[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
TRACKING TRANSFORMATION: VA MISSION ACT IMPLEMENTATION
=======================================================================
JOINT HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
and the
COMMITTEE ON VETERANS' AFFAIRS
U.S. SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, DECEMBER 19, 2018
_______
Serial No. 115-85
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
35-950 WASHINGTON : 2019
HOUSE COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SENATE COMMITTEE ON VETERANS' AFFAIRS
JOHNNY ISAKSON, Georgia, Chairman
JERRY MORAN, Kansas JON TESTER, Montana, Ranking
JOHN BOOZMAN, Arkansas Member
BILL CASSIDY, Louisiana PATTY MURRAY, Washington
MIKE ROUNDS, South Dakota BERNIE SANDERS, Vermont
THOM TILLIS, North Carolina SHERROD BROWN, Ohio
DAN SULLIVAN, Alaska RICHARD BLUMENTHAL, Connecticut
MARSHA BLACKBURN, Tennessee MAZIE K. HIRONO, Hawaii
KEVIN CRAMER, North Dakota JOE MANCHIN, III, West Virginia
KYRSTEN SINEMA, Arizona
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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Wednesday, December 19, 2018
Page
Tracking Transformation: VA Mission Act Implementation........... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman, U.S. House Committee on
Veterans' Affairs.............................................. 1
Honorable Johnny Isakson, Chairman, U.S. Senate Committee on
Veterans' Affairs.............................................. 2
Honorable Mark Takano, Ranking Member, U.S. House Committee on
Veterans' Affairs.............................................. 4
Honorable John Tester, Ranking Member, U.S. Senate Committee on
Veterans' Affairs.............................................. 6
WITNESSES
Honorable Robert Wilkie, Secretary, U.S. Department of Veterans
Affairs........................................................ 9
Prepared Statement........................................... 51
Accompanied by:
Melissa Glynn Ph.D., Assistant Secretary, Office of
Enterprise Integration, U.S. Department of Veterans
Affairs
Steven L. Lieberman M.D., Executive in Charge, Veterans
Health Administration, U.S. Department of Veterans
Affairs
STATEMENT FOR THE RECORD
Veterans Of Foreign Wars Of The United States (VFW).............. 56
American Veterans (AMVETS)....................................... 58
Jacob Gillison (Sanders)......................................... 60
American Health Care Association (AHCA).......................... 65
Goverance Charts................................................. 67
National Committee for Quality Assurance (NCQA).................. 68
TRACKING TRANSFORMATION: VA MISSION ACT IMPLEMENTATION
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Wednesday, December 19, 2018
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committees met, pursuant to notice, at 2:00 p.m., in
Room HVC-210, Capitol Visitor Center, Hon. David P. Roe
[Chairman of the House Committee on Veterans' Affairs]
presiding.
Present from the House Committee on Veterans' Affairs:
Representatives Roe, Bilirakis, Coffman, Radewagen, Dunn,
Arrington, Bergman, Banks, Takano, Brownley, Kuster, O'Rourke,
Lamb, and Esty.
Present from the Senate Committee on Veterans' Affairs:
Senators Isakson, Moran, Boozman, Tillis, Sullivan, Tester,
Murray, Sanders, Brown, Blumenthal, Hirono, and Manchin.
Also Present: Representative Sablan.
OPENING STATEMENT OF HONORABLE DAVID P. ROE, CHAIRMAN
The Chairman. The Committee will come to order.
Before we begin, I'd like to ask unanimous consent that
Congressman Sablan be allowed to sit on the dais and
participate in today's proceedings.
Hearing no objections, so ordered.
Welcome, and thank you all for joining us today for the
joint hearing of the House and Senate Committees on Veterans'
Affairs.
This afternoon, we will discuss implementation of the John
S. McCain, Daniel K. Akaka, and the Samuel R. Johnson
Department of Veterans Affairs Maintaining Internal Systems and
Strengthening Integrated Outside Networks Act of 2018, better
known as the VA MISSION Act.
The MISSION Act is a truly transformative piece of
legislation that will impact virtually every aspect of care
that VA provides. Developing it took many months of intense
negotiation and close collaboration between our Committees, the
Trump administration, the Department, and numerous veterans
service organizations, stakeholders, and advocates. We should
all be proud of our work on the VA MISSION Act and of the
benefits our Nation's veterans will derive from it in the years
ahead.
However, in many ways, the real work has just begun. Almost
6 months ago, the MISSION Act was signed into law. Almost 6
months from now, one of the act's most noteworthy requirements,
the creation of a consolidated community care program, will go
into effect.
Today, at the midpoint between enactment and execution, we
are here on a bicameral and bipartisan basis to evaluate both
the progress the VA has made thus far with regard to the
implementation of the MISSION Act and the barriers that may
exist to full, on-time, and on-budget implementation in the
coming months.
Seeing the MISSION Act signed into law took the collective
effort of all of us working closely together with one another
and with the VA's senior leaders, with the White House, and
with our veteran's service organization partners. Seeing the
MISSION Act implemented appropriately will require no less than
the same amount of teamwork.
In 2014, we passed the Choice Act in response to what can
rightfully be categorized as a crisis in access. A recent news
article has criticized the execution of that program--namely,
the high cost of administrative fees. While I do not dispute
that the costs of this community care expansion were higher
than typical government insurance coverage, the Choice program
represented a transformational first step in how VA provides
care where and when it is needed. These contracts were stood up
in record time, and changes were made both legislatively and
contractually over the past 3 years as the program matured.
And I will say this. As a physician, we asked the VA at
that point in time to do something no one could do, which was
to stand up a nationwide network in 90 days. No one could have
accomplished that on time.
The Choice program is not perfect, but it did allow for an
undeniable expansion of access and care, both internal to VA
and in the community for veterans. This is why it is so vitally
importantly that the MISSION Act, which will guide VA's future
coordination of care, be executed efficiently and thoughtfully.
Mr. Secretary, thank you for being here today to provide
concrete answers to our many questions about the work that the
agency has been doing these last 6 months and the work that
lies before you in the next 6 months and beyond. The importance
and the enormity of the task ahead cannot be overstated. But I
have faith in you and your team, and I know that considerable
support from this administration and this Congress is behind
you. We want you to succeed.
I implore you to be as up front as possible today and every
day about the challenges you are facing and the help that you
need from us to ensure success for our veterans. I look forward
to working together to overcome any barrier that may be in your
way.
I will now yield to Chairman Isakson any opening statement
that he may have.
OPENING STATEMENT OF SENATOR JOHNNY ISAKSON, CHAIRMAN
Senator Isakson. Well, Chairman Roe, thank you very much
for the introduction, and thanks for spearheading the calling
of this meeting today to look at the first 6 months under the
MISSION Act. I am glad we are doing it.
And before I make my comments on the MISSION Act, I want to
say this. Your service when working with you has been a
privilege. You have done a phenomenal job as Chairman in the
House, have helped us in the Senate immensely. Your goal-
setting and what you focused on has been unbelievable. And with
the exception of a few minor things, mainly where we might have
dropped the ball, we have carried the ball and made significant
changes in the Veterans Administration that are going to serve
us well for a lasting and long period of time.
So I just wanted to publicly thank you for your cooperative
spirit, your desire to work. It is so great to have a physician
at the top of the leadership in the House, or the Senate for
that matter, because we make better decisions when we have
people who actually have done it. Talking about it is easy for
somebody like me. I am a professional patient. We need a
professional doctor. And you have done a great job. And I
appreciate your friendship, what you have done, and the
leadership you have provided the Committee.
And John Towers deserves a lot of credit too. He does a
great job.
And let me say this. We are prepared in the next 2 years to
do everything we can do to continue the cooperative spirit
between Republicans and Democrats that we have had on the
Senate side and to work on fine-tuning the acts that we have
passed and implementing things that need to be done to help you
in the VA, those that are here from the VA, get your jobs done.
We understand that what is ahead of us is tough, but we
have no choice but to see to it the VA is functioning at the
highest possible level so those who have risked their life for
our Nation and pledged their service to us as soldiers have the
same treatment back to them when we are ensuring their health
care and those benefits they are promised under the laws of the
United States of America.
So I look forward to serving with you and working with you,
and I want to tell you how much I appreciate the great job that
you have done. I want to tell my Senate membership and our
Committee Members that are here, Democrat and Republican, we
have had the greatest cooperative spirit we could have. We had
the MISSION Act, passed in Committee with only one negative
vote, sail through the floor. You all did a great job on your
end.
We realize that we dropped the ball with you on one thing.
You all got the Blue Water Navy through on a voice vote on the
floor, or a suspension vote, I think, on the floor. We failed
in the Senate on two UCs, one today and one last week. And we
are going to try one time or another, but I still have a
difficulty with one or two objections.
But we are going to come right back and hit the ground
running. Secretary Wilkie has done a great job of indicating
that he wants to work with us and help us where he can. And I
am not going to take that bone out of my mouth. This is one
bulldog from Georgia that is going to keep that bone in my
mouth until we get it done. Because a lot of people on the
House Committee have worked on the Blue Water Navy issue, and
we have in the Senate as well, and we want to do the same
teamwork where possible.
But I primarily want to just thank you and thank Secretary
Wilkie for bringing a breath of fresh air to the leadership of
the VA. He has done a great job. He took over after a
problematic and a tumultuous time, but he has a good bedside
manner, which most physicians--good physicians have. He is a
good leader for the agency. He is doing a great job.
We welcome you and all your VA membership here today.
So thank you very much, Chairman Roe.
Merry Christmas to everyone in the audience today.
The Chairman. Thank you, Mr. Chairman. And I wish that
bulldog for Georgia could have done something to those folks in
Alabama. I really wish that could have happened, but--
Senator Isakson. I can't talk about what we want to do to
the Alabama people in public, but I will do one other thing. I
have to slip out in a minute, and I apologize. When you see me
slip out, it is not that I am walking out on you, but I have
one more thing to do on our side.
Thank you, Mr. Chairman.
The Chairman. Yes, sir. Thank you, Mr. Chairman. It has
been a privilege to work with the Senate this year too--this
term, I should say, the last 2 years. And I was going to
reserve my remarks until the end for you, but I didn't realize
you had to leave. But how incredible you and Senator Tester
have been to work with this year. My goodness, we could have
never passed 80 bills in the House and had so many heard in the
Senate. And our staffs, as you pointed out, worked hand-in-hand
behind us to make this possible. It wouldn't have happened
otherwise. And I think either 29 or 30 pieces of legislation.
And just very briefly, a small thing like a contract, a
cable contract you might have signed, or a contract on an
apartment, and then your spouse loses their life in service to
the country, and you not being able to get out of that contract
for a year; now you are going to hopefully be able to do that.
Little things like that that don't seem like big things, but if
you are the person on the end of that, they are big things. And
I personally have seen it and witnessed it with my friends that
have had to deal with this.
So these are ideas that came from both sides of the aisle,
and I want to thank all of my colleagues, both in the Senate
and the House, for those ideas.
I will now yield to Mr. Takano for any remarks he may have.
OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER
Mr. Takano. Thank you, Chairman Roe.
And, Chairman Isakson, I look forward to working with you
in the next Congress to serve our Nation's veterans.
Thank you, Ranking Member Tester, for also being here.
Good afternoon, Mr. Secretary. Thank you for taking the
time to testify before us today. We will always welcome the
opportunity to speak with you about the progress you have made
regarding the implementation of the MISSION Act.
It has been a little over 6 months since the MISSION Act
was passed and 7 months since you were confirmed as Secretary
of Veterans Affairs. I commend you on your hard work so far and
assure you that, as we move into next Congress, you will
continue to find a willing partner on this Committee, meaning
me, and that, as the most bipartisan Committee in this
Congress, I intend to work with my colleagues on both sides of
the aisle, with you, Mr. Secretary, and with our VSO partners
to ensure veterans get the benefits that they have earned.
Transparency and open communication between the Department
and Congress is key to our oversight efforts and to ensure that
our work here is effective.
Now, we have asked for and need information from the
Department so that we have an understanding of the steps VA
must take to achieve the objectives mandated under the MISSION
Act over the next 6 months. We also need to know more about the
reported outsized influence a group of advisors may have had on
your decisions, as VA should not be subject to outside
influence or the whims of individuals or interests who cannot
be held accountable and who do not have veterans' best
interests in mind.
However, VA should ensure that the voices of veterans
expressed through our veterans' service organizations are
adequately considered when important decisions, such as the
adoption of the designated access standards, are made.
The term ``designated access standard'' seems a bit wonky,
so what I would like to hear from you today is a simple
explanation of what those different scenarios look like in
practice. And I think, to unpack designated access standards, I
think, for the public, we can just simply understand them as
the criteria by which the VA refers veterans out to private-
sector doctors, outside the VA, non-VA providers.
What are those criteria? And, of course, we only began with
an arbitrary criteria of living 40 miles outside of a VA
radius, the radius of a VA health center, and somebody who has
been waiting for more than 30 days. Without those arbitrary
standards initially, we would have spent large sums of money,
diverted large sums of money of VA health care dollars. So it
is important that we get these standards right.
The truth is we have always, always at the VA--the VA has
always embraced outside, non-VA medical providers as part of
the solution. And so this is nothing new in terms of how we
take care of our veterans. But we can't do that at the expense
of maintaining and adequately growing the internal capacity of
the VA.
So these access standards will outline when and where and
how veterans will be referred to private-sector providers under
the MISSION Act and how much of your budget will be needed to
pay for this private-sector care, which we know is often more
expensive than VA's internal services.
And we know based off of multiple studies by the likes of
the RAND Corporation and Dartmouth University, VHA care is
often--or is frequently of higher quality than the private
sector. So standards that are too liberal for access to private
care could easily jeopardize that high-quality VA care that our
most vulnerable veterans rely on as the dollars that support
this care will be diverted into private-sector care. So we need
that right balance.
So we need answers to these questions, and I remain
concerned with the Department's lack of transparency. For
instance, yesterday we discovered via the media, not the VA,
that yet another veteran has taken his life at the Bay Pines VA
medical facility. This is the fifth suicide since 2013. We
should not be first learning about this in the press. We should
be notified immediately with facts that will help us act so
that we can prevent other veterans from taking their lives.
The GAO report requested by Ranking Member Walz demonstrate
a lack of leadership and commitment by the Department to
prevent veteran suicide. This is the Department's top clinical
priority. When veterans between the ages of 18 and 34 are
committing suicide at the highest rate, the Department's
failure to communicate services and attempt to reach veterans
in this age group via social media is shameful. VA offers
excellent mental health services, but to quote disabled
American veterans, they are useless in actually preventing
suicide if veterans and family members don't know they exist or
are unable to access them.
Now, it is simply wrong--simply wrong--that only $57,000 in
funds Congress prioritized to address preventing veteran
suicide has been sent and $6.2 million has been left on the
table. Now, I am committed to achieving progress over the next
2 years. And I hope that you will, in fact, make suicide
prevention the priority that the department claims it to be so
that we, as Congress, can support, not criticize, your efforts.
The same offer applies to the implementation of the MISSION
Act. Now, the implementation of the MISSION Act thus far has
been rocky, and, all too often, Members, their staff, and
veterans feel misled or misinformed.
In the next Congress, let's work towards having a
productive relationship and open dialogue so that we can work
together on behalf of the veterans we serve. And I look forward
to our discussion today and hope that it is the beginning of a
strong partnership between the Department and Congress.
I yield back, Mr. Chairman.
The Chairman. I thank the gentleman for yielding.
I now yield to Ranking Member Tester for any opening
comments that he--
OPENING STATEMENT OF SENATOR JOHN TESTER, RANKING MEMBER
Senator Tester. Yeah, thank you, Chairman Roe, Chairman
Isakson. If Tim Walz was here, I would be thanking him too.
And, Congress Takano, thank you very, very much.
Before I get into my written statement, I just want to say
it has been a pleasure, this last Congress, working with all
the other three corners. And I think what has made the
relationship work is communication. We have tried not to
surprise one another. We have tried to keep one another
informed of where we want to go.
And I just want to give you a prime example of it. When I
was walking over here to this hearing just now, one of my staff
Members said: Dr. Roe wants to say something about
confirmations, and he is concerned it might embarrass you. That
is damn nice of you. I just want to tell you that.
And, by the way, give them hell on the confirmations,
because it is ridiculous that these folks aren't confirmed for
ID and the Office of Whistleblower Protection.
The last thing I just want to say before I go to my opening
statement is Blue Water. We just did a live UC in the Senate,
and it was objected to. I know that the VSOs in this room have
been providing information after information after information
on this issue.
I am going to tell you, if we aren't willing to take care
of our veterans, we shouldn't be making them. And the bottom
line is we have to get this done. The science is clear.
And I would say that I think that maybe the folks in the
legislative branch don't realize it, but we are different than
the executive branch, and we need to make the call. And if they
want to veto the damn bill, then let the executive branch veto
it. In the meantime, we need to take care of our veterans.
Secretary Wilkie, thank you for being here.
Implementation of the MISSION Act was going to
fundamentally transform the delivery of health system for our
Nation's veterans. For more than a year, we all worked
carefully with the White House and the VA to negotiate the text
of that bill. We were in regular communication with the VA on
how it would interpret and implement the bill, passing it back
and forth for technical assistance, ensuring that we were all
on the same page. Since that time, though, I have grown
increasingly concerned with the Department's planned
implementation of the new Veterans Community Care Program
created in the bill.
Mr. Secretary, the VA is moving away from the direction it
was headed just 6 months ago; make no mistake about that. The
most dramatic example has to do with the VA designating certain
types of care as nearly automatic eligibility for community
care. Six months ago, we agreed that if veterans faced
excessive wait times or driving times or distance to access
certain services at a VA facility, they should be offered
referrals in the community. Specifically, we discussed
designating access standards for services like routine lab work
and x-rays. But we agreed to give the VA the authority to
decide exactly which services or categories of care should make
veterans automatically eligible to receive care within the
community.
Now that we have passed the VA MISSION Act, VA has decided
to head in what I believe is a completely different direction.
VA now indicates it plans to designate access standards that
apply to each and every type of care a veteran might need. This
would essentially outsource all segments of VA health care to
the community based on arbitrary wait times or geographic
standards, which we were supposed to be moving away from by
ending the Choice program.
And that is despite the fact that several studies, one as
recently as last week, have indicated the quality of care at
the VA is good or better than the private sector. Let me say
that one more time, because it is not said enough. As recently
as last week, we received yet another study that indicated that
VA care is as good or better than the private sector.
To make matters worse, VA officials have offered only vague
verbal descriptions of the various sets of potential access
standards under consideration by you, Mr. Wilkie.
It also concerns me that, each time we have discussed this
issue in the last 2 months, VA officials have given us wildly
different estimates of budgetary resources needed to implement
these sets of access standards that you are considering. For
example, if the Department chooses to go with the same access
standard used by TRICARE Prime, we have been told it could cost
anywhere from $1 billion for the first year to more than $20
billion over 5 years.
Some of the VA estimates indicate that costs will be less
than what we spent on Choice but would make a greater
percentage of veterans eligible for community care referrals.
That doesn't make sense.
So we need to know what you are doing, Mr. Secretary, and
how much it is going to cost. No conflicting or vague answers,
no fuzzy math, no games, because the stakes are simply too
high.
Mr. Secretary, not even 6 months ago, you came before the
Senate Veterans' Affairs Committee, and you said you would
oppose attempts to privatize the VA health care system. I
believe you. I believed you then; I believe you now. But if you
move further down this path, gutting the VA health care system
for those veterans who want and need to use it, you will end up
bringing down the whole boat. And you are going to spend a
whole lot of time and money sending veterans in the community
for care that is less timely and not as high in quality.
That is a bad deal for our taxpayers. It is a bad deal for
our veterans, who would ultimately bear the brunt of cuts to
other services or benefits to cover the increased costs of
community care. And that will lead to a bad deal for veterans,
because, at some point, you will burn through the funds quicker
than expected and come to us because VHA is running out of
money again. Veterans will be in limbo when seeking community
care as Congress sorts out the VA's fiscal issues.
I am frustrated because this hearing would have been a
great opportunity to talk about the great work being done by VA
employees across this country every single day--and, indeed,
they are--and about how their critical work will be bolstered
by additional high-quality health care professionals hired
under the new authorities within the MISSION Act and about how
streamlining various community care programs in the new
Community Care Network will make care more efficient, more
timely, and more seamless for veterans.
Instead, we are here left trying to figure out why the VA
decided to take things in a different direction than what I
believe Congress has intended and certainly what veterans have
advocated for. My suspicion is that it is politics. I hope I am
wrong, because at the end of the day I really hope that
meaningful consultation will take place before final decisions
are made. We have gotten this far by working together and by
taking our cues from veterans, and it would be a shame to
undermine those efforts and relationships because of a
political agenda.
I have said it before, and I will say it again: I have
tremendous faith in you, Secretary Wilkie, to make sure that
the VA is run in a way that our veterans deserve. We need to
really step up and do it.
Thank you for being here.
The Chairman. I thank the gentleman for yielding.
We are joined on our first and only panel today by the
Honorable Robert Wilkie, Secretary of the Department of
Veterans Affairs.
And welcome, Secretary Wilkie. Thank you for being here
this afternoon.
The Secretary is accompanied by Dr. Melissa Glynn, the
Assistant Secretary of the Office of Enterprise Integration,
and Dr. Steven Lieberman, the Executive in Charge of the
Veterans Health Administration.
Thank you all for being here.
Secretary Wilkie, you are now recognized.
STATEMENT OF THE HONORABLE ROBERT WILKIE
Secretary Wilkie. Thank you, Mr. Chairman, and thank you,
Chairman Isakson, Chairman-elect Takano, and Senator Tester,
and distinguished Members of both Committees. I want to thank
you for the opportunity to address the efforts underway to
implement the VA MISSION Act as well as share with you the
governance and management approach instituted over the last 130
days.
As you have said, we are on cusp of the greatest
transformative period in the history of VA, and your leadership
led to the passage of that historic legislation.
As I testified in front of the Senate Veterans' Affairs
Committee earlier in the year, I am happy to report that the
state of the Department of Veterans Affairs is better. And it
is better because of the work of these Committees and the
attention paid to our department by the President.
As Secretary, I have visited 17 States in 130 days, 23
hospitals from Anchorage to Orlando, 4 claims processing
centers, and the Veterans Treatment Court in Maryland, and I,
as Senator Tester said, am astounded by the commitment of the
VA workforce. It is dedicated, and it is, in my opinion, the
finest workforce in the Federal Government.
Today, I am honored to have with me two senior VA leaders:
Dr. Steven Lieberman, the current Executive in Charge of the
Veterans Health Administration, and Dr. Melissa Glynn, the
Assistant Secretary for Enterprise Integration.
We are committed to implementing the MISSION Act by June
2019 and describe how that commitment is being fulfilled. We
have established a task force representing key offices across
VA and guided by experienced program leaders. We now have a
battle rhythm of progress reviews to align resources, identify
and mitigate risks, and deliver on the promise to transform VA
health care that puts veterans at the center of everything that
we do. This effort is emblematic of the new governance and
management structure we established throughout the Department.
That is how we were able to identify that the technology
supporting the GI Bill implementation was untenable. I made the
decision to define a new approach to deliver education and
housing benefits to our veterans and their family members. And
I want to emphasize that we will execute the law as written and
every post-9/11 GI Bill beneficiary will be made whole for
their housing benefits based on both Sections 107 and 501 of
the Forever GI Bill. I made the decisions not only to stabilize
the delivery of services but to improve the current Choice
programs.
