base requirement. VBC has long been an effective way for
health systems to control cost while promoting quality care. It
is a concept that is fully vetted and tested by Medicare, and
it is long overdue in health care access for veterans in the
communities where they live. I am glad that we will be able
to--that we will be paying providers for the health care they
deliver rather than services they bill.
Another new feature of this contract is utilization
management, or UM. This is an important cost control tool, but
it is also sometimes seen as a burden placed on providers and
patients. One example of UM is the dreaded prior authorization.
Now, without it, payers would have no way to stop unnecessary
spending. With it, some doctors have to move heaven and earth
to get the right treatment for their patient. Needless to say,
we are interested know how VA plans to strike the proper
balance that ensures veterans receive the care they need and
deserve while also preserving and maintaining programs
integrity.
VBC and UM are only two of the many new features of the CCN
Next Gen contract.
I bring up these two because they are both rich in
opportunity and in need of congressional oversight. Neither of
these are new concepts in American health care, but they are
new to the VA. I want to know how well VA is preparing to
implement these features in the Community Care Program. Having
Mr. Topping at the helm does give me confidence, but as a great
man once said, trust but verify. I want assurance backed with
details and explanations that VA will make every effort to
ensure that the real world execution matches the vision. I need
to know that VA will innovate where necessary and lean on
existing resources and expertise. For instance, the Department
of War is constantly managing complex contracts, and the U.S.
Department of Health and Human Services (HHS) has whole
divisions dedicated to payment policies. There will be new
ground that VA must break, and let us not reinvent the wheel.
Mr. Topping, we are all eager to hear how you will be
bringing this together for the millions of veterans in VA
services. We are eager to hear what your team has been working
on, from the CFO and all the way down to the contracting
officer. Also, we are eager to hear in details how you
implement--how you will implement such a complex system and
bring veterans care into the next generation. As I understand
it, there are some topics that VA will choose not to get into.
I understand the VA finds it unprecedented to hold a hearing on
an active contract solicitation. I appreciate the sensitivity
of the contract, but it is also unprecedented to avoid
Congress's oversight of $1 trillion of spending.
My staff and the ranking member's staff have been told that
some topics are off limits because of the sensitive nature of
the contract and solicitations. We will have--we have tried to
create a venue in which VA would feel comfortable to speak
candidly to our members, but unfortunately, VA failed to assure
us of such candor. As such, we are not able to close portions
of this hearing for more candid conversation.
I would also like to thank the Ranking Member Takano and
his staff for working with us to exercise this oversight. Mr.
Takano, I assure you this hearing is only the beginning of
congressional oversight.
Community care is an extension of VA care. It should go
without saying that VA must get this right. When veterans call
my committee, they want to know how they can access their
earned health benefits at VA. They do not ask contracts what VA
is used to provide the care. That is the core of the Next
Generation contract and why we must have this hearing. We must
deliver modern health care access and choice to our veterans
without run around--running around or red tape. Veterans have
been enrolled in VA at unprecedented rates in every part of
this country. Community care is the only way that VA can keep
up with this mission. It is the best way we have to get health
care to the veterans with the right treatment, at the right
time, at the right place. If we do not do our due diligence to
maintain and improve community care, we dishonor the memory of
the countless veterans who have lingered on a secret wait list
at the VA medical centers without receiving the care they
earned. Let me say that again. We must get this right.
Before turning to the ranking member, I would also like to
take a moment to thank Representative Brownley for her years of
service to this committee. You have done amazing work on Health
Committee, Health Subcommittee relating to suicide prevention
and also improving services for women veterans. I want to say
how thankful we are. Thank you. I know you have the rest of the
session, but I hope you enjoy retirement and that life is
better on the outside for you in the future. Yes, yes.
With that, Ranking Member, I now recognize you for your
opening statement.
OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER
Mr. Takano. Thank you, Mr. Chairman. As you mentioned,
your--the very beginning of your opening comments, you referred
to the untimeliness of the testimony from VA that was due at 10
a.m. on Tuesday. We did not receive the testimony until 6 p.m.
last night. I advise the VA witnesses to review on YouTube, and
I will have my staff look it up and send it to you, the
reaction of Republican--of the Republican chairman of the
Judiciary Committee from the State of Wisconsin, James
Sensenbrenner's reaction when testimony arrived late. He
canceled the hearing.
We are reviewing a contract of enormous proportions,
historic proportions. You gave our committee staff way less
time than they were owed under the--under this--under our
committee rules. I, if I were its chair, I would have postponed
the hearing because we need to review your testimony and
prepare the questions for this committee. It is inexcusable.
This should never happen again. I want to reiterate that. It
will not happen again, or I will lodge an even larger protest
with the chairman. This is disrespect to Congress, and I, in my
opinion, we are showing way too much deference to the
administration in this case. We represent the American people,
and this is a near-trillion-dollar contract. Enormous
disrespect. Get your testimony here on time, especially when we
are reviewing a trillion dollars.
Thank you, Chairman Bost, for yielding. As I said, nearly a
trillion dollars. I must admit I am a bit taken aback hearing
our Republican colleagues speak positively about the government
spending such a large sum. Although, in the chairman's words,
he showed some concern, actually a great deal of concern, about
the amount of money that we are talking about spending here.
To put it in perspective, the $700 billion ceiling on this
contract for VA community care is equivalent to what President
Trump offered Denmark to purchase Greenland. Just as I believe
the president is unnecessarily agitating our most important
allies, I fear VA's plans for Community Care Network Next
Generation contract will put the agency on an unsustainable
course, barreling toward privatization, hollowing out direct
care. I believe as my colleagues will go through the
questioning, we are going to look at what appears to be an
unsustainable trend in the increase in spending in the
community care accounts. I am willing to pay any price for
veterans to receive every benefit they deserve, including
access to high-quality health care.
When we passed the largest expansion of veterans benefits
in history, the Sergeant First Class Heath Robinson Honoring
our Promise to Address Comprehensive Toxics (PACT) Act, we knew
more veterans would use VA services and that we would need to
invest in VA to pay for the costs of war. VA is the best place
for veterans to receive care. Throughout the chaos of the last
year, my Democratic colleagues and I have loudly voiced our
concerns about VA's future. VA's future is dependent on its
people. VA is understaffed. VA is understaffed. If we walked
into any VA facility in the country right now, I guarantee that
the director would tell us their number one concern is
understaffing. It is difficult for me to sit here and discuss
this enormous contract for community care, which is one of the,
if not the largest, procurement in VA's history, when we have
not seen this administration make similar investments in VA
direct care itself.
Instead, every headline we read, every whistleblower email
we receive, every veteran perspective shared at our town halls
is about cuts and how those cuts are impacting veterans'
ability to receive the VA care they know, love, and rely on.
Secretary Collins proudly carried out the performance--the
performative Office of Management and Budget (OMB) decree to
illegally terminate probationary employees, only to be ordered
by the courts to reinstate them. He oversaw and encouraged the
departure of nearly 40,000 employees last year, including
thousands who vacated frontline veteran-facing positions. Now
we are anticipating the impact of his directive to cut nearly
30,000 positions from VA's roles. There have been no hiring
incentives, no investments in VA itself under Secretary
Collins, only cuts.
Yet today, VA comes before us with a grand vision to
continue to grow community care. VA has tripled how much it
spends annually on community care since 2018. This Request for
Proposal (RFP), valued at nearly a trillion dollars over 10
years, would continue the exponential, out of control,
unsustainable growth of Community Care. You wonder why I am
ticked off that you come here and bring your testimony, and
give it the--submit it at 6 p.m. last night.
Now, we have here, behind me, a poster. According to VA's
own data, the number of individual veterans using community
care increased by only 34 percent between 2021 and 2024.
However, during that same period, expenditures for community
care grew a whopping 67 percent from $19.7 billion in 2021 to
$32.9 billion in 2024. This far outpaces the growth of health
care costs for civilians also receiving care in the private
sector. Civilians also know that the cost of health care rises
faster than regular inflation. VA health Care is growing faster
than civilian health care.
We should all be asking ourselves why? Why did the cost of
community care so drastically outpace the number of veterans
using it? What controls is VA putting in place in the next
generation of this contract to contain those costs? Sadly, I
fear the answer to that question will disappoint us. If we
divide the $700 billion ceiling for the contract over its 10
year span, that leaves us with VA averaging about $70 billion
in annual spend on community care going forward, which is over
double what VA is spending today.
Again, what is the justification for this rapid growth?
VA's testimony today will claim that it is implementing cost
containment--a cost containment framework. It expects to reduce
community care spending by $54 billion over the next decade.
Even if that speculative cost savings pans out, this RFP still
estimates VA will spend $30 billion more a year over the course
of the new contract than it is spending now. I am sorry, this
is not cost containment, it is cost explosion.
While this RFP is lengthy and dense, it provides little
detail as to how the new structure will address the issue I
believe is most important when we evaluate community care, and
that is the quality of care veterans receive outside of VA. The
patient experience is tantamount. I fear this RFP does not
adequately address persistent issues veterans face when
receiving care in the community.
When asked how VA will oversee contracts of this magnitude,
Mr. Topping indicated that VA may procure contractors to
perform that oversight. Procure contractors to perform. We are
going to get contractors to oversee a contract. This is a
recipe for disaster. Oversight of contracts is an inherently
governmental function. An outsourcing that function to the
private sector will leave this behemoth of an acquisition
vulnerable to waste, fraud, and abuse.
VA has historically struggled with contract oversight due
to lack of staffing. In 2024, VA had only half the staff it
said it needed to oversee community care contracts. We have no
reason to believe that VA staffing levels have improved,
considering the mass departure of employees, experienced
employees last year through the deferred resignation program,
voluntary early retirement, and natural attrition, coupled with
the consequences of governmentwide hiring.
In addition to leaving the contractors to oversee
themselves, this RFP leaves open the door for the insurance
companies we expect to bid to enrich themselves beyond the cost
of the contract. Insurance companies have been on--insurance
companies have been on acquisition sprees, vertically
integrating and buying up hospitals, clinics, pharmacies, and
other parts of the healthcare supply chain across the country.
This trend toward consolidation is increasing care costs and
diminishing patient access.
Now, what does this mean for veterans? It means that when
veterans need care in the community, they are going to have
fewer choices. Perhaps an insurance company that wins a CCN
Next Gen contract chooses to create a network of only of
providers whose practices that insurance company--that the
insurance company owns. Nothing in this RFP prevents that from
happening.
I fear this RFP does nothing to guard against the issues VA
experience with the current third-party administrators who won
the contract during Donald Trump's first term. The third-party
administrators failed to coordinate network adequacy with the
172 VA medical centers nationwide. As a consequence, we have
networks that are not reflective of demand, and wait times for
community care often exceed those of VA. Let me repeat that.
Community care often--the wait times for community care often
exceeds those of VA because of the insufficient contract that
was approved during the first Donald Trump administration.
We have heard complaints that there are providers who are
currently considered in network for the CCN who are not
actually accepting veteran patients. The current third-party
administrators only grew the provider network by 7,000
providers between 2021 and 2024. That is a paltry 4 percent
growth in the supposed quote-unquote choice veterans are
promised for care in the community. Additionally, nothing in
this RFP requires the contractors to build a network of only of
providers who have the same level of training as VA providers,
including on veteran cultural competence. We had no way to
ensure that veterans were going to see a culturally competent
provider in the community because there was no way to ensure
that those community providers would undergo that level of
training or certification. This will invariably lead to worse
patient outcomes and a negative experience for many of the
veterans who have complex medical needs directly related to
their military experience.
Chairman Bost, I hope that we can work together to develop
a robust oversight plan, and I am glad to hear that this is the
first of hearings that we expect to have regarding oversight of
community care. We need to work together to develop a robust
oversight plan with a regular cadence of required briefings and
hearings with VA. As this contract is executed and hopefully
with testimony that arrives on time, we must chart a path
forward that adequately balances investments of VA care and
community care.
We were given little opportunity to prepare for this
procurement as VA posted this RFP in December with absolutely
no heads up to Congress. My staff repeatedly asked VA for
briefings on plans for the CCN Next Gen contract to 2025, but
those requests were never fulfilled. We were ignored, and I am
offended. Those requests were never fulfilled. We, the members
of this committee, who have a constitutional oversight
responsibility of VA, found out about a nearly trillion-dollar
contract competition at the same time as the general public.
This is unacceptable. We did not receive testimony for today's
hearing as I said until 6 p.m. last night, giving us little
opportunity to review it prior to this hearing. VA has done
nothing leading up to this hearing to inspire confidence or
trust in this process.
In closing, like signing a bad mortgage contract or opening
the credit card without reading the fine print, rushing into
this huge taxpayer investment is a recipe for financial
disaster. The contract terms alone lock VA into a long-term
commitment with very little certainty about whether this
contract will improve veterans' access or outcomes. When
confronted with a deal that sounds too good to be true, it is
important to take a step back and not jump headfirst into a
rushed, untested, costly proposal. Until we see a plan that
reinvests in VA, VA direct care, not just private contractors,
and until oversight is restored, this process cannot earn the
trust of this committee or the veterans we serve.
With that, I will yield back.
Mr. Chairman. I thank the Ranking Member for his opening
statement and yielding back.
Ladies and gentlemen, a vote has been called in the House.
The committee will stand in recess, subject to the call of the
chair. It is my intent that we expect to be back 10 minutes
after the final vote. At that, we are in recess.
[Recess]
Mr. Chairman. Committee will come back to order. Sorry for
the interruption. Kind of what we do around here.
As mentioned earlier, joining us today is the Department of
Veterans' Affairs. Mr.--the Department of Veteran Affairs, Mr.
Topping.
Mr. Topping, you are now recognized for 5 minutes to
present your opening statement.
STATEMENT OF RICHARD TOPPING
Mr. Topping. Mr. Chairman, thanks for having me. Thanks for
having us on this very busy day in Congress. Certainly, I hear
you on the delay on the testimony getting to you all last
night. In my short time at VA, I have found it is actually
easier to fix CCN than it is to get testimony approved through
the process. I own the delay, and we will do a better time next
time, sir.
Mr. Takano. Parliamentary inquiry. Mr. Chairman, is not it
customary that we swear on the witnesses?
Mr. Chairman. It is. If the witnesses will rise. Raise your
right hand, please. Do you say--I do not have the script in
front of me. You got it? I think I can do it off, but let us do
it anyway.
[Witnesses sworn.]
Mr. Chairman. The witness answered in the affirmative. Now
you can open.
Mr. Topping. Thank you. Mr. Chairman, Ranking Member,
distinguished members of the committee, thank you for the
opportunity to discuss Veterans Community Care Program and the
Community Care Next Gen contract procurement. I am accompanied
today by Ms. Alicia Skolrood, executive director of External
Integrated Networks, Office of Integrated Veteran Care,
Veterans Health Administration (VHA).
VA has long been recognized for the world-class care we
provide to veterans across our more than 1,500 medical
facilities. In addition to the Direct Care System, VA has also
been a purchaser of healthcare since before the World War II
era. As a healthcare payer, VA partners with local hospitals,
doctors, and other healthcare providers to ensure that veterans
have access to the care they need, where and when they need it.
Caring for veterans is about more than operating hospitals. It
is about supporting veterans' physical and mental health and
wellness, their families, caregivers, and leveraging community
services beyond the walls of our facilities.
Recognizing the key role that purchase care plays in VA's
ability to provide for veterans health and wellness, President
Trump and Congress passed the bipartisan John S. McCain III,
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal
Systems and Strengthening Integrated Outside Networks (MISSION)
Act, which expanded access and choice for veterans and
reinforced veterans mission as both a health care provider and
payer. Today, VA is the largest single health care provider
through our hospitals and our clinics, our 1,700 sites of care,
and the fourth largest healthcare payer.
In Fiscal Year 2025, 41.8 percent of all VA health care
appointments were in the community. Next Gen is VA's first
major procurement effort to support this program. It is our
opportunity to increase competition, upgrade and modernize the
provider network, enhance services to ensure that veterans
receive the very best health care possible, whether they are at
a VA facility or in their community from a local healthcare
provider.
We did not design Next Gen alone. We talked to our
veterans, who overwhelmingly want the flexibility to choose
between direct care and community care based on medical
interest, availability, and convenience. We talk to our
government partners. The Departments of Health and Human
Services and of War have decades of experience and data on
improving healthcare quality, reducing costs, and aligning
incentives for better health and wellness. We talk to industry,
which is constantly innovating with new delivery models,
leveraging data analytics, striving to be consumer-oriented
while tackling costs that remain too high.