The expansion and extension of the TriWest contract ensures
access to community care for our veterans. The decision allows
for smoother transition to the Community Care Network contracts
when awarded. After multiple delays prior to my arrival at VA,
the acquisition process and subsequent awards are back on
track. Community care regions 1 through 3 will be awarded
before the end of February 2019, and region 4 is expected to be
awarded in March. Once active, these contracts will support a
key pillar of the MISSION Act by giving veterans expanded
choice in their health care.
As part of our new community care program, we are
addressing the timeliness and accuracy of payments to
providers. We are moving away from paper claims and requiring
providers to submit electronic claims through our new
electronic claim administration and management system that will
be deployed next year.
Through the MISSION Act, we have established a Center for
Innovation for Care and Payment to develop new approaches to
testing payment and service delivery methods. The Senate has
developed a charter and is developing criteria for pilot
projects to drive health care quality and efficiency.
Another pillar of the MISSION Act is groundbreaking support
for caregivers. There are 5.5 million veteran caregivers across
the country. I had the privilege several weeks ago to address
the third annual national convening of military and veteran
caregivers, jointly sponsored by the Elizabeth Dole Foundation
and Veterans Affairs. The work of Senator Dole to invest in
caregivers and their experiences will strengthen our ability to
successfully execute an expanded program of comprehensive
assistance for family caregivers under the MISSION Act.
I would be remiss if I did not thank the foundational VSOs
for their efforts to making sure that this benefit was
incorporated into the legislation.
And I will take the opportunity also to thank in person
someone who is familiar to all of you and who was instrumental
not only in the development of the MISSION Act and the
caregiver program but someone who has been on point for
veterans for many years. He is retiring. And that is Garry
Augustine of Disabled American Veterans. And I thank him for
being here as well.
The other most meaningful aspect of this legislation is the
series of related products that ultimately support the work of
the Asset Infrastructure Review Commission. These include
outputs of national market assessments and our strategic plan
and a data-driven asset and infrastructure assessment and
recommendations with input from our veterans, employees, VSOs,
local communities, and other key stakeholders. The VA is
embracing the opportunity to assess our footprint and develop
recommendations for modernization and realignment of
facilities.
Mr. Chairman, I would like to beg your indulgence for a
minute, and I am going to go off script. And it is partially in
response to a series of stories that I read this morning,
stories that have particular meaning to so many Members of
these Committees, and that is on the issue of suicide
prevention.
When I was Acting Secretary of the Department for 8 weeks,
I declared that suicide prevention is the number-one clinical
priority of the Department. In addition to that, I named a
permanent head of our Office of Suicide Prevention, Dr. Keita
Franklin, who was the head of our efforts at the Department of
Defense when I was the Under Secretary.
In addition to that, we have developed with the Department
of Defense a streamlined and comprehensive program to begin
addressing the issues that impact our veterans and the issue of
suicide beginning from the time that they enlist. Our
Transition Assistance Program is done in conjunction with
Secretary Mattis. And now, thanks to the work of this
Committee, we are including other-than-honorable dischargees in
our education and outreach efforts when it comes to suicide.
The tragic aspect of this is that, for the 20 American
warriors who take their lives on a daily basis, 14 of those
warriors are outside of the Department of Veterans Affairs.
When I have gone across the country, I have asked Governors, I
have asked mayors, I have asked VSOs to help us find those
veterans. When I was in Alaska recently, I spoke to the Alaska
Federation of Natives. Fifty percent of the veterans in the
State of Alaska are outside of the VA system. And I have asked
them to help us find those who might be in danger.
Suicide prevention is the number-one priority of this
department when it comes to our clinical efforts to keep our
veterans healthy and well.
In addition to that, I do want to say that I echo what
Senator Tester said. Last week, Dartmouth, in the Annals of
Internal Medicine, indicated that the Department of Veterans
Affairs' health care, medical care, is as good or better as any
in the private sector. That is a story I wish to tell.
The other part of that story is--and it will come as a
confounding statement for some in the press that a conservative
Republican is here saying this--I am incredibly proud to be
part of the workforce that I consider to be the finest in the
Federal Government. In my travels, I have seen the dedication
of our men and women, 370,000 strong. And it is my pledge to
tell the good news stories that they have created on the behalf
of our veterans.
In addition to that, another story that I am proud of is
that the Partnership for Public Service for the first time in
memory has now included the Department of Veterans Affairs in
the top third of all Federal departments when it comes to
workplace satisfaction and the pride that our workers have in
being part of the VA. That is a great step forward. Without
that pride, we will not be able to deliver the kind of customer
service that our veterans expect.
In addition to that, I am also happy to say that the
Department of Veterans Affairs, when Time issued its list of
the 50 most influential health care minds and providers in this
country, the Department of Veterans Affairs had researchers on
that list.
It is a good news story to tell. It is one that I am proud
to tell. And I am very happy and humbled to be part of that
outstanding workforce that, on a daily basis, helps veterans
remind all of us why we sleep soundly at night.
Mr. Chairman, I thank you for the indulgence and look
forward to your questions.
[The prepared statement of Secretary Wilkie appears in the
Appendix]
The Chairman. I thank you very much.
And just very quickly, since we have a large number of
people here, I will be dropping the gavel at 5 minutes,
including myself.
I appreciate you being here, but I would like to focus
today, in this hearing, on the implementation of the VA MISSION
Act, specifically the community care part, because that is
coming up in 6 months.
And, really, it is literally--if we can do three things, I
think, Mr. Secretary, and if you can lay out and give me some
ease about how I feel about this: One, will we have networks in
place? Number two, can you schedule an appointment to the
doctor in those networks? And number three, will you pay the
bills once the veterans have seen them, so they don't get
dunned for the bills? I think if we can do those three things.
And my concern--we have the four regions of the country.
The various regions have a year, according to the law, to put
these networks together. And I know you are signing the
contracts for 3, you said, hopefully by February and then
region 4 by March. That is less than 90 days from the time this
thing goes live, that last contract. Because I remember very
well in 2014 the fiasco that occurred there.
So, of those three things, when we go live--or are you
going to need more time? And, quite frankly, if you see it
isn't happening, I would rather keep doing exactly what we are
doing and implement it a month later than I would have this
thing fall on its face and we fold up all the community care
programs we have into one and it not work.
Secretary Wilkie. Yes, sir. Obviously, the goal is to
fulfill those time commitments. I am going to take a step back
and answer the third part of your question first, and that is
the timely payment to our community caregivers and particularly
our small-town doctors across the country. Without that, the
entire Choice system contained in the MISSION Act fails.
We have learned valuable lessons from the experience of
Choice. I do believe that we have the beginnings of a
comprehensive set of standards we will take to the country to
bring those community care providers into the networks. Those
contracts are ready to go. We do have the lessons learned from,
as I said, the problems that we had with Choice right now.
And I will go ahead and address an issue that was raised in
the media this morning. TriWest is the bridge to the expansion
of our program through the community care networks. And I am
confident that, given the governance structure that we have in
place, that we will be able to reach those goals.
I will also say that if at any time I don't think we can, I
will be up here posthaste to make sure that we inform the
Congress of that contingency.
I don't know if Dr. Lieberman wants to say anything about
where we are in terms of the contracts.
Dr. Lieberman. So we are really pleased with how our
contracting has been going. We have been meeting weekly on
this, and, as the Secretary said, we expect it to be completed
on schedule, as he told you. And then we are ready to go with
all the topics that you have brought up.
You know, we certainly are implementing a number of things
to help with timeliness, including the timeliness of the
payments. We are going to be requiring, except in rare
circumstances, that the payments be electronic, which speeds up
the claims process. We also are going to have an off-the-shelf
product that will auto-adjudicate the claims and pay them
timely.
Secretary Wilkie. And I would note--sorry, Steve--that is
key. The Department of Veterans Affairs, as these Committees
have noted on more than one occasion, has an IT problem. When
it comes to claims processing, hands have to touch each claim.
What we have done is look to the market for off-the-shelf
technology that will allow us to automate the claims process so
that individuals are not having to touch each claim. And this
will put the Department of Veterans Affairs in line with the
most modern health care administrations in the country.
The Chairman. Well, my time has about expired, but this is
what I want to have happen. If I am a patient and I come to see
the doctor, and I need to go see a neurologist or whomever,
well, I am seeing the VA doctor that day. I walk out front. The
VA doesn't have that specialist in the hospital. I get my
appointment scheduled, I get it made. I go see the doctor. That
information is transmitted back, and the doctor gets paid. That
is how the system work.
I had surgery 2--well, 18 months ago. Two weeks after
surgery, the bills had been paid by the third-party
administrator. And that is the kind of--I know it is not going
to be that quick, but that is the kind of efficiency we want,
and I hope that we have it. I am not expecting it on June 7,
but I am expecting it sometime fairly soon.
Mr. Takano, you are recognized.
Mr. Takano. Thank you, Mr. Chairman.
Mr. Secretary, over the last few months, Committee staff
has heard from various stakeholders, including VA, conflicting
information regarding VA's development and/or adoption of what
I talked about in my opening statement, designated access
standards.
We have also heard from VA staff the President is likely to
announce the adoption of a designated access standard model
during his State of the Union address. However, Congress has
not yet been made aware of which models are being considered
and the reasoning behind any imminent decisions.
Would you commit to us today that you are willing to offer
each of the four corners--and, I would say, Members of the
Committee, but, I mean, it should be made available to all of
us--a briefing by Milliman, who is the actuary, prior to the
State of the Union, and reasonably before the State of the
Union?
Secretary Wilkie. Well, Mr. Takano, what I will promise is
that, as soon as the President is briefed--I owe him that
courtesy, and certainly he is responsible for the final
decision. And once he makes that decision, I will be up here
with our team to brief this Committee, these Committees, for
any comments and advice you have and any corrective actions
that you might have.
It is absolutely vital. I think I mentioned in my
confirmation hearing, I grew up in this institution. I know why
Article I is the first article. And I will commit to coming up
here when the President does make his decision.
And it is still not clear if he is going to announce
anything at the State of the Union, but I hope to have him
briefed and have those decisions made before then.
Mr. Takano. Well, Mr. Secretary, I am a little concerned
that this decision could be made, you know, the night before he
delivers his speech and makes a grand speech about how every
veteran is going to be able see any doctor they want to see. I
mean, that is one model, any veteran they can see any doctor
they want to see. Of course, that sounds good, but there are a
lot of downsides to that kind of a model.
All the more reason why the VSOs are--many of them are
complaining that there is a lack of participation as per what
we said in the MISSION Act, that they should be participating
in the development of these access standards.
And so I am not really satisfied with the answer. I wish we
were able to get better insight as to what models you are
considering, what the costs are associated with each of those
models. Because that has a lot to do with how much money might
be diverted from, you know, regular central VA care.
Secretary Wilkie. Mr. Takano let me answer the second part
of the question first, in terms of engagement with the VSOs.
I can say that they are a vital part of what we do at the
Department. In my time as Secretary, we have doubled the number
of VSO engagements that the Department had prior to my arrival.
The majority of our VSO engagements are handled at the Under
Secretary level or above. Over the last 9 weeks, our VSOs have
experienced briefings from senior leadership in the Department
that last well over 4 hours a week.
I will also tell you that in my travels across the country
I have made it a point to reach out to veterans' organizations
in the rest of the United States. In Alaska, I spoke to the
largest VFW post, I think, west of the Mississippi. I was just
in your area of California, spent 2 hours with veterans'
leadership in southern California. Did the same thing with the
Indian Nations, the Native Nations in Oklahoma and also in
Senator Hirono's State, in Hawaii, on the Big Island and also
in Oahu. So that is important to me. If the veteran is not at
the center of the decisions, it won't work.
But I will say, when it comes to access standards, I have
in mind not only Senator Tester's State of Montana when it
comes to the ability of our veterans to get to services but
also have in mind some of the most heavily congested
metropolitan areas of this country. We have to make it easier
for our veterans to get the care that they need.
But I will also say--and I will repeat what I said when I
testified in the Senate in September. My observation, my
experience--and Senator Tester said it earlier today--veterans
are happy with the service they get at the Department of
Veterans Affairs. I have not seen any indication that the
majority of our veterans are champing at the bit to find
alternative ways to take care of themselves.
The most important of this is the one that is not
quantifiable, and that is the communal nature of veterans'
care. Veterans want to go places where people speak the
language and understand the culture. That is what I have
experienced in my lifetime around the military, and that has
certainly been validated in the travels that I have undertaken
in the very short time that I have been the Secretary. Veterans
will always be at the center of any decision that I make.
The Chairman. Appreciate the gentleman for yielding.
Senator Tester, you are recognized.
Senator Tester. Yeah, thank you, Mr. Chairman.
I want to thank, Mr. Secretary, you and Dr. Glynn and Dr.
Lieberman for being here.
I am sure, Mr. Secretary, you are aware of an article that
was published yesterday outlining the overhead costs of the
Choice program. It was reported that $1.9 billion, nearly a
quarter of the funds spent on Choice, were for admin fees. I
have a huge problem with that. Do you have a problem with that?
Secretary Wilkie. Absolutely.
Senator Tester. Okay. So, moving forward, what are you
going to do, or what are you doing, when it comes to admin
costs from the private providers?
Secretary Wilkie. Well, in order to move forward, Senator,
may I please take a step back?
Senator Tester. A quick step.
Secretary Wilkie. This Committee addressed the problems
with Choice with the MISSION Act. The article in question
addressed the problems with the system before MISSION was
passed, before I became the Secretary. I am cognizant of what
went on with Choice, and you mentioned it: hastily put together
in response to a tragedy in Arizona.
So it is my direction and I believe, because of the
negotiations that we have been having with potential community
care providers, that those administrative costs you will not
see at the level that we experienced during Choice, because the
Department, I will admit, was taken advantage of because of the
hasty nature--
Senator Tester. Okay.
Secretary Wilkie [continued].--that took place when the
program was put together.
Senator Tester. I will kind of accept that. But a lot of
the folks who are delivering the care now under your thumb are
close to one-quarter in admin costs--close to one-quarter. Now,
I asked my staff to find out where the VA was before Choice for
admin, but, as I recall, it was one of, if not the cheapest
delivery care systems in the Nation when it comes to an admin
cost. So I would say that.
The other thing I would say is this. And Congressman Takano
talked about this. If access standard models are expanded to
the point--and I don't think it was congressional intent for
this; in fact, I know it wasn't--for unfettered choice, we got
a big problem. Because it is going to cost more money. The care
isn't going to be good. I talked in my opening statement about
Blue Water veterans. You know why we can't get Blue Water folks
covered? Money.
So extrapolate this out a little bit. If it costs more to
be in the private sector, if admin costs are higher, benefits
are going to be cut. And so, while you say it is the
President's decision--and it is; he is the boss--there better
be some good, good information coming from you and the people
that know better that this access standard needs to have some
controls around it.
Would you agree?
Secretary Wilkie. I agree with you.
Dr. Lieberman. I just want to mention that the
administrative costs were not as high as was quoted in that
article. The number is less, and it has actually been over
years, so it is a much lower percentage.
We have learned since Choice was first implemented in a
hurry. What we have now moved towards is itemization of the
administrative charges, so there is now a range of what the
charges are, and to--close to the amount that was in the
article for individual. But then with the Community Care
Network, we actually have learned more, and we are going to go
to a new model which will further decrease the administrative
costs.
Senator Tester. Okay. And so are you planning on putting
overhead caps in those contracts?
Dr. Lieberman. We are moving towards a standard similar to
what the community does.
Senator Tester. So that is a no, correct? You are not going
to put caps in them?
Dr. Lieberman. We certainly can--
Senator Tester. No, I am not advocating for it, but what I
am saying is somebody has to have the finger on these costs.
Because I will tell you, we are talking billions of dollars,
and, after the fact, we can't get it back. And those are
dollars that should be spent taking care of veterans.
So do we have a plan? Because the truth is the MISSION Act,
we passed it with the best of intentions, but it could be a
train wreck too. And I hate to tell you this, but it is kind of
in your lap. It is in your lap. And so, when we are talking
about too-high admission costs, when we are talking access
standard models that were basically unfettered choice, we could
end up with a problem where we are actually cutting benefits
for our veterans moving forward. And my guess is, if you asked
any of the VSOs, that that would not be a good thing. So I just
want to make sure that is on your radar screen.
I have to have one more because I have to get it--I only
have 25 seconds left. You talked about giving information to
the VSOs, you talked about briefings. Are you gathering
information back from them? That this isn't an information dump
on the VSOs, that you are actually listening to them and
finding out what their concerns are. Because I am telling you,
it is critical. It is critical for us; it is critical for you.
Did you want to answer that, Dr. Glynn?
Secretary Wilkie. I can do it.
Senator Tester. Go ahead.
Secretary Wilkie. Absolutely. In fact, many of the people
in the audience will be with me tomorrow morning in my office
discussing what was discussed here, and they will be telling me
their input after--
Senator Tester. So I am not throwing anybody under the bus
here, but I am going to tell you that a lot of VSOs have talked
to me about the communication within the VA. It is not where it
needs to be.
Secretary Wilkie. Senator let me add one thing to that.
Senator Tester. Okay.
The Chairman. If you could add that quickly.
Secretary Wilkie. I will do it real fast.
Something has happened in the makeup of our veteran's
population. For the first time since the fall of Saigon, half
of our veterans are now under the age of 65, which means they
have different cares, they have different interests.
What I have done in my short time is actually opened the
aperture to the table at the Department of Veterans Affairs to
bring in veterans who are not traditionally part of the
system--Purple Heart, blinded veterans, student veterans. In
fact, we have more veterans at the table discussing their
issues with us than we have ever had, and that mirrors the
change in the Active Duty, Reserve, and retiree population that
we have seen.
So you have my commitment that every veteran who wants to
talk will be heard and input be given.
Senator Tester. Thank you.
The Chairman. I thank the gentleman for yielding.
Senator Moran, you are recognized.
Senator Moran. Chairman, thank you very much.
Mr. Secretary, thank you for you and your team's presence
today.
I asked my staff to give me the statutory requirements of
your consultation with Congress, and it turned out to be pages.
In the MISSION Act, you are directed to consult with us as you
develop regulations. And the goal of that language was to make
certain that Congress was informed before the regulations were
determined, not a consultation that says: This is what the
regulations will be.
My understanding is that those consultations that have
occurred have progressively gotten better. We still want more
specificity, and you seem to be headed in that direction, but I
would encourage you and your team, as we get those briefings,
to give us the details so that we can encourage, comment,
suggest in advance of decisions made at the Department of
Veterans Affairs. That was a very intentional aspect of the
language included in the bill.
Let me see if I can get a couple of things in the 4
minutes, I now have left that are specific.
First of all, how you define how the Department of Veterans
Affairs defines episodic care is a hugely important issue in
regard to how the MISSION Act will be implemented and what kind
of care our veterans will receive.
Can you, Mr. Secretary, in a specific way tell me how you
will define episodic care?
Secretary Wilkie. Well, I will let the doctor describe
that.
Senator Moran. Doctor, thank you.
Dr. Lieberman. So it will depend on what the issue is.
Certainly, we have the six different criteria that go into it.
If it is something where you require orthopedic surgery,
require physical therapy, we will bundle the care for that,
whereas, if we can't provide it, we would provide it outside.
So--
Senator Moran. Obviously, in 4 minutes there is not a way
to be terribly specific, but it will be something we will
continue to ask you.
Dr. Lieberman. Sure.
Senator Moran. I would tell you that my interest in these
topics is generated by our casework, what veterans bring to our
office and what problems they have had under Choice. The idea
that you have to go back to the VA every time to get the
laboratory work, the x-ray, that is not an efficient system and
one that is designed to fail and not be beneficial to the
veteran.
Would you commit that we will be able to review your
definition, Mr. Secretary, of episodic care before the
regulatory process--
Secretary Wilkie. Absolutely.
Senator Moran. Thank you, sir.
Let me then turn to access standards, which has been a
topic of conversation by most of my colleagues who have spoken
already this morning.
Here is what I would look for in today's setting: I would
like to have assurance that access standards will be applied to
where a veteran actually lives, not his or her post office box,
as has been the case in the past.
Secretary Wilkie. Absolutely. And I have said on many
occasions--and most of my focus has been on the western United
States. That is absolutely necessary if we are going to make
Choice work. It is striking to me that still, in 2018, we don't
understand the scale of the American West. And what you have
said is absolutely essential if we are going to make access
standards work.
Senator Moran. Another piece of casework that has become a
challenge for us is the definition of ``in the VA.'' And that
is that, in circumstances in which our veterans are trying to
access care, the VA's response is: The care is available within
the VA broadly. In my view, the question is, is the care in the
VA available at the facility, the hospital where the veteran
lives? And our veterans are being asked to travel long
distances because the care is available in the VA but not
geographically available.
Secretary Wilkie. And that is one of the things that we
will fix as a result of the MISSION Act, and we will get a
system in place that allows the veteran the opportunity to get
that care that is most convenient to him and to his family.
Senator Tester is gone. The example I use is the 700-mile
round trip in Montana. In Kansas, the distances are almost as
great. So, absolutely.
Senator Moran. Thank you, Mr. Secretary.
Thank you, Mr. Chairman.
Secretary Wilkie. Thank you, sir.
The Chairman. I thank the gentleman for yielding.
Senator Murray, you are recognized.
Senator Murray. Yeah, thank you very much, Mr. Chairman.
Mr. Secretary, before I get into the main focus of this
hearing and my concerns about the caregiver bill, I do want to
mention the current chaos with the GI Bill.
Secretary Wilkie. Yes.
Senator Murray. It is unacceptable to leave veterans
without a stipend or an incorrect stipend or a delayed stipend,
especially when they rely on that to pay for rent or food. And
it is unacceptable to put veterans' enrollment at risk by
failing to get tuition payments to the universities, as well,
on time. These are basic tasks that the VA cannot get wrong.
You have had more than a year now to implement the changes
in the Forever GI Bill. I have written you two letters, one
more than a month ago, one 3 weeks ago, looking for answers on
how the VA is going to fix these payment problems, how they are
going to address the shortcomings with the GI Bill comparison
tool, and, especially in light of the recent collapse of the
ECA, to explain why the Department of Education has stopped
sharing accreditation information with the VA.
I don't want you to take the time to answer right now. I
would like a written response back to those--
Secretary Wilkie. Yes.
Senator Murray [continued].--and I want you to know we are
all very concerned about it.
Senator Murray. But I do want to ask about the caregivers
program, because, according to briefings from the VA, the
Department has ruled out trying to narrow the eligibility
criteria for the caregiver program, but I am still very
concerned that there is a number of issues the VA is looking at
that I am concerned about, including changes to the stipend,
restricting veterans based on their type of injury, or
requiring a minimum disability rating. This seems to be VA
still focused on keeping people out of the program instead of
making it work better for our veterans.
And, yesterday, NPR reported on several cases where
veterans, including a double and a triple amputee, were
downgraded or kicked out of the program completely
inappropriately. And these are, by the way, not one-off VA
cases; we are hearing that this is a continuing problem in the
VA's management of this program.
When the VA previously downgraded and terminated
caregivers, the VA assured me that it had resolved the problems
that led to these types of actions, but it is very clear that
is not true. And I would like you to immediately reinstate a
ban on downgrades and terminations until VA can demonstrate to
us that the serious management problems have been corrected and
these types of outrageous errors will not occur again.
Secretary Wilkie. Senator, I will say that caregivers is
especially important to me. I am the son of a gravely wounded
Vietnam--
Senator Murray. I appreciate that.
Secretary Wilkie [continued].--warrior, and I have seen my
mother and family take care of my father prior to his passing
last week.
Senator Murray. I appreciate that.
Secretary Wilkie. The--
Senator Murray. So will you reinstate the--
Secretary Wilkie. Yes?
Senator Murray [continued].--ban? Will you reinstate the
ban?
Secretary Wilkie. I am not familiar with all the rules, but
I will tell you that the National Public Radio story, that
problem was corrected within 24 to 48 hours.
Senator Murray. Those are not isolated cases. We are
hearing many of them.
Secretary Wilkie. And those cases, is my understanding,
have been corrected because of directives from this department,
that people were not reading the regulations properly.
So my promise to you is that I am going to do everything I
can to make sure everybody stays in the program. It is that
important to me personally.
Senator Murray. Can I have your assurance that no one else
will be downgraded or kicked out of the program until you look
and make sure that the regulations are being implemented at
every level correctly?
Secretary Wilkie. Absolutely. I will make that commitment
and will brief these Committees.
Senator Murray. Okay. And also--I won't have enough time,
but I would like you to get me what your guidance to the
program office is and your guidance to the field on how this is
being implemented so that we can see what you are telling your
staff.
Secretary Wilkie. Yep. Yes.
Senator Murray. Okay. And I am also very concerned about
the implementation of the changes to the caregiver program that
were passed as part of the MISSION Act. Before the expansion
can begin, you have to certify that a new IT system is in
place. And the law required you to have that system in place by
October 1st. That was a month and a half ago.
This was not a new requirement. GAO's initial
recommendation to fix the IT system was made in September of
2014. And the VA has repeatedly assured us that it is working
on that issue. I want to know when you will have that IT system
in place and make the certification as the law requires.
Secretary Wilkie. The goal is October 1st.
Senator Murray. That--
Secretary Wilkie. I would not be telling you the truth if I
told you that that I was absolutely certain that, given the
state of VA's IT system, that that date will be met.
Senator Murray. That was a month and a half ago. The date
has passed.
Secretary Wilkie. No, I am talking about for--no, it is
October of 2019--
Senator Murray. No.
Secretary Wilkie [continued].--to certify that the IT
works. Are we confusing two dates?
Senator Murray. That is your new goal. That is not the goal
you were given by Congress.
Secretary Wilkie. Go ahead.
Ms. Glynn. The timeline to certify the new system is ready
is 2019--October 2019.
Senator Murray. Okay.
Ms. Glynn. We did miss the October 2018 date to support the
new system.
Senator Murray. So you gave yourselves another year?
Ms. Glynn. Well, there were two dates--there are two dates,
Senator, associated with the requirement. The first date, which
was October of this year, was for validating and deploying a
new system. We have not deployed the new system, but--the
certification of that system, which is required prior to
expansion--
Senator Murray. Okay. Have you fully defined all of the
requirements for that system?
Ms. Glynn. We have worked on--we have fully defined
requirements. We are working, as the Secretary mentioned, on
user-acceptance testing of the system, and we are working
through that. We do not want to deploy a system until it has
been thoroughly tested and we feel it is capable of serving
caregivers' and veterans' needs.
Secretary Wilkie. And I would say that has been the problem
that I identified and talked, discussed, with the Members of
this Committee. GI bill was a classic case, Senator, of a
program being imposed on a system that was incapable of
handling it. That is why I had to make the decision to go back
to the old system on the GI bill.
The same applies here. The system was not capable of
addressing it. I give you my commitment: I am doing everything
that I can, and so is the Department, to bring the IT system up
to modern standards.
The GI bill, we were talking about a 50-year-old IT.
system. And it is not acceptable, but you have my commitment
that we are working with the best minds we can find to make VA
a modern health care administration and benefits--
Senator Murray. Mr. Chairman, I know my time is out. I have
been on this Committee for more than 20 years, and I always
hear we are not going to get an IT system because there is a
problem. Every time it changes, every time, there are problems.
We have got to get this right. People are counting on it.
The Chairman. I appreciate the gentlelady yielding back,
and all I can say is amen to that IT. I have heard it for 10
years.
I now yield--and please be respectful of everyone's time.
There is a lot of people here. General Bergman, you are
recognized for 5 minutes.
Mr. Bergman. I could yield back right now. But I won't.
Folks, we will get to the heart of the matter very quickly.
You are designing a system that you are going to implement for
the benefit of the outcome of the veterans. In my district, the
First District of Michigan, if any system will work in that
district, it will work anywhere because you have a largely
rural district with some small cities. So I am hoping, or at
least optimistic, that you have factored that in, that whatever
system you are designing to get the veterans, caregivers in
this case, into a functional status, that you consider the
tyranny of distance, the tyranny of weather, and all of that.
Now, in setting up your network, I am guessing--although I
don't see it in the slides--there are certain assumptions that
you have made, and certain risk assessment involved with those
assumptions. And I would like to ask you to just take this for
the record. If you could--we don't need to talk about it here,
but if you would give us that list of assumptions and the risks
that you have, you know, put together, that would be greatly
helpful.
And I noticed in the slides here--great slides--I would
guess that these meetings that are, whether they be weekly,
daily, bimonthly, when you find there is a course correction as
a result of a meeting or an update, that needs to be made, what
do you do? I mean, I don't see that in the slides, okay, we
have ID'd it--and I am a pilot. You see a need to change your
heading, change your heading. Don't wait.
Ms. Glynn. Thank you, Congressman. Right now, our team
actually is engaged in 180-day reviews back at the VA on all
elements and the provisions of the MISSION Act. And we are, as
you say, identifying risks and identifying, as Senator Murray
highlighted, concerns with things like IT, how do we take
different, parallel paths towards getting to that October date.
So we are bringing that through our executive Committee, and
then issuing guidance to the teams, working through resource
requirements, working through changes in project plans,
understanding what our needs are, and bringing forward a
stakeholder engagement protocol so we can continue to uplift
this program and make sure we can hit the--
Mr. Bergman. Do you feel that there is--seems like--you
know, as a Chairman on the Subcommittee on Oversight and
Investigations, one of the questions was always asked in every
hearing: Is there a sense of urgency? You know, within your
folks that are trying to implement, you got good people trying
to do the right things. Is there a sense of--this may sound
like an oxymoron--bureaucratic urgency?
Secretary Wilkie. Yes, sir. And that is one of the reasons
why a battle rhythm was implemented. I have, as you know, a
military background, not as extensive as yours. The Department
has never had a governing structure for anything this--and we
do now, and we have timelines to meet just as we would on the
flight line in my Air Force life. So, yes.
And I will also point back to what I said earlier about the
attitude of those in the Department. It has been my experience
that we have incredible support from those in the career
leadership because they understand that VA can't fail on this
one. And I am very happy with that attitude.
Mr. Bergman. Okay, well, number one, thank you for your
service, and all honorable service is--it should be respected
by all. And I could just say personally the biggest, proudest
moment I have had is to lead marines and be mentored by lance
corporals who have a 20-year-old view of the world, and that is
what drives us.
But, with that, in the interest of time, I am going to
yield back 50 seconds.
The Chairman. I thank the gentleman for yielding. And one
of the things our Senate colleagues could do to help the
Secretary is to confirm his Assistant Secretary for IT That
would be helpful.
I now yield to Ms. Brownley for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman, and thank you, Mr.
Secretary for being with us today. I wanted to follow up with
Senator Murray's questioning with regards to the caregiver
program. And if I could, I heard you make a commitment, but I
want to be abundantly clear that you are committing to us today
to not modify any of the current eligibility requirements
within the caregiver program as it expands?
Secretary Wilkie. I am committing to review every case
involving a caregiver who is in distress. I am also committed
to making sure that before any decision is made on the future
of the program, that this Committee is involved in it. And as I
told Senator Murray, I will be reporting to her on the path
forward.
It is important to me personally because of my own
experiences. And we are going to get this right for the 5.5
million family caregivers out there.
Ms. Brownley. You had mentioned earlier in response to some
other questions with regards to the importance of the input of
VSOs and veterans in general. You responded, I think, by
saying, you have even expanded that audience of veterans from
younger veterans and trying to get a broader representation,
which I think is good.
On the other hand, the leadership of the VSOs really lead
by consensus within their organization, and representing that
broad census. And I, too, have heard from many of the VSOs that
they don't feel, and particularly in the caregiver expansion,
that they are--or have not been involved to the degree that I
believe, and I think we all believe that they should be, in
terms of properly making right decisions as you move through
this process.
Secretary Wilkie. Well, you have my commitment, and so do
they, that they will be involved, they are involved, in making
sure that we make the right decisions. But I will fall back on
what I said earlier. It is important for us, as you pointed
out, to make sure that we hear from the entire cross section of
the Nation's veterans.
I said in my statement that, on the caregiver effort, that
would not have been able to come to the finish line without the
work of what I call the foundational VSOs, and that is my
recognition that they are central to the entire issue of
caregivers because the majority of veterans who are in that
category and who need that family care at home come from
Vietnam, the Vietnam era. Some less in the Korean era. And the
foundational VSOs are the ones who represent the community most
impacted by the caregiver.
Ms. Brownley. And can you commit to providing our Committee
progress reports in terms of the IT system for the caregiver?
Secretary Wilkie. Yes.
Ms. Brownley. So that we can feel as confident as you do in
terms of meeting the October 2019 deadline.
Secretary Wilkie. Absolutely.
Ms. Brownley. That would be great.
Just in terms of broadly, you know, the governance
structure that you have set up for assistance in the
implementation of the MISSION program, I think, you know, one
of my frustrations on the Committee--I have served on the
Committee now for 6 years--is that we have VA representatives
come to testify that are updating--in this case, we are going
to want, obviously, frequent updates on the progress with the
implementation of the MISSION program. But many times they
come, they avoid answering the tough questions. The response is
usually: We will take it for the record; we will get back to
you.
I have found that I don't get--I don't get responses. If I
do, it is months and months later. So I just, you know, would
like, again, to get your commitment that if it is you or others
representing you, that you will provide us with the best
information possible to be informed and prepared for our
questions, and at the end of the day, given you have set up a
governance structure that--I want to hear from you that, at the
end of the day, the buck stops with you and that you alone are
accountable for the successful, hopefully, completion of the
MISSION Act.
Secretary Wilkie. Congresswoman, that is right. I mean, I
am accountable to you. I am accountable to the VSOs. And I am
accountable to veterans. I will say--and I mentioned having
grown up in this institution--that I will note that in the time
that I have been the Secretary and the Acting Secretary, we
have seen a 20-percent increase in terms of the number of
roundtable briefings that we have given to Committees--the
Committee and staff.
And we have seen a 50-percent increase in terms of the
number of actual individual congressional engagements with
offices across the Congress. That is part of the commitment I
made to Senator Isakson and Senator Tester in my confirmation
hearing. I will make that better. Again, having grown up in the
institution, I am aware of Article I.
Ms. Brownley. Thank you, Mr. Secretary, and I yield back.
The Chairman. I thank the gentlelady for yielding.
Mr. Banks, you are recognized.
Mr. Banks. Thank you, Mr. Chairman.
Mr. Secretary, in my mind, the MISSION Act is about making
sure the community care dollars that Congress appropriates
actually makes it and reaches the veteran. Our Committees have
a spirited debate every year about the funding levels, but the
reality is--and you can pick your analogy here--it seems like
we have been pouring money into a leaky bucket, or through a
clogged-up pipe.
When authorizations get delayed or lost, the veteran does
not receive the necessary care in a timely fashion. When the
providers do not get paid, they eventually drop out of the
network, and the veteran far too often winds up in collections.
So, by consolidating all of the different, legal authorities
and programs for community care, the MISSION Act actually gives
the VA the first chance in years to actually make the system
work.
My question to you, though, is this: Do you agree that the
MISSION Act merely makes it possible, and the law's
implementation is only the beginning of a lot of hard work to
establish better payment procedures, stronger audits, connected
IT systems, improved customer service, clear communication to
veterans, and in so many other areas?
Secretary Wilkie. Absolutely. Absolutely, it is the
greatest first step, but it can't stop.
Mr. Banks. I appreciate that sentiment. But I do want to
explore one aspect of that hard work. Achieving
interoperability with the community providers and their EHRs is
one of my top priorities. And I know, from speaking with you
personally, it is one of your top priorities as well.
The VA implementing Cerner is going to advance
interoperability with community providers that already run
Cerner, but what about the other medical practices that have
other EHRs? What is the linkage between the Office of Community
Care and the Office of Electronic Health Record Modernization
to start specifically attacking that problem?
Secretary Wilkie. Right now--I will confess I am not an IT
expert, but right now, we are testing those standards, those
operations in the Pacific Northwest and in Alaska so that these
systems talk to each other. Our first goal was to make sure
that DoD and VA talk to each other. I think we are pretty far
along the road on that.
The next is to make sure that we communicate with doctors
in the private sector, community-care hospitals, as well as
private pharmacies, and to talk to those systems that are not
part of the Cerner network. It is done in other areas of the
country. I am confident that it will be done here.
I will say quickly, you are absolutely right about the
interoperability, and I will also say to the issue of
privatization, I have argued that the success of the electronic
health record system ensures that VA will stay at the center of
a veteran's health care, that VA will be the central node, no
matter what that veteran decides to do, and that that is one of
the answers when it comes to the issue of privatization. I see
that as a veteran myself, I see that when I look at the
experiences of people in my family as well.
Mr. Banks. I appreciate that. One of the other key areas is
claims processing. We have talked about this a little bit
already, but the VA is essentially asking the consolidated
community care network contractors, whoever wins the contracts,
to bring to the table a new and improved claims processing
system. VA is still going to have to pay the company somehow,
though. But the idea here seems to be to outsource the IT
system along most of the claim--along most of the claims-paying
function. Can you please comment on the thinking here and how
that will improve the situation?
Ms. Glynn. Thank you, Congressman. Overall, we are making--
as you have mentioned specifically, there are many changes. It
is not just the consolidation of the regulations that govern
the Choice Program now. We are implementing an electronic
claims payment system so we can auto adjudicate claims.
We also are changing the way we will pay the third-party
administrators as well so that they have the funding available
to pay the providers. So all of that has to happen in tandem
and as part of the implementation to get to June 6. So, as you
mentioned, there are many aspects of this, and it is certainly
not just the consolidation of programs and new regulations; it
is building up the technical infrastructure associated with the
community care program.
And there will be changes in how the TPAs are paid as well.
And we have committed significantly to looking at the potential
for fraud, waste, and abuse in that system.
Mr. Banks. Thank you. My time has expired.
The Chairman. I thank the gentleman for yielding.
Mr. Lamb, you are recognized for 5 minutes.
Mr. Lamb. Mr. Secretary, thank you for joining us today.
Are you aware the Congressional Budget Office estimated that
the MISSION Act would cost around $46.5 billion over the 4
years from 2019 to 2023?
Secretary Wilkie. Yes, sir.
Mr. Lamb. That number is familiar to you?
Secretary Wilkie. Yes.
Mr. Lamb. Now, as far as I am aware, there is no pay-for
that is specifically for that $46.5 billion, right?
Secretary Wilkie. Correct.
Mr. Lamb. Okay. And those would be discretionary funds?
Secretary Wilkie. Yes.
Mr. Lamb. So they would count against the budget cap on VA
under the current arrangement?
Secretary Wilkie. Yes, sir.
Mr. Lamb. And if we went over that budget cap because of
this $46.5 billion or any other spending, that would trigger
sequestration, right?
Secretary Wilkie. Correct.
Mr. Lamb. So, in other words, for that $46.5 billion, in
order to avoid the sequestration, we will have to find the
money within VA's current budget, right?
Secretary Wilkie. Correct.
Mr. Lamb. Okay. Now, are you aware that the President has
asked that each of his agencies cut their total budget by 5
percent?
Secretary Wilkie. Yes, I am.
Mr. Lamb. Did you receive that request yourself from the
President?
Secretary Wilkie. I did. I did.
Mr. Lamb. Okay, now do you have a plan to do that?
Secretary Wilkie. I have discussed the plan with OMB.
Mr. Lamb. What is the plan?
Secretary Wilkie. I have discussed the plan with OMB. The
President hasn't approved it, so I will wait for his decision.
Mr. Lamb. Will the money for community care be cut by 5
percent?
Secretary Wilkie. I am--well, first of all, for the--I will
just say for the Choice Program, we are fully funded. We are
funded into next year. I have no--and I will say that in the
submission that I made, there were no cuts in community care.
Mr. Lamb. There were no cuts in community care. So the 5
percent would come from the rest of the VA's budget that does
not involve community care, correct?
Secretary Wilkie. Absolutely. And as a steward of the
taxpayers' money, I am going to do my best to make sure that we
are as efficient and lean as possible.
Mr. Lamb. So actually the non-community care part of the
VA's budget is going to be cut twice, right? It is going to be
cut by this 5-percent requirement, and it is going to be cut by
whatever needs to be spent on community care?
Secretary Wilkie. Well, we don't know where it is going to
be cut. I have made--I have made proposals--
Mr. Lamb. You have made a proposal?
Secretary Wilkie. I have made a proposal.
Mr. Lamb. And you are not sharing with us any of the
details of that proposal?
Secretary Wilkie. Because I have not had that conversation
with the President.
Mr. Lamb. Does it involve cuts to personnel?
Secretary Wilkie. It makes efficiencies in the system, I
will say that.
Mr. Lamb. Does it involve fewer personnel 2 or 3 years from
now than there are today?
Secretary Wilkie. No, I can't say that. I can say that in
the last fiscal year, we have hired 11,000 more employees at
VA. So we have been hiring at a very steady rate.
Mr. Lamb. Will you commit to providing us, before the end
of this year, an itemization of the things that you propose to
be cut with that 5-percent requirement?
Secretary Wilkie. I commit to discussing with the
Committee, at the earliest possible date, the decisions that
are made by the people who are responsible for those decisions.
Again, I owe the President the courtesy of having him make the
decision and then come to the Congress. And you are the
ultimate arbiter of what that budget will be.
I can tell you from my experience what usually happens in
Democrat and Republican administrations when a budget comes to
Congress. I can't think of the last time one was passed as it
came over from the White House. That is just the practical
nature of the business.
Mr. Lamb. Do you know when you will find out from OMB or
from the President?
Secretary Wilkie. Oh, I certainly hope in the next few
weeks.
Mr. Lamb. Okay. And we do have your commitment, once you
receive word from them, to brief us on your proposed cuts to--
Secretary Wilkie. Once the President has given the all-
clear--and you know the dance that goes on with the budget
process, usually coming in to the finish line sometime in
February. I will be as transparent as I can be within the
strictures of the system as it has existed all the way back to
1974.
Mr. Lamb. Well, we would like to see an itemized proposal
that you have given to the White House as to what should be
cut, and we would like to see that at the earliest possible
date.
Secretary Wilkie. Absolutely.
Mr. Lamb. Thank you.
Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding. Just to
clarify a little of this, it does get wonky, but the fact that
you would cut 5 percent doesn't necessarily mean it would come
out of the VA's budget. And I would refer to this graph right
here. You can take a look at--these are the number of employees
right here, Mr. Lamb, that have been hired. And I have been
here 10 years and looked at this, and the VA has had an average
of employees who left, from 2013 to 2017, of about 25,000 per
year, and they have averaged hiring 31,000 during that time.
And on the budget caps, if we go back to the sequester
levels--that was the way for 2 years--we have gone from $97
billion when I showed up here in 2009 to this--I think this
last budget was $206 billion, so it is over doubled in the last
10 years, and we found that money elsewhere in the caps. It
didn't necessarily come from the VA. The VA actually benefitted
under the caps.
Secretary Wilkie. Mr. Chairman, may I make one more
comment--
The Chairman. Yes.
Secretary Wilkie [continued].--to Mr. Lamb's line of
questioning? And I may be out ahead of my skis--I have come
from the Department of Defense. I am now at the other
Department in the Federal Government whose needs, its mission,
is unique. I mean, you have served in one of the two--one of
the two Departments. As the Chairman has said, our budget has
been going up. It is at record levels.
I do expect the President to continue his robust support
for this Department, as he has for the Department of Defense.
We are different, and as the Chairman has said, that has been
reflected in the increase of our budget and the priority which
this administration has placed on both Department of Veterans
Affairs and the Department of Defense.
The Chairman. I thank the gentleman for yielding.
Thank you.
Mrs. Radewagen, you are recognized.
Mrs. Radewagen. Talofa. I want to thank Chairman Isakson,
Chairman Roe, and Ranking Members Tester and Walz, who is not
here, for holding this joint hearing, and greetings, Chairman-
elect Takano.
I want to thank Secretary Wilkie and the panel for their
testimony.
I also want to thank the VA for working directly with my
staff in keeping me informed on the status of the community
care network contracts in the U.S. territories.
The Pacific territories, including my home of American
Samoa, face unique challenges due to their relative isolation
both physically and economically from the rest of the United
States. So one-size-fits-all measures simply do not work for
the territories, and special care must be taken to ensure that
the unique health care needs of Pacific veterans are
considered.
To that end, I am glad that VA is considering the
uniqueness of the territories in handling their CCN contracts
separately.
Secretary Wilkie, VA staff briefed my office on CCN
contracts just last month, and I would like to take this
opportunity to touch on the topic once again. Could you go over
how the unique challenges faced by the Pacific territories will
affect both the timeline for the CCN contracts and your ability
to comply with MISSION Act requirements?
And could I also get your commitment to work with Congress
so that implementation of the MISSION Act, the contracts, and
any future related legislation is in line with the needs of the
territories? To put it another way, will you help us help you
provide for our Pacific veterans? Timeliness is always a
factor, but we also want to make sure we get this right.
Secretary Wilkie. Thank you. I just returned from Hawaii,
and I made a commitment to one of your counterparts, the
Governor of the Northern Marianas, that I will be visiting
American Samoa, Guam, and the Northern Marianas. It is
important to me.
I have made a commitment in the continental United States
to reach out to the Native peoples of this country. The same
applies to the American citizens in the Pacific. No group
serves in the military at a greater rate than the men and women
of the Pacific Islands or the Native peoples of the continental
United States.
The unique nature of the challenge is 4.5 million square
miles that we have to take care of in the Pacific. My
commitment is that that special categorization of the community
care network for the Islands in the Pacific will address the
unique needs.
We will make sure, particularly through the implementation
of additional telehealth services, more robust visits from our
major medical center in Hawaii, to the Pacific Islands, that we
always take care that the Islands are recognized for the
special needs that they have.
Dr. Lieberman. And I just wanted to add--and you probably
are also briefed on this--that we want to look at how TRICARE
has succeeded in these areas, lessons learned from them also.
And, yes, we have to get this right, and so we will continue to
work until we get this right.
Mrs. Radewagen. Thank you, Mr. Chairman.
I yield back.
The Chairman. I thank the gentlelady for yielding.
Ms. Esty, you are recognized for 5 minutes.
Ms. Esty. Thank you, Mr. Chairman.