Combining VA's history, the data, this external input, VA
successfully issued the CCN Next Gen Request for proposals on
December 15th, 2025. We are leading the Nation with an
innovative 10-year multiple award indefinite delivery/
indefinite quantity contract vehicle, which has several key
advantages over traditional Federal healthcare contracts.
First, the IDIQ drives and delivers competition and
flexibility by allowing both national and regional health plans
to successfully bid and be awarded a spot on the IDIQ. This is
the best of both worlds. We will have vendors with national
reach and efficiencies of scale, but also regional health plans
with unique capabilities that are locally adaptable to serve
our veterans.
Second, through the use of multiple rounds of task orders,
this allows VA to iteratively adapt Next Gen to meet veterans'
changing needs over time, changing demographics and
infrastructure, and to improve VA sophistication to manage the
program over the 10 year performance period of the contract.
The IDIQ is the how of this procurement, but the most
exciting part of CCN Next Gen is the what. Next Gen is designed
on five pillars: quality, value, alternative payments,
utilization management, and program integrity.
VA will implement a comprehensive quality program for
community care providers based on nationally recognized
measures for the Agency for Healthcare Research and Quality and
the Healthcare Effectiveness Data and Information Set (HEDIS).
Contractors will track patient safety events, identify veterans
at risk of avoidable visits and readmissions through predictive
analytics, and, while respecting their choice, guide veterans
toward higher performing providers.
Next Gen will modernize how VA pays its contractors for the
care furnished to veterans by implementing value-based payment
models. We will begin with episode-based payments for lower
extremity joint replacements. As we gain the data and the
expertise to manage alternative payments, we will introduce at
least three additional models over the performance period of
the contract to continually improve care. These models will
shift payment away from volume and toward outcomes and total
cost of care, which aligns contractor incentives with veterans'
health and system sustainability.
We will introduce utilization management. This includes
active management of inpatient admissions, emergency department
use, concurrent hospital reviews, high cost drugs administered
in clinical settings. This will reduce unnecessary
hospitalizations and inappropriate care while protecting
veterans' access to medically necessary services.
Next Gen will include a program integrity function to
ensure that VA resources are protected and maximized. We will
identify providers at high risk of improper building--improper
billing, formalize oversight processes, expand data and
technology for improper payment detection, use independent
audits, and ensure veterans receive what VA is paying for.
Next Gen also changes how VA pays our contractors to
incentivize performance and outcomes. Next Gen will incorporate
incentives and disincentives based on the total cost of care,
quality, performance, value based adoption, and payment
integrity. Ultimately, contractors who achieve VA's quality
targets while reducing our costs will share the value of--will
share in the value that they create for VA and our veterans.
Speaking of costs, along with our improved care for
veterans, Next Gen provides real savings for taxpayers. Next
Gen's actuarial estimates based on independently verifiable
data show significant savings of 8 to 14 percent over the life
of the contract. These savings range from a low-end estimate of
$54 billion to a high-end estimate of $100 billion over the
life of the contract. These are gained--these savings are
gained by fewer unnecessary hospitalizations, improved
management of high-cost services and drugs, improved quality,
and stronger fraud prevention and payment controls.
Mr. Chairman, Next Gen is leading the way in how Federal
health care programs can be designed, procured, and operated. I
appreciate the opportunity to share this information with you
and the committee and look forward to answering any questions
you may have. Thank you, sir.
[The Prepared Statement Of Richard Topping Appears In The
Appendix]
Mr. Chairman. We are going to now go to questions.
I will recognize myself for 5 minutes.
Mr. Topping, the community ambulance services have shared
that there is no way to know when a patient is a veteran. I
would like to see if the Next Gen addresses this for all
providers with limited claim windows? How will VA help the
community providers' experience in a case where they do have a
short claim window for filing? Is there a process by which that
will be part of this?
Mr. Topping. Thank you, Mr. Chairman. First of all, the
claim window is 6 months, and as you know, we have got proposed
legislation in the Access Act that would expand that to 12
months, which would match how Medicare does this. There is a
window in which a provider who provides a service can bill VA
after they determine veteran status after the fact. Part of how
we intend to design and manage this network and the capability
to verify eligibility enrollment, these will be addressed
through this. Our ability for a provider, a network provider,
an ambulance provider, an emergency service to then be able to
bill VA for the cost of that covered care again on the agreed
payment schedule, absolutely. Those are the types of things we
are tackling in this reprocurement, sir.
Mr. Chairman. Okay, so what accounts are--will the fund--
will fund the CCN Next Gen?
Mr. Topping. CCN Next Gen, sir, has a direct appropriation.
One of the things that we are doing at VA is not just the
purchase cost of care and accounting for that as a program
cost, but also the administrative cost. There are three costs
that go to our inputs on community care. One is the
administrative cost for the agency to administer our internal
program management costs. We are organizing those directly to
this program. Second is the cost that we then pay to our health
plan partners and our vendors to manage this network. The third
are the purchase cost of care that the providers are paid who
directly provide the service to the veterans.
Mr. Chairman. Is it the intent or any anticipation that you
will be using the toxic exposure funds resources for the
community care?
Mr. Topping. Sir, we are going to maximize the resources
available to us to ensure that the veterans get the care that
they have earned, that they deserve, that they are eligible for
under this program. We intend to do so in a way that maximizes
our efficiency so that we get the highest quality, lowest cost
care. We will reuse the resources that Congress has afforded us
to do so.
Mr. Chairman. Okay. The Next Gen contract would include
many features that are found in Medicare and other programs.
How deep is your ongoing engagement with other agencies to help
implement the new community care system?
Mr. Topping. Number one, this year we partnered a program
where we are working with Centers for Medicare and Medicaid
Services (CMS) on improper payments and overpayments. For the
first time, VA has partnered with CMS on payment because we
have got veterans who move between our systems and their
systems. We have begun that work on how our systems collaborate
and work together.
Second, as VA builds out its program management capability,
what we are talking about today is the program design of CCN
Next Gen. What comes next for VA is program management, our
ability to operate this program. We are going to use the models
that we see in other places in government. For example, the
Center for Medicare, which provides a framework for how VA
would manage and operate a program of this size. There are
State models. We will incorporate the best of both to bring in
how VA is organized, how VA manages this, how we use ingest and
action data for the outcomes that we are seeking in this
program.
Mr. Chairman. Yes, my big fear would be that you would not
pay attention to mistakes that Medicare has made over the
years, and get on the right track right off the start, and take
advantage of someone that has already got a system in place.
Mr. Topping. Absolutely. When we talk to CMS, and same deal
when we talk to Department of War, our colleagues at the
Defense Health Agency, is what were their lessons learned? What
works, what has not? The five pillars that we are introducing
in this program are tried and true methods. These are tools
that have been used in other programs and in some cases for
decades. We are importing what we know works. We have looked at
the lessons. Some have been good, some have not. We have
brought those in our program. This is a program that takes what
has worked elsewhere. Again, we are the fourth largest payer
program, but we are not the only and HHS operates the top
three. We have looked at their successes, their failures,
gotten their input, and we have done the same with industry. We
did not just say what is government's view on this. We went and
talked to industry and said you tell us how this has worked.
You tell us where you have been successful, where you have been
not. What have your pain points been? We have incorporated that
and built that into this program design.
Mr. Chairman. Well, I am telling you, before I yield back,
I want to let you know that we do not--this--as I said in my
opening, this is just the first of many meetings. We need to
keep you here on a regular basis, talking to this committee, so
we can watch this process. We have had other things that VA has
done that they go off on their own, and we do not get the
oversight that we need. I want the commitment from you that you
will--we can do that.
Mr. Topping. Mr. Chairman, anytime you will have me to come
back and talk about Next Gen, I will come.
Mr. Chairman. Okay, thank you very much. I yield back.
I recognize the Ranking Member for his 5 minutes.
Mr. Takano. I will expect prompt answers from my staff from
you as well. I cannot have delays in, and I do not ever want to
see a major program announced at the same time the public hears
it. Do I have a commitment from you on that?
Mr. Topping. Yes, sir, you do.
Mr. Takano. Thank you. Community care spending is out of
control across multiple administrations. I have raised concerns
about how much spending is going into the community care
account at the expense of direct VA-provided care. Underscoring
these concerns are VA--underscoring these concerns are VA's
transfers so far this Fiscal Year of over $2 billion into the
community care account. Mr. Topping, from what account did you
transfer the $2 billion?
Mr. Topping. Ranking Member, there have been no transfers
this year into the community care account.
Mr. Takano. There have been no transfers? That is what--
that is your answer?
Mr. Topping. Correct. Yes, sir.
Mr. Takano. Okay. You stand by that? You are under oath.
Mr. Topping. Yes, sir. There have been no transfers this
year. In Fiscal Year 2026, there have been no transfers.
Mr. Takano. In Fiscal Year 2025, we are talking about.
Mr. Topping. Yes, sir. In Fiscal Year 2025, there were
transfers.
Mr. Takano. From what accounts were the $2 billion
transferred?
Mr. Topping. As I recall, sir, I think it came from Medical
Support and Compliance, and there was a transfer of one--I
forget the exact number--but I believe the transfer is $1.3,
$1.4 billion into the account.
Mr. Takano. Can you make sure that you get us the accounts
that that money was transferred in Fiscal Year 2025, the $2
billion?
Mr. Topping. Yes, sir.
Mr. Takano. Thank you. VA requested $48 billion in
mandatory and discretionary funding for community care for
Fiscal Year 2026, and that is what you received. As of now,
VA--will VA need to transfer more money into the community care
account before the end of Fiscal Year 2026?
Mr. Topping. I am sorry, sir, was that a question as to
whether we will need to transfer?
Mr. Takano. As of right now, will VA need to transfer more
money into the community care account before the end of this
Fiscal Year of 2026?
Mr. Topping. Sir, as of right now, my financial cost
estimates, along with my spending to date, again, understanding
that there is both a data and a claim lag. As of right now----
Mr. Takano. My time is short. Just answer the question.
Mr. Topping. Sir, as of right now, my data does not show
that.
Mr. Takano. Okay, so the answer is no, you will not. You
are telling me that you do not need to--that you--that you are
saying you have sufficient funding from your $48 billion Fiscal
Year 2026 appropriation, and you do not plan to ask for any
more money, right?
Mr. Topping. Representative, as of right now, my
appropriation for Fiscal Year 2026----
Mr. Takano. It is a simple question. Yes or no?
Mr. Topping. Sir, my appropriation is $50.174 billion, $206
million. That is the appropriation, and, sir, that is the
budget that I am managing too.
Mr. Takano. Well, I asked you about a $48 billion Fiscal
Year 2026 appropriation to the community care account. You do
not plan to ask for any more money than that?
Mr. Topping. Sir, the number is $50.174 billion, $206
million.
Mr. Takano. All right. Okay. Well, so you do not plan to
ask for any more money for that account?
Mr. Topping. No, sir. At this time, my data does not show
that I will need to do that. No, I do not, sir.
Mr. Takano. Okay. Well, Ms. Skolrood, contractors are
required to self-report conflicts of interest, even though many
insurers own clinics and provider networks. How will VA
independently detect and prevent contractors from steering
veterans to affiliated providers for profit?
Ms. Skolrood. Thank you very much for that question. Our
Third Party Administrators (TPA) do not steer our veterans to
providers. Those decisions are made by the veterans.
Mr. Takano. Well, how would you know that? You just claim
that our TPAs do not do that. Is there--how is VA going to hold
our TPAs accountable?
Ms. Skolrood. They do not have the opportunity to do that.
That is not how a veteran gets to the community provider. The
veteran gets to the community provider either by choice,
because they have selected them. Now, the network is built by
the TPAs. That we control via our credentialing process, our
accreditation process, and our assessment of the provider's
quality abilities.
Mr. Takano. You are going to represent to me in this
committee that every clinic, every provider, you know, is not
owned by the TPA?
Ms. Skolrood. I am not representing that at all, sir.
Mr. Takano. Well, then, how is it that you are able to
answer my question and the way that you have answered it? You
know, how will VA independently detect and prevent contractors
from steering veterans into affiliated providers for profit? If
you cannot figure that out, you cannot tell me that.
Mr. Topping. Ranking Member, the way the system currently
works, VA controls the clinical referral, and VA controls the
placement with the community provider. The TP, the vendor does
not control the steerage. VA does. These are people.
Mr. Takano. You are not really answering my question. You
are evading the question. You are avoiding the intent of my
question. You are not able to answer how TPAs avoid this
conflict of interest. You do not--there is no--I do not--you
are not answering. You are not talking about any enforcement
mechanisms beyond simply trusting contractors to disclose
conflicts.
Mr. Topping. TPA----
Mr. Takano. I would suggest, sir, that is a huge flaw in
the assumptions that you are bringing forward to us.
My time is up. I yield back.
Mr. Chairman. Representative Radewagen, you are not
recognized for 5 minutes.
Ms. Radewagen. Thank you, Chairman Bost and Ranking Member
Takano, for holding this hearing today. Thank you to the
witnesses for your testimony, for your appearance.
Mr. Topping, what was the contract type for the First
Generation of contracts? What is the contract type for the Next
Generation? What is the significance of the difference for
veterans?
Mr. Topping. Thank you for the question, Representative.
The First Gen contracts were direct sole source contracts to
the awardees. There are two vendors under the current Next Gen
contracts that operate those exclusively. The difference with
Next Gen being an IDIQ is that the government will have the
ability to bring on multiple vendors and multiple contractors.
Those contractors can then compete across the life of the
contract for different task orders. That allows VA to change
program design, to learn from mistakes, to increase our
capabilities and capacities, to innovate and evolve the program
over time. The difference will be we picked a program, we
awarded contracts, and that is what we have had for the past
contract. What we are able to do under the IDIQ and why this is
so unique and so different is it allows us the flexibility to
pick, innovate, and for vendors to compete and improve
continually across the life of the contract.
Ms. Radewagen. Mr. Topping, does VA believe it needs any
additional legislative or regulatory authority to act on the
Next Generation contract?
Mr. Topping. Ma'am, at this time, we do not. We believe we
have it. However, as we go through this process, engage with
the oversight of this committee, stay engaged, making sure we
report as we may or may not need additional authorities, we
intend to come to this committee and work with you and your
staff to ensure that we have it.
Ms. Radewagen. Thank you, Mr. Chairman. I yield back the
balance of my time. Thank you.
Mr. Chairman. Representative Brownley, you are recognized
for 5 minutes.
Ms. Brownley. I apologize. My staff was just telling me I
have a vote in another committee, but I will take my time.
Thank you to the both of you for being here today. I have
to say that, you know, everything you have said in your opening
comments with regards to your stated goals, I agree with. You
know, and if you succeed in raising and having higher quality
of care with less resources, I will be the first to commend
you. Honestly. Honestly.
When I review the one trillion dollar contract that you
have put forward, I am just absolutely not convinced that you
can succeed in those goals. Better quality, less resources.
Over the last decade, community care continues to increase
exponentially. I think we can agree on that. Turning VA, I
think more into a payer system rather than a provider of
healthcare. It seems that the Next Gen contract is not. It is
clear to me, let me just say, that you are not shutting down
and the contract's not shutting down VA facilities whatsoever.
It does not require, in my opinion, any kind of important
oversight like requiring prior authorization to receive care in
the community. It seems to me, based on what you are saying,
that competition is the oversight piece within the contract. If
people cannot compete, they are out. If they can compete, they
are in, and they will be doing a good job.
Do you agree with that assessment in the simplest terms,
that you believe that competition is the--is the main component
for oversight?
Mr. Topping. Thank you, Representative. I believe the main
component of this contract and why this is different is this
gives VA the tools, and again, tried and true tools, the five
tools we are going to use. This gives us the tools to hold our
contractors accountable. Our ability under the IDIQ to off-ramp
non-performing contractors, that is what I believe is different
about this. I do not believe that the competition is what is
going to drive the outcomes. I believe VA's management is what
is going to drive the outcomes. The competition is a tool that
allows us to ensure that only vendors that are achieving our
expectations for them are hitting those quality scores, are
achieving the cost savings, and doing it in a way that VA
oversight agrees with and is consistent with our values. That
is what we are able to do in this, and that is what is
different. We do not have that ability under the current
contract.
Ms. Brownley. You know, your first point of control, if you
will, and using your words, that would be a prior
authorization, whether, you know, it is appropriate for the
veteran to go into the community or not. I believe what you are
proposing is that a veteran just can go into the community, and
these other tools that you have can control that?
Mr. Topping. Well, let us--let us talk about the
utilization management part of this program and prior
authorization, which is one part of that, and had been one part
of UM used differently over time. Fundamentally, what UM is,
and UM has been around for 30 or 40 years, it says that for any
given diagnosis, there is a finite universe of treatments to
treat that diagnosis. For example, when we send a veteran to
the community for Post-Traumatic Stress Disorder (PTSD) could,
you know, could be, could be therapy, could be medication,
could be psychiatric care. It is not a knee replacement. A knee
replacement is not responsive to that veteran's need. What UM
allows us to do is package this up and know that we ensure that
veterans are receiving the care that is responsive to and
therapeutic to the diagnosis. That is how we are going to use
that tool in this contract.
Ms. Brownley. You said in your testimony that you have
talked to many with regards to this new proposal, new system
within the VA, and you said you talked to industry. I am
curious to know how much engagement you have had with veterans
across the country.
Mr. Topping. Ma'am, we have been very engaged with
veterans, both through our Veterans Service Organization (VSO)
groups, through our individual outreach, through the Request
for Information (RFI) feedback that we have had. We have been
engaged with veterans who are the users of this system. They
are the end state. The goal of this is ensuring that our
veterans are best served. They are our customers and so that is
why we are doing this.
Ms. Brownley. Can you--my time is limited and it is almost
over. Can you just give me a list of the VSOs that are
supporting this program? Can you name them now for me?
Mr. Topping. Ma'am, I can take that and bring you the list.
Ms. Brownley. Thank you. I yield back.
Mr. Chairman. General Bergman, you are recognized for 5
minutes.
Mr. Bergman. Thank you, Mr. Chairman. It has been
interesting to sit here and listen. I have got a lot of
prepared questions in front of me, and I will get to some of
them. As I listen, I recall the MISSION Act of 2018, which
started this ball in motion. Okay. The point is, has there been
any lessons learned that have been tabulated by the VA since
that time? Maybe, you know, by your predecessors or whatever,
that when we implement anything, the ability, you know, in the
military, no battle plan survives first contact because the
plan is the plan until you put it into kinetics, and then it is
modified.
We could talk for hours, and maybe the time is right now.
As a follow on, I would suggest to have a closed meeting with
our committee where there is no cameras, just to really get,
because you cannot cover this, and a dialog that involves
honesty. Is there anything that has appeared to you that has
become redundant, that is necessary? The redundancy is
necessary, or the opposite is that it is unnecessary, the
redundancy that you put into place? Okay, any--anything pop out
in your--as you look at what you have seen and what you are
trying to do, do you try to evaluate, do we need to continue to
do this step? Does it add value?
Mr. Topping. General, thank you for the question. I think
so, absolutely. As we look back on lessons learned and some of
the--and some of the issues that we had, the prior contract was
not designed to be a program of the size, scope, and scale that
it now is, serving 9.1 million veterans literally wherever they
live. Our ability to make sure that this program is
sustainable, but also achieving the outcomes and access that we
are looking for--for our veterans has been our guide stone in
this.
Mr. Bergman. Has there been anything that is just--that you
could give us a data point, and if the answer is none, okay. Is
there anything that, since trying to implement this and get
everything up and running that you have said, absolutely, this
is a waste of time and money. It is not adding value to the
veterans. Has there been any list of things so that people
could say, well, did not see that coming, but okay, it makes
sense. I think as a committee, we want to hear confidence in
your ability at the Veterans' Administration to create this and
to keep it going, to make the necessary change, to stop doing
stuff and not let bureaucrats and contracts that, you know, a
reason to not do something that you know deep down because
that--but that is--that is a unit that is in the military. It
is within the unit to make changes that they see because they
are right in the middle of the fight.
Mr. Topping. Representative, so three things. One, this
program has been unmanaged since its inception. None of the
tools, none of the controls that we are talking about
introducing here have been available for. VA had no ability to
manage this program, to drive quality, to focus on the outcomes
for veterans, to focus on cost. We have now got the ability to
do that in this contract. That is number one.
Number two, the way we designed this unmanaged program made
it very difficult for industry to partner with us. It made it
very difficult for community providers to serve our veterans.
Made it difficult for our TPAs because it did not operate like
any other payer program, which made it one off anomalies that
made it difficult to be part of this.
Then third, and I think most importantly, and this is the
one that VA owns, that we are working on together, is our
program management, for this was not built to run a payer
program. We are focused. The program design is----
Mr. Bergman. I hate to cut you short, but my time is
running. I would suggest to you that under Secretary Collins'
leadership, we have seen the reorganization of the Veterans
Integrated Service Networks (VISN) and how they are set up.
What I would like to see is, in that, the already existing and
announced VISN reorganization plan, how that will affect, or
maybe no effect, no effect on your ability to do what you are
tasked to do. With that, I yield back.
Mr. Chairman. Mr. McGarvey.
Mr. McGarvey. Thank you, Mr. Chairman. Appreciate you all
being here. I mean, look, my focus is the veterans. It is the
focus of this committee. It is my focus. We have to do what is
best for our veterans. They put on a uniform, they served, they
sacrificed for us, and we promised we would take care of them.
When I think about this, I want our veterans who need it
and want it to get their care through the VA. I know the VA
cannot necessarily provide every single service available. We
got to have a VA that functions. When we are here talking about
these community care networks right now. I want to talk about
what it looks like in Kentucky because in Kentucky, we have a
lot of veterans, and we have a lot of veterans in rural areas.
We cannot look at this in a vacuum in this hearing. This year,
the Trump administration, last year, the Trump administration
passed a bill they refer to as The One Big Beautiful Bill.
Well, the Kentucky Hospital Association, which is not exactly
some flaming liberal organization, has predicted that 35 rural
hospitals in Kentucky could close because of the funding cuts
that are going to come through this. This means our veterans,
our men and women who served, who are already in health care
deserts, 41 counties in Kentucky, do not have an obstetrician-
gynecologist (OBGYN) right now. This is going to get worse with
what is coming in these funding cuts. The system cannot
continue like this.
My concern is that when we think about community care
filling the gaps, we have to look in places like mine, where
community care is already struggling, and it is expected to get
worse. Again, I understand we cannot rely on the VA for
everything, but thinking that community care is a silver
bullet, I do not think is the solution either to what we are
looking at.
What happens to veterans when these community care network
contractors build networks that look adequate on paper but do
not reflect real provider capacity? Let us get the Washington
speak out of this. Looks good on paper, but our vets are not
going to be able go to the doctor. Right? That is what we are
worried about here. These are some of the questions we have to
ask ourselves about this because of the promise, the legal and
moral promise we have made to our veterans to take care of
them.
Mr. Topping, I am going start with you. What safeguards are
in place right now to prevent a lot of these large national
insurers, you know, the big companies we are talking about,
from bypassing rural providers because they are less profitable
to contract with?
Mr. Topping. Thank you so much for that question. Number--
so number one, I think there is three things in there that I
want to hit. Number one, community care is one tool that VA has
to serve our veterans. We talk about this being a trillion-
dollar, 10-year contract, and it is. At the same time, we are
going to spend $2 trillion in direct care during that same
timeframe. These are two tools. We have our facilities. We
opened 25 new facilities last year. We have got five more
coming on. That is 30. We have invested $800 million in
infrastructure under Secretary Collins' leadership. We are
engaged on that part of this as well. That is number one.
Number two, network adequacy in rural areas. Rural veterans
disproportionately rely on community care. It is more important
for rural veterans in Kentucky and other states to ensure that
we have got the providers and the adequacy. Our work here is
complementary to what we are doing in rural health in America
because we are one more payer, and we are going to manage this
like a payer. This creates predictability for those hospitals,
those rural hospitals, those providers to participate in this
program and be with us. Back to if we have got a national
company who is looking at this nationally they have 50 states,
25 states, one of the major, the key change in this on using
IDIQ again, VA is going first. One of the innovations on this
is if we cannot get the coverage we need in Kentucky, we can
bring in a Kentucky provider to support VA in Kentucky. We can
do that. We can off-ramp a national that is not meeting the
needs and bring in a local company that knows Kentucky, that
knows the rural areas, knows the urban areas, and we can use
their network to serve our veterans. The flexibility under this
program is unique and----
Mr. McGarvey. I am just going to interrupt you there
because, like, look, this is a perfect example of okay, that
all sounds great. I trust this committee to have veterans'
interests first and foremost. I do not trust big insurance
companies to take care of anybody. The sole thing that
motivates them is profit. It is not people, and it is certainly
not our veterans. You can talk about $1 trillion and $2
trillion, and those are really big numbers that you can paper
over in front of this committee. Until we are looking at those
contracts and we are looking at those numbers, those are just
assurances. We have the right to be skeptical when we are
talking about private insurance companies taking care of
people, because right now, they do not.
I want to go to the next question. Many of these CCN
bidders are vertically integrated insurers. That means again,
let us take the fancy. They own doctors' practices. Their
motive is profit. What they want to do is make the most profit.
How is the VA going to prevent these companies from steering
veterans into their own facilities to maximize profits? You
talk about what is going on the ground. I look at what is going
on in their books because I think that is what they care about.
Mr. Topping. Representative, that is a fair question. I go
back to what I said earlier. The vendors, our health plan
partners on this, a) do not make the clinical referral from the
Direct Care System to community care. VA does that. They do not
make the referral to the provider. VA determines that. They do
not determine eligibility. VA drives where and how our veterans
respond, receive care, and the whole, you know, going back to
the pillars that we are using, including quality, we want to
know what we are buying. We want to steer our veterans to the
highest quality, lowest cost providers. Again, that is a goal
that is not unique to VA. It is new to us. We are bringing this
into this program. We are going to make those determinations.
Our vendors, our health plan partners on this, do not drive
that. VA does. We own our veterans, and we are accountable for
their care.
Mr. McGarvey. Yes. Thank you. I am out of time. Mr.
Chairman, thank you for letting that go on. I just will--I just
will say again, our focus is not on VA versus primary or
community care. Our focus is on the veterans and what is best
for them. I really want to continue working with you on this.
Thank you.
Mr. Chairman. Representative Van Orden, you are recognized
for 5 minutes.
Mr. Van Orden. Mr. Topping, there are very few occasions
where Mr. Takano and I agree. This is one of them. How big is
your staff? Is it more than one?
Mr. Topping. Sir, to support me on this, I have two.
Mr. Van Orden. Okay, well, I have one. My--he goes by
Dutch. His real name is Clark. He puts together these awesome
binders for me. It has got everybody's bios and stuff in there
and everything. Then this morning, he had to hand me this. You
know what this is? This is your testimony. This should be in
here, but it is not because you did not provide it until last
night. We are not putting up with that. It does not matter who
is in the White House. Secretary Collins, I think, is awesome.
He is doing great. I love Donald Trump. We are not going to put
up with that. Period. Just never do that again. It is
unacceptable. I agree with Mr. Takano on this. I also agree
with Mr. McGarvey, who went out skateboarding or something
right now, about this vertical integration of insurance
companies.
Okay, so here is the issue. I think I am the only member of
this committee that is actually used community care. I get all
my health care through the VA system. Community care is part of
the VA system. It Is. I have had tremendous experiences with
community care for dental stuff and orthopedics, because I am
old and whatnot. Here is what I hear from my veterans. The
bureaucracy at the VA tries to slow-roll community care. One of
the things that they have come up with is very innovative.
Within like 45 minutes, you are supposed to go to the VA. If
you are outside of the 45 minutes, they have created all these
Community-Based Outpatient Clinics (CBOC) everywhere so that
more and more people are within this 45-minute radius, so then
they do not have to be referred to community care.
We are talking about--it is 1, 2, 3, 6--it is 1 with 12
zeros after it is what we are talking about. I really am
interested to know how much of this, you know, one with 12
zeros behind it, the VA is going to be spending to create these
CBOCs, to, in my opinion, intentionally exclude the veteran's
ability to seek community care. I know you do not have that
answer. I am not trying to--I am not going to punk you here. I
know you do not have that answer, but we need to have that
answer. As my colleague Mr. McGarvey said, this ain't about the
VA, dude. It is not about the bureaucracy. It is about the
veteran. If our veterans are not getting timely, high-quality
health care, there is a problem when we are talking about
spending a trillion dollars on this. I want to implore you, I
will implore you to make sure that you are focusing a trillion
dollars to make sure that our veterans' health care is a
trillion times better, not that we create a trillion more
bureaucratic positions.
What is the average time from the request for health care
that is unavailable at the VA to the point where the veteran is
referred to and treated in the community care system?
Mr. Topping. Representative, there is a range of times
depending on location, and those range all the way from 4 days
up to 54 days, depending on where it is and what the service
is.
Mr. Van Orden. Okay. Do you think that a veteran waiting 54
days to get healthcare is acceptable?
Mr. Topping. I do not.
Mr. Van Orden. Okay, then, how are we fixing that, sir?
Mr. Topping. Through the proposal around Next Gen and how
we intend to bid and run this program. Sir, I want to go back
to, I want to go back to one of the points I think you made
that is critical about CBOCS and referrals, and community care.
I think that is incredibly important. Number one, Secretary
Collins has made clear we are investing in infrastructure, we
are opening facilities, and that is so that there is more
direct care capacity for veterans. Absolutely, we are doing
that. The other thing that Secretary Collins said is we are
very well aware that in the last administration, bureaucratic
impediments were thrown up to prevent veterans from going to
the community if they wanted to, even if it was a continuity--
--
Mr. Van Orden. I experienced that firsthand.
Mr. Topping. What Secretary Collins introduced last spring
is the best medical interest. Best medical interest allows the
veteran, with the provider, not the bureaucrat, not the
referral, but the provider and the veteran to make, to
determine whether the veteran should go to the community, and
then that allows that, sir.
Mr. Van Orden. What percentage of veterans that should be
eligible for community care are turned down or pushed into the
more than four 50 day window?
Mr. Topping. Sir, I will have to take that and bring you
back that data.
Mr. Van Orden. I would really appreciate that answer.
Listen, man, I got a tremendous amount of confidence in Doug.
He is a personal friend of mine. He is a chaplain. He is a good
man. He is a veteran. I know that you serve in the Army. Sorry
about that. Mike is right. We expect--we do not expect good
things from you. We expect great things from you. We will hold
you accountable regardless of who is in the White House. Is
that clear?
Mr. Topping. Yes, sir.
Mr. Van Orden. Very well. I yield back.
Mr. Chairman. Congressman Ramirez, you are recognized.
Ms. Ramirez. Thank you, Chairman. Well, it has been a year.
It has been a very long year. I have been really thinking about
the work that we do here. I want to talk a little bit about a
recap. Since the Secretary stepped into leadership, the VA has
eliminated diversity, equity, and inclusion initiatives. It has
allowed Department of Government Efficiency (DOGE) access to
VA's data. It has made it its mission to help reduce the VA
workforce by 30,000 employees by the end of 2025. It has also
doubled down, removing 35,000 healthcare positions this month,
according to an internal memo, according to VA staffers and
congressional aids.
I got to say, folks, it is hard to believe that Secretary
Collins gives a damn about veterans when he is actively
undermining the mission of the VA. You cannot say you serve
veterans when their doctor appointments are being delayed and
canceled due to staffing shortages. You cannot say you serve
veterans when you repeatedly attack the VA workforce. Who
actually serves our veterans? Today, we are going to talk about
the Community Care Network Next Generation contracts. Well,
Collins tears down the VA with one hand. He then doles out the
pieces to corporate interests, with the other enriching them,
while veterans are going to go unserved and uncared for. In his
actions, we see exactly who Secretary Collins really serves.
Driving the VA toward privatization we know only serves
corporate interests, and it puts profits over veterans.
I want to get into some of these questions. Despite the
VA's severe staffing shortage, the Next Gen contract structure
introduces significant oversight complexity. The VA is planning
to establish a bench of contractors through this 10-year
indefinite delivery, indefinite quantity multi-award contract
model. Contractors on the base IDIQ will compete on task orders
that the VA will have many layers of contractor activity to
oversee.
Mr. Topping, given that the VA is down to down 30,000
employees with the plan to get rid of 35,000 more positions, it
is really hard for me not to wonder who exactly you plan on
having oversee this contractor activity. Because, according to
a U.S. Government Accountability Office (GAO) report released
in August 2024, the VHS Office of Integrated External Networks,
which is involved in oversight of the contracts, was staffed at
57 percent of its authorized level as of February 2024. At the
same time, the Contracts Management and Performance Team within
that office was staffed at about 50 percent of the authorized
level. Committee staff asked for updated staffing numbers
during our recent briefing with you on the CNN Next Gen
procurement, but the VA has yet to provide those to the
committee.
Mr. Topping, here is my question. How do you anticipate
meeting its contract oversight and execution obligations,
particularly given the President's ongoing limitations on
hiring?