I want to thank Chairman Roe and Chairman Isakson and
Ranking Members Tester and Walz, in particular for their
efforts on the Blue Water Navy veterans. This is an incredibly
important issue. These are folks who served decades ago, and we
owe it to them, and it is relevant to today's hearing. Because
if we are not managing these budgets appropriately, they will
not be able to get the care they deserved.
They say: If you bought it, you broke it.
When we break people, when we ask them to serve this
country, we owe it to them to find the means, not just the
will, but the means to do right by them, and I, again, thank
our colleagues in the Senate for their enduring efforts to get
this passed.
I wanted to quickly say something on the CARE for All
caregivers, as Senator Murray did. Several of us have worked on
these issues. And, again, this is an area where we have made
commitments; we know it is the preference of our veterans; and
we need to find a way to honor those commitments.
And that brings me to today's hearing, the utter importance
of managing these budgets appropriately. We have made promises
to people that we are going to get them care where they want
it, how they want it. And in order to do that, we have to
manage those budgets. So first--and I see I have not lost all
my time here, but we will continue on. They have me at negative
12 seconds already.
Will you have sufficient funds in the 802 account given
what we know right now? Do you have sufficient funds for the
community care networks in the 802 accounts, given closeout
costs, given authorizations and contested claims, that you
still need to finish? So this wanting to make sure that we make
that transition to MISSION, but we can't let go of what we
currently have.
Ms. Glynn. Let me assure you that overall we are
monitoring, on a very close basis, the expenditures related to
802 and the current Choice and PC3 Programs, and we do believe
and forecast that we will have funding available through the
end of this fiscal year and have taken account all closeout
costs and what we believe from a claims perspective in those
projections.
Ms. Esty. Thank you, Dr. Glynn. And if it turns out not to
be correct, please do let us know because obviously it is very
important. We should not leave anything in that transition.
Secretary Wilkie. And I would add to that: You are correct.
This is the wave of the future for medicine, for VA care,
particularly for--even though the majority are from the Vietnam
era--for the new veteran. They demand service at home. They
expect service at home, and the trends in medical care in this
country, as you have rightly pointed to, are that people get
better when they are at home.
And you have my commitment to do everything I can to make
sure that this is fully funded, and it reaches every veteran
that we can touch.
Ms. Esty. Thank you. Thank you again, Secretary, for being
with us here today. I wanted to just review again, from the
very beginning, what timeline we are to expect right now with
the awarding of the contracts for Regions 1, 2, 3, and 4,
because they are a little bit different than what we had in
briefing, and I want to make sure we are all on the same page,
please.
Dr. Lieberman. For 1 to 3 is by the end of February, and 4
is by the end of March.
Ms. Esty. All right. Well, we will want to be, you know,
looking at that timeframe again.
And I would like to return for a moment to the discussion
we had on the number one clinical priority, and that is on
military suicide prevention. And it is, Secretary Wilkie, in
part that connection between the handoff from DoD to the VA
that is something we need to do a much better job of. I would
suggest those of us working on this, on the Committee, really
do believe a checkback in 6 months after returning would be a
very helpful time, to make sure people are in the system; that
is number one.
But, number two, I do have to push back, as my colleagues
have, if we know for younger veterans that they are using
social media and they are not already involved in the system
with VA, why in the world have we barely touched the money that
this Congress has allocated for you to do that outreach? It is
just astounding to me, knowing that this is a group who is not
in the system, they need different ways of being connected. We
are baffled as to--with this epidemic of military suicide, how
we have done so little to use those funds that we have
allocated.
Dr. Lieberman. So we actually used $1.5 million of that,
not as--as the year went on, we used $1.5 million, but overall,
we actually have used--$12.2 million we spent last year in
outreach, and we have done a number of different efforts.
We were in the Nielsen top 10 for the public service
announcements. We did 22,000 outreach events. Last week--last
year our suicide coordinators reached 2.2 million individuals.
We also had the Be There campaign. I don't know if you saw the
advertisement with Tom Hanks. And we actually set up a Web site
with information and actually had over 100,000 hits to that
site. So we have actually been very active.
And this year, I am making sure that we are spending the
funding 100 percent, and so I am reviewing the budget monthly
and making sure that this moves forward. We certainly have
obligated all the dollars, and we have plans to reach out,
including social media this year. We have to get it right.
Secretary Wilkie. And I would also say that I was
responsible, as the Under Secretary of Defense for Personnel
and Readiness, for instituting the training and the awareness
on the part of Pentagon commands on the challenges and the
threats to our servicemen and women, regarding suicide. We
instituted the Transition Assistance Program to include those
markers indicating that there is a potential for a very tragic
event. Secretary Mattis has committed to that. I am committed
to being part of that.
We also, thanks to these Committees, are treating those who
have other than honorable discharges and making sure that they
have that transition assistance and that we join with the
Department to try to catch this before it becomes tragic.
Ms. Esty. Thank you, and I yield back.
The Chairman. I thank the gentlelady for yielding.
Senator Boozman, you are recognized.
Senator Boozman. Thank you, Mr. Chairman.
Secretary Wilkie, thank you for being with us, and we
really do appreciate your service very, very much. I have had
the opportunity to serve on the House or Senate VA Committee
since I came to Congress, and over the years, I have seen the
VA go, repeatedly, through pains of implementing many new
programs.
This Congress may pass significant legislation that will
bring, quote, fundamental transformation to the VA. As you
know, when the VA fails to properly implement programs, these
Committees become the backstop to ensure resources are surged
to mitigate the impact to the greatest degree possible.
During a staff briefing about how the VA is going to fix
its implementation of the Forever GI Bill monthly housing
stipend payments, the VA was unprepared to answer basic
oversight questions about how much funding had been spent on
failed attempts, how much funding had been spent on efforts to
react to the problem, and what lessons the VA had learned from
the situation that it can take forward to other implementation
efforts in the future and under way at the current time.
These aren't hard-hitting questions. These are just the
basics. More to the topic of this hearing, MilCon-VA staff had
a meeting with your staff to get an update on where the
Department is with determining access standards, a key factor
that will have an impact on our VA funding levels.
When I hear that one set of information is provided to
authorizing staff, another set of information is provided to
appropriating staff, and a different set of information is
provided in briefing to all Committee staffers, that is a
problem.
And I agree with you, totally, the VA is filled with truly
wonderful people, but when your staff comes over without their
act together, with no semblance of transparency, that reflects
on VA leadership, which you have direct control over. We know
that it just works better when we can trust each other and work
together. We simply don't have any other choice.
For fiscal year 2019, the Congress appropriated $5.2
billion for the Veterans Choice fund and $9.4 billion for
community care. Can you tell us what the current burn rate is
of community care in the Choice programs?
Dr. Lieberman. It is--I don't remember the exact number,
and we can get it for you, but it is somewhere--
Senator Boozman. We have gotten two different ones, 460 or
340.
Dr. Lieberman. Yeah. My understanding is, it is around the
460 one.
Senator Boozman. Okay.
Dr. Lieberman. But we will get back to you with the exact
number.
Senator Boozman. And you are saying under current
estimates, funding is sufficient. I guess the next question
would be: If it is not--and times have come up in the past when
it wasn't--how does VA intend to address any possible
shortfall?
Secretary Wilkie. Well, I would certainly come to the
Congress with that, but let me talk about the burn rate for a
second. One of the things that we saw with the Choice Act is
that many fewer veterans decided to take advantage of it than
was originally projected after what happened in Phoenix. Of
those veterans eligible for 100 percent care outside of the VA,
less than 1 percent took advantage of that. That number of
veterans is in the three- or four-thousands.
So every trend that I have seen indicates that we are well
positioned to take care of Choice funding for the rest of this
year.
Senator Boozman. As the VA develops regulations that will
govern things like rates and access standards for the MISSION
Act implementation, many decisions will have significant budget
implications. Certainly those do.
We understand VA continues to explore multiple options,
ranging from TRICARE standards to variations of Choice and
Medicare Advantage. What is the estimated budgetary impact of
the range of options? When will you be prepared to let the
Committee know how much you expect MISSION Act-compliant,
community care to cost annually?
Secretary Wilkie. Senator, I expect to be up here as soon
as the President approves the recommendations that I give him.
In terms of the access standards, I perceive them to be a
hybrid of several of those programs that you just discussed--
CMS, TRICARE--and that we will come to a conclusion based on
the combination of those standards and what is best for
veterans. But I will be up here as soon as the President
approves the access standards.
Senator Boozman. Good. Thank you, and thank you, Mr.
Chairman.
The Chairman. Thank you for yielding back.
Senator Sanders, you are recognized for 5 minutes.
Senator Sanders. Thank you, Mr. Chairman. Let me get
unanimous consent to place into the record a recent article
that appeared in ProPublica and PolitiFact.
The Chairman. Without objection.
Senator Sanders. Thank you. And it talks about the fact
that several private companies have been paid nearly $2 billion
for overhead, including profit, to provide health care to
veterans, and that is about 24 percent of the company's total
program expenses.
So we have enormous administrative costs in private care
for veterans at a time when I hope we could agree that the
function of the VA is to provide the highest quality care to
all veterans in a cost-effective way.
And, Mr. Chairman, my ongoing concern--and this article
kind of demonstrates that--is that we are in the process of
dismembering the VA, taking resources away from the VA, putting
it into the private sector, and the results will be that many
of our veterans will not get the quality care that they
deserve.
Mr. Secretary, it is no secret--and by the way, thank you
very much for being here--it is no secret that I opposed the
MISSION Act. There are parts of the law that I obviously
support, like expanding the caregivers support program and
increasing loan repayment through the education debt reduction
program.
However, I remain very concerned that, as written, and
without needed funding, this law puts us into a situation where
we are forcing the VA to pay for private-sector care at the
expense of investing in its own facility budget, staff, and
infrastructure. And I remain very concerned about the level of
understaffing at the VA that continues to exist.
I fear this is nothing short of a steady march toward the
privatization of the VA. And I think sometimes when people talk
about the privatization of the VA, they think that one day the
Secretary is going to come forward, and he is going to announce
the VA is now privatized. That is not the way it is going to
happen.
It is going to happen piece by piece by piece until, over a
period of time, there is not much in the VA to provide the
quality care that our veterans deserve.
No one disagrees--we have been through this discussion a
million times--that veterans should be able to seek private
care in cases where the VA cannot provide the specialized care
they require or when wait times for appointments are too long
or when veterans might have to travel long distances for that
care. There is no disagreement. The VA has done that for
decades.
But to my mind, the way to reduce wait times is not to
direct resources outside the VA as the MISSION Act does, but to
strengthen the VA. VA should be focused on recruiting and
retaining the best health care professionals in our country to
care for those who have put their lives on the line to defend
us. VA should be focused on investing in its aging
infrastructure so veterans can benefit from the best health
care facilities, and VA should be focused on figuring out the
budget it needs to provide the demands of our veterans--our
veteran patients.
Mr. Secretary, let me start off by asking you a simple
question, and that is: The veterans' organizations, to my mind,
do a very good job in understanding where the veterans are at,
the problems that the veterans of our country see when they
interface with the VA. To my mind, what the law says is that
you are to consult with the VSOs. That is what we have in law,
but that does not simply mean a one-way discussion. It does not
mean simply you telling them what is going on. It means you are
listening to them.
So let me just ask you this, Mr. Secretary, can you tell me
exactly, in as precise a way as you can, how you have solicited
feedback from the VSOs, and how that feedback has been
incorporated into the regulations currently being written on
quality and access standards, Mr. Secretary?
Secretary Wilkie. Well, thank you, Senator. In the little
less than 4 months that I have been the Secretary, I have
doubled the number of VSO engagements. I have also opened the
aperture on VSO engagements by including groups that represent
the new breed of veterans, even some that represent veterans
going back to Vietnam that have not been included, like the
blinded veterans, the Purple Heart veterans.
I am meeting tomorrow with many of the people who are in
the audience today. It is absolutely essential. I have served;
I have a long line of family service. Without talking to the
veterans--and when I say, ``talking to the veterans,'' when I
am out in the country, in the great Nations of the plains, when
I was out in Oahu--
Senator Sanders. I am sorry to interrupt.
Secretary Wilkie. I do meet with them. It is not a one-
way--
Senator Sanders. Here is the point, here is the point. And
I appreciate that, and I know you are trying to do that. But
meeting with them and talking to them is different than
listening to them. Can I have your commitment that you will
incorporate their ideas and their concerns into the work that
you do?
Secretary Wilkie. Absolutely.
Senator Sanders. I think my time has expired.
Secretary Wilkie. Mr. Chairman, may I add, sir, a comment--
The Chairman. Go ahead.
Secretary Wilkie [continued].--make a comment about what
Senator Sanders said. I agree with him about privatization, and
I agree with him about understaffing the VA. But I do need to
make it clear that we do not exist in a vacuum.
The United States, as you have pointed out in many floor
debates that I heard when I worked in this institution, is
suffering from a shortage of mental health professionals. It is
suffering from a shortage of women's health professionals. It
is suffering from a shortage of primary care and internists. We
are competing for those.
What has happened with the MISSION Act, and one of the
benefits that I have now, is that I have the opportunity to
offer more impressive packages to bring those health care
providers into the VA. We are doing our level best because you
are absolutely right: we are short on those.
And I will also say that when it comes to privatization,
you and I discussed this in your office several months ago
prior to my confirmation. I believe this strongly. I have said
it all across the country. I don't believe that veterans will
allow VA to be privatized, and I will tell you why. It is not
anecdotal, but it is emotional. Veterans want to be where
people understand their culture and speak their language.
Senator Sanders. Good.
Secretary Wilkie. I am from that world; I understand it.
And I agree with you that my job right now is to ensure that
those veterans who need that care outside of the VA--and we
don't have it--get it. So--
Senator Sanders. Thank you. Let's continue the discussion.
Secretary Wilkie. Yes, sir. Thank you.
The Chairman. I think, gentlemen, I would also encourage
support from the VA and from the Senate and House on a bill
that I have on an immigration bill to help allow doctors who
are trained here in this country to stay here. We are sending
them out of the country, and it is ridiculous that we are doing
that when we have such a need here.
Mr. Arrington, I recognize you for 5 minutes.
Mr. Arrington. Thank you, Mr. Chairman, and Mr. Secretary,
thank you for your service.
If a veteran doesn't get good care at the VHA, do the
doctors still get paid over there?
Secretary Wilkie. Well, they get paid because they are on a
Federal scale. However--
Mr. Arrington. So the Federal Government will pay them
whether they serve the veterans or not. Will the administrators
get a paycheck whether or not the veterans are receiving good
quality care and service?
Secretary Wilkie. Well, I can give you an example of how I
acted on that.
Mr. Arrington. Just historically, just historically, is the
answer that they get paid regardless of the outcome for the
patient?
Secretary Wilkie. Historically, before the Accountability
Act was passed, historically, before the MISSION Act was
passed, the Secretary of the Department of Veterans Affairs was
under the same strictures that every Cabinet leader was under,
that there was a laborious process involved in removing Federal
workers who did not perform. That does not exist anymore.
In the 1 year that--well, the 1 year that I had been in and
out of VA, we have removed 5,000 employees, including the
director of one of our largest VA medical centers. I did that
because the work was not getting done, veterans were not
getting treated, and I felt that the powers that the Congress
had given us needed to be exercised.
And I intend to exercise those powers whenever I see a
problem because veterans are first; the institution is not
first. And--
Mr. Arrington. And I hope you continue to do that. That is
the only way you are going to stay relevant. It is the only way
you will prevent the veterans from voting with their feet about
where they want to go and what this all is going to look like.
Let's not be so arrogant that we think we can build a mouse
trap from the Federal Government from Washington that is going
to satisfy the customer.
Either you deliver good service and either they are
satisfied, or they are not. And if they aren't, they will make
the decision on whether this is privatized or not privatized,
or some hybrid. Good for you, I hope you continue to do it.
Because in the private sector, if they don't delight the
customer, the private providers, they don't have a business;
they can't pay the bills; they can't feed their families. That
is the incentive you are competing with, and that is why I am
for choice.
That is why I am for giving the veterans freedom to choose,
to opt out of a system that may not be working for them. Maybe
a union-controlled monopolistic bureaucracy isn't the best way
to provide service to our heroes. I don't know. Where it is
working, good, great. Continue to do good. Where it is not, I
get why it is not because it is a very different animal
altogether. So, okay.
It was good to meet you the other night, by the way.
Secretary Wilkie. Good to meet you too, sir.
Mr. Arrington. And your wife. I am really not an angry guy.
I just get fired up when I talk about this, and I know you're
passionate about it, too.
Let me ask you this. Are people choosing to go to community
care at a greater rate today than they did a year ago?
Secretary Wilkie. They are not choosing to go to community
care at a greater rate than they did when Omar Bradley ran the
VA in 1945 to 1947. It has been about the same level, which is
30 to 35 percent, historically. I think we are even seeing, Dr.
Lieberman, a slight dip in the use of community care.
Mr. Arrington. So fewer veterans are choosing to go outside
of the VA today than they did a year ago, 2 years ago, 5 years
ago?
Secretary Wilkie. A little bit. A little bit. It is a
small, small number.
Mr. Arrington. Let me ask you--I will take your word for
it--I assume you guys measure the quality and the overall
service that veterans get at the VHA. Do you all measure the
quality of care and overall service at your various facilities
in the VHA? Yes or no, Doctor?
Dr. Lieberman. Within VHA?
Mr. Arrington. Yes, sir.
Dr. Lieberman. Yes, sir.
Mr. Arrington. And do you all compare the quality metrics
and the service metrics in community care with the quality care
and service at the VHA?
Secretary Wilkie. Absolutely. But we also compare it to--
Mr. Arrington. How do they compare, Mr. Secretary? Are they
comparable? Are they better at the VA?
Secretary Wilkie. I will tell you, The Dartmouth released
its most recent study a week or so ago in the Annals of
Internal Medicine, and their conclusion was that care at the
Department of Veterans Affairs is as good or better than any
care in the rest of the country. Of course, that includes
community care. So we are being judged by comparison to--
Mr. Arrington. Well, that is good--that is good to hear.
Secretary Wilkie [continued].--the biggest health networks
in the country.
Mr. Arrington. Last question. I represent a big swath of
rural west Texas. How are the access standards going to affect
their access to VA care?
Secretary Wilkie. I have talked a lot--
Mr. Arrington. And I yield back.
Secretary Wilkie [continued].--Congressman, about the scale
of the American West. I have sometimes joked that the loneliest
sign in America is on Interstate 10 in Houston that says, ``El
Paso, 910 miles.'' What we see access doing is, is offering our
veterans, particularly in rural America, the opportunity to
alleviate a burden on themselves and their families by giving
them the option to seek care that is closer to home, if they
have to embark on a 300-, 400-, 500-mile round trip journey to
get to a VA center.
As I have said many times, it is incredible that in 2018--
and I saw this in Hawaii last week--we do not understand the
scale of the West, and we certainly don't understand the scale
of the Pacific.
The Chairman. I thank the gentleman for yielding.
Mr. Arrington, I was in Greg Walden's district in Oregon a
year ago. And his congressional district has more square miles
than the State of Tennessee does. So our challenge in this
Committee was to devise a MISSION Act, a program that was good
for rural America and for urban America, and that is hard to do
when you are trying to do both.
So, if you are on the 405 in Los Angeles, you may be
quicker to somewhere else, if you are stuck on there to get an
appointment, if you don't live 10 miles from somewhere. So it
is a real challenge to do this, and to get it right where you
provide the care at the point of service for those veterans.
And I think the VA's moving in the right direction with
their CBOC model, taking the care of the veterans, I absolutely
believe that.
Mr. O'Rourke, you are recognized.
Mr. O'Rourke. Thank you, Mr. Chairman.
Mr. Secretary, in answer to Senator Tester's question about
administrative costs totaling around 24 percent, and then that
number was disputed, but in response, you said: We were taken
advantage of.
Could you clarify by whom the VA was taken advantage of?
Secretary Wilkie. I meant in a generic way, that the Choice
Act--and I think there is agreement from the leadership of both
Committees--that the Choice Act was rushed, and we were given
such unreal, unnatural timelines to implement a program in a
370,000-person Department.
Mr. O'Rourke. So there was no actor or third-party
administrator or outside contractor who took--
Secretary Wilkie. We were forced to take what we could get
to implement a law based on the timeline that was created by
that act which has now been rectified by the MISSION Act. So,
when I said, ``taken advantage of,'' we--and I wasn't there; I
was happily in the Department of Defense.
Mr. O'Rourke. But--
Secretary Wilkie. My understanding was VA had to move as
rapidly as possible, and there was not that time for reflection
that you would usually have in an issue like this.
Mr. O'Rourke. The articles about the recently released GAO
report about unspent suicide prevention outreach dollars, $6.2
million allocated, as of September, 57,000 spent, and then,
Doctor, you suggested there was, perhaps, another 1-, 1.5
million spent on top of that out of the 6.2. You say you will
exhaust that before the end of the year. You say that you got
100,000 hits on the Web site. Another thing the GAO says that
is perhaps more alarming than the unspent money is that you
have not established targets for the efficacy of this outreach
effort.
So hits to the Web site, don't know what it means and don't
know if it matters. How do you know how you are doing on what
you have established as your number one clinical priority,
suicide reduction, which I am grateful for, that that is a
priority? How do you know how you are doing against that
priority? What are your goals?
Secretary Wilkie. Well, let me talk about the national
situation that we face. First of all, I was responsible for the
Department of Defense end of this.
Mr. O'Rourke. I have got limited time. I don't want to hear
an anecdote. I want to hear the goals--
Secretary Wilkie. I am not going to give you an anecdote.
Fourteen of the 20 veterans who die by their own hands every
day are outside of VA.
Mr. O'Rourke. Correct. We have known that for years.
Secretary Wilkie. We spent $12.2 million on that outreach
just in the time I believe that I have been in charge, which is
just a few months. But I have to go beyond what that GAO report
says, talk with Governor Brown, talk with Governor Inslee, talk
with Governor Ige. I am busy.
Mr. O'Rourke. If it is your priority, what is your goal,
and how are you doing against your goal? I am not blaming you
for where we are.
Secretary Wilkie. No.
Mr. O'Rourke. And I don't know what to know what you have
done in the short tenure. I want to know what your goal is and
how we are doing against it.
Secretary Wilkie. The goal is to do our best to make sure
that we have done everything possible.
Mr. O'Rourke. And we will never be able to judge you on
that.
Secretary Wilkie. And that's right. We can't.
Mr. O'Rourke. Do our best, what does that mean.
Secretary Wilkie. The majority of those warriors who take
their own lives come from my father's warrior generation. That
means these are problems that are 50 years in the making. I am
not going to tell you that I can wave a magic wand and correct
problems that began when Lyndon Johnson was President. I am
doing my best through the outreach that we have, and the
resources that start with the Department of Defense. We never
had a transition program or and awareness program on suicide
until the last year or so at the Department of Defense. That is
where it has to start so that we make sure that the mistakes
that began back in 1968 and 1969 and 1970 are not replicated
now. That is not anecdote. That is just historic.
Mr. O'Rourke. I hear you, but if you don't measure it, you
will never be able to improve it. So do you or do you not agree
with the GAO's finding that you have not established targets
for the majority of metrics you use to gauge the effectiveness
of your suicide prevention outreach campaign. If you agree with
that, what are you doing to correct the finding?
Dr. Lieberman. So we concur that we did not have robust
enough metrics at the time of the GAO evaluation. We have
responded to the report. We are in the process of developing
more robust ones.
Mr. O'Rourke. When will you have them?
Dr. Lieberman. Later this year.
Mr. O'Rourke. This year. This year, or--
Dr. Lieberman. I'm sorry. 2019.
Mr. O'Rourke. Okay. Thank you.
Secretary Wilkie. As I said, Congressman, I put in place,
that is as the number one clinical priority, and I can promise
you that we will expend everything that we can to try to
correct this and address this great national tragedy.
The Chairman. I thank the gentleman for yielding. I think
Mr. O'Rourke's question was if you don't know where you are
going, you might end up someplace else. If you don't have your
goals set, you don't meet those goals. I think that is what you
were asking. Mr. Coffman, you are recognized.
Mr. Coffman. Thank you, Mr. Chairman. Mr. Secretary, I
think the VA has always had the authority to reach out to
community providers. Prior to the Choice Act, I think in
specific relationships--I am trying to remember the name of the
program. Is it the P3 program? P3 program. One of the
complaints I have heard about that program that still exists
today is that every separate agreement is negotiated
independently, and what I think--in Colorado, we have had some
potential providers under the P3 program drop out because of
the length of the negotiations and the complexity of the
negotiations where I think one question they always raise to me
was why don't we simply use Medicare rates as reimbursement on
the P3 program so we are not renegotiating every new agreement
from scratch?
Dr. Lieberman. Well, we actually are moving away right now
with the TriWest and in the future with the agreements, the
community care agreements with the MISSION Act, and right now,
we have--TriWest has stood up, actually, in Colorado, in
Denver, and in the first week--and they are getting Medicare
rates. And in the first week, they actually have entered 2,700
consults, and already scheduled 500 patients, and so they have
been able to create the network that the facilities have been
struggling to do on their own, and so they are creating it. And
that is what is going to be part of the community care networks
as we roll them out.
Mr. Coffman. Okay. And how are we doing in terms of
efficiency on telemedicine? I think it was raised about rural
America, certainly rural Colorado. It is a struggle. We have
got people in Grand Junction, Colorado. There is a CBOC there,
but for--oftentimes for care, they have to go to the VA medical
center, regional medical center which is now in Aurora. That is
a 4-hour drive. I know they are reimbursed for the mileage for
that, but are we doing better in terms of telemedicine?
Dr. Lieberman. Through support of the Congress, we are
investing in increasing bandwidth at many of our CBOC locations
which is really important. We also are doing the anywhere-to-
anywhere, so when someone has internet access in their own
home, we can provide telehealth into the home.
We also are joining in partnerships with different private
entities to--they are going to give us a private room in a more
rural area, and the veteran can go there and have their
appointment in that location that is closer to their home. So
we are really working a lot in this area.
Mr. Coffman. Okay. There was legislation passed that I
authored, I think it was included in a larger bill, that
requires an independent study as to those veterans who died,
who committed suicide who were under VA care, and I think one
of the objectives of it is to go look into what prescriptions
that they had at the time of their death, because I do have a
concern that we are overprescribing some of our veterans in
mental health.
Secretary Wilkie. Yeah. Let me talk about the opioid issue,
which is part of that continuum, and also to Congressman
O'Rourke's well-founded observations about the suicide program.
I do want to say that we are not divorced from national
problems. We are one part of that, which is why, in the answer
to your question, I will say in this case, VA has taken the
lead in creating alternative therapies, alternative
prescriptions for those with great pain. The one factor about
VA care that is not shared in the private sector is that we
help people who come from a dangerous profession, people like
my father after 30 years of jumping out of airplanes, needed
two knees, two new hips, and had lead in his body from Vietnam.
So what we have done is we have been able to reduce the amount
of opioid prescriptions by 41 percent, just in the last 2
years.
In addition, we are on the cutting edge of alternative
therapies, occupational therapies, Tai Chi, acupuncture, things
that would have been unimaginable 10, 15, 20 years ago. And
that is part of the answer to those veterans who are suffering
from pain and subsequent issues like mental health.
Mr. Coffman. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding. Ms.
Kuster, you are recognized.
Ms. Kuster. Thank you. Thank you very much. And just to
pick up right there, I very much appreciate the progress that
is being made by the VA on the opioid epidemic, and I hope that
we can spread new alternative pain management strategies not
only within the VA, but frankly, within the private sector as
well.
I just want to revisit briefly this issue because I think
certainly my constituents, but I think constituents across this
country were so shocked and concerned to read today about this
issue that your Department had only spent 1 percent of the $6
million for suicide prevention. We have had a little bit more
testimony on that today. You say that you are doing your best,
but what I am concerned about is that that can't be true when
we have so many leadership vacancies at key posts in the VA
related to these programs. What are you going to do about
getting the right people in the right place? And I just want to
give you one chance to revisit Mr. O'Rourke's question because
we can't really respond here in our oversight function to the
concept of doing your best if we don't know what your goals
are. And you talk about the majority of the suicides are
committed by people outside the system. That is true. That is
our frustration. How do we bring them into the system?
Secretary Wilkie. As Dr. Lieberman said, we began to move
when I became Acting. The vacancy that you talked about at the
head of the Suicide Prevention Office was immediately filled by
me by making permanent the position.
Ms. Kuster. And does that person have the staff they need
on board.
Secretary Wilkie. Yes. Also the expertise as having been
the leader at the Department of Defense in the Suicide
Prevention Office.
Dr. Lieberman. We are in the process of hiring staff just
for the record.
Ms. Kuster. I am sorry. There are other vacancies, and you
are in the process of hiring for that.
Dr. Lieberman. We are building a larger office underneath
this individual, so we are hiring more people to support her.
Ms. Kuster. And does that program have functional capacity
at all the VSNs around the country as well.
Dr. Lieberman. They certainly work with all the VSNs. The
VSNs have their own responsibility to roll out and work with
her what ideas are coming out. I also just want to let you know
that we really are focusing in a new way on the high-risk
veteran populations, both within VHA and the ones outside. And
so number one, there is an executive order to work on
transitioning veterans, and so we have been working with DoD on
that. The Other Than Honorable, we have been working on that
since 2017, but this month--this week, I am sorry, and the rest
of the month, we are actually mailing out letters to the over
500,000 Other Than Honorable encouraging them to come to us to
seek whether they are eligible for care here in mental health.
And we are also looking at the Reserve and the Guard that
have never served. They have been identified recently. As our
data gets mature, we can identify more at-risk populations, and
they are at risk, and so we do mobile vet center outreaches to
them on the weekends when they are doing their drills, and we
are reaching out to leadership in those areas. And then,
finally, another risk that we identified recently was that if a
veteran came to the emergency room in the prior 3 months, and
had just a little bit of suicidal ideation, not enough to have
to admit them or--if we did research, and we found that if we
made a suicide safety plan with them where if they are having
suicidal thoughts, what are they going to do? Are they going to
call a loved one? Are they going to call their therapist? Are
they going to listen to music? What are they going to do? And
it has been shown to reduce the suicide rate by 50 percent. And
so, what we have done is we have actually implemented this
rapidly at all our VAs across the country. So we are trying new
novel things as they come along.
Ms. Kuster. Well, and I think the research is important. My
time is running short. I had another question about the whole
issue under the VA MISSION Act and the designated access
standards, but I guess I will just leave it at this. New
Hampshire is one of the rare States without a full service VA
Hospital, and I think we are all trying to find this balance of
care at the VA, and if that is not possible, then care within
the community, but I would just use New Hampshire as a
cautionary tale and the problems that we had recently at
Manchester when the level of care drops below what is necessary
for a robust VA going forward. And I think that was the point
that Senator Sanders was making, and I think it is instructive
as we move forward. But at that, I yield back.
Secretary Wilkie. And I would just add. I agree with you
completely about suicide. I mentioned that I was in and out of
the VA as Acting, and then had to go back to DoD and wait
confirmation. In my first week, I laid down the first path on
the suicide issue. I will tell you, there is nothing more
important, and there is nothing more tragic, and you have my
commitment that as long as I am privileged to be part of the VA
team, that will continue to be the case.
Ms. Kuster. If I could, one quick second. I have been in
Congress for 6 years. You are our fifth VA Secretary in those 6
years, so I appreciate your personal commitment. I have
literally heard that five times, and veterans are dying every
single day, so we will hold you to the commitment. We will want
to know the metrics. I appreciate the innovative solutions, and
we will look forward to continued discussion. Thank you.
The Chairman. I thank the gentlelady for yielding. Senator
Hirono, you are recognized for 5 minutes.
Senator Hirono. Mr. Secretary, I am glad to know that you
are in Hawaii and you obviously--not to mention I have a cold.
Let me slide over to this mic. Okay. This one is working. Can
you add to my time? Are you listening?
The Chairman. We froze the clock.
Senator Hirono. Thank you very much. I am glad you were in
Hawaii, and obviously you spoke with Governor Ige, but did you
let the congressional delegation know that you were going to be
in Hawaii?
Secretary Wilkie. Yes. In fact, I think I mentioned it to
you the last time we spoke, that I would be in Hawaii in
December.
Senator Hirono. I don't think we got the date, but not to
beat you over the head with it, but I think that it would be
good for your team to alert the congressional delegation--
Secretary Wilkie. And we do. We do.
Senator Hirono [continued].--when you are in our State so
we can to maximize our ability to support and work with you.
Secretary Wilkie. We did, and I will go back on what you
and I discussed last time. I made two commitments: one to go to
Hawaii, and one, to go--if you are not there, I have got to go
back because I am going to go to Samoa and Guam.
Senator Hirono. Oh. There you go.
Secretary Wilkie. Go there when you are there.
Senator Hirono. Thank you very much. The VA, over the
years, of course, not only have we had so many Secretaries over
the last 5 years, as mentioned, though, their ongoing
challenges whether it be IT, homelessness, suicides,
construction delays, of course, access to care. So you have
been asked whether there is a sense of urgency at the VA, but I
ask you whether you have a sense of urgency?
Secretary Wilkie. Absolutely.
Senator Hirono. So if you have a sense of urgency, what are
your top priorities for the VA?
Secretary Wilkie. Well, my top priorities for the VA, and I
mentioned the first clinical priority, which is suicide
prevention.
Senator Hirono. Right. That is one.
Secretary Wilkie. My top priority is to create, with the
assistance of these Committees, a modern 21st century health
care administration that keeps veterans at the center of their
health care. This Committee has already laid down the template
for that, and it is my duty to carry that out.
Senator Hirono. So I think I am looking for something a lot
more measurable. So, for example, you were asked how can we
verify whether you are reaching your goal regarding suicide
prevention. So a former VA Secretary said that his goal would
be to end homelessness. So those are the specific kinds of
priorities that I am asking you to articulate if you have them.
Secretary Wilkie. Well, I will tell you. I am not going to
come to this Committee and tell you that I will end
homelessness, and I am not going to come to this Committee and
tell you that I can eliminate suicide amongst veterans.
Senator Hirono. Well, that is not what I am asking you.
What I am asking is, out of a sense of urgency, what are your
top priorities for the VA? So whether it be decreasing
suicides, increasing--decreasing homelessness, do you have
those kinds of priorities?
Secretary Wilkie. Well, I just mentioned them. Modern 21st
century health care administration for the VA, which means
modern IT meaning the best medical care possible.
Senator Hirono. When you say something like best medical
care possible, you know, how do you come up with a verifiable
matrix?
Secretary Wilkie. Well, I can tell you that our health
care--we have the standards. We have the metrics which we share
with this Committee. We compare what we provide with health
care across the country. I have referenced the latest
comparison that Dartmouth Ivy League has done that was in the
Annals of Internal Medicine last week, that says--
Senator Hirono. I am running out of time.
Secretary Wilkie [continued].--that our care is as good or
better than any in the country. I want to make sure that--
Senator Hirono. If you have those priorities for you
because, you know, I think it would be good for us to hold
people accountable, and that there be transparency and
accountability, and I would certainly want to apply that to
you. So if you have those priorities, and they are listed and
how you are going to--whether you have verifiable metrics to
enable us to realize whether you have attained those
priorities, that would be great.
I have a question about the family caregiver, comprehensive
assistance for family caregivers. That is a very important
program for a lot of veterans, and I am glad that we expanded
it. So I have received, though, for example, a note from a
caregiver in Hawaii just this week, and she wrote, quote, ``I
just received the devastating news that we were no longer
eligible for the caregiver program. I did not even receive a
phone call, follow up from my coordinator,'' or even an
explanation other than the fact that her husband is simply no
longer eligible. So how are you communicating with the 5,500
family caregivers as to what it happening with this program and
what the requirements are, et cetera?
Dr. Lieberman. So first of all, if your office could share
with us that individual so we can follow up on it.
Senator Hirono. Certainly.
Dr. Lieberman. So the MISSION Act is giving us the tools to
do this right moving forward and making sure that we have
objective ways so that we make sure that we are implementing
the same, no matter what State you are in across the country,
and part of it is we want--what we are proposing is to move
away from these reassessments and more towards wellness checks
to make sure that the caregiver has what they need to succeed,
and the veteran is receiving the services that they need.
We have regular ways that we communicate with the
caregivers. We have phone calls with them around the country.
We have a phone line where they can call in, but we have not
yet made our decision on how we are rolling it. We are still
getting input. Right now it is in the Federal Register, some of
the ideas of how to improve upon the services available in the
program.
Senator Hirono. Thank you.
Secretary Wilkie. And you are absolutely right. It is 5.5
million family caregivers--
Senator Hirono. Oh. Did I say 5,500?
Secretary Wilkie [continued].--that we have to support.
Yes, ma'am.
Senator Hirono. Yes. That is a lot of people to stay in
touch with. Thank you for the information--
Secretary Wilkie. Absolutely. But it is the wave of the
future.
Senator Hirono [continued].--regarding this particular
inquiry I got. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator. Senator Blumenthal, you
are recognized.
Senator Blumenthal. Thanks, Mr. Chairman. Thank you for
having this hearing. Thank you to the Secretary and your
colleagues for being here today. I want to thank my House
colleagues for passing the Blue Water Navy bill unanimously. I
want to say how disappointed, in fact, ashamed I am that the
Senate failed to do the same, even though as recently as a
couple of hours ago, I was on the floor of the Senate asking
for unanimous consent from my colleagues to move ahead so that
that bill would become law. If the VA were doing its job and
supporting this bill, it would have overcome the opposition of
a small number, a handful of my colleagues, who are blocking it
now.
I am going to ask you to commit, as I have before in
hearings, that you will help us pass that Blue Water Navy bill.
Secretary Wilkie. I committed to the Chairman and to
Senator Tester, that I would do everything I could to help your
Committee.
Senator Blumenthal. Well, you have done that before, but
unfortunately, that support has not been translated into active
advocacy with my colleagues, and I hope you will do better
during the next session.
I want to follow up on a number of questions asked by
Congressman O'Rourke about metrics. You can't do better unless
you measure what you are doing, and so far, as I can see, one
of the chief criticisms of the GAO report has been the lack of
metrics and measurement. And I would suggest to you,
respectfully, the two good ones would be whether the rate of
suicide is coming down, which it is not, and whether the GAO is
using all the resources at its disposal to bring it down, which
it is not. Would you agree?
Secretary Wilkie. Well, I agree with the state of affairs
at VA that the GAO laid out.
Senator Blumenthal. You agree with the GAO report?
Secretary Wilkie. Which is why--
Senator Blumenthal. And so you would agree that the reason
that you failed at the VA to spend more than a fraction of the
money given to you by the United States Congress is, I am
quoting, ``The reason they did not spend the remaining funds on
suicide prevention paid media in fiscal year 2018 was that the
approval of this paid media plan was delayed due to changes in
leadership and organizational realignment of the suicide
prevention program,'' and they go on more specifically to say
on pages 15 and 17 that it was a ``lack of leadership available
to make decisions about the suicide prevention campaign.'' And
then on page 17, ``By not assigning key leadership
responsibilities and clear lines of reporting, the VHA's
ability to oversee the suicide prevention media outreach
activities was hindered, and these outreach activities
decreased.'' That is a failure of leadership.
Secretary Wilkie. Senator, I am going to agree with you,
and you and I, I think, discussed in your office when I was the
Acting Secretary, that the first thing I did when I became
Acting, which is sort of being in limbo, but I did it anyway,
was to start moving on the suicide prevention issue. I
identified leadership, and I made this the number one clinical
priority. I agree that the Department had not done what this
Congress and what veterans demand of it, and that is--
Senator Blumenthal. Well, let me ask you because my time is
limited. I apologize for interrupting. Can you commit that the
VA will spend every dime devoted by the Congress, allocated by
us, to suicide prevention during the coming fiscal year?
Secretary Wilkie. Absolutely, and I will probably ask for
more or allocate more because of this national tragedy.
Senator Blumenthal. How much more do you think is
necessary?
Secretary Wilkie. I don't know. I don't know. That is why I
mentioned it, and you weren't here. In the last few weeks, I
have been on the phone, or in person with Jerry Brown, with
Governor Ige, with Governor Inslee, discussing the way ahead.
We have not had a comprehensive nationwide response to
veterans' suicide. I need the cooperation of our governors, and
that is why I put in train the development of the metrics that
Senator Hirono talks about that you talked about so that we
have, in place, a program to go and attack this problem. That
is the best answer I can give you, that I moved on it as soon
as I moved into VA.
Senator Blumenthal. Well, I know that you have moved on it,
but you have to forgive me, and maybe us, that we have seen
this movie before. As one of my colleagues remarked, we have
seen a slew of Secretaries who have made commitments and
promises, and I think we are, at least speaking for myself,
expressing the frustration and impatience that is well-founded,
in fact, because of the turnover in leadership from the top
through the middle ranks, and with all due respect, Dr.
Lieberman is an example. He follows others who have been in
that position for small lengths of time. We can't demand
accountability if there is this constant churn and turnover in
leadership, which then becomes a failure to spend the money
that is allocated to suicide prevention and maybe other
programs.
Secretary Wilkie. And I agree with your observation about
suicide. The program, at best, it was inchoate in 2017, and
that is why I permanently appointed the DoD leader in suicide
prevention, the person with the most expertise in this matter
available to the government, and that we are increasing the
size of that operation. I agree with your criticisms.
Senator Blumenthal. My time has expired. I apologize, Mr.
Chairman.
The Chairman. Thank you, Senator Blumenthal.
First of all, thank you all for being here, and I would
like to yield to my colleague, Mr. Takano, next year's
Chairman, if he has any closing comments.
Mr. Takano. Thank you, Mr. Chairman.
Mr. Secretary, I do look forward to hearing as soon as
possible more about the designated access standards. I know you
told me in your response to me that you still need to await the
President's choices, but I hope that you will consider speaking
to us before that time because I see no reason why the VSOs and
Congress cannot participate with you, I think, as the spirit of
the MISSION Act does stipulate that these access standards were
not to be developed alone between you, Mr. Secretary, and the
President. And I certainly don't want to see expectations
unnecessarily raised at the State of the Union speech, and
Congress being in the position to have to try and pull those
expectations back.
So I would like to, in the time between now and the third
week of January, like to see your Department work more closely
with the VSOs and Congress in developing these access
standards, because so much is at stake, and we need to do some
trust building among the stakeholders, Congress, and your
department.
I want to reiterate what Senator Blumenthal has said, the
frustration of Congress being able to hold, you know, the VA
accountable when we have seen such changeover or Acting
Secretaries, and some of it is on, I hate to say, the Senate,
for not confirming people in a timely manner. But nevertheless,
it has been very disappointing to see, in the last 2 years, an
administration that has not been able to put in place stable
leadership at the VA. And I see the IT failure with regard to
the BAH payments, the issue with the social media, and adequate
marketing being done to inform veterans about suicide
prevention hotlines, all leading back to the same fundamental
problem which is the unstable leadership at the very top. And
this has got to change.
And, so, Mr. Secretary, I would like nothing more than to
see you succeed and for you to serve out a tenure which allows
you to implement changes. I certainly do appreciate the
sentiment you expressed when you quote the Dartmouth study
recently, and further back, the RAND Study, and that you have
an understanding about how well our VA does deliver health
care, and you recall that the RAND Corporation Study indicated
that the main problem is access. And we have still 41,000
vacancies. I want to work with you, Mr. Secretary, on not slow-
walking those vacancies, but doing all that we can to improve
the personnel function of the VA, so that applications are
acknowledged, people are quickly made offers, and that we also
take a look at what we need to do to develop the health care
workforce of this country, because I think that is part of the
problem. It is not just doctors, it is the technicians. It is
the allied health professions that we need to pay attention to.
So not everything needs to be resolved with medical degrees
and 4-year degrees. Some of this could actually be putting a
lot of Americans to work in the service of our country. So Mr.
Secretary, in the spirit of that, I hope we--I intend to work
with you, and I intend that we change and turn around the
situation.
Secretary Wilkie. I thank you, sir, and I intend to work
closely with both Committees. I mentioned earlier this is where
I was trained. My respect for this institution knows no bounds,
and the beauty, as you said at the beginning, is that this is a
bipartisan effort. I like to think of the Department as being
nonpartisan, like the Department of Defense, and you have my
commitment to do everything that we can to make sure that the
lives of our veterans are better.
The Chairman. I thank the gentleman for yielding, and I
will, first of all, thank you, Mr. Secretary, and your team for
being here today. I want to thank our staffs. We passed a major
piece of legislation in the VA MISSION Act that would not have
happened without the staffs, and John and Ray, thank you for
your leadership in the Senate. We worked very closely with our
Senate colleagues on both sides of the aisle, so thank you for
the work that you all did. You were very, very helpful in this.
And I personally, just as a point of personal privilege,
one of the great honors of my life is serving as the Chairman
of this Committee, and I will continue to serve as Ranking
Member just as passionately as I did before. I also want to
thank--I look around this room, and I see a lot of our veteran
service folks out there, our veterans' organizations, and they
were very instrumental. I remember sitting around that table in
my office for hours on end hammering out the details of this,
so you had tremendous input, and it would not be the bill it is
today without your input, so thank you for that.
The VA MISSION Act, the idea was to take a bill, a piece of
legislation, and as I said before, make it applicable to rural
America, and make it applicable to urban America and make sure
that the number one thing that happened was that the veteran
got the absolute very best care this Nation has to offer,
whether it was at the VA, whether it was outside the VA. I was
one of those physicians who provided care outside the VA. I
have also worked in a VA with some of my medical training. I
have also been a doctor in the Army, so I think I understand
the system fairly well. And I want to get three things out
before we leave.
Number one, on June 6, we are ready to go, and if we are
not, would you be willing to come back, Mr. Secretary, let's
say, at the end of March, and give us one more--it could be a
combined meeting or however we want to do it?
Secretary Wilkie. Absolutely.
The Chairman. It would be informal to let the Members know
we are ready to go live on the June 6 or thereabouts. Number
two, that we can make appointments at the VA for our veterans
in a timely fashion. Number three, can we pay our providers so
they will stay in the network, because I have lots of friends
personally who want to serve veterans right now who won't
because they can't get paid. And these are good doctors that
want to serve, so I would like to see those three things
happen. And certainly there will be other hearings on the
caregiver bill and on the asset review. We will certainly do
that.