Mr. Topping. Representative, thanks for the question and
the chance to set the record straight on--on this. Let us talk
about staffing. VA is appropriated for 455,000 employees. Our
operational strength is 447,000 employees. That is a delta of
8,067, actually. That is the delta. 5,000 of those are
clinicians in the clinical setting. In VHA, we are working to
fill those to ensure that we are fully staffed. There is an
8,000 employee difference, not 35,000. This garbage story from
the Washington Post about 35,000 positions being cut it is not
true. The Post reached out to us, to my staff----
Ms. Ramirez. Mr. Topping, I want to really specifically
come back to CCN contract oversight, and I want to just do a
follow-up question because I know we have limited time here.
How many positions, so let us go specifically here, are
currently authorized for CCN contract oversight and execution?
Number two, do you intend to increase the number of authorized
positions for the Next Gen?
Mr. Topping. We will build the program management
capabilities necessary to manage a contract----
Ms. Ramirez. Do you have a number of how many you are going
to authorize?
Mr. Topping. I do not have a number yet because we have not
built it yet. We are in the process of doing that. What we
are--what we are bringing to you today for your oversight is
the design of CCN Next Gen, program management is the next.
Again, I say what I said earlier, this is not unique to VA. We
have the Center for Medicare, CMS does this. We are not the
only ones to manage a program like this. We will look at best
practice, best structure. We will bring those to VA. It is not
just the Federal level.
Ms. Ramirez. As you are looking at this best practice, let
me ask you a follow-up question. As you are doing the planning,
tell me a little bit about how you are considering what
percentage of the currently authorized contract oversight
positions you already have available to be filled.
Mr. Topping. The way we manage the current contract, which
is an unmanaged contract and very different from what Next Gen
is, is not the same as we are going to program management and
design the new one. We will design program management inside VA
to match the----
Ms. Ramirez. Mr. Topping, my time is up, but I definitely
want to make sure that we have a follow-up on these staffing
numbers that it seems like you have a number, and we have
another based on the memos that we have seen. We will follow
up. Thank you.
Mr. Chairman. Representative Self, you are recognized for 5
minutes.
Mr. Self. Thank you, Mr. Chairman. I have got questions on
kind of going forward on this because IDIQ in some government
contracts are the race to the bottom.
Let us just be honest. When you--and I understand we have
been told that you are going to have a vendor that might have
the capability, might submit the capability, but you will not
use the services currently, but you might get to them later. Is
that not going to make first of all, their submission more
expensive? You are going to have them in a contract that you
may or may not be paying them for. Then you might limit the
numbers of vendors, too, because that requires a vendor to have
a wider range of services. Can you address that? It looks to me
like you might be limiting to the larger vendors who are going
to be able to meet that requirement.
Mr. Topping. Representative, we are very much intentionally
not limiting the large vendors. The intention and the ability
to use the IDIQ is to open this up to competition to non-large
vendors, but to those who might bring regional capabilities,
regional capacity that would not be able to operate on a
national or semi-national scale. We want those vendors on the
vehicle. They will incur a cost to bid and--and be awarded a
spot on the vehicle. Once they do that, the vendors who are on
the vehicle with us, large and small, have a seat at the table
with VA, with our program management team to design those next
task orders. There are two initial task orders in the initial
award. Those look a lot like what we have now, large regional.
We are going to immediately partner with the vendors on the
vehicle to--to begin to build the next, more regional, more
adaptable, more local models in our task orders.
Mr. Self. You have already heard our concern about $1
trillion. These are inputs. This committee, and particularly
me, are always concerned about the VA. I want to give you the,
and you have got it, the range to run on. These are inputs,
outputs. How are you going to identify to off-ramp vendors who
are not participating? This is where the rubber meets the road.
How are you going to make sure you have an efficient process to
do this?
Mr. Topping. The vendor oversight process, the contract
requirements will be spelled out. Those will be very specific.
Unlike in the current program, where really all we can do is
bicker about that, all we can do is litigate that, and the only
remedy is the ultimate remedy, which is termination or
replacement, our ability for vendors who do--do not meet our
technical requirements or even our value requirements and how
they are serving our vendors. We have, the government has the
ability to off-ramp that vendor off that contract.
Mr. Self. Who is that person who has that decision-making
authority to make the decision you are now off-ramped?
Mr. Topping. That is the Department of Veterans' Affairs
and the Program Management team.
Mr. Self. What level is that?
Mr. Topping. That would be inside the agency and the lead
program for this office.
Mr. Self. Okay, that is a little nebulous. Look, 40 percent
of care is now under community care, right? This is a
rhetorical question. Once we get over 50 percent, you are going
to hear the privatization argument ramp up. Then right now we
know--we know that veterans get the private coverage. More of
them say they are in good health than the veterans who get care
in the big VA. I am concerned about the future here because
once we get over 50 percent and you start hearing this argument
about privatization, you have privatized care, how then are we
going--is the VA then going to be expensive, specialized care
only? Give me your vision for the future and basically in 10
years, what does the success of this program look like if we go
over 50 percent of care is given by community care is provided
by community care providers?
Mr. Topping. Representative, Secretary Collins has been
very clear. We are not privatizing the VA. We are investing in
the Direct Care System, and we are investing in the Community
Care Program. We want veterans to have the choice where he or
she receives the care, and if they prefer direct care, we want
them to have the access to that and the world-class care they
get there. If they choose the community, we want them to have
access to that as well, too.
What this program looks like 10 years from now, and where
we are moving to, and we are starting with where we are, we
will progress through this as task orders again with the
vendors on the vehicle, is we ultimately want to be focused on
paying for the highest quality cost, the highest quality care
that we can receive. That is based on agreed upon measurements
and metrics, our data, and our ability to action that for the
lowest possible cost of care. That is what success looks like.
Ultimately, that the veteran can choose where he or she
receives or wants to receive his or her care.
Mr. Self. I have more questions, but my time is up. I yield
back, Mr. Chairman.
Mr. Chairman. Dr. Dexter, you are recognized. Dr. Dexter.
Ms. Dexter. Thank you, Mr. Chair. I love and thank you, Mr.
Topping. I love hearing that you want to pay for the highest
quality care veterans can receive. I think we all want that. I
would like to ask first, which healthcare organizations in the
U.S., either government, nonprofit, or for-profit, have
utilized this indefinite delivery/indefinite quantity, IDIQ,
contract structure you are proposing?
Mr. Topping. Representative, VA uses IDIQs and uses them in
multiple areas and multiple spaces. This is the first time for
a healthcare contract that VA is using this. This is used
outside of our agency and other parts of government as well,
too. The IDIQ is a vehicle which allows the government to buy
services, and if it does not know up front exactly what it
needs and when, but can pick a stable of vendors that we know
are capable of delivering that. That is the use of the IDIQ.
The model of an IDIQ is not new, not new to VA, not new to
government.
Ms. Dexter. I do want----
Mr. Topping. It is new to healthcare.
Ms. Dexter [continuing]. to get through a lot of questions,
so I appreciate that. I think I understand it is not new, but I
think that we all have concerns with some of those well-vetted
vendors, that there have been misuse of Federal dollars that
should have been taking care of veterans, and may have been
misbuilt, let us say. For our committee to do effective
oversight, I would like to see a list after this hearing of
those entities in any market research VA has conducted on those
organizations that we are considering using this contract.
Based on your testimony, it seems contractors alone will
propose and pilot alternative payment models to test on the
veteran population. How, how does the VA plan to evaluate these
care models, especially related to quality outcomes, when they
are being offered outside the Direct Care System?
Mr. Topping. VA will make the determination on which models
we use. VA will drive this. VA will make the ultimate decision.
What we do want to do, and again, this goes back to the IDIQ
vehicle, is we want different vendors with different
capabilities, and they will be regional. We understand that. We
want these vendor partners to come in and make proposals based
on what they have used and what has been successful in their
network in their areas. Those will be different in different
parts of the country. What we are going to be able to do in
terms of value-based care in the upper Midwest, largely rural,
where you have got potentially, you know, limited providers,
versus what we could do in metro DC very different. That is why
we want them to bring the proposals, but we will make the
decision.
Ms. Dexter. I appreciate that, and I think it all sounds
fantastic, but really putting it into practice has been
extraordinarily difficult. I come from a healthcare
organization. I know this very well. I just want to use as an
example my team sent a letter to Secretary Collins on September
22d, asking for what was required by Congress in December 2022
for the VA to develop a plan to ensure veterans are informed of
expected wait times at VAs and in the community. That was over
3 years ago. We asked for that information, and our team has
been reminding folks weekly since September that we are waiting
for that information and still have not gotten an answer. I
find it hard to believe that we are still waiting for just how
long does it take for a veteran to get an appointment in the
community, over 3 years from when Congress said it should be,
so that we actually have the capacity to have appropriate
oversight and transparency for outcomes for our veterans if we
cannot even tell when they are getting appointments. I would
love your response to that.
Mr. Topping. Representative, let me take that. I have not
seen the letter. I am not aware of the ask. Let me take that
and come back to you.
Ms. Dexter. Mr. Chair, if I may ask to submit into the
record the letter dated September 22d, 2025. It will be
available for all. I also want to just----
Mr. Chairman. Without objection.
Ms. Dexter. Thank you, sir. I appreciate that.
You noted in your testimony also that the VA will implement
comprehensive quality programs for community providers based on
nationally recognized measures that will ``ensure veterans are
not simply referred to any available provider but to those
demonstrating strong outcomes and safe, high-quality care.''
Again, I share this goal. However, given that vertically
integrated health care entities often restrict patient visits
to their own providers, how can you clarify any guardrails that
will be in place to ensure that veterans in the community care
programs will be referred to providers with highest quality
outcomes rather than just those preferred by any contractor?
Mr. Topping. Representative, number one, we are using
healthcare research and quality data. You have seen and you
have worked with those. HEDIS, you have seen, and you have
worked with those. These are well-known, well-understood by
both payers and providers. We are using the metrics that the
industry understands. We are going to measure to those. Where
we set the goals and the outcomes and the requirements, VA will
determine that. All that is to say, too, and I think probably
this is the fourth time I have said it here today, too, the
plans will not determine where the veteran goes. We will make
the referral. We will determine where the veteran receives the
care. We want our veterans to go to those providers that can
provide the highest quality at the lowest cost. The intent of
this program and the tools that we have built into it enable us
to do that.
Ms. Dexter. I will follow up on that because I worry that
in the actual delivery systems, the VA is not going to have the
level of engagement to actually be able to direct those visits.
We know that those vertically integrated systems are already
shunting lower-paying patients to different outcomes. I am
concerned that you actually can deliver on that, and would love
to understand some details on that and follow up.
Thank you, Mr. Chair. I apologize. I yield back.
Mr. Chairman. Representative Barrett, you are recognized
for 5 minutes.
Mr. Barrett. Thank you, Mr. Chairman. Appreciate it. Thank
you for being here today, and thank you for your testimony.
Obviously, it is of high interest to this committee the amount
of investment and commitment that we have for a contract of
this nature. I do want to start by just kind of reminding folks
of before we had community care options available to veterans,
what that looked like.
I was early in my tenure in the State legislature in
Michigan, I heard testimony from a veteran in Michigan who had
a hip replacement done at a VA hospital several hours from his
home, probably 3 hours away. They prescribed him physical
therapy, as is expected and normal after that. He could not get
physical therapy at the clinic 2 miles from his house, because
he was technically in an area that had a VA facility within a
commutable range. They did not offer physical therapy at that
place. They wanted him to go back to the hospital. He had the--
the hip replacement two or 3 hours from his home. Entirely
impractical.
Obviously, changes needed to be made. I think one of the
lessons learned post-9/11 is that the VA was not really set up
for the wave of veterans that came home off the battlefields in
Iraq and Afghanistan, and the unique circumstances that they
were facing. I think reminding us of why we are here and why
community care can work for veterans is important for things
that they need. Obviously, we need the VA for very, very
important things as well. This is not an either-or thing. It is
a both thing. I think we can acknowledge that as well. It does
not need to be one at the expense of the other. They can work
in concert with one another.
I have the privilege of chairing the technology
modernization subcommittee on this committee. One of the things
we are really investing heavily in is this Electronic Health
Record Modernization (EHRM) that is coming. I guess what I
would like to hear from you is, as we roll that out, are we
going to see a better integration with community care for
veterans as they move portability, their electronic health
records? Veterans like me who go to a VA hospital for part of
my care, but also take care in my community for things that I
feel I can realistically get there, but there is not a way of
sharing those records. I had the same back X-ray no less than
three times because one was within the VA, then to my primary
care at the VA, then to the place they referred me to. They
cannot even share an X-ray scan between one another. Are we
going to see a benefit of that coming? Is that contemplated
under this contract, and how do you see that performing?
Mr. Topping. Representative, let me answer both those
questions. One about the constituent that you had that had
surgery in one place referred to the other.
Mr. Barrett. This was long ago, so it is not current.
Mr. Topping. Could have been long ago, but I am sure there
may be other stories out there like that, too. This was when
Secretary Collins introduced best medical interest; this is
exactly the type of thing he wanted to tackle. Where you have
got for a veteran, where the quality of care, but also
continuity and convenience makes sense, the veteran should be
able to drive that, not their bureaucracy. That is the intent
of that change. Absolutely, the impacts both direct care and
community care that is part of it.
In terms of portability and the ability for our electronic
medical system to speak to--to work with compatibility, one of
the things that under the current contract that has really been
unfunctional is we do not have an easy way for providers to
transmit records. We have the same challenges with claims which
really should not even be there. We have the same, very much a
problem with provider record transmission. Yet, there are easy
and commercially available exchanges that every other provider
does this. Different providers from different systems move
claims, move records all day, every day. The new contract
requires the use of commercially available and compatible
systems. The new system that VA is implementing, again Veterans
Health Information Systems and Technology Architecture (VistA)
is homegrown 30 years.
Mr. Barrett. Mm-hmm.
Mr. Topping. The new system does have the ability to do
that. It can ingest those records and then populate it through
the new system.
Mr. Barrett. Very good. I do not want to cut you off, but I
do want to move to the second part of that, which is I have
seen through the electronic health record program just how
these contracts can balloon into a cost that is way beyond what
is initially advertised. You know, we get into one of these
contracts, and we are too far into it to really claw back or
pivot or change or make adjustments to that. What
accountability measures can you assure us of so that, as we go
through this process, knowing that contractors are going to try
and charge us, nickel and dime us every change order along the
way, and everything else? How are we going to extract the best
value for the taxpayers and for the outcomes for veterans to
know that we are not going to have a contract swallowed up into
something that is unmanageable, and 5 or 10 years from now, we
are in a position where this thing is ballooned completely out
of control?
Mr. Topping. Representative, one thing, again, the IDIQ
gives us the flex--the flexibility to bring in, choose, and
swap between different vendors in the program to change the
program as we go. That is what is novel about that. That is
what is exciting about this. That is what gives us those tools
and our ability to do that. We do not get swallowed up on this
because we have time as we go across.
Then ultimately, the cost of care and community care is not
the administrative cost of the program. It is not what it costs
VA to operate it. It is not even what we pay our health plan
partners. It is the cost of purchased care. We want those
health plan providers to have skin in the game in lowering our
cost of care. Ultimately, where this contract does go is we are
paying for quality. If they hit our targets, they hit our
scores, and they save money for us, they will share in those
savings. That is how we drive and pull down the cost of care in
this.
Mr. Chairman. Representative Kennedy.
Mr. Kennedy. Thank you, Mr. Chairman. Today's hearing on
Community Care Network Generation requires clarity about what
the program is and what it is not. Community care was meant to
supplement VA health care when timely care is not available. It
was never meant or intended to replace the VA or be a vehicle
for privatization.
Veterans are a unique patient population with complex
service-connected needs from combat injuries to toxic exposures
that the VA was specifically built to treat through
coordinated, holistic, and specialized care. Shifting more care
into fragmented, private systems risks quality, continuity, and
outcomes. This model is also unworkable. CCN Next Gen demands
strong oversight, yet this administration has cut tens of
thousands of VA staff and failed to fill vacancies, including
staff responsible for overseeing these contracts. You cannot
howl about the workforce and expect the system to function
effectively. We all know that. Billions will flow to
contractors with limited accountability. When care fails or
becomes fractured, veterans will pay the price. Veterans kept
their promise to our country. We should be strengthening the VA
and not hollowing it out.
I am a healthcare practitioner myself, an occupational
therapist. I was trained to look at the whole patient:
function, recovery, long-term outcomes, and continuity across
providers. The CCN Next Gen RFP provides extensive detail on
contract structure and payment, but very little on requirements
for clinical quality, continuity of care, or experience
treating high-risk veterans.
My question, Mr. Topping, is where in the RFP have you set
specific quality of care metrics for community providers to
meet?
Mr. Topping. Representative, thanks. Good to see you again.