And I would really encourage my Senate colleagues. We have
a couple of people, your IT position and the accountability and
whistleblower protections. The young woman who is a staff
member on our Committee right now, Tammy Bonzanto, an
incredible young woman, an immigrant to this country who came
here without any education, served in the U.S. Navy, has gotten
an RN degree, now a doctorate degree, and has done
investigations of VAs all over this country. And she could be
in that position right now doing her job, and I don't go to a
speech that the President gives if he doesn't talk about the
Accountability and Whistleblower Protection bill. We need to
get that done, and she needs to be confirmed sooner rather than
later. That is a point of frustration for me to hold her up.
On the mental health side, and we started with Mr. Takano's
help and Mr. O'Rourke and others. Certainly, Mr. Coffman needs
to be shouted out for the work he has done. We held a hearing,
and I looked at this 20 number. That is veterans and Active
duty military, that number is. I said if we are spending $8, $9
billion a year, and we haven't moved the needle at all, why
don't we thoroughly evaluate that and change what we are doing?
And there are plans out there, one in my State, Guard Your
Buddy. The commander of the Guard, he took over in 2011, had
four suicides the first 40 days he was the commander of the
Tennessee State guard. He instituted a plan called Guard Your
Buddy. I won't go into the details of it, but he has lowered
the suicide rate among our Guardsmen in continues by 70
percent. That is scalable, and it is inexpensive. We should do
that across the country, evaluate what works and what
absolutely we are doing. And. Mr. O'Rourke made a great point.
I was at Canandaigua. We had this great call center there.
There is one in Atlanta another standing up, but I said are we
changing anything? We are spending all this money and talking
to people, but is the number still the same? We need to do
something different. That is where the metrics are so
important.
So, I think working with Mr. Takano, we will continue to
work on that. It is a tragedy beyond calculable, the suicide
rates are, because I have said it many times. I have spent
hours in the operating room operating on a cancer, and then
treated the patient afterwards and saved one life. Dr.
Lieberman, what you mentioned, if you have lowered the rate by
as much as 55 percent by doing a simple thing in the emergency
room, why are we doing that in every emergency in the United
States whether you are a veteran or not? That should be done.
And to Senator Hirono, your question about--it is fairly simple
in medicine now. If you are looking at quality metrics, they
are fairly standard, and if you just look at it, you look at
what Medicare uses. Basically, the VA does the same. And if you
come in, you are a certain age, you know, you get screened for
hemoglobin, A1C, have you had your mammogram if you are female,
your blood pressure checked, do you exercise.
Always irritates me when my doctor asks me can I stand up.
I always get a little offended by that, but they ask you those
questions, and those are scalable. And vision screen, hearing
screening, all of those things are measurable, and I think the
VA does an outstanding job. And I want to finish by saying
this: If what I hear about my VA at home, and this is Mountain
Home VA in Johnson City, Tennessee, and I have traveled from
Long Island to Los Angeles and Puerto Rico in the last 2 years,
is that all, not 100 percent, but a vast majority of people
like the care they get at the VA. I almost never hear anything
negative. I do occasionally, as you would in a big organization
like that. And it is very customer-friendly. The veterans
believe, and I believe they are getting great care. I want to
see every veteran get that kind of care, and I am committed to
that, and other people, the men and women in this room, and Mr.
Secretary, I absolutely know in your heart that you are
committed for that.
I thank you all for being here today, and I thank you for
the point of personal privilege, and if there are no further
questions, I ask unanimous consent that all Members--Mr.
Takano.
Mr. Takano. I just want to mention. I don't know if I
mentioned this, but Mr. Sablan could not be with us for the
questions, but I will be submitting questions on his behalf.
The Chairman. Okay. That will be fine. I think you are
going to visit the Northern Marianas also.
If there are no further questions, I ask unanimous consent
for all Members to have 5 legislative days to revise and extend
their remarks and include extraneous material.
Without objection, so ordered.
The hearing is adjourned.
[Whereupon, at 4:40 p.m., the Committees were adjourned.]
A P P E N D I X
----------
Prepared Statement of Honorable Robert Wilkie
Chairman Isakson, Ranking Member Tester, Chairman Roe, and Ranking
Member Walz, distinguished members of the Committee: Thank you for this
opportunity to discuss the current state of the Department of Veterans
Affairs (VA) and my vision for the future of America's Veterans.
After serving two months as Acting Secretary, and now four months
as Secretary, I am happy to say that the VA is better. It's better
because of the work of this Committee; better because of the attention
paid to Veterans Affairs by the President; better because the turmoil
of early 2018 is in the rearview mirror; and better because we have a
workforce dedicated to the care of America's warriors.
While all Executive Branch departments and agencies must carry out
their missions without consideration or influence of partisan politics,
I have said in my visits across the department - visits that in the
last five weeks cover ten VA hospitals from Boston to Las Vegas--that
there are two departments of the Federal Government that must be
especially careful to rise above partisan politics: the Department of
Defense (DoD) and the Department of Veterans Affairs-this Committee is
proof of that postulate.
Now more than ever we are seeing the need for DoD and VA to work
together to provide quality care for the Nation's Service members and
Veterans. And now more than ever we also are seeing the benefit of
strong bipartisan support for our DoD/VA partnership in the many major
acts of Congress passed in the recent years. Congress has infused VA
with a $200 billion budget. You have passed the Accountability Act to
shake up complacency, and you have passed the MISSION Act to strengthen
VA's ability to ensure Veterans have access to the best care available
when and where they need it. The future now is up to the department. I
look forward to working with the Committee and Congress to carry
forward that work of transformation, and I pledge to make our efforts
as transparent as possible to you, to Veterans, and to the American
people.
I would like to acknowledge the recent Veterans Day observance. For
the second year in a row, President Trump declared November as National
Veterans and Military Families Month. On November 11, the 100th
anniversary of the ending of World War I, I gathered at Arlington
National Cemetery with my colleagues from VA, DoD, Veterans Service
Organizations, and others to pay tribute to those who have served and
sacrificed on our behalf. It was a privilege to attend this ceremony
and I am honored to serve as Secretary of Veterans Affairs and work
daily to remember, honor and thank the men and women who embody the
values and ideals of this great Nation.
Initial Assessment
From what I have seen and from what I have been told by Veterans'
advocates, it is clear to me that the Veteran population is changing
faster than we realize. For the first time since the fall of Saigon in
1975, more than half of our Veterans are under the age of 65. They are
computer savvy, they expect quick service, and they expect that service
to be delivered closer to home. They expect an integrated VA that is
agile and adaptive and will do what they need, when they need it. My
goal is to provide them with that service.
In many cases, I have seen wonderful examples of VA accomplishments
that deserve more attention than they normally get.
Not enough Veterans and Americans know that the VA health
care system continues to outperform the private sector in the quality
of care and patient safety for our Veterans.
We are on the cutting edge of medical care and
rehabilitative services, prosthetics, traumatic brain injury, spinal
cord treatment, opioid management, mental health care, and telehealth.
The Department has added its 136th National Cemetery in
Colorado Springs at Pikes Peak. The first burial took place last month.
Fifty-two state Veterans homes received construction and
renovation funds this year.
For the first time in many years, overall VA customer satisfaction
rate is on a steady rise. Thanks to an unprecedented series of
legislative actions aimed at reforming the Department and improving
care and benefits for our Veterans, we are now tackling issues that
have vexed VA for decades, including:
Giving Veterans more choice in health care decisions with
the historic MISSION Act.
Increasing accountability and protecting whistleblowers
with the Whistleblower Protection Act.
Improving transparency - VA is the first hospital system
in the Nation to post wait times, opioid prescription rates,
accountability, settlements, and chief executive travel.
Adopting the same electronic health record as DoD so
there can be a seamless transfer of medical information for Veterans
leaving the service.
Overhauling the claims and appeals processes to create a
simplified system for filing to provide Veterans with clear choices and
timely decisions.
We are on the cusp of the greatest transformative period in the
history of VA. With the support of the President, the Congress, and our
many partners, we are now tackling head-on issues that have lingered
for years. This is not business as usual. This is fundamental
transformation, not seen at VA since just after World War II, when
General Omar Bradley headed the VA.
My Vision for VA
Many of the issues I encountered as Acting Secretary and more
recently as Secretary were not with the quality of medical care but
with getting our Veterans through the door to reach that care. Those
problems are both administrative and bureaucratic. Alexander Hamilton
said that the true test of a good government is its aptitude and
tendency to produce a good administration. That is where VA must go.
Our first challenge is to improve the culture to focus our
attention and efforts on offering world-class customer service through
all our operations. Our second challenge is increasing access to care
and benefits through VA MISSION Act implementation and business
transformation, which includes adopting a new electronic health records
system, implementing a new appeals process for disagreement on VA
claims, and modernizing our human resources, financial management,
construction program, and supply systems.
For the purposes of this hearing, I will focus my testimony on our
efforts to deliver world-class customer service while implementing the
historic VA MISSION Act.
Customer Service
My prime objective is customer service. When an eligible Veteran
comes to VA, they shouldn't have to hire a team of lawyers to get VA to
say yes. It is up to VA to get the Veteran to yes, and that is customer
service.
VA receives 140 million phone calls a year. Ten million people
contact VA online each month. We have 348 contact centers, hundreds of
websites, and dozens of databases. Veterans think of VA as a single
entity, but we deliver services in silos, forcing the Veteran to figure
out which VA phone number to call, website to search, or office to
visit. For many, finding the right office to access the right benefit
or service is a fractured, frustrating experience.
Driven by customer feedback, we are integrating VA's digital
portals, contact centers, and databases so that Veterans easily find
what they need no matter which channel they choose. On Veterans Day, we
re-launched our www.VA.gov Website and we are unifying Veteran data,
adding customer preferences for electronic correspondence to our new
Vet360 database, and integrating the Vet360 profile service with mobile
apps. VA has been identified as the ``co-lead'' of the White House
cross-agency priority goal on improving customer service.
These efforts were recently recognized by the nonprofit Partnership
for Public Service which honored VA employee Marcella Jacobs and the
Digital Service Team during the 17th annual Samuel J. Heyman Service to
America Medals (Sammies) awards gala in Washington D.C. We are
demonstrating that it is possible for Federal agencies to give the
American people the online experience they expect and deserve.
Our goal is to make accessing VA services seamless, effective,
efficient, and emotionally resonant. The delivery of world-class
customer service is my responsibility and the responsibility of all VA
employees. When the interactions between VA employees and our Veteran
customers in these areas are positive, our Veterans will trust and
Choose VA, for their care, benefits, and memorial services across their
lifetime.
Customer service must start with VA employees not talking at each
other but with each other across all office barriers and across all
compartments. If we don't listen to each other, we won't be able to
listen to our Veterans and their families and we won't be able to
provide the world-class customer service they deserve. We must be a
bottom-up organization, with energy flowing upward from those who are
closest to those we are sworn to serve. It is from our dedicated
employees that the ideas we carry to Congress, to Veterans Service
Organizations, and to America's Veterans will come. Our highest
imperative to deliver customer service to our Veterans is to execute
the legislation passed by this Congress and signed by President Trump
giving Veterans the choice they deserve.
Implementing the VA MISSION Act
The VA MISSION Act is landmark legislation that will fundamentally
transform VA health care and improve Veterans benefits and services. To
successfully implement this historic legislation, we must engage
stakeholders at all levels and be transparent throughout the process.
We have established an enterprise program management office reporting
to Acting Deputy Secretary Jim Byrne with integrated project teams to
implement specific MISSION Act provisions. We are providing recurring
updates to Congress, VSO's and others to hear feedback, address
concerns and course correct when necessary. Mr. Chairman, it is
critical that we deliver a transformed VA health care system that puts
Veterans at the center of everything we do.
Community Care
A key provision of the VA MISSION Act is the consolidation of our
community care programs into a new Veterans Community Care Program that
will be much easier to navigate for Veterans, families, VA employees
and community providers. My vision is to keep VA at the center of any
Veteran's care to ensure we deliver world-class customer service as
Veterans navigate the continuum of care between internal and external
providers. This will ensure our Veterans receive the best health care
possible, whether delivered in VA facilities or in the community.
Since October 2017, VA has completed approximately 24 million
appointments in the community and 58.1 million in our facilities.
Veterans may now request an appointment without a referral in numerous
clinics including: audiology, optometry, orthotist (braces and
splints), prosthetist (prostheses, artificial limbs), women's health,
podiatry, nutrition, and wheelchair and amputee services. The average
time it took to complete an urgent referral to a VA specialist has
decreased from 19.3 days in FY 2014 to 3.2 days in FY 2017 and less
than 2 days in FY 2018. This figure continues to improve and is now
down to 1.4 days in October of 2018. In FY 2018, VA completed more than
619,000 appointments when compared to the previous fiscal year. The
average new patient wait times for an appointment at a VA health care
facility were 21.2 days for Primary Care, 22.1 for Specialty Care, and
11.2 for Mental Health services.
VA has also made notable progress in ensuring Veterans receive
time-sensitive follow up appointments. Currently 95 percent of all
time-sensitive appointments are completed within the provider
recommended date. Additionally, all VA Medical Centers and Community
Based Outpatient Clinics now provide same-day services in primary care
and mental health for Veterans who need them. I have found many
Veterans prefer to receive their care at VA facilities and we are
increasing access to meet this need.
Upon enactment of the VA MISSION Act, we began developing
regulations required to implement the new community care authorities.
To ensure continuity of operations, VA extended and expanded its
contract with TriWest Healthcare Alliance to ensure access to community
care while the next generation of community care network contracts are
awarded and implemented.
As part of our new community care program, we are addressing the
timeliness and accuracy of payments to providers. We must ensure
community providers are paid in a timely manner so they are willing and
able to deliver services to our Veterans. To this end, VA is moving
away from paper claims and requiring providers to submit electronic
claims in most cases through a new claims processing system. This
automated electronic Claims Administration and Management System (e-
CAMS) uses technology with workflow-based analytics to provide feedback
on potential bottlenecks and business performance issues in our claims
process. Additionally, providers will have 180 days to submit claims
for reimbursement rather than waiting years to submit them. This will
align VA with industry standards and ensure providers are receiving
timely payments.
Through the VA MISSION Act, we are establishing a Center for
Innovation for Care and Payment to develop new approaches to testing
payment and service delivery models to reduce expenditures while
preserving or enhancing the quality of VA health care. The center will
explore models for incentivizing performance internally and when VA
purchases care in the community. With the support of this Committee we
hope to improve the lives of those we serve by accelerating and scaling
VA innovation.
Eligibility for Community Care
Veterans deserve access to the best health care providers, state-
of-art facilities and cutting-edge technology. The VA MISSION Act of
2018 will strengthen VA's ability to deliver the quality care and
timely service Veterans have earned. Eligibility for community care
will be Veteran-centric and enable VA to deliver care more efficiently.
With only specific exceptions, VA will stop paying providers above
Medicare rates and will minimize the use of local contractual
agreements to further reduce variability in payment rates. Under the
new walk-in/urgent care authority, we will ensure that if eligible
Veterans have an urgent health care need, they will be able to see a
provider quickly. In developing access standards, VA has specifically:
Discussed access standards with DoD and the Centers for
Medicare & Medicaid Services.
Performed research on industry standards including state
insurance and state Medicaid programs.
Solicited feedback with a notice in the Federal Register
published June 29, 2018, and hosted public comments on July 13, 2018.
As a guiding principle, I have reviewed DoD's TRICARE standards and
continue to promote interoperability of our health care systems. My
objective is to ensure Veterans receive care where and when they need
it and to ensure VA remains on the leading edge for access and quality
of health care.
Standards for Quality
A study released this year by the RAND Corporation found VA health
care generally outperforms the private sector in quality and patient
safety, but recommended VA address variations in quality among VA
health facilities. The VA MISSION Act will do this and more by
requiring VA to establish standards for quality for hospital care,
medical services and extended care services delivered by VA and
community providers and establish a remediation process for service
lines that do not meet those standards.
We are committed to using industry-standard quality measures to
compare our performance to that of the community, with consultation
from key stakeholders, and to use those comparisons to ensure the best
possible outcomes for Veterans. Our commitment to transparency will
allow Veterans to compare data across VA and community care and make
informed decisions when selecting a provider. In developing quality
standards, VA has:
Assessed existing industry quality standards including
those used by DoD, the Department of Health and Human Services, and the
Centers for Medicare & Medicaid Services.
Solicited feedback with a notice in the Federal Register
published August 24, 2018, and hosted public comments on September 24,
2018.
Hosted several Veteran Insight Panels, which are online
focus groups, to hear directly from Veterans about their experiences
and how we can bridge the gap between VA and community care specific to
quality.
We recognize the high level of interest from Veterans, community
providers, and others in VA about the access standards and standards
for quality and I am deeply committed to ensuring an open, transparent
process for implementing the VA MISSION Act. We have developed
communications products and tools, including a public-facing Website,
talking points or key messages, frequently asked questions, fact
sheets, and handouts covering various provisions of the law.
In May 2018, we began hosting monthly webinars for community
providers to provide updates and keep them informed of changes to the
community care program. In September, we participated in a
collaborative webcast with the Association of American Medical Colleges
and presented an update on the VA MISSION Act community care
requirements. In November, we began hosting listening sessions in VA's
four community care regions to hear directly from Veterans, employees
and other stakeholders. Our goal is to host 20 listening sessions with
stakeholders by the end of the calendar year. It is critical that we
continue to engage stakeholders as we implement this historic
legislation.
Caregivers Expansion
As VA expands the Program of Comprehensive Assistance for Family
Caregivers, we recognize the incredible sacrifice of families who have
cared for a loved one injured in the line of duty. We expect tremendous
interest in the program's expansion and anticipate a significant
increase in applicants. We are also addressing issues identified in the
August 2018 Office of Inspector General's report on the program.
VA has engaged with key stakeholders including VSOs, members of the
public, and House Veterans Affairs' Committee round tables. Several
consistent themes emerged during these engagements. In expanding the
program, VA must ensure:
Eligibility determinations are Veteran and caregiver-
centric, easy to understand and transparent.
Participation is targeted to those Veterans who will
benefit the most.
Program requirements are less burdensome for caregivers
and Veterans (e.g., a different track for the catastrophically inured).
While the timeline for expanding the program to all eligible
Veterans is still under development, VA must develop and implement a
new information technology system to support administrative and record-
keeping needs. We are working with a developer on a new IT system known
as the Caregiver Tool, or CareT, to manage the new requirements. Once
we have fully fielded the new system, we will develop and implement the
functionality required by the MISSION Act. We need to ensure high
system reliability before enrolling a new Caregivers cohort.
VA supports and recognizes the sacrifice and value of Veterans'
family caregivers not only through this program but through its first
Federal Advisory Committee for Veterans Families, Caregiver and
Survivors and its new Center of Excellence for Veteran Caregiver
Research. Caregivers and Veterans can learn about the full range of
available support and programs by visiting www.caregiver.va.gov or by
contacting the Caregiver Support Line toll-free at 1-855-260-3274.
Hiring and Vacancies
The VA MISSION Act gives us greater ability to recruit and retain
the best medical providers through improvements to the education debt-
reduction program and improved flexibility for bonuses for recruitment,
relocation and retention. VA will also pilot a scholarship program for
Veterans to get medical training in return for serving in a VA hospital
or clinic for four years. VA is keeping pace with both normal
retirements and job changes and has added nearly 14,000 more employees
onboard since January 1, 2017 (3.8 percent growth), which is keeping
pace with VA's patient base (enrollees) growth of 1.4 percent during
the same period.
As required under the law, we are posting quarterly vacancy data
online. Our recent data shows as of September 30, 2018, VA had 46,522
overall vacancies and a total of 377,210 employees onboard for an 11
percent vacancy rate. Indeed, most large organizations will have what
appears to be many vacancies due to normal retirements and job changes.
VA's vacancy rate of 11 percent is a normal part of doing business and
reflects the historical annual 9 percent turnover rate and a 2 to 3
percent growth rate.
VA vacancy rates mirror those of the health care industry. There is
a national shortage of healthcare professionals, especially for
physicians and nurses. VA remains fully engaged in a fiercely
competitive clinical recruitment market and has increased its number of
clinical providers including hard-to-recruit-and-retain physicians such
as psychiatrists. Additional steps to attract qualified candidates
include:
Mental Health and other targeted hiring initiatives.
Leveraging flexible pay ranges resulting in competitive
physician salaries.
Utilization of recruitment/relocation and retention
incentives.
Utilization of the Education Debt Reduction Program for
recruitment and retention of hard-to-recruit/retain healthcare
providers, including the new higher award amounts authorized by the
MISSION Act up to $200,000 over a five-year period.
Targeted nationwide recruitment advertising and
marketing.
The ``Take A Closer Look at VA'' trainee outreach
recruitment program.
Expanding opportunities for telemedicine providers.
DoD/VA effort to recruit transitioning servicemembers.
Asset and Infrastructure Review (AIR) Commission
The VA MISSION Act provides an opportunity for VA to assess our
health care infrastructure footprints and develop recommendations for
modernization and realignment of facilities to meet the demand for VA's
services both today and for years to come. Our Asset and Infrastructure
Review assessment and recommendations will be data-driven with input
and feedback from our Veterans, employees, VSO's, local communities,
and other key stakeholders throughout the process to ensure VA's
recommendations are robust and fair.
The AIR process will be informed by the assessment of 96 local
market areas to identify availability and gaps in furnishing health
care services to veterans. Each local assessment will consider short
and long-term demand; VA staffing capacity; VA infrastructure capacity;
VA's facilities conditions and future costs to maintain or modernize
them, and non-VA health care capacity. We will provide robust
recommendations for modernizing and realigning the Veterans Health
Administration facility footprints to ensure the finest integrated care
delivery to our Veterans.
Given the oversight and approval process outlined under the MISSION
Act for the Asset and Infrastructure Review, VA is confident that the
AIR Commission, the President, and ultimately, Congress will concur and
approve our recommendations.
Conclusion
I would like to again thank Congress for passing VA's FY 2019
funding bill. Starting the fiscal year with our full year's
appropriations in place is extremely important as we implement the laws
Congress has passed.
As I mentioned, we have instituted strong governance and management
processes that will facilitate successful implementation of the VA
MISSION Act. This will be a long journey that will not be accomplished
overnight. I am committed to providing you with regular updates on our
progress and the challenges that arise.
As we look to the next few years and full implementation of the new
Veterans Community Care Program and an expanded Caregivers Program, VA
will need to address the necessary funding requirements to meet the
requirements of the law. We are embarking on the most comprehensive
improvements to Veterans care and benefits since World War II. Our
transformation will require fiscally responsible use of additional
resources and for us to streamline and improve our internal operations
to become as efficient as possible.
I look forward to working with you and this Committee and
appreciate your many courtesies to me. I am also eager to continue
building on our reform agenda. The mission of this Committee is clear-
you help remind all Americans why they sleep soundly at night because
of those who sacrificed in uniform. There is no more noble mission in
all of government.
Thank you.
Statement For The Record
Veterans Of Foreign Wars Of The United States (VFW)
KAYDA KELEHER, ASSOCIATE DIRECTOR
NATIONAL LEGISLATIVE SERVICE
After four years of tireless work and development, the VA MISSION
Act of 2018 was signed into law on June 6, 2018. The main prerogative
of the VA MISSION Act of 2018 is perfectly stated as Title I--Caring
for Our Veterans. The Veterans of Foreign Wars of the United States
(VFW) believes that to successfully implement this multifaceted portion
of the law, the Department of Veterans Affairs (VA), Congress, and
veterans service organizations (VSOs) must collaboratively work
together, while maintaining its implementation as the top priority of
the 116th Congress. The VFW thanks the Committees for the continued
oversight of this important law and leadership in ensuring VA has the
resources to properly implement it.
If the law is effectively implemented, veterans' health care will
enter a new era of timely access to high-quality care. However, if
implementation strays from the overwhelming consensus reached by
stakeholders involved in development of the law, VA health care could
decline, resulting in negative consequences for the millions of
veterans who rely on VA for their health care, and threaten the
viability of VA's teaching, world-class research, and emergency
response missions. While there are groups that believe VA facilities
should be downsized and that veterans should receive more care through
private sector doctors, the VFW's numerous surveys show veterans want
VA to hire more doctors and increase internal capacity. In fact, our
latest VA health care survey indicates nearly 60 percent of veterans
who were offered community care elected to stay with VA. The main
reason veterans prefer VA is they like the quality of care they
receive, which a recently published peer-reviewed study entitled
Veterans Health Administration Hospitals Outperform Non-Veterans Health
Administration Hospitals in Most Health Care Markets found is better
than the private sector.
The law requires VA to develop regulations for new access and
quality standards to replace the current arbitrary rule of a 30-day
wait and 40-mile distance standards, by March 6, 2019. This will be
done by consolidating seven current community care programs, including
the Veterans Choice Program, into one. This program will be the
Veterans Community Care Program (VCCP), and will use local health care
networks and academic affiliates to provide care to all eligible
veterans. The VFW has serious concerns about the lack of collaboration
and working communication from VA with VSOs to establish these new
regulations. While VA has held consistent meetings between VSOs and the
Office of Community Care, the majority of such meetings have been one-
sided conversations. Without proper stakeholder input, VA will fail.
For example, VA is considering up to 20 different access standard
models, none of which have been shared with VSOs. The VFW understands
Congress intended for VSOs to receive specific data and to work in
cooperation with VA to develop these future regulations that will
affect the lives of millions of veterans. The VFW also has concerns
with the lack of participation at Office of Community Care meetings
from VA's Executive Steering Committee, which will ultimately assist
the Secretary in choosing access standard models and how the law is
implemented. The VFW is encouraged by this past week's decision to
include VSOs in VA MISSION Act workgroup meetings with VA leadership.
We hope such meetings will be more productive, and look forward to
working with VA to ensure this important bill is implemented in the
best interest of the veterans VA was created to serve.
The VFW has made clear time and time again that VA must back away
from setting arbitrary standards for when patients using VA are given
the option to use community care. VFW members have made clear the many
negative unintended consequences of not upholding the decision to use
community care as a clinical decision made between a patient and their
provider. It is optimistic to hear VA working toward solutions in
overcoming this range of arbitrary barriers, such as when a patient
lives within close proximity to a VA facility based on miles, but must
overcome geographical difficulties such as mountains. VA must adapt
lessons learned from the Veterans Choice Program and study
recommendations from industry experts, such as the Transforming Health
Care Scheduling and Access: Getting to Now independent review conducted
by the National Academy of Medicine, formerly known as the Institute of
Medicine, to establish access standards that are appropriate for the
users of the VA health care system. The VFW warns VA against adopting
arbitrary standards which would fail to address the uniqueness of the
VA health care system and the needs of our nation's veterans.
It is important for VA to establish access standards that define
objective criteria for access to VA community care networks. Unless
these standards are pragmatic and clinically appropriate, both veterans
and VA will suffer negative consequences. VA must establish standards
that are sensible for VA's capacity, and comparable to measures of
local health care systems outside VA. As with access standards, quality
standards must balance the need to maintain the unique features of VA
that effectually serve veterans, but are different than those in the
private sector.
The VFW also has concerns with feedback from facilities that
veterans are being automatically placed into community care based on
arbitrary guidelines without discussion or input from their providers.
The VFW continues to oppose patients being involuntarily placed into
community care simply because their appointments may not be scheduled
within 30 days. First and foremost, veterans and their providers must
remain part of this process to ensure patient understanding and
continuity of care. Second, many of these patients would prefer to stay
with VA. Finally, not every appointment must be fulfilled within the 30
days. If the appointment is not medically necessary in that timeframe,
veterans must be able to choose whether to wait for VA or seek care
through the community care networks.
The VFW also urges VA to account for how the implementation of a
new electronic health care record impacts productivity. In partnership
with the Defense Health Agency (DHA), the VFW has kept a keen eye on
the implementation of the Military Health System GENESIS electronic
health care record, which is the same system VA has elected to adopt
for the VA health care system. While the VFW hopes VA adopts lessons
learned from DHA to ensure a more seamless implementation, we are
certain VA medical facilities will experience a temporary reduction in
productivity that comes with change management. However, military
treatment facilities report an eventual increase in productivity after
full implementation. The VFW suspects VA medical facilities will
experience a similar trend in productivity, which will lead to a
temporary increase in demand for community care.
This and other temporary spikes in demand for community care, such
as snowbirds, will require VA to adjust its community care networks and
VA medical facility capacities to ensure veterans can receive the care
they need where they need it. VA must make certain that temporary
increase in demand for community care does not jeopardize the long-term
viability of capacity at VA medical facilities. That is why the VFW
urges VA and Congress to consistently evaluate whether VA should be
expanding its community care networks or increasing internal capacity.
This must be done by hiring more doctors or having VA deploy a quick
reaction force of VA doctors to areas facing temporary spikes in demand
for care.
VA facilities with service lines that fail to meet established
quality standards will undergo remediation. Patients who rely on the 36
service lines that fall under the quality standards will have the
opportunity to choose if they would rather stay with a VA doctor or use
private sector doctors in their community. It is important that VA take
into account what options veterans use and where they would prefer to
go when developing remediation plans. VA must also take into account
the ability for VA medical facilities to provide severely disabled
veterans, such as those in spinal cord injury centers or polytrauma
network sites, a full continuum of care. Simply closing such service
lines in favor of community care would fail veterans who prefer to see
a VA doctor and those who are unable to use community care.
To ensure access and quality standards are fully vetted and
understood, the VFW urges VA to issue notice of proposed rulemaking in
the Federal Register to allow sufficient time for public comments. It
would be unacceptable for VA to issue an interim final rule, which does
not allow for public input, specifically if stakeholders were not
incorporated in developing it. Aside from stakeholders who must be
consulted in the development of these rules, veterans and individuals
who will be impacted by them must have their voices heard and
considered through public comment. Doing so may mean that VA will not
meet the deadlines established in the law. To the VFW, it is more
important that VA produce high-quality and accurate regulations than it
is for VA to rush the decision-making process and repeat previous
mistakes in order to meet such deadlines. Also, there must be an
organized outreach campaign for veterans who use VA once these
regulations are finalized. Since the VA MISSION Act became law, VA has
worked with VSOs to design pamphlets and other educational materials to
share with patients when the law is ready to be implemented. This must
be done so thoroughly and on multiple platforms, while also promising
that all VA employees who will be involved in this transition
completely understand the program and are able to explain it to
patients.
As the regulations for the VA MISSION Act continue to be planned
and implemented, the VFW looks forward to continuing to prioritize the
remaining sections of the law. This includes working with VA and
Congress to perfect billing, market assessments, expansion of the
caregiver program, provider education and training programs, and the
asset and infrastructure review.
American Veterans (AMVETS)
Chairman Isakson, Chairman Roe, Ranking Member Tester, Ranking
Member Walz, and members of the Joint Veterans Affairs Committee, on
behalf of the men and women of American Veterans (AMVETS), as well as
the 21 million American veterans in our country who we represent, thank
you for allowing us this platform to contribute to this very important
discussion on the implementation of the Maintaining Internal Systems
and Strengthening Integrated Outside Networks, or MISSION, Act of 2018.
When President Donald Trump signed the highly anticipated VA
MISSION Act into law on June 6, 2018, it was an inflection moment in
our country's effort to devise a system of healthcare that our veterans
have needed and deserved for quite some time. The new law's
predecessor, the Veterans Access, Choice and Accountability (Choice)
Act of 2014, had created a new paradigm for delivering care, albeit
imperfect and challenged by its previously untested standards involving
coordinating care outside of the Department of Veterans Affairs (VA).
The VA Mission Act is intended to build on the lessons learned as
veterans' healthcare continues to evolve.
For the new law to be effective, it requires all involved to
account for those lessons learned as we approach the end of one
community care program and the beginning of another. Along with this
notion is a requirement that next-generation vision will inspire into
existence a new system of care that will look as good in three-
dimension as it does on paper through timely and effective
implementation. Without good implementation in this effort, vision will
be just another word for hallucination.
With that in mind, every vision must be driven by a leader. Since
the law's passage, we have seen changes in leadership in the VA
Secretary and VHA Under Secretary for Health Offices with the
unceremonious removal of Drs. David Shulkin and Carolyn Clancy,
respectively. The Office of Information and Technology, which will be
critical to the success of the VA Mission Act, also faced a leadership
shuffle after Scott Blackburn resigned as the chief information officer
in April 2018. His successor, Camilo Sandoval, has filled the role in
the interim amid negative reports and skepticism. It is our hope that
he will be the right person for the job, for the sake of progress above
politics. VA has not had a permanent CIO in more than 18 months, which
explains, at least in part, the fits and starts that have hindered
progress in the plan to fix the VA's IT infrastructure.
AMVETS calls on our political leaders, from the White House to
Capitol Hill, to take every necessary step to ensure these important
offices are staffed and stabilized by permanent decision makers who
have the freedom to do their jobs without fear of politically motivated
reprisal. The American taxpayers do not get a refund on wasted time,
but that is exactly what has happened when key leaders were removed and
progress stalled by uncertainty.
One project that has seen much uncertainty is the establishment of
a Veterans Electronic Health Record system. The VA Mission Act provides
$1.1 billion for the ongoing integration of VA and Department of
Defense records to improve the efficiency and quality of veterans'
health care.
Creating the largest EHR in the country is an extraordinary
undertaking, and we anticipate issues along the way, as with any
endeavor of this scale. However, when asked why the Interagency Program
Office was not being used as a single point of governance for the
project, officials reported to the Congress that they did not have the
authority, staff and funding for the undertaking, an all-too-familiar
refrain whenever the agency falls short of expectations. These self-
inflicted wounds cannot continue.
The planned rollout of the EHR for year 2020 in Veterans Integrated
Service Network 20 in the Pacific Northwest means that veterans will
have to endure a two-year wait before seeing progress on the initial
operating capability pilot site to test the Cerner project. Whether
this two-year wait will be worth the time and expense remains to be
seen. But veterans and other stakeholders can no longer accept a
``moving of the goal posts'' like we are already seeing with the
Program of Comprehensive Assistance for Family Caregivers (PCAFC).
One of the key provisions of the VA Mission Act is the long-awaited
expansion of the PCAFC. The law mandates the development and
implementation of a new information technology system to support
administrative oversight and record-keeping needs. Section 162 of the
VA Mission Act directs, ``Not later than October 1, 2018, the Secretary
of Veterans Affairs shall implement an information technology system
that fully supports the Program and allows for data assessment and
comprehensive monitoring of the Program.''
The implementation deadline, which has since passed, was critical
because the caregivers who attend to the needs of severely disabled
veterans who served before September 11, 2001 will not receive benefits
until the VA Secretary certifies to Congress a viable IT system.
However, questions persist regarding this mandate to implement a new
technology because the VA already has the ``Caregiver Application
Tracking System,'' which is used to manage nearly 20,000 caregiver
cases. The glitches that need to be addressed, oversight and medical
records management chief among them, apparently call for the complete
overhaul of the existing system, to the chagrin of veterans and
caregivers whose livelihoods are now inextricably linked to the
agency's ability to correct longstanding IT problems, an ability that
remains challenged.
Moreover, given how forcefully some VA leaders had opposed the
expansion of the program to Pre-9/11 caregivers in the past, many of
our constituents fear that the VA has found a way to indefinitely stall
expansion by conditioning progress on a new system in the distant
future instead of fixing the existing one so that expansion can happen
much sooner - this while the VA already faces problems with the system
that manages Post-9/11 GI Bill housing stipends that affect 360,000
veterans and family members. AMVETS will remain vigilant for evidence
that either proves or disproves these suspicions as the situation
unfolds. We encourage VA leaders to remain transparent about all
milestones and goals, to include timelines, so that progress is
measurable and expectations more manageable.
To that point, AMVETS commends TriWest for the corporation
leadership's transparency and diligence in managing expectations as its
services expand to all 50 states.
When Health Net's Veterans Choice Program contract expired on
September 30th, there was little basis for optimism among veteran
advocates. VA leadership recruited TriWest to expand services to bridge
the gap and deliver health care until all community care contracts are
implemented, which offers lukewarm comfort, at best, given the lack of
a clear timeline for complete implementation.
However, TriWest has reportedly been actively engaging VA Central
Office, Veteran Integrated Service Networks, and VA Medical Centers in
order to prepare for staggered transition of support in all states
previously covered by Health Net, while handling an average of 120,000
requests for care per month. We were pleased to hear from VA leadership
that the 60,000 consults that were returned to the VA from Health Net
did not create an immediate backlog or affect future consults. We hope
this trend will continue and will be monitoring to ensure that it does.
Chairman Roe, Ranking Member Walz, and members of the Committee, on
behalf of the men and women of AMVETS and the nearly 21 million
veterans in the United States whose interests are served by our
mission, we thank you for the opportunity to contribute to this
important discussion. AMVETS looks forward to working with this
Committee and the Department of Veterans Affairs to take every step
necessary to ensure the successful implementation of the VA Mission
Act.
Jacob Gillison (Sanders)
The VA's Private Care Program Gave Companies Billions and Vets
Longer Waits
Trump wants to supersize a program that spent almost a quarter of
its funds on overhead.
by Isaac Arnsdorf, ProPublica, and Jon Greenberg, PolitiFact
Dec. 18 1:30 pm EST
For years, conservatives have assailed the U.S. Department of
Veterans Affairs as a dysfunctional bureaucracy. They said private
enterprise would mean better, easier- to-access health care for
veterans. President Donald Trump embraced that position,
enthusiastically moving to expand the private sector's role.
Here ' s what has actually happened in the four years since the
government began sending more veterans to private care: longer waits
for appointments and, a new analysis of VA claims data by ProPublica
and PolitiFact shows, higher costs for taxpayers.
Since 2014, 1.9 million former service members have received
private medical care through a program called Veterans Choice. It was
supposed to give veterans a way around long wait times in the VA. But
their average waits using the Choice Program were still longer than
allowed by law, according to examinations by the VA inspector general
and the Government Accountability Office. The watchdogs also found
widespread blunders, such as booking a veteran in Idaho with a doctor
in New York and telling a Florida veteran to see a specialist in
California. Once, the VA referred a veteran to the Choice Program to
see a urologist, but instead he got an appointment with a neurologist.
The winners have been two private companies hired to run the
program, which began under the Obama administration and is poised to
grow significantly under Trump. ProPublica and PolitiFact obtained VA
data showing how much the agency has paid in medical claims and
administrative fees for the Choice program. Since 2014, the two
con1panies have been paid nearly $2 billion for overhead, including
profit. That's about 24 percent of the companies' total program
expenses -a rate that would exceed the federal cap that governs how
much most insurance plans can spend on administration in the private
sector.
Since 2014, the VA's Veterans Choice Program has spent $10.3
billion. Most of that money went to private contractors.
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According to the agency's inspector general, the VA was paying the
contractors at least $295 every time it authorized private care for a
veteran. The fee was so high because the VA hurriedly launched the
Choice Program as a short-term response to a crisis. Four years later,
the fee never subsided- it went up to as much as $318 per referral.
``This is what happens when people try and privatize the VA,'' Sen.
Jon Tester of Montana, the Ranking Democrat on the Senate veterans
conunittee, said in a statement responding to these findings. ``The VA
has an obligation to taxpayers to spend its limited resources on caring
for veterans, not paying excessive fees to a government contractor.
When VA does need the help of a middleman, it needs to do a better job
of holding contractors accountable for missing the mark.''
The Affordable Care Act prohibits large group insurance plans fron1
spending more than 15 percent of their revenue on administration,
including marketing and profit. The private sector standard is IO
percent to 12 percent, according to Andrew Naugle, who advises health
insurers on ad1ninistrative operations as a consultant at Milliman, one
of the world's largest actnarial firms. Overhead is even lower in the
Defense Department's Tricare health benefits program: only 8 percent
last year.
Even excluding the costs of setting up the new program, the Choice
contractors' overhead still amounts to 21 percent of revenue.
``That's just unacceptable,'' Rick Weidman, the policy director of
Vietnam Veterans of America, said in response to the figures. ``There
are people constantly banging on the VA, bnt this was the private
sector that made a total muck of it.''
Trump's promises to veterans were a central message of his
campaign. But his plans to shift their health care to the private
sector put him on a collision course with veterans groups, whose
members generally support the VA' s medical system and don't want to
see it privatized. The controversy around privatization, and the
outsize influence of three Trump associates at Mar-a-Lago, has sown
turmoil at the VA, endangering critical services from paying student
stipends to pi-eventing suicides and upgrading electronic medical
records.
A spokesman for the VA, Curt Cashour, declined to provide an
interview with key officials and declined to answer a detailed list of
written questions.
One of the contractors, Health Net, stopped working on the program
in September. Health Net didn't respond to requests for comment.
The other contractor, TriWest Healthcare Alliance, said it has
worked closely with the VA to improve the program and has made major
investments of its own. ``We believe supporting VA in ensuring the
delivery of quality care to our nation's veterans is a moral
responsibility, even while others have avoided making these investments
or have withdrawn from the market,'' the company said in a statement.
TriWest did not dispute ProPublica and PolitiFact's estimated overhead
rate, which used total costs, but suggested an alternate calculation,
using an average cost, that yielded a rate of 13 percent to 15 percent.
The company defended the $295-plus fee by saying it covers ``highly
1nanual'' services such as scheduling appointJnents and coordinating
1nedical files. Such functions are not typically part of the contracts
for other programs, such as the military's Tricare. But Tricare's
contractors perform other duties, such as adjudicating claims and
monitoring quality, that Health Net and TriWest do not. In a recent
study comparing the programs, researchers from the Rand Corporation
concluded that the role of the Choice Program's contractors is ``much
narrower than in the private sector or in Tricare.''
Before the Choice Program, TriWest and Health Net performed
essentially the same functions for about a sixth of the price,
according to the VA inspector general.
TriWest declined to break down how much of the fee goes to each
service it provides.
Because of what the GAO called the contractors' ``inadequate''
performance, the VA increasingly took over doing the Choice Program's
referrals and claims itself.
In many cases, the contractors' $295-plus processing fee for every
referral was bigger than the doctor's bill for services rendered, the
analysis of agency data showed. In the three months ending Jan. 31,
2018, the Choice Program made 49,144 referrals for primary care
totaling $9.9 million in medical costs, for an average cost per
referral of $201.16. A few other types of care also cost less on
average than the handling fee: chiropractic care ($286.32 per reterral)
and optometry ($189.25). There were certainly other instances where the
1nedical services cost much more than the handling fee: TriWest said
its average cost per referral was about $2, I00 in the past six months.
Beyond what the contractors were entitled to, audits by the VA
inspector general found that they overcharged the government by $140
million from November 2014 to March 2017. Both companies are now under
federal investigation arising from these overpayments. Health Net's
parent con1pany, Centene, disclosed a Justice Department civil
investigation into ``excessive, duplicative or otherwise in1proper
claims.'' A federal grand jury in Arizona is investigating TriWest for
``wire fraud and misused government funds,'' according to a court
decision on a subpoena connected to the case. Both companies said they
are cooperating with the inquiries.
Despite the criminal investigation into TriWest's management of the
Choice Program, the Trump administration recently expanded the
company's contract without competitive bidding. Now, TriWest stands to
collect even more fees as the administration prepares to fulfill
Trump's campaign promise to send more veterans to private doctors.
Senate veterans Committee Chairman Johnny Isakson, R-Ga., said he
expects VA Secretary Robert Wilkie to discuss the agency's plans for
the future of private care,when he testifies at a hearing on Wednesday.
A spokeswoman for the outgoing Chairman of the House veterans
Committee, Phil Roe, R-Tenn., didn't respond to requests for comment.
``The last thing we need is to have funding for VA's core mission
get wasted,'' Rep. Mark Takano, a California Democrat who ,viii become
the House panel's Chairman in January, said in a statement. ``I will
make sure Congress conducts comprehensive oversight to ensure that our
veterans receive the care they deserve while being good stewards of
taxpayer dollars.''
Many of the Choice Program's defects trace back to its hasty
launch.
In 2014, the Republican Chairman of the House veterans Committee
alleged that 40 veterans died waiting for care at the VA hospital in
Phoenix. The inspector general eventually concluded that no deaths were
attributable to the delays. But it was true that officials at the
Phoenix VA were covering up long wait times, and critics seized on this
scandal to demand that veterans get access to private medical care.
One of the loudest voices demanding changes was John McCain's.
``Make no mistake: This is an emergency,'' the Arizona senator, who
died in August, said at the time. McCain stiuck a compromise with
Democrats to open up private care for veterans who lived at least 40
miles from a VA facility or would have to wait at least 30 days to get
an appointment.
In the heat of the scandal, Congress gave the VA only 90 days to
launch Choice. The VA reached out to 57 companies about administering
the new program, but the companies said they couldn't get the program
off the ground in just three months, according to contracting records.
So the VA tacked the Choice Program onto existing contracts with Health
Net and TriWest to run a much s1naller program for buying private care.
``There is simply insufficient time to solicit, evaluate, negotiate and
award competitive contracts and then allow for some form of ramp-up
time for a new contractor,'' the VA said in a formal justification for
bypassing competitive bidding.
But that was a shaky foundation on which to build a much larger
program, since those earlier contracts were themselves flawed. In a
2016 report, the VA inspector general said officials hadn't followed
the rules ``to ensure services acquired are based on need and at fair
and reasonable prices.'' The report criticized the VA for awarding
higher rates than one of the vendors proposed.
The new contract with the VA was a lifeline for TriWest. Its
president and CEO, David J. McIntyre Jr., was a senior aide to McCain
in the mid-1990s before starting the company, based in Phoenix, to
handle health benefits for the 1nilitary's Tricare program. In 2013,
TriWest lost its Tricare contract and was on the verge of shutting
down. Thanks to the VA contract, TriWest went from laying off more than
a thousand employees to hiring hundreds.
McIntyre's annual compensation, according to federal contracting
disclosures, is $2.36 million. He declined to be interviewed. In a
statement, TriWest noted that the original contract, for the much
smaller private care program, had been competitively awarded.
The VA paid TriWest and Health Net $300 million upfront to set up
the new Choice program, according to the inspector general's audit. But
that was dwarfed by the fees that the contractors would collect.
Previously, the VA paid the companies between $45 and $123 for eve1y
referral, according to the inspector general. But for the Choice
Program, TriWest and Health Net raised their fee to between $295 and
$300 to do essentially the same work on a larger scale, the inspector
general said.
The price hike was a direct result of the time pressure, according
to Greg Giddens, a former VA contracting executive who dealt with the
Choice Program. ``Ifwe had two years to stand up the program, we would
have been at a different price structure,'' he said.