Number one, Community Care Next Gen is a supplement to the
Direct Care System and the things that VA does well and VA does
uniquely. Again, this is a trillion-dollar over 10 program, but
our direct care is 2 trillion over 10. This is 1/3. That is 2/
3. We are investing in those. We are opening new facilities. We
have invested $800 million last year alone. We are investing in
our direct care capabilities. For veterans who either need to
go to VA for direct care because it is a unique capability that
VA has or who choose to go, that they have that ability and
they have that choice, we are investing in that.
Second, how quality will be measured, again, we are using
standard industry metrics for this. These are not unique to VA.
These are not unique to providers. We are focusing on HEDIs, we
are focusing on the types of scores and measures that make a
difference, that we know providers are used to working to a
measure. We are going to use that as we then determine who and
how and under these contracts, whether we are meeting the
requirements that we are setting out for them. These--so that
is contemplated and included in this program.
Mr. Kennedy. I understand the goal. The goal should be the
golden standard of care, the top quality care for our veterans.
I believe we all should aspire to hit that goal. If the quality
care standards are not put into the contracts, they are not
clearly defined. Is not it fair to say that the quality and the
continuity of care are not being prioritized in the contract?
Mr. Topping. Representative, they will be included in the
contract. We have identified what our mandatory quality
requirements are and what our scores are. They are mandatory
and optional, but we have already identified those, and those
will be in the contract, and they will be required.
Mr. Kennedy. Well, it seems to me the oversight of these
contracts, though are going to be left onto the contractors
themselves, that the quality of care is going to be left to a
standard like they are policing themselves when it comes to
quality of care. Like the fox watching the hen house. You know,
how do we assure our veterans and this committee and Congress
and the people that veterans are going to be provided that
golden standard of care if we do not provide for the proper
oversight of those contracts?
Mr. Topping. Representative, we will manage our vendors. We
are accountable to our veterans for the care they receive. We
are accountable to you as Congress. We will manage the vendors.
This is our program. Our vendors will operate this as our
partners on agreed-upon terms and requirements. Again, we have
the ability to off-ramp vendors who do not meet our
requirements, do not match our values.
Mr. Kennedy. Will they be self-policing their own
contracts----
Mr. Topping. No.
Kennedy--for quality of care? There will be oversight?
Mr. Topping. Yes, sir.
Mr. Kennedy. How is that oversight provided in the
contract? How is that outlined?
Mr. Topping. We will manage that. The requirements will be
in the contract. We will manage that through our program
office. Again, the IDIQ gives us the ability to off-ramp
vendors who do not meet those requirements. Those will be
required. We will manage that, and we will be accountable for
their performance.
Mr. Kennedy. Well, just short on time here. Mr. Chairman, I
will yield back.
Mr. Chairman. Thank you. Representative Cherfilus-
McCormick, you are recognized for 5 minutes.
Ms. Cherfilus-McCormick. Thank you so much, Mr. Chairman.
Thank you for being here and answering these questions. You
know, the possibility that our veterans could have access to
care wherever they live is actually, I think, our shared goal.
However, the VA does not have a good history of implementing
any kind of technology modernization. I love what you are
saying, but I think the scrutiny is coming because of VA's
history. Looking at that, I want to dive into what mechanisms
were used in determining to go with Next Gen as far as
acquisition.
Mr. Topping. Representative, so in terms of the contract
vehicle or in terms of the technology that we are going to use
to administer the----
Ms. Cherfilus-McCormick. The decision-making process.
Mr. Topping. The decision-making process around CCN and to
use the IDIQ vehicle was to introduce flexibility and
competition. Then the choice to use the 5 pillars were based on
we know that those are controls that exist in every other
healthcare program that have been successful. We know that we
can leverage those to get to the outcomes that we are looking
for. We made those choices based on that. Then our next step on
this, too----
Ms. Cherfilus-McCormick. Well, I want to interrupt you real
quick because what I am looking at is the price point and what
the decision-making behind the acquisition. For example, as a
mission-critical, highly complex, and high-dollar value
acquisition, Next Gen clearly qualifies as a major acquisitions
program under VA's acquisition lifestyle framework. Could we go
into the framework that you used in choosing Next Gen?
Mr. Topping. Representative, I am not--I am not sure I
clearly understand the question. The framework that we chose
were based on what are the outcomes we are trying to achieve
for our veterans. Ultimately, what we want is veterans to have
choice, we want veterans to receive high-quality care, and we
want taxpayers to get the best value for that care. That was
the framework that we--that we choose.
Ms. Cherfilus-McCormick. Would Ms. Skolrood be able to
answer that question? I know you do the financial parts of it.
Ms. Skolrood. We did follow the acquisition lifestyle
framework. That was--that have been--I have learned a lot about
that in the last year and a half since I have been with the
Federal Government and the VA, and we followed and worked
closely with SAC, the Strategic Acquisition Office, and you
know have followed that process as it is laid out.
Ms. Cherfilus-McCormick. Have you already had the
acquisition decision events A and B?
Ms. Skolrood. I am not familiar enough with it to speak to
those details, but I know that we can provide you that
information.
Ms. Cherfilus-McCormick. That would be excellent. We want
to know also who was provided or who was actually a part of
those decision-making. Like I said, the extra scrutiny is
because the VA has not been successful in implementation. We
want to make sure that a lot of the failures we had in the past
are not being repeated.
In addition to that, I have heard you say several times
that we are looking at best practices, even with CMS. There is
a unique culture within the VA that has caused the VA's
transition to different types of technology unsuccessful. One
of the things that, you know, the last 5 years we have been
doing this, I have learned, is the presumptions that we make in
private industry or in other government sentences--other
government settings do not necessarily apply here in the VA. As
we are going forward, we do want to get more data and more
information as implementation goes on. This process of flying,
building the plane while flying it, has not led to success.
Do you know offhand any safeguards of reporting that are
going to be present? As we see the implementation, we are
knowing wait times, for example. Do you have any of that lined
up?
Ms. Skolrood. We do. We have an extensive implementation
team that has already began meeting. We have over, well over
200 team members throughout the VA that are participating in
that. Right now, the primary--the primary focus of that team,
once we have--we have created the infrastructure and the work
streams that will oversee the implementation, the predominant
thing of importance right now is care coordination.
Ms. Cherfilus-McCormick. Yes.
Ms. Skolrood. If we were to select a provider, a TPA, when
we select a TPA, it will be very important that veterans who
are getting care currently in the field, in the community, that
those referrals, that all of that is hand--hand by hand, one by
one, transferred over to community, to the other provider.
Ms. Cherfilus-McCormick. As I am running out of time, I
just want to make sure that when we have another opportunity to
convene, that we can actually have all that information in
front of us.
Ms. Skolrood. Absolutely.
Ms. Cherfilus-McCormick. That as we are doing the oversight
process, we can work together to make sure that this is
actually successful. As I mentioned, too many projects that we
have spent a smaller amount of money on have failed. That ends
up hurting our veterans. It ends up hurting our finances as we
are funding it, and it hurts everybody, all across the board.
We are like 10 years in trying to get it right. The goal is to
get it right as much as we can and spend the least amount.
Flying the plane while building it has historically caused
failure, and we want to make sure we prevent that.
Thank you so much. I yield back.
Mr. Chairman. Dr. Morrison, you are recognized for 5
minutes.
Ms. Morrison. Thank you, Mr. Chair. Health care workers are
increasingly facing burnout. I hear about the administrative
burden my physician colleagues are facing with an alarming
frequency. A major part of what compelled me to serve in
Congress was my firsthand experience as a doctor, seeing how
difficult navigating our healthcare system can be. It is one of
the reasons I fought so fiercely in my home State of Minnesota
to pass legislation that reduces this burden. It is why I have
serious concerns with the significant changes that have been
proposed to VA's Community Care Network. The focus should be on
delivering the best care for our veterans, prioritizing their
needs and access to care. I am sure you agree.
Mr. Topping, the CCN Next Gen contract will include
incentives and disincentives to be implemented over the life of
the contract. The incentive and disincentive plan for the East
Region task force only identified two performance objectives,
both of which seem concerningly easily attainable. The first
incentive VA lists is adverse credit reporting. That is
ensuring veterans are correctly billed for copays and not
improperly billed for services to avoid having unpaid bills
being sent to collections.
It is my understanding that among the pressing concerns
with vulnerabilities in the CCN, this has not been an issue in
the Community Care Program under the current structure. My
colleagues that have served on this committee for longer than I
have shared that they cannot remember the last time a veteran
reached out, sharing that their community care claim was sent
to collections. I am having a difficult time understanding the
logic between tying incentive payments to metric contractors
that will ease--that will easily be able to to achieve.
Mr. Topping, briefly, how does small, easily achieved
incentives protect the quality of care veterans receive and
safeguard taxpayer dollars?
Mr. Topping. Representative, thanks for that question.
Again, the purpose and the intent of this contract is to be
iterative and for us to be able to scale and evolve over time.
Adverse credit reporting is a proxy for whether or not these
TPAs are doing their job, which is processing and paying for
claims. That is the number one thing they are supposed to do,
is to ensure that our veterans do not receive bills for the
services they have provided. This has been a management issue
inside VA, and this is an easy, clear metric that they can
manage too and that we can manage and report on, to ensure that
they are doing their number one task, which is paying and
managing claims. That is number one.
The second thing we chose is the inclusion of value based--
value based contract provisions in their network. You can see
that it starts with a zero and ratchets up over time. The
reason why we have done that is value based is a key component,
a key control in this contract to ensure that we can pay
differently for the quality that we want and with the integrity
that we are looking for. This ratchets up over time, the
ability to ensure that they are--that we have these in the
provider network. Then what we intend to do is then drive the
requirements on what we want out of VBR. It is ensuring that
the infrastructure is in place.
Last, the lower extremity joint replacement, this is
already a procedure and a process that VA has. We use this in
the community. This is a well-known bundled payment. We are
starting with where we know we can manage, we can be effective,
we can provide the oversight, and we know industry can deliver.
Ms. Morrison. Would you----
Mr. Topping. These are our starting points.
Ms. Morrison. I am sorry to interrupt, sir. Would you be
willing to commit to working with us to implement meaningful
guardrails that can prevent these incentives from becoming
mechanisms that will actually be used to just drive excessive
money to health insurance companies and payers that will be
awarded these contracts?
Mr. Topping. Absolutely, yes, Representative. We share that
with you.
Ms. Morrison. Fantastic. It is my understanding that VA
anticipates it will take until Fiscal Year 2028 for full
healthcare delivery under the CCN Next Gen contracts. What is
VA's plan to bridge the current CCN contracts and services
until the Next Gen contractors are in place and able to provide
the full spectrum of care needed in Fiscal Year 2028?
Mr. Topping. Representative, we would love to have no
bridge. We would love to implement the new contracts as soon as
we can, on time. To the extent a bridge is needed, when that
comes and that goes through the acquisition and contract office
process, to the extent a bridge is needed, we will implement
that at the time. Our goal is to get this done, get this bid,
get this right, and get these awarded, and to begin to manage
and operate this program as soon as possible.
Ms. Morrison. How will you ensure proper continuity of care
for veterans during this transition?
Ms. Skolrood. Thank you for the question. That goes to what
we were talking about a few minutes ago, our implementation
team. Right now, our primary focus and the priority for the
work stream is care coordination. These things occur in
industry not infrequently, where a TPA changes. There is a
process in place to make sure that that care coordination is--
is done very well. We are pulling again from industry expertise
to make sure we are thinking of every single avenue that we
need to, to make sure that no veteran falls through the crack
during--during that transition.
Ms. Morrison. Thank you very much. Mr. Chair, I see my time
has expired. I yield back.
Mr. Chairman. Thank you. Representative Budzinski, you are
recognized for 5 minutes.
Ms. Budzinski. Thank you, Mr. Chairman and Community Care
Takano, for holding this hearing. One of the major limitations
of the current Community Care Program is that there are about
four, five different ways for providers to return medical
records, ranging from faxing copies to participating in
electronic health information exchange. Many of the existing
mechanisms rely on manual retrieval of records and importation
into VA's electronic health record, which is both time-
consuming and lacking in true interoperability. Most records
never make it back to the VA, which limits our ability to
monitor the quality of care veterans are receiving in the
community.
My question, Mr. Topping, is to what extent does the CCN
Next Gen request for proposals address the technology needed to
facilitate the return of medical documentation to the VA from
network providers? Then, as a second question, what challenges
do you anticipate in getting that information to the VA?
Mr. Topping. The first challenge on medical records, which
is well known at this point and documented, is driven in part
by the fact that VA still uses an EHRM that is homegrown, at
about 30--30 plus years old. We are transitioning on a very
aggressive schedule. Secretary Collins has been clear that his
expectation is this will be done. This is being led by the
Deputy Secretary. We are transitioning to a new EHRM that has
these capabilities. Currently, for a provider to share records
with VA and for those to then get into the VistaA system, it is
a manual process, and that is unacceptable.
Under the HRM system and in this contract, we are requiring
the use of commercial exchanges. We are going to transfer
medical records, share medical records in the same way the rest
of industry does. The providers can use the systems they
already have. They will be in exchange, and then we can bring
those records into our system going forward as part of, part of
our EHRM implementation.
Ms. Budzinski. I serve as the Ranking Member on the Tech
Modernization Subcommittee. Definitely very much tracking this
EHRM implementation as it has been going. This is going to be a
big process. What you are saying is that, through the manual
process, that is how manually we will be able to have to, until
EHRM is fully implemented, it will be a manual process in
ensuring that community care records get back to the VA?
Mr. Topping. We will likely during this transition between
now and when EHRM will be completed. It is a completely
electronic process, straight data exchange from the provider
through the exchange to our new system. That is fairly
straightforward in the way that the rest of industry operates.
We will still, while we have VistaA, likely have to take from
the exchange, and there will likely be a process by which we
will then have to pull those records in. That will continue.
That is part of the goal on EHRM, ensuring that we do not have
to do that going forward.
Ms. Budzinski. There is----
Mr. Topping. It will be a bridge.
Ms. Budzinski. There is a commitment that those records
will get to the VA. Is there, you know, returning of these
medical records, would there be a condition of payment? You
know, maybe if they do not return those payments to or they do
not return those records to the VA, would there be some kind
of, you know, condition on payment to the vendor if they do not
receive it?
Ms. Skolrood. Thank you for that question. We are not
linking payment to the vendor directly to the return of medical
records. However, we have put into the Next Gen contracts more
of responsibility on the TPA to ensure that their providers are
compliant with the rules. The contracts that the TPAs have with
the providers must include the return of medical records. We
also--we have also streamlined the way in which we will receive
those medical records, so the fax, the phone in all of that, we
have streamlined what the expection--expectation is for return
of those.
Ms. Budzinski. Okay. If there, I mean, if you are--if you
are taking kind of payment off the table, is there--will there
be a process in place to just ensure when you see there is that
gap, records are not being, I mean, it is just important----
Ms. Skolrood. Absolutely.
Ms. Budzinski [continuing]. that the VA be the place where
all that is housed.
Ms. Skolrood. Absolutely. We also are utilizing that as a--
as a data point for our preferred provider program. If we have
a provider who is not--who is not doing that, then they can
lose designation as a preferred provider.
Ms. Budzinski. Okay. This might go to my next question. Is
it the VA's expectation that contractors will provide a system
that will be truly interoperable with VA's electronic health
records, both VistA and Oracle? I think you have answered that
question, but just anything further to elaborate on that point?
Mr. Topping. Yes.
Ms. Skolrood. Yes.
Ms. Budzinski. Okay. One other thing I just want to ask
really quickly about the RFP. It includes optional line items
related to the development of software processes. Could you
just quickly say to what extent do you think the VA sees
development of Information Technology (IT) systems and software
is a part of this effort?
Ms. Skolrood. Thank you for that question. The intent of
the IDIQ is to be broad. That should again, so that we are
nimble. Should we come to a point in time where that makes
sense and we need that, then we can utilize the multi-award
IDIQ and issue a toper for that particular need, whatever it
may be.
Ms. Budzinski. Would that be an additional cost in addition
to the trillion if you do decide that you need it?
Mr. Topping. The cost--the cost for the technology
requirements for the management of this program--so let me
first go back to the program management part of this, which VA
is now focused on our ability to manage these contracts. We are
building that, and that includes a technology build. We are
getting ready to focus on a $300 million acquisition around
that to ensure we have the capability to do that. That is
number one, making sure that we have the resources, make sure
we have got the team, the capabilities, and the resources to do
that.
How that then fits in with the network and our providers is
that we want to be as plug-and-play as possible. We are the
fourth largest payer, but we are one of the payers. These
providers also work with Medicare, they work with Medicaid,
they work with Tricare. We want our system to be complementary
to work that they are doing with the most interoperability as
possible. Those have been our focus, and that is a commitment
to it. Both a financial commitment and a management focus on
the build.
Ms. Budzinski. Okay. Thank you for the extra time, Mr.
Chairman. I yield back.
Mr. Chairman. I am going to explain to the audience, the
panel, and the members what the intent of the chair is at the
request of the Ranking Member. He does want to ask one more 5-
minute, we are going to grant him that opportunity, and then
one on our side for Keith, or for Self, instead of doing a
second round, because we have got another panel we are trying
to get to. Are you all right with that?
Well, what I am trying to do is get to the second panel as
fast as possible. That is why I said we were--we will just go
over here to everybody that is here.
Mr. Takano. Okay.
Mr. Chairman. So----
Mr. Takano. Appreciate it.
Mr. Chairman. You are recognized.
Mr. Self. Thank you, Mr. Chairman. Mr. Topping, you have--
you have given us the mantra several times. I am trying to get
to the details. I do not think you answered Mr. Barrett's
question about do you have a plan. Can you assure Congress that
the $1.049 trillion is the final cost for this program? In the
VA, we find they come back for more money almost every time. I
think that is what Mr. Barrett was asking, and I would ask you
directly how will you manage that in this managed program, so
that when you reach that--that end dollar, what are you going
to do to make sure you do not come back for open-ended funding
from Congress?
Mr. Topping. Representative, there are three things that
drive, ultimately, you know, our VA's on cost. Number one are
the original cost estimates, which to tend to be inaccurate.
The reasons why they are inaccurate are there are things that
are not in the model. For example, congressional changes,
congressional intent, larger demographic shifts. There are
things that we cannot quantify in a 10 year model, in our
enrollee healthcare cost model, that make the model sometimes
inaccurate. That is number one.
Number two, by design, the VA system cost shifts. Veterans
and their care, they can go from direct care to community and
back again. Our system, in terms of letting the veteran choose
where he or she receives care, is designed to shift that cost
and that care. That is number two.
Then number three, both of those programs, both the Direct
Care System and the Community Care Program, up until now have
been completely unmanaged. We have had no tools, no levers, no
capabilities to manage those costs, to make adjustments. What
CCN Next Gen does on community care is it gives us program
integrity, it gives us quality, gives us value based care,
gives us utilization management, and it gives us alternative
payments. It allows us to use those tools and levers to begin
to be accountable for those costs and to pull those levers.
For the first time, and in the cost estimates I provided
this committee, where we show savings of 8 to 14 percent over
10 years, $54 to $100 billion, those cost estimates are not
based on VA data. Those cost estimates are based on CMS data on
these tools used in other programs over the past 10 years. It
is verified data. I believe those numbers and those projections
are accurate and as accurate as they can be. I believe we can
come back to you on time and on budget.
Mr. Self. Okay. IDIQ contracts have a habit of not being
solid. Veterans, the population between 2004 and 2024, I think,
decreased by 30 percent. The enrollees have been stable, the
way I understand it, but the population has gone down by 30
percent over those last 10 years. As the population goes down,
we are losing, obviously, our World War II vets and our Korean
vets in great numbers. Frankly, we are not--we are not in any
active conflicts now. I think that will change. Your transition
plan, I believe that you do have a transition plan over 2 years
because you have got like $425 million over 2 years for
implementation. I assume you are having a soft opening, which
people would call a soft opening. You roll it out over time.
Question, do you have community care--and this may be
something I just do not know. VISN boundaries have been
sacrosanct heretofore. Is this--is this--under this contract
going to be different? El Paso, Texas, for instance, is at a
VISN boundary. Can you speak to that under this contract?
Mr. Topping. Representative, yes, and no. Yes, we are going
to have VISN boundaries. This is part of the VHA restructure in
which we are moving from 18 business to 5, plus with health
service areas as well. Our regions match those. However, under
the IDIQ and bringing in regional vendors, our intent is that
those regions can then be broken up further, redesigned. We
could have partnerships in those regions. What we want to be
able to do is match the care we can deliver, what we are paying
for, and what we are achieving, and what we need. We want to be
able to match to the region in which we need to deliver it.
There is flexibility for us to do that. We will use the same
regions, we will have the same boundaries, but we do have the
ability to be flexible based on the needs of the veteran.
Mr. Self. Cross VISN boundaries. You have that flexibility?
Mr. Topping. Yes, sir, we do.
Mr. Self. Okay. Mr. Chairman, I yield back. Thank you.
Mr. Chairman. Ranking Member, you are recognized for 5.
Mr. Takano. Oh, you can go. You can go.
Mr. Chairman. Okay, go ahead.
Ms. Brownley. Trouble hearing you today, Mr. Chairman.
Thank you for the opportunity. Just a couple of last questions
here. I--earlier you told the Ranking Member that VA will not
require any transfers to the Community Care account for Fiscal
Year 2026. I just want to make sure that that is absolutely
correct.
Mr. Topping. Representative, I want to be a little hedgy on
that. What--and what I said and which is what I have right now
is my data right now, my utilization data, my cost data,
understanding that there is a data lag and there is a claims
lag, providers can bill me 6 months after the fact. The data
that I have right now shows that our appropriation for Fiscal
Year 2026 is accurate, and that is the number that we need.
That is what we are managing, too.
Ms. Brownley. Okay. I also want to just confirm that you
have not had any discussions with our Appropriations Committee
counterparts about possible transfers. I just want to make sure
we are absolutely clear on this. If you can answer that,
please.
Mr. Topping. Representative, I always have conversations
with our appropriators. They are--they are my best friends as
the CFO, making sure they know what I am managing, managing to,
where I see risk, where I see opportunity, and making sure they
know. I have got maximum flexibility to meet the aids--needs of
the agency. Coordinate with them and frequently----
Ms. Brownley. Let me re-ask. Let me re-ask the question in
a different way. What you just told us about transfers in 2026
is the same thing that you have said to the Appropriations
folks in your ongoing conversations?
Mr. Topping. In my ongoing conversation, it was, this is
the data I have. This is the number we have. This is what we
are managing, too. I want--but I want all of my appropriators
to know that as we manage this, we want to ensure that we have
the resources we need to meet the mission and care for the
veterans. Those are the conversations I have had with my
appropriators.
Ms. Brownley. Okay, thank you. One last question. I think
the--when your plan, this new plan will be fully operational,
will be in 2028, is that correct?
Mr. Topping. Yes, ma'am.
Ms. Brownley. Okay. In 2028, we are going to have a new
administration. What that administration looks like, we do not
know. Right? My concern is, while we are working really hard on
this new delivery system, if you will, for community care, how
are we--what are you doing to ensure that we, under the current
system is delivering high-quality--high-quality care and timely
care to our veterans? That is my concern, because I do not want
to be talking about something that may or may not happen, and
meanwhile, our veterans are getting less care.
Every veteran that I speak to, almost every veteran I speak
to, prefers to get their health care within the VA. I am, you
know, I have always advocated for community care. It is
necessary to provide care to all of our veterans across our
country in terms of everything that they need for their health
care and mental health care. I am not against community care. I
want to be clear on that. I just want to make sure that we are
providing the high quality care and that we have the ability
today. I worry about all of the cuts and vacancies that are in
the VA that we do not have the ability to provide the care, the
high-quality care that we need. I need some insurances--
assurances from you on how you are handling that.
Mr. Topping. Representative, so as a veteran who uses both
direct and community care and also prefers direct care when I
can get it and community care when I cannot, I share your
interest in that too. The system that we have in place today,
both with direct community, is a system that we have and we
will operate until this contract is live. The tools that we
have, the limitations that we have, those exist today. Today,
the team that has focused on serving veterans through this
program continues to focus on ensuring----
Ms. Brownley. Okay.
Mr. Topping. they get what they need, when they need it.
Ms. Brownley. As we go through, you know, 2026, 2027, and
2028, so when there are vacancies that occur, you are going to
fill those vacancies? You are not going to say, oh, I can now
take those resources and make some kind of investment in the
new system versus the existing system?
Mr. Topping. VA has a huge investment in Next Gen, getting
this right, and being accountable for it. As we build the
program management team and the design of that team, we will
resource that to ensure that it is staffed appropriately, that
it is got the right technology, that it is got the right tools,
that they can manage this contract, and we can be accountable
for these outcomes to you and to our veterans.
Ms. Brownley. Okay. It sounds to me like you may indeed, if
there are folks that leave the VA, there are vacancies there,
that you may use those resources for the new system versus the
old system.
Mr. Topping. We want to ensure that the program management
capabilities of VA can manage this program. The program we have
today, we want to manage that as best as we can, as effective
as we can. We are excited about these new tools, these new
capabilities for better outcomes, better cost as we move
forward.
Ms. Brownley. Thank you. I yield back. Thank you, Mr.
Chairman.
Mr. Chairman. You are recognized for 5 minutes.
Mr. Takano. Thank you. I want to take this opportunity to
clarify this issue over referrals from the VA--and TPA's
ability. This is a problem of the vertical, the challenge of
vertical integration of the healthcare industry. Third-party
administrators build. Currently, they build the network, right?
They build the CCN network. Is that my understanding? That s
what--that is what part of their job is, right?
Mr. Topping. Yes, Ranking Member.
Mr. Takano. If they pick and choose which providers are
part of those networks, we are presented with an issue. If
those networks are full of providers that the third-party
administrators own themselves because of the vertical
integration, it does not matter that the VA is doing the
referrals. They have set--the situation that we have set up
structurally, is that they are, in a sense, going to be able to
have veterans referred to providers in the networks that they
already own. Do you follow what I am trying to say here?
Mr. Topping. Yes, sir.
Mr. Takano. You have not given us any assurance that you
are preventing this scenario under the current contracts or
that you will prevent it under future contracts. How will--how
will your proposed contract deal with the scenario I just
presented to you?
Mr. Topping. Sir, so the goal is to ensure----
Mr. Takano. No, no, I do not want to know the goal. What
mechanisms, what manner of enforcement, what ways, what--what
tools will you have in the contract to prevent what I just
described?
Mr. Topping. The mechanism is ensuring that VA has the
authority to make the referral and determine where the veteran
receives the care.
Mr. Takano. I just showed you how the referral--what good
is VA's authority to refer when they have--when they refer, all
they are going to be able to do is refer, the TPA refers them
into providers that they already own?
Mr. Topping. The referral and the placement VA owns that.
VA is accountable for the veterans' care. The TPA does--the TPA
does not have the authority to steer veterans into a provider
that the veteran and or the VA does not choose. The issue is
not vertical providers owned by payers. In some cases, that
might be the highest quality, lowest cost care. That is
something that VA would benefit from in our veterans were .
Well, what we want to do is, regardless of who owns a provider,
ensuring that the veterans go to the highest quality, lowest
cost provider. VA controls the steerage. VA places the patient.
They belong to us. We make those decisions. VA will place the
veteran.
Mr. Takano. Well, does the VA--do the VA schedulers have
any visibility into which network providers are owned by the
TPA?
Ms. Skolrood. Currently, to my knowledge, they do not. I
think that is something we can take back and contemplate. We
have talked a little bit about preferred providers, and that is
something that we are building in a more robust way in Next
Gen.
Mr. Takano. Yes, well, so this is a major flaw in the
current system and one which leads to some self-dealing by the
third-party administrators. They put the network together and
say they have set up VA with a limitation, and if the VA has no
visibility into where the veteran is referred to, you can see
the conflict right there.
Ms. Skolrood. Again, the VA is the one who makes that
decision. As we select preferred providers----
Mr. Takano. VA is making a very limited decision. Right?
You are making it sound like they have this choice, but there
is none. The VA does not have a choice here. The TPA has been
able to set it up to their benefit.
Mr. Topping. Sir, so that is not true. Under Next Gen, VA
does have the choice because we have the quality----
Mr. Takano. I am sorry. I am interested in knowing more
about that, but I need to get to another question. I want to
know more if you would get back to me about how, under Next
Gen, we prevent this situation. I have no assurance that this
current flaw is going to be prevented in Next Gen. If community
care is VA care, then the knowledge and skills of the providers
should be equivalent. If that--if that representation--if
that--we are going to represent community care as VA care.
Well, currently, suicide prevention training to bring the
knowledge of CCN providers to equivalent VA standards.
Currently, that is voluntary, right? That is not something that
VA can insist that CCN providers get or do in order to be able
to treat our patients, is that right?
Mr. Topping. We want to ensure that all network providers--
--
Mr. Takano. Well, just to answer the question. Do you know
if that is true or not? Now I can tell you it is not. If it is
voluntary. It is voluntary. VA cannot insist that they do--that
our providers, the CCN providers, must go through suicide
prevention training equivalent to VA providers. Do you know
why?
Mr. Topping. Ranking Member, we want to ensure that all of
our providers----
Mr. Takano. Do you know why?
Mr. Topping [continuing]. have the training----
Mr. Takano. Do you know why?
Mr. Topping [continuing]. and skill set----
Mr. Takano. You do not. You do not know why? The answer is
you do not know. The answer is that, my understanding is that
third-party administrators have resisted in negotiations with
VA the requirement that VA be able to insist that CCN providers
receive trainings like suicide prevention because it would be
too hard to recruit for their network. They have that power to
push back on VA. VA should be able to insist that all CCN
providers are trained to equivalent standards that are within
VA direct care. Do not you think that--do not you think that is
a reasonable level of standard in?
Ms. Skolrood. In Next Gen, we do have the requirement that
certain training that we require will be required of providers,
and the TPAs have responsibility to ensure that that happens. I
will say we can put in the contract that all physicians must
wear purple shirts on Tuesdays. That does limit our ability to
build a robust network. I do not like the word----
Mr. Takano. You just parroted what I just said. Right?
Ms. Skolrood. Right.
Mr. Takano. The reason why--the reason why that this is not
a requirement and is not enforceable is--is exactly what you
just said.
Ms. Skolrood. It is enforceable.
Mr. Takano. It impairs the ability--it impairs the ability
of the third-party administrator to recruit and build out their
network. That is basically yes.
Ms. Skolrood. No. In Next Gen----
Mr. Takano. No?
Ms. Skolrood. In Next Gen, we do have the requirement. We
have to--we have to understand and identify that that is a
risk. That is absolutely a risk. As we require more and more
providers in the network to do things specific to what the VA
needs and wants for our veterans, it will impact potentially
the network. That is--that is our problem, and that is our
TPA's problem. We then have to address it. We have to then
build not an adequate network, but a robust network that meets
the needs of----
Mr. Takano. I can tell you it is a huge frustration of mine
that the CCN providers we have now, we have not been able to
get them to do suicide prevention training, which is one of the
biggest, biggest challenges we have at VA.
Ms. Skolrood. Absolutely.
Mr. Takano. You have not given me any clear answer that
Next Gen is really going to solve this problem.
I yield back.
Mr. Chairman. Thank you. On behalf of the committee, I want
to thank you for your testimony for joining us here today. You
are now excused because we do have another--we will wait a few
seconds and get the second panel up. Thank you for being here.
We want to welcome everyone and thank the next panel for
being here.
On our second panel, we have Mr. John Vick, executive
director of Concerned Veterans for America (CVA), and Dr.
Rachel Madley, Ph.D., director of policy and advocacy at the
Center for Health and Democracy. Thank you once again for being
here and attending today.
I would like to, if each one of you would rise and raise
your right hand.
[Witnesses sworn.]
Mr. Chairman. Let the record reflect that both witnesses
answered in the affirmative.
Mr. Vick, you are now recognized for 5 minutes.
STATEMENT OF JOHN VICK
Mr. Vick. Thank you, Chairman, Boss, Ranking Member Takano,
and members of the committee for the opportunity to testify
today at today's oversight hearing on the future of the
Veterans Community Care Program on behalf of Concerned Veterans
for America. CVA is a Grassroots network of thousands of vets,
family members, and patriotic citizens that advocates for and
defense policies to preserve freedom and prosperity for all
Americans. Our organization builds engaged communities of vets,
elevating their unique experiences and perspectives to help
improve American lives. We believe that strong and healthy vets
make for strong and healthy American communities.
While CVA is focused on many issues, since its
establishment over 14 years ago, the organization has
consistently fought to empower vets to be at the center of
their health care journey. Excuse me. As an enlisted Marine and
later as a Navy Officer and now as executive director for CVA,
I know a lot of veterans. I have seen how the ability or
inability to access quality and timely health care has
profoundly impacted the lives of those that I have served with.
That is why we advocate for choice and accountability.
CVA helped elevate the voices of veteran VA whistleblowers
who revealed that veterans had died while waiting for care on
secret wait lists during the Phoenix VA scandal of 2014. CVA
helped shape and support the 2018 MISSION Act, which passed
with overwhelming bipartisan support and created the Veterans
Community Care Program that we are talking about today.
Community care now accounts for about 40 percent of overall VA
health care, and that is growing, which is a testament to both
veterans' preferences and to this committee's willingness to
tackle tough problems on their behalf.
CVA's view of veterans' healthcare is simple. At all times,
veterans should have the choice of seeking care either at a VA
facility or a community care provider, depending on which best
meets their needs. It is the same choice that the congressional
staffers get sitting behind you, and it is the same choice that
the CVA staffers get sitting behind me somewhere back there. It
is also the same model that our retired military and civilians
are able to use.
The Community Care Network's Next Gen contract offers an
important investment in sustaining the hard-won health care
choices of the VA MISSION Act and ensuring that veterans have
quality choices to choose from. At the same time, Members of
Congress and policymakers at the VA will need to work together
to ensure that the Next Gen contract is carefully and
efficiently managed to limit the potential for waste, fraud,
and abuse. This contract should empower the thousands of
incredible people at the Department of Veterans' Affairs who
truly want to be a partner in getting veterans the care that
they need as soon as they can get it. Veterans need these
community care options.
Here in DC alone, the consequences of pushing veterans away
from community care and toward sole reliance on the VA or would
be disastrous. As of January 20, 2026, new patient wait times
for primary care at the Washington VA Medical Center were at
over 35 days, according to the VA's own wait time tracking
tool. This is well over the 20-day wait standard for non-
specialty treatment in the community. The same query found new
patient wait times of 62 days for dental care, 66 days for
OBGYN treatment, 65 days for podiatry appointments, and 56 days
for oncology appointments. That last one is for cancer. Mental
health availability in DC is actually pretty decent at about 8
days, but up the road in Baltimore, it is 26 days, Phoenix is
39 days, and Los Angeles is 55 days. People that are finally
ready to get mental health care treatment often just do not
last that long.
Rural veterans that volunteer for CVA often report the
additional burden of onerous travel requirements to VHA
facilities, sometimes hours away and across State lines for an
appointment that took too long to get in the first place. That
is why over 84 percent of veterans enrollees at VHA rely on
supplemental insurance outside the VA, such as Medicare,
Medicaid, Tricare, or some other private insurance.
Unsurprisingly, the veterans that have other insurance also
report being healthier, about 44 percent. We should embrace
what works.
Protecting and expanding community care options is not
about privatizing or otherwise eliminating the VA, so that--
that so many veterans do rely upon. I myself utilize VA in
addition to my other health insurance. This is about making VA
a better partner to veterans and all the folks that treatment--
that treat them. Congress and the Department of Veterans'
Affairs should protect and expand our veterans' treatment
options and thereby prioritize dignity and agency, and how each
of us cares for our minds and our bodies.
Thank you again for having me today. I will try my best to
answer your questions.
[The Prepared Statement Of John Vick Appears In The
Appendix]
Mr. Chairman. Dr. Madley, you are now recognized for 5
minutes.
STATEMENT OF RACHEL MADLEY
Dr. Madley. Chairman Bost, Ranking Member Takano, members
of the committee, thank you for the opportunity to testify.
The Veterans Community Care Program and the proposed
Community Care Network, or CCN, Next Generation Initiative
represent a significant shift toward veterans receiving care in
the private sector rather than through the VA. This expansion
is based on the assumptions that private sector care is higher
quality and more efficient and that private contractors will
prioritize veterans over profits. The evidence does not support
these assumptions. This pattern is familiar across Federal
healthcare programs. Privatization is often promised as a way
to improve care and lower costs, but in practice, it frequently
leads to higher spending, worse patient outcomes, and increased
corporate profits.
The Community Care Program was created under the 2018 VA
MISSION Act and is currently administered through contracts
with TriWest Healthcare Alliance and Optum Serve. These
contractors build provider networks and process claims for
veterans receiving private sector care. The VA is now seeking
contractors for CCN Next Generation, an expanded program
projected to cost up to $1 trillion over the next decade.
This proposal dramatically expands a model that has already
shown serious weaknesses. Experience with current contractors
raises red flags. The VA Office of the Inspector General, or
OIG, found that Optum Serve and TriWest billed the VA nearly $1
billion more for dental services than they reimbursed community
care providers between 2020 and 2024. While permitted due to a
gap in contracts, this practice highlights the risks of relying
on private-driven intermediaries to administer public health
programs.
These issues mirror well-documented failures in the private
Medicare Advantage (MA) program. Insurers have marketed
Medicare Advantage plans to veterans who primarily rely on VA
care and use little or no Medicare services. Yet the government
still pays MA insurers the full amount. In 2020 alone,
taxpayers paid more than $1.3 billion to insurers for veterans
enrolled in MA who used no Medicare services that year.
UnitedHealth Group, the parent of both Optum Serve and
UnitedHealthcare and MA Plan, directly benefits from this
duplication. These behaviors demonstrate that private company
incentives are misaligned with the goals of the VA to care for
those who served and used tax dollars efficiently.
A substantial body of research shows that VA care
frequently matches or outperforms private sector care. A
comprehensive review published by the VA in 2024 found that
most studies show VA care is equal to or better than community
care, and no studies found better patient experience in the
private sector. Many private providers also lack military
cultural competency, particularly in mental health care.
Access problems further undermine community care. The OIG
found that community care contractors failed to maintain
adequate provider networks, with VA staff repeatedly reporting
that many listed providers were not actually accepting VA
patients.
The VA also delivers care more efficiently. Studies show
shorter wait times for many specialties within the VA, and VA
clinicians are less likely to deliver low-value, high-cost
care. Administrative efficiency is another key advantage the
VA-- another key advantage. The VA employs far fewer
administrative staff than private health systems, mirroring
traditional Medicare's substantially lower overhead costs.
Proposed increases in community care funding are paired with
reductions in funding for direct VA care, weakening the VHA's
role as an emergency backstop training system and research
leader. Expanding community care without fixing existing
problems risks scaling these issues.
CCN Next Generation also imports Medicare Advantage-style
payment models, including capitation, risk adjustment, and
shared savings incentives that allow contractors to retain up
to 50 percent of savings from providing less medical care. In
this context, these mechanisms have consistently led to care
rationing and upcoding, raising costs while harming patients.
In Medicare Advantage, insurers are overpaid by $84 billion
each year due to their gaming of the very risk adjustment
system proposed for these community care models.
Instead of this community care expansion, the VA should
reinvest the proposed increased CCN funding into expanding VA
capacity by modernizing facilities and building additional
facilities where needed, as well as hiring additional
clinicians. When veterans do require specialized care
unavailable within the VA, traditional Medicare should
administer that care using its efficient claim system to reduce
overhead costs and protect both veterans and taxpayers.
Thank you for the opportunity to testify, and I look
forward to taking your questions.
[The Prepared Statement Of Rachel Madley Appears In The
Appendix]
Mr. Chairman. Thank you. I now recognize myself for 5
minutes.
Mr. Vick, Going forward, how can VA maximize veteran input
in major contract actions such as this one?
Mr. Vick. Thank you, Mr. Chairman. Notably, according to
the VA, a VA survey in 2022, which is the last year that the
survey was conducted, 83 percent of veterans are satisfied with
community care versus 69 percent for their VHA experiences. I
do believe that, you know, whereas VA does play a critical role
in any future administration, of VA plays a critical role in
contractor accountability, in all VA accountability. I would
love to see a time when VA accountability did not mean all of
the oversight things that you guys do that we do and also, but
rather meant like VA being accountable for patient outcomes, no
matter where those patients get their care. I do think a
critical component of that, too, is surveying the people that
are getting the care and following up on what their health care
outcomes are, not just how much we spend.
Mr. Chairman. What are some of the opportunities you see
for expanding, improving, and delivery of health care with this
Next Generation contract structure?
Mr. Vick. Yes, well, I think it is going to be critical to
expand the pool of people that can treat veterans. You know, it
is always seemed crazy to me and I have used the VA in my life
and I have used--I am also a military reservist, so I also have
access to TriCare. I have had multiple different kinds of
insurance, and I have used them all over the country. It always
seemed crazy to me that I was not able to necessarily go to the
same doctor that the rest of my family used. I think that if
you can expand the pool of people that can treat our veterans,
and you are layering that into the feedback that veterans give
on what works best for them. By the way, some of them
absolutely prefer going to a VHA facility. If you can track
accountability for the outcomes, expand this pool, and I think
most importantly, when somebody does underperform, whether it
is something like electronic health records and not getting
records back on care, not making it possible to have a solid
continuum of care, being able to off-ramp those contractors
efficiently without a bunch of red tape, that is critical.
Mr. Chairman. Also, what are some important things VA to
keep--do you think VA should keep in mind when they are
evaluating proposals on these contracts to ensure the benefits
are best for the veterans?
Mr. Vick. I think past performance, you know, one of the
things that community care does is lean into the existing
healthcare infrastructure. You know, unlike the VA system,
which, you know, some of these facilities were built decades
ago when populations existed in different places and where
specialty care existed in different parts of the system, the
private health care industry, for instance, in Orlando, where
I--where I call home, it mirrors exactly what the local
community needs, right? I think that being able to match that
for veterans, right, and finding out exactly how to streamline
service delivery directly to the vet, that is the most
important thing to do.
Mr. Chairman. I have no more questions. Ranking Member, you
are recognized for 5 minutes.
Mr. Takano. Thank you. Thank you for the patience of our
witnesses for staying till this--tell their--till this time. I
am sorry that the VA witnesses have left and are not going to
benefit from the answers that you are going to--they could use
your expertise, frankly.
You have testified, Dr. Madley, that CCN Next Gen leaves
open the door to gaming and misuse of taxpayer funds. What
specific flaws in the RFP create these risks, and what changes
are needed to protect veterans and taxpayers?
Dr. Madley. Thank you for that question, Ranking Member.
One of the biggest flaws is the incorporation of what is called
value-based care models. In this case is use of capitated
payments and risk scoring of veterans, where the contractors
will be running these models, that--and they get to keep any 50
percent of any savings that they are able to get. And now----
Mr. Takano.It is a Medicare Advantage model?
Dr. Madley. Exactly.
Mr. Takano. Capitated payments. They actually benefit by--
by withholding care.
Dr. Madley. Exactly. When the lower extremity joint
replacement model that is being prescribed for contractors here
was run in CMS, it was actually found that safety net hospitals
were unable to achieve savings because they had more complex,
more vulnerable patients who needed more care. That savings is
often coming from not providing needed care.
Mr. Takano. Are these safety net hospitals, are they
located in rural areas? I mean, rural areas, I know that
hospitals are under tremendous pressure because of the cuts in
Medicaid.
Dr. Madley. It was in both rural and urban areas. Those
safety net hospitals, and this is mirrored in the CCN Next Gen
documents, were then forced to repay CMS the money that they
overspent.
Mr. Takano. I am just incredulous. Capitated payments on
them along the lines of Medicare Advantage. VA is going to do
the same thing to our veterans?
Dr. Madley. Yes, and it is also importing the risk
adjustment system that bipartisan Members of Congress have
raised red flags about because it leads to upcoding of these
patients and making them look sicker, meaning that they get
higher payments from the government.
Mr. Takano. Okay, so profit incentives are often in
conflict with care quality. How do those incentives manifest
under the CCN Next Gen, and how are VA safeguards sufficient to
counteract? We kind of already covered it, but maybe you can
sum it up real quick.
Dr. Madley. Definitely. The way these contracts involve
incentive payments means that contractors who do enact these
value-based care models, and they are required to implement
four, get to keep 50 percent of the savings that they generate.
That savings comes from lowering costs, which comes from
providing less care.
Mr. Takano. We are going to incentivize private providers
to increase their profit margins for their shareholders and for
their executives by potentially denying care to veterans. This
is incredible. This is a beautiful--well, whatever.
Dr. Madley and Dr. Vick, I am going to ask you both this
question. Who are your major donors to your organizations? Dr.
Madley, I start with you first.
Dr. Madley. We are funded by grants from philanthropic
organizations such as Arnold Ventures, as well as small-dollar
donations from supporters who want more affordable health care.
Mr. Takano. Mr. Vick.
Mr. Vick. I do not work in donor development. CVA has about
40 full-time staff. The donors that I am mostly concerned with
are literally thousands of volunteers----
Mr. Takano. Oh, come on. Mr. Vick, CVA is a 501(c)(4), not
a (c)(3), unlike the person sitting next to you, which means it
is political and it does not publicly disclose donors. Will you
commit today to provide the committee a confidential list of
CVA's top donors over the last 5 years?
Mr. Vick. I would not be able to do that. We respect donor
privacy.
Mr. Takano. You can, and you are not. You are here today
asking Congress to allocate large amounts of veteran health
care spending without telling veterans or taxpayers who is
paying for your advocacy, is that correct?
Mr. Vick. I advocate for the thousands of Grassroots
volunteers.
Mr. Takano. I am correct. I am correct. You are here--
Grassroots my--your organization is paid for by--it is not paid
for by those folks. That is not the majority of who funds you.
Who funds you are donors that are very much interested in
certain outcomes. Do any of CVA's donors, major partners, or
board affiliates have financial interests in healthcare
delivery, insurance, managed care, or provider networks related
to VA community care?
Mr. Vick. I am unable to answer that question. I do not
know.
Mr. Takano. Well, so you cannot answer the question, but I
am sure that this will come out in due course. Is Concerned
Veterans for America currently affiliated with Americans for
Prosperity (AFP) and governance, staffing, shared services, or
funding streams?
Mr. Vick. AFP is a sister organization of us. Yes.
Mr. Takano. Say again?
Mr. Vick. A sister organization.
Mr. Takano. A sister organization. Is your political arm
branded CVA Action, registered as a service mark of Americans
for Prosperity for Action?
Mr. Vick. I have to get that answer back to you.
Mr. Takano. Okay, so when CVA engages in advocacy and
political equity, is it fair to say it is operating as----
Mr. Chairman. The gentleman's time has expired.
Mr. Takano [continuing]. AFP organizational ecosystem? The
answer is yes.
Mr. Chairman. Okay.
Mr. Takano. Thank you, and I yield back.
Mr. Chairman. Thank you. Just for the record, the Center
for Health and Democracy is a (c)(3) but also a (c)(4). They
are both. They are both.
Any rate, Ms. Brownley.
Ms. Brownley. Dr. Madley, is that true?
Dr. Madley. We have a (c)(4) arm as well as a (c)(3) arm.
Ms. Brownley. Your (c)(4) arm is involved in?
Dr. Madley. Advocating for policies to lower health care
costs and bring more transparency to insurance companies.
Ms. Brownley. Thank you. Thank you.
Mr. Vick, first, let me just say thank you for your
service. I do not dispute any of the facts that you stated in
your testimony. I just disagree with how we solve some of these
issues. I think, do you consider yourself a VSO?
Mr. Vick. We are Veterans of Foreign Wars. We also are--
there is also CVA foundation, which is a (c)(3), which is
wholly involved in educational programming. The reason why it
is called Concerned Veterans for America is because we advocate
for things that benefit all Americans. Right? And so,----
Ms. Brownley. They advocate for all veterans?
Mr. Vick. We advocate for things that matter to all
Americans, but we also get into veterans' issues as well.
Ms. Brownley. For all Americans. I see.
Mr. Vick. Yes.
Ms. Brownley. It is hard to kind of reconcile, you know,
the political side of your organization that is supporting--
supporting candidates here in Congress, you know, making
campaign contributions, supporting their campaigns, and so
forth, who are advocating for X, Y, and Z. That might not be
what all Americans support. You know, I have trouble sort of
reconciling how you can represent all Americans when all
Americans may not have--have the same point of view as you do.
Mr. Vick. For sure, all Americans definitely do not have
the same points of view. For me, the reason why I am passionate
about this, especially talking about healthcare choice, I talk
to veterans all over the country. I get emotional about it when
I talk about it sometimes, is because for me, it is a matter of
human dignity. I do believe that any government-sponsored, you
know, healthcare subsidized program, there is problems with it.
We face it with Medicare, with Medicaid, we face it with
TriCare, a lot of different things. I think that that is always
going to be an accountability piece, and CVA will always be
there to talk about the accountability piece, too, in as
nonpartisan a way as we possibly can. I really do believe that
if we make VA a prime partner in this service delivery journey
for veterans, that we are going to have better healthcare
outcomes. We definitely have to have accountability in it.
Ms. Brownley. Have you been at the table for all of the
planning of this Next Gen proposal on the VA?
Mr. Vick. Not all the planning. I do not--I do not work for
VA. So----
Ms. Brownley. No, I understand, but I am just wondering if
you or someone else in CVA has had a seat at the table.
Mr. Vick. No, not, not directly. I do not believe so. I
take a lot of meetings with Members of Congress. We do talk
to--had a chance to sit down and chat with Secretary Collins
one time, so that was pretty neat.
Ms. Brownley. You have never come to my office. I will just
say that.
Mr. Vick. I can commit that we absolutely will come.
Ms. Brownley. Okay. Well, I have been on the committee for
14 years, and you have never knocked on my door. Anyway.
Dr. Madley, you know, you just talked about with the
Ranking Member some of the issues with regards to financial
incentives conflicting with quality healthcare. I want to ask
you, based on everything that you have heard today and
testimony and what the VA is proposing, I do not know if you
have had a chance to really study the contract and so forth,
but do you see other ways in which contractors will be more
profitable based on this new contract?
Dr. Madley. Thank you for the question, Congresswoman. I do
see, aside from the alternative payment models, the ability for
contractors who run integrated healthcare systems.
Ms. Brownley. I am sorry. Integrated what?
Dr. Madley. Integrated healthcare systems.
Ms. Brownley. Uh-huh.
Dr. Madley. That is, they have an insurance arm, that they
then have a provider arm, sometimes a Pharmacy Benefits
Management (PBM) arm, and so on. In the design of the networks,
contractors are responsible for choosing providers who will be
in the networks. This was talked about at length with the
witnesses from the VA. To my knowledge, reading the contract
documents and hearing the testimony, there is no way for the VA
to prevent a contractor from creating a network that is
disproportionately made of providers that that contractor owns.
I will just say that there is evidence in the commercial market
of insurers who own providers treating those affiliated
providers very differently. For example, UnitedHealthcare pays
Optum providers, which are providers that they own up to 61
percent more than non-affiliated providers in the same network.
Optum Serve is currently a contractor for the community care
program right now. We have--we have seen this evidence, and
there are no requirements as of now in the VA documents that
would prevent it from happening.
Ms. Brownley. Thank you. My time is up. I yield back.
Mr. Chairman. Dr. Dexter, you are recognized by minute.
Ms. Dexter. Thank you very much, Mr. Chair, and thank you
to our witnesses for coming. One thing I just wanted to respond
to, Mr. Vick, is you are talking about waiting times at the VA.
I used to practice in the VA. I know many who still do. I have
been told by several, not just at one VA, that a lot of the
administrative staff that were scheduling and screening
patients for appointments have actually been let go, fired.
They are having a hard time filling their appointments. I just
would elevate the need for us to actually staff our VAs so that
we can actually deliver on the care, even when doctors are
sitting there with unfilled spots.
Also, I, having worked at a VA, I will just push back on
the concerns about driving many hours to VA facilities. I had a
lot of patients that would rather wait to go to a VA or would
drive long distances to go to a direct care facility. I do want
us to have a balanced perspective on the fact of the matter is
the veterans should have a choice, and they should have
transparency so that they can decide, which we do not have
right now. I brought that up earlier, so I will not wax poetic
about that. I do have very significant concerns about the
promises we are hearing from community care providers versus
what reality is. The fact of the matter is, as Dr. Madley has
raised, that they can make a lot of money off of veteran
contracts and not necessarily deliver because we are not great
at holding them accountable.
As a member of this committee, Dr. Madley, I take really
seriously, as I understand many of us do, my role to steward
our taxpayer dollars. As you cited in your testimony, there
have been instances, for example, over $900 million in
overpayments for dental services to Optum and TriWest. That
appears to be a waste of taxpayer dollars in the community care
program. Would you like to comment further on that at all?
Dr. Madley. Thank you for that question. Yes, the
overpayments to the dental providers, as it was explained from
the third-party administrators, were due to the contracts not
having language essentially that said they could not do that. I
think it really illustrates, as I said in my testimony, how
oftentimes private contractors have incentives and fiduciary
responsibility to their shareholders. That is fundamentally
misaligned with what the VA and what the Community Care Program
is trying to do, which is trying to provide care for our
veterans and use our taxpayer dollars efficiently. I think it
is a very good illustration. Due to the fact that we have not
been able to conduct as much oversight on these contractors,
there is probably a lot more examples of that happening, and
those misaligned incentives leading to wasting money.
Ms. Dexter. I will just follow up on that that I think it
is a similar issue to the training that provider network or
providers in networks are being asked to have the same level of
training that our veteran providers do. I will just say, as
somebody who vehemently was against more mandates for my
education, as a physician who has a lot of time being used for
other administrative issues, I absolutely, as a professional,
agree with that. You know that you are going to limit the
networks if you are demanding that, because doctors, nurse
practitioners, and others are already overstretched. It is
irrational for us to think that we are going to have robust
networks and have all these requirements. It is simply not the
case that we can get to the same level of quality for out-of-
network community care providers as we do for people who take
care of veterans every day. We were motivated to want to know
about the impacts of exposures and toxins.
Which is another thing I wanted to follow up with you
about. How do you see, Dr. Madley, the ability for community
care providers to have the level of understanding of veteran
exposures and other diseases are airborne divisions who have
many, many joint replacement issues and skeletal issues? How
can we provide transparency and accountability for quality and
service in these contracts? What can we do better?
Dr. Madley. That is a great question. I would recommend
first making sure that the contractors have to maintain
accurate network data. In that listing of the providers within
the community care network, I would recommend adding in which
providers have fully completed the training, such as suicide
prevention training, opioid prescribing training, and things
like that that VA clinicians have gone through. Now, with the
contractors that were used in the First Generation of this,
they were not able to keep their provider network data up to
date. Again, going with similar contractors this time, they
will likely not be able to provide that data. How can we find
contractors who are motivated to be able to keep that accurate
data? I would recommend that.
Ms. Dexter. I will just raise up, Mr. Chair, what you
stated at the beginning that we need to trust but verify----
Mr. Chairman. Mm-hmm.
Ms. Dexter [continuing]. someone great, per your words,
said that. I do not think that we have established the
mechanisms here in government to do that. I certainly would
argue that contractors overseeing contractors is probably not
the right way. I know that this is a bipartisan issue and I
very much hope that we will continue to----
Mr. Chairman. As I said at the very beginning, we--this is
the beginning.
Ms. Dexter. Right.
Mr. Chairman. The beginning.
Ms. Dexter. No, I very much appreciate that, and I know my
time has run out. I will yield back. Thank you.
Mr. Chairman. Well, let me tell you, rest assured, all of
our--all of everybody on this committee I know wants to help
the veterans and make sure they realize that they get the best
benefits they possibly can and the best places they possibly
can.
On behalf of the committee, I want to again say thank you
to the witnesses and members who are being here--for being here
today. I look forward to working with you to address the issues
facing our veterans.
Now, the committee's written statements, the complete
written statements of today's witnesses, will be entered into
the hearing record, and I ask unanimous consent. Do you need to
be--no. Okay.
All right. I ask unanimous consent that all members have 5
legislative days to revise and extend their remarks, including
extraneous material into the record. Hearing no objection, so
ordered.
This hearing is now adjourned.
[Whereupon, at 1:44 p.m., the committee was adjourned.]
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A P P E N D I X
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Prepared Statements of Witnesses
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Prepared Statement of Richard Topping
Mr. Chairman, Ranking Member, and distinguished Members of the
Committee, thank you for the opportunity to discuss the Veterans
Community Care Program (VCCP) and the Community Care Network (CCN) Next
Generation (Next Gen) contract procurement. I am accompanied today by
Ms. Alicia Skolrood, Executive Director of Integrated External
Networks, Office of Integrated Veteran Care, Veterans Health
Administration.
VA has long been recognized for the world-class health care we
provide to Veterans across more than 1,500 medical facilities. In
addition to the direct care system, VA has also been a purchaser of
health care since before the World War II era. As a health care payer,
VA partners with local hospitals, doctors, and other health care
providers to ensure that Veterans have access to the care they need,
where and when they need it. Caring for Veterans is about more than
operating hospitals. It is about supporting Veterans' physical and
mental health and wellness, their families and caregivers, and
leveraging community services beyond the walls of our facilities.
Recognizing the key role that purchased care plays in VA's ability
to provide for Veterans' health and wellness, President Trump and
Congress passed the bipartisan VA Maintaining Internal Systems and
Strengthening Integrated Outside Networks (MISSION) Act of 2018 (P.L.
115-182). The VA MISSION Act expanded access and choice for Veterans
and reinforced VA's mission as both a health care provider and payer.
Today, VA is the country's largest single health care provider through
our hospitals and clinics, and the fourth largest health care payer
through VCCP. In Fiscal Year 2025, 41.8 percent all health care
appointments Veterans booked with VA were in the community. CCN Next
Gen is VA's first major procurement effort to support this program
since shortly after enactment of the VA MISSION Act, when the legacy
CCN contracts were awarded in 2018. CCN Next Gen is our opportunity to
increase competition, upgrade, and modernize the provider network, and
enhance services to ensure that Veterans receive the very best health
care possible, whether at a VA facility or in their community from a
local health care provider.
Fortunately, VA has had significant input and support in designing
CCN Next Gen. We talked directly with our Veterans. We asked what they
need and want from community care, and how the program can best serve
them. Veterans overwhelmingly want choice. They want the flexibility to
choose between direct care and VCCP based on best medical interest,
availability, and convenience. Most importantly, Veterans want health
care choices that meet them where they are.
We talked to other Government Agencies. The Department of Health
and Human Services (HHS) operates the country's three largest payer
programs. HHS brings decades of experience and data on improving health
care quality, reducing costs, and aligning incentives for better health
and wellness. The Department of War (DOW) also operates both a direct
care system and a payer program, with expertise in managing capacity
and access across both while maintaining an overall focus on quality
and cost. HHS and DOW both have insights into what works, what does not
work, and where VA can have maximum impact by leveraging lessons
already learned.
We engaged with industry leaders. Non-VA hospitals and insurers are
constantly innovating in the health care marketplace. They are
experimenting with new delivery models, leveraging data and analytics,
striving to be consumer-oriented, and tackling costs that remain too
high. Industry has provided VA with a roadmap of successes and failures
and how VA might capture the best of the innovation in health care and
apply them to VA's model for the benefit of our Veterans.
By combining VA's history as a health care payer with the
improvements made by the VA MISSION Act, incorporating Veterans' needs
and demographics, and leveraging external innovation, VA successfully
issued the CCN Next Gen Request for Proposals on December 15, 2025. VA
is leading the Nation with an innovative 10-year, multiple award
Indefinite Delivery Indefinite Quantity (IDIQ) contract vehicle which
has several key advantages over traditional Federal health care
contracts.
First, this approach allows VA to make multiple awards to offerors
that meet our requirements, but vary in size, capabilities, and
regional presence. Under a traditional Federal health care procurement
model, only the largest national third-party administrators (TPA) would
have the scale to propose on CCN Next Gen. However, with the multiple
award IDIQ, VA expects responsive proposals from regional health plans
that have unique capabilities that are locally adaptable.
Second, the multiple-award structure enables VA to iteratively
adapt CCN Next Gen to meet Veterans' changing needs over time and to
match VA's increasing sophistication to manage the program. Over the
10-year performance period of the contract, VA can issue multiple
rounds of task orders for which contractors can compete. Our initial
task orders will resemble current CCN operations: large, fee-for-
service TPAs with expanded requirements from legacy CCN contracts, and
incentives and penalties tied to that performance. However, immediately
after issuing these initial task orders, VA will begin designing the
second round of task orders. The second round of task orders will be
more regional and increase both the requirements and the opportunities
for the vendors. The sequential use of task orders will give industry
the opportunity to adapt its capabilities to better serve Veterans, but
it will also allow VA to improve and enhance our internal program
management capabilities.
Third, by allowing for multiple contractors to compete for multiple
rounds of varied task orders, CCN Next Gen will ensure continuous
competition over the performance period of the contract. Contractors
who fail to perform may be off-ramped, task orders can be modified, and
more sophisticated requirements may be introduced. The design of the
multiple award IDIQ allows ongoing quality and performance improvement
between VA and our contractors.
The IDIQ is the how of this procurement, but the most exciting part
of CCN Next Gen is the what. CCN Next Gen will be a dramatic
modernization of the current CCN contracts. It will begin with the
recognition that VA must have the tools and capabilities to drive
outcomes, ensure quality, and manage costs effectively. CCN Next Gen is
designed on five pillars: Quality, Value, Alternative Payments,
Utilization Management, and Program integrity.
VA will implement comprehensive quality programs for community
providers based on nationally recognized measures from the Agency for
Healthcare Research and Quality (AHRQ) and the Healthcare Effectiveness
Data and Information Set (HEDIS). Contractors will track patient safety
events, identify Veterans at risk of avoidable emergency visits and
readmissions through predictive analytics, and, while respecting their
choice, guide Veterans toward high-performing providers using data-
driven algorithms. This program ensures that Veterans are not simply
referred to any available provider, but to those demonstrating strong
outcomes and safe, high-quality care.
CCN Next Gen will modernize how VA pays its contractors for the
care furnished to Veterans by implementing value-based payment models.
Based on existing needs and capabilities, VA will begin with episode-
based payments for lower-extremity joint replacements. As we gain the
data and expertise to manage alternative payments, we will introduce at
least three increasingly sophisticated models over the performance
period of the contract. These models will shift payment away from
volume and toward outcomes and total cost of care, aligning contractor
incentives with Veteran health and system sustainability.
CCN Next Gen's care coordination incorporates utilization
management processes proven in other payer programs and aligned with
industry standards. This includes active management of inpatient
admissions, emergency department use, concurrent hospital reviews, and
high-cost drugs administered in clinical settings. VA will measure and
report performance, benchmark results, and drive continuous
improvement. These measures are designed to reduce unnecessary
hospitalization and inappropriate care while protecting Veterans'
access to medically necessary services.
CCN Next Gen will include a full program integrity function to
ensure that VA resources are protected and maximized. Contractors will
maintain compliance committees, appoint dedicated compliance officers,
and operate Special Investigations Units to detect and investigate
fraud, waste, and abuse. They will identify providers at higher risk of
improper billing, formalize oversight processes, expand data and
technology for improper payment detection, and submit to independent
audits. This shifts VA from a system that paid bills after-the-fact to
one that actively prevents and detects abuse.
The last exciting innovation in CCN Next Gen is how VA will manage
its contractual relationship with contractors. VCCP's ultimate goal is
to provide the highest quality care for Veterans at the lowest cost to
taxpayers. Achieving this outcome depends equally on the agency and
industry. CCN Next Gen will be a contractual relationship with
contractors, leveraging all VA and industry brings, in the service of
our Veterans. Historically, VA's approach, like most Government
Agencies, has been to try to predict the next several years, compete
it, award it, and then manage it. CCN Next Gen will allow VA to gain
the information needed during the contractors' performance on capacity,
capabilities, regional adaptations, innovation, and pricing and to do
so continuously through the task order formation and issuance process.
CCN Next Gen will change how VA pays our contractors to incentivize
performance and outcomes. CCN Next Gen will incorporate incentives and
disincentives based on the total cost of care, quality performance,
value-based care adoption, and payment integrity. Contractors may earn
up to 2.25 percent in incentive payments or be subject to disincentives
of up to 3 percent of administrative fees if they fail to meet contract
requirements. This ensures that contractors have ``skin in the game''
and remain accountable for how well they serve Veterans and manage
taxpayer dollars. Ultimately, contractors who achieve VA quality
targets, while reducing costs, will share in the value they create for
VA and for Veterans.
Taken together, the payment changes included in CCN Next Gen will
be significant. We will change how contractors pay community health
care providers by introducing value-based care and require alternative
payment models that align with evolving industry standards. We will
also change how VA pays our contractors, introducing incentives and
disincentives that move away from fixed administrative costs. These
payment changes align VA with contractors and with our community
providers.
Our actuarial analysis of the CCN Next Gen program design changes,
along with these payment changes, estimate significant savings of 8-14
percent over the life of the contracts. Under conservative assumptions,
the cost-containment framework is expected to reduce community care
spending by approximately $54 billion over the next decade. Under
stronger performance scenarios, the cost-containment framework's
estimated reduction could approach $100 billion. These savings will be
driven by fewer unnecessary hospitalizations, improved management of
high-cost services and drugs, improved quality, and stronger fraud and
payment controls.
Mr. Chairman, CCN Next Gen is leading the way in how Federal health
care programs can be designed, procured, and operated. I appreciate the
opportunity to share this information and look forward to answering any
questions you or the other Members of the Committee may have.
Prepared Statement of John Vick
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Rachel Madley
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Statements for the Record
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Letter to Douglas Collins from Maxine Dexter
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Questions for the Record Submitted by Abe Hamadeh
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