Even though the whole point of the Choice Program was to avoid 30-
day waits in the VA, a convoluted process made it hard for veterans to
see private doctors any faster. Getting care through the Choice Program
took longer than 30 days 41 percent of the time, according to the
inspector general's estimate. The
GAO found that in 2016 using the Choice Progran1 could take as long
as 70 days, with an average of 50 days.
Sometimes the contractors failed to make appointments at all. Over
a three-month period in 2018, Health Net sent back between 9 percent
and 13 percent of its referrals, according to agency data. TriWest
failed to make appointments on 5 percent to 8 percent of referrals, the
data shuws.
Many veterans had frustrating experiences with the contractors.
Richard Camacho in Los Angeles said he got a call from TriWest to
make an appointment for a sleep test, but he then received a letter
from TriWest with different dates. He had to call the doctor to confinn
when he was supposed to show up. When he got there, the doctor had
received no information about what the appointment was for, Cainacho
said.
John Moen, a Vietnam veteran in Plano, Texas, tried to use the
Choice Program for physical therapy this year rather than travel to
Dallas, where the VA had a six-v,eek wait. But it took 10 weeks for him
to get an appointment with a private provider.
``The Choice Program for me has completely failed to meet my
needs,'' Moen said.
Curtis Thompson, of Kirkland, Washington, said he's been told the
Choice Program had a 30-day wait just to process referrals, never mind
to book an appointment. ``Bottom line: Wait for the nearly 60 days to
see the rheumatologist at the VA rather than opt for an unknown delay
through Veterans Choice,'' he said.
After Thompson used the Choice Program in 2018 for a sinus surgery
that the VA couldn't perform within 30 days, the private provider came
after him to collect payment, according to documentation he provided.
Thousands of veterans have had to contend with bill collectors and
credit bureaus because the contractors failed to pay providers on
tin1e, according to the inspector general. Doctors have been frustrated
with the Choice Program, too. The inspector general found that 15
providers in Nmih Carolina stopped accepting patients from the VA
because Health Net wasn't paying them on time.
The VA shares the blame, since it fell behind in paying the
contractors, the inspector general said. TriWest claimed the VA at one
point owed the company $200 million. According to the inspector
general, the VA's pile of unpaid claims peaked at almost 180,000 in
2016 and was virtually eliminated by the end of the year.
The VA tried to tackle the backlog of unpaid doctors, but it had a
problem: The agency didn't know who was performing the services
arranged by the contractors. That's because Health Net and TriWest
controlled the provider networks, and the medical claims they submit to
the VA do not include any provider information.
The contractors' role as middlemen created the opportunity for
payment errors, according to the inspector general's audit. The
inspector general found 77,700 cases where the contractors billed the
VA for more than they paid providers and pocketed the difference,
totaling about $2 million. The inspector general also identified $69.9
million in duplicate payn1ents and $68.5 n1illion in other errors.
TriWest said it has worked with the VA to correct the payment
errors and set aside money to pay back. The company said it's waiting
for the VA to provide a way to refund the confirmed overpayments. ``We
remain ready to complete the necessary reconciliations as soon as that
process is formally approved,'' TriWest said.
The grand jury proceedings involving TriWest are secret, but the
investigation became public because prosecutors sought to obtain the
identities of anonymous commenters on the jobs website Glassdoor.com
who accused TriWest of''mak[ing] money unethically off ofveteransNA.''
Glassdoor fought the subpoena but lost, in November 2017. The court's
opinion doesn't name TriWest, but it describes the subject of the
investigation as ``a government contractor that administers veterans'
healthcare programs'' and quotes the Glassdoor reviews about TriWest.
The federal prosecutor's office in Arizona declined to comment.
``TriWest has cooperated with many government inquiries regarding
VA's com1nunity care programs and will continue to do so,'' the company
said in its statement. ``TriWest 1nust respect the government's right
to keep those inquiries confidential until such time as the government
decides to conclude the inquiry or take any actions or adjust VA
programs as deemed appropriate.''
The VA tried to make the Choice Progrmn run more smoothly and
efficiently. Because the contractors were failing to find participating
doctors to treat veterans, the VA in mid-2015 launched a full-court
press to sign up private providers directly, according to the inspector
general. In some states, the VA also took over scheduling from the
contractors.
``We were making adjustments on the fly trying to get it to work,''
said David Shulkin, who led the VA's health division starting in 2015.
``There needed to be a more holistic solution.''
Officials decided in 20I6 to design new contracts that would change
the fee structure and reabsorb some of the services that the VA had
outsourced to Health Net and TriWest. The department secretary at the
time, Bob McDonald, concluded the VA needed to handle its own customer
service, since the agency's reputation was suffering from TriWest's and
Health Net's tnistakes. Reclaiming those functions would have the side
effect of reducing overhead.
``Tell me a great customer service company in the vvorld that
outsources its customer service,'' McDonald, who previously ran Procter
& Gamble, said in an interview. ``I wanted to have the administrative
functions within our medical centers so we took control of the care of
the veterans. That would have brought that fee down or eliminated it
entirely.''
The new contracts, called the Community Care Network, also aimed to
reduce overhead by paying the contractors based on the number of
veterans they served per month, rather than a flat fee for every
referral. To prevent payment errors like the ones the inspector general
found, the new contracts sought to increase information- sharing
between the VA and the contractors. The VA opened bidding for the new
Community Care Network contracts in December 2016.
But until those new contracts were in place, the VA was still stuck
paying Health Net and TriWest at least $295 for every referral. So VA
officials came up with a workaround: they could cut out the 1niddleman
and refer veterans to private providers directly. Claims going through
the contractors declined by 47 percent from May to Deceinber in 2017.
TriWest's CEO, McIntyre, objected to this workaround and blamed the
VA for hurting his bottom line.
In a Feb. 26, 2018, email with the subject line ``Heads Up...
Likely Massive and Regrettable Train Wreck Coming!'' McIntyre warned
Shulkin, then the department secretary, that ``long unresolved matters
with VA and cutTent behavior patterns will result in a projected $65
million loss next year. This is on top of the losses that we have
amassed over the last couple years.''
Officials were puzzled that, despite all the VA was paying TriWest,
McIntyre was claiining he couldn't make ends meet, according to agency
emails provided to ProPublica and PolitiFact. McIntyre explained that
he wanted the VA to waive penalties for clai1ns that lacked adequate
documentation and to pay TriWest an administrative fee on canceled
referrals and no-show appointments, even though the VA read the
contract to require a fee only on completed claims. In a March letter
to key lawmakers, McIntyre said the VA's practice of bypassing the
contractors and refen-ing patients directly to providers ``has resulted
in a significant drop in the volume of work and is causing the company
in-eparable financial harm.''
McIntyre claimed the VA owed TriWest $95 million and warned of a
``negative impact on VA and veterans that will follow'' if the agency
didn't pay. Any disruptions at TriWest, he said, would rebound onto the
VA, ``given how much we are relied on by VA at the moment and the very
public nature of this work.''
But when the VA asked to see TriWest's financial records to
substantiate McIntyre's claims, the numbers didn't add up, according to
agency emails.
McIntyre's distress escalated in March, as the Choice Program was
running out of money and lawmakers were locked in tense negotiations
over its future. McIntyre began sending daily emails to the VA
officials in charge of the Choice Program seeking updates and warning
of impending disaster. ``I don't think the storm could get more
difficult or challenging,'' he ,vrote in one of the 1nessages.
``However, I know that I am not alone nor that the impact will be
confined to us.''
McIntyre lobbied for a bill to permanently replace Choice with a
new program consolidating all of the VA's 1nethods of buying private
care. TriWest even offered to pay veterans organizations to run ads
supportiI1g the legislation, according to e1nails discussing the
proposal. Congress overwhelmingly passed the law (named after McCain)
in May.
``In the campaign, I also promised that we would fight for Veterans
Choice,'' Trump said at the signing ceremony in June. ``And before I
knew that much about it, it just seemed to be common sense. It seemed
like if they're waiting on line for nine days and they can't see a
doctor, why aren't they going outside to see a doctor and take care of
themselves, and we pay the bill? It's less expensive for us, it works
out much better, and it's immediate care.''
The new permanent program for buying private care will take effect
in June 2019. The VA's new and improved Community Care Network
contracts were supposed to be in place by then. But the agency
repeatedly missed deadlines for these new contracts and has yet to
award them.
The VA has said it's aiming to pick the contractors for the new
program in January and February. Yet even if the VA meets this latest
deadline, the contracts include a one-year ramp-up period, so they
won't be ready to start in June.
That means TriWest will by default become the sole contractor for
the new program. The VA declined to renew Health Net's contract when it
expired in September. The VA was planning to deal directly with private
providers in the regions that Health Net had covered. But the VA
changed course and announced that TriWest would take over Health Net's
half of the country. The agency said TriWest would be the sole
contractor for the entire Choice Program until it awards the Community
Care Network contracts.
``There's still not a clear tin1eline moving forward,'' said
Giddens, the former VA contracting executive. ``They need to move
forward with the next program. The longer they stay with the current
one, and now that it's down to TriWest, that's not the best model.''
Meanwhile, TriWest will continue receiving a fee for every
referral. And the number of referrals is poised to grow as the
administration plans to shift more veterans to the private sector.
American Health Care Association (AHCA)
Chairman Phil Roe, M.D.
United States House Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, D.C. 20515
Chairman Johnny Isakson
United States Senate Committee on Veterans' Affairs
Russell Senate Building - Room 412
Washington, D.C. 20510
Chairmen Roe and Isakson:
I serve as the Senior Vice President of Government Relations at the
American Health Care Association (AHCA), the nation's largest
association of long term and post-acute care providers. The association
advocates for quality care and services for the frail, elderly, and
individuals with disabilities. Our members provide essential care to
millions of individuals in more than 13,700 not for profit and for
profit member facilities.
AHCA, its affiliates, and member providers advocate for the
continuing vitality of the long term care provider community. We are
committed to developing and advocating for public policies which
balance economic and regulatory principles to support quality of care
and quality of life.
Therefore, I appreciate the opportunity today to submit a statement
on behalf of AHCA around the joint Senate Veterans Affairs Committee
and House Veterans Affairs Committee hearing entitled, ``Tracking
Transformation: VA MISSION Act Implementation.''
Prior to the VA MISSION Act, if extended care providers, including
nursing care centers, accepted a veteran patient, they were considered
to be a federal contractor and subjected to additional red tape -
simply because the patient was a veteran. Our centers already meet very
strict compliance guidelines under the Medicare and Medicaid programs.
Adding additional regulations on top of this is simply inefficient,
redundant, adds cost and takes staff time away from these veterans at
the bedside. This disparity of contracting and reporting requirements
has deterred many long term care providers around the country from
accepting veteran patients. As our veteran population ages, we must be
able to provide them with a continuum of care for their dedicated
service. Furthermore, we must be able to provide this care closer to
their home communities or in close proximity to their families and
support system.
The American Health Care Association and National Center for
Assisted Living (AHCA/NCAL) represent more than 13,700 non- profit and
proprietary skilled nursing centers, assisted living communities, sub-
acute centers and homes for individuals with intellectual and
developmental disabilities. By delivering solutions for quality care,
AHCA/NCAL aims to improve the lives of the millions of frail, elderly
and individuals with disabilities who receive long term or post-acute
care in our member facilities each day.
It is long-standing policy that Medicare (Parts A and B) or
Medicaid providers are not considered to be federal contractors.
However, if a provider currently has VA patients, they are considered
to be a federal contractor and under the Service Contract Act. The
Office of Federal Contracting Compliance Programs (OFCCP) has
administered onerous reporting requirements and regulations even beyond
those required by Medicare and Medicaid rules, which have dissuaded
nursing care centers from admitting VA patients. This limits the care
available to veterans needing long term care in their local
communities. Our veterans should not have to choose between obtaining
the long term care services they need and remaining near loved ones in
their community. Conversely, the same centers contracting with the
Centers for Medicare and Medicaid Services (CMS) are not subject to the
OFCCP regulations.
AHCA has long been advocating for policies that would make the VA
requirements for providers the same as they are for CMS and waives the
OFCCP federal contracting requirements. Provisions in the VA Mission
Act will help remove some of the existing red tape that may prevent
providers from being able to provide care to veterans. More
specifically, the VA Mission Act will ensure that extended care
providers, including nursing center care, can legally enter into
Veteran Care Agreements (VCAs). As the VA is working on implementation
of these agreements we must ensure that they are subject to the same
rules and regulations as any other Medicare or Medicaid provider as the
law intended. We also must ensure that the law is implemented in a
timely manner and our providers have access to VA staff with any
implementation concerns or questions.
The use of VCAs for extended care services would facilitate
services from providers who are closer to veterans' homes and community
support structures. Once providers can enter into VCAs the number of
providers serving veterans will increase in most markets, expanding the
options among veterans for nursing center care and home and community-
based services. AHCA appreciates the fact that your Committees have
worked to make these VCAs a reality. AHCA asks for your assistance in
ensuring proper and timely implementation of these agreements so those
veterans who have served our nation so bravely have appropriate access
to quality health care.
Thank you again for the opportunity to comment on this important
matter. If you have any questions, please do not hesitate to contact me
at [email protected] or AHCA's Senior Director of Not for Profit &
Constituent Services, Dana Halvorson, at [email protected].
Sincerely,
Clifton J. Porter II
Senior Vice President of Government Relations
GOVERANCE SLIDES
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National Committee for Quality Assurance (NCQA)
Better health care. Better choices. Better health.
Key Points
The National Committee for Quality Assurance is a non-profit that
works to improve health care quality and value through measurement,
transparency and accountability.
NCQA programs and extensive expertise align with MISSION Act
requirements and can help the VA expedite the law's implementation.
NCQA is the nation's largest health plan accreditor, stewards
HEDIS \1\ - the most widely used set of clinical performance measures,
and has the nation's largest Patient-Centered Medical Home (PCMH)
program.
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\1\ The Healthcare Effectiveness Data and Information Set (HEDIS)
is a registered trademark of NCQA.
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NCQA also has the nation's only Patient-Centered Specialty Practice
(PCSP) program, which closely aligns with VA Mission Act requirements
for provisions for ensuring quality and access for non-Department
clinicians.
The PCSP program requires agreements for information exchange
between specialty practices and primary care clinicians who refer to
them.
The program also includes optional criteria practices can meet to
earn additional points needed for recognition, such as electronic and
same-day access, patient experience surveys, and measuring and
reporting their performance.
We would be happy to work with the VA and its stakeholders to
tailor the PCSP program to meet specific MISSION Act provisions.
For example, we have a PCMH standard on query of
prescription drug monitoring program we could add to PCSP to align with
the MISSION Act provision on monitoring opioids.
We also could make optional criteria like same-day access
and measuring patient experience must-pass to fully align PCSP with
other MISSION Act provisions.
PCSP Recognition there could be a basis for certification of
eligible providers, as required by the statue, without requiring the VA
to ``reinvent the wheel'' that we developed through extensive
literature review, stakeholder engagement and public comment.
The Honorable Johnny Isakson, Chairman
U.S. Senate Committee on Veterans' Affairs
The Honorable John Tester, Ranking Member
U.S. Senate Committee on Veterans' Affairs
The Honorable Phil Roe, MD, Chairman
U.S. House Committee on Veterans' Affairs
The Honorable Tim Walz, Ranking Member
U.S. House Committee on Veterans' Affairs
Dear Chairmen Isakson and Roe & Ranking Members Tester and Walz:
Thank you for the opportunity to submit a statement for the record
on VA MISSION Act Implementation. The National Committee for Quality
Assurance (NCQA) is a non-profit organization established in 1990 to
improve health care quality through measurement, transparency and
accountability. We work to build consensus among stakeholders from
government, private industry, consumers and academia on ways to improve
quality. As a result, our programs are nationwide market leaders that
enjoy broad public and private sector support.
Our programs also closely align with critical Mission Act
requirements, allowing the VA to adopt them without ``reinventing the
wheel'' that we already developed through our extensive experience and
consensus-building approach. We stand ready and eager to help in any
way we can and hope the Department of Veterans' Administration will
consider NCQA a valued partner to support its quality improvement
efforts.
NCQA's Evidence- & Consensus-Based Process: We develop NCQA
programs and measures through a systematic, evidence- and consensus-
based process. We start with literature reviews to identify evidence
and guidelines on the most appropriate or best practices. We then
establish expert Committees representing patients and families,
clinicians and other health professionals, employers, insurers and
industry, academics and state and federal government to build consensus
on the best way to measure adherence to the evidence. We put the
resulting consensus out for public comment from all stakeholders and
incorporate those comments into final decisions. Once implemented, we
monitor the scientific literature and seek ongoing stakeholder feedback
on challenges, potential improvements or updated evidence and
incorporate as needed. And we post results in report cards on the
ncqa.org website.
Accreditation: NCQA has the nation's largest health plan
accreditation program, with over 181 million Americans in NCQA-
accredited plans. We accredit plans by rating their actual performance
and make the results publicly available to help the VA and many others
set benchmarks. The federal government requires such performance-based
accreditation for all plans participating in the Affordable Care Act
Marketplaces. As a result, more than 85 percent of Marketplace plans
are NCQA Accredited. In addition, 26 state Medicaid programs
specifically require NCQA Accreditation for managed care plans and
another 4 accept NCQA Accreditation. In addition, NCQA has the only
long-term services and supports (LTSS) accreditation program, which
four states require for managed care plans providing LTSS.
We also have accreditation programs for managed behavioral health
care, case management, disease management, utilization management,
credentialing, provider networks, wellness and health promotion, and a
multicultural health care distinction program to help address
culturally and linguistically appropriate services and reduce
disparities. We are happy to share the Standards and Guidelines
materials for any of these programs and explore how they, or parts of
them, might help meet MISSION Act requirements.
Quality Measures: NCQA stewards the Healthcare Effectiveness Data
and Information Set, or HEDISr quality measures. HEDIS is the most
widely used clinical quality performance measures and includes more
than 90 measures that track prevention, management of chronic
conditions, misuse and patients' experience of care. Medicare, most
states and many private purchasers require HEDIS, and insurers covering
57% of all Americans now report HEDIS.
We continuously update HEDIS for new scientific evidence, to remove
``topped out'' measures with little further opportunity for
improvement, and to raise the bar in areas that need improvement.
We are fortunate to have a liaison from the VA, along with other
private and public entities, on our HEDIS Committee for Performance
Measurement (CPM) Committee, which guides this work.
We have specific HEDIS sets tailored to the populations of
different product lines, such as Medicare, Medicaid and CHIP,
Marketplace and Commercial plans. We would be happy to work with the VA
to similarly tailor a set of HEDIS and other measures that meet the
specific needs of the veterans you serve.
Comparable Results for Public Reporting: It is critical to have all
clinicians within each specialty report the same measures to ensure
comparable information for MISSION Act public reporting. Programs that
let clinicians choose measures from a menu get the false impression
that quality is higher than it actually is because people will report
measures that make them look best.
It also is important to ensure that clinicians have sufficient
numbers of patients to obtain statistically valid measurement results.
Results for clinicians with small numbers of specific types of patients
are unreliable and will not provide useful comparative information to
VA stakeholders. Medicare's ``virtual group'' option addresses this
small numbers problem by letting clinicians voluntarily join together
for measurement as a group to achieve numbers large enough for valid
measurement results. The VA therefore may also want to explore virtual
groups as a way to obtain more valid comparable information for the
MISSION Act.
Reporting Burden & Meaningful Measures: We are well aware of the
amount of time clinicians now spend to report on quality, which takes
time away from patient care. We are diligently working to reduce
reporting burden by moving to a system in which we automatically derive
measurement data from electronic health systems, registries and other
electronic sources. This will allow us to access more robust clinical
data that are in these systems compared to health care claims that are
primary sources for most measures today. It also will let clinicians
report measures by merely entering data electronically as they do in
the normal course of patient care without additional data entry as
required today.
Additionally, we are working toward the same goals as the Centers
for Medicare & Medicaid (CMS) Meaningful Measures Initiative that seeks
to minimize reporting burden, streamline measures and focus on
outcomes. This includes automated reporting, systematic review of
measures to retire and developing outcome measures, especially patient-
reported outcome measures (PROMs).
Patient-Centered Medical Homes & Neighborhoods: NCQA has the
nation's largest Patient-Centered Medical Home (PCMH) program which
includes nearly 20 percent of all primary care physicians, plus
additional primary care clinicians, at over 14,000 sites.
PCMHs transform primary care into what patients want by building
better relationships between patients and the teams who care for them
and directly addressing fragmentation \2\ that plagues health care.
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\2\ Frandsen et al, Care Fragmentation, Quality, and Costs Among
Chronically Ill Patients, 2015.
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PCMHs do this by:
Helping patients get care when they need it, including
electronically and after hours.
Coordinating personalized, comprehensive, integrated
care.
Preventing costly, avoidable hospitalizations and
emergency department visits - particularly for complex chronic
conditions.
Improving staff satisfaction by ensuring practices have
systems and structures to work efficiently.
Leveraging health information technology (HIT) to enhance
access and coordinate care.
Reducing health care disparities and clinician burnout.
A growing body of evidence documents that PCMHs improve cost,
quality and patients' experience of care while reducing both
disparities and clinician burn-out. \3\ In Medicare, for example, PCMHs
reduce per capita spending by 4.9%. \4\
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\3\ NCQA, Benefits of NCQA Patient-Centered Medical Home
Recognition, 2017.
\4\ Health Services Research, Total Cost of Care Lower among
Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-
Centered Medical Homes, 2015.
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We also have related ``medical neighborhood'' programs for
specialists, retail and other clinics. Over 100 public and private
payers support our patient-centered care programs. Congress recognized
the value of PCMHs and Patient-Centered Specialty Practices (PCSP) by
legislating automatic credit for them under Medicare's Merit-Based
Incentive Payment System. The Department of Defense has worked with
NCQA to help XXXX of its primary care practices transform to PCMHs.
Similarly, the Health Resources Services Administration has worked with
NCQA to transform XXXX federally qualified health centers as PCMHs.
Patient-Centered Specialty Practices: Our PCSP program, in
particular, aligns with MISSION Act provisions for quality and access
of non-Department clinicians. We launched the program in 2013 and
updated it in 2016. It builds off of a PCMH foundation to establish
``medical \5\neighborhoods. \6\
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\5\ American College of Physicians, The Patient-Centered Medical
Home Neighbor, 2010.
\6\ Agency for Healthcare Research & Quality, Coordinating Care in
the Medical Neighborhood: Critical Components and Available Mechanism,
2011.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The program requires agreements for two-way information exchange
between specialty practices and primary care clinicians who refer to
them. The program also includes optional criteria practices can meet to
earn additional points needed for recognition, such as electronic and
same-day access, patient experience surveys, and measuring and
reporting their performance.
PCSP Recognition therefore could be a basis for certification of
eligible providers, as required by the statue, without requiring the VA
to ``reinvent the wheel'' that we developed through extensive
literature review, stakeholder engagement and public comment.
The chart below shows how our PCSP standards align with key VA
MISSION Act provisions for access - including same-day appointments,
measuring and reporting on quality, coordination and patient surveys.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We would be happy to work with the VA and its stakeholders to
tailor the PCSP program to meet specific MISSION Act provisions. For
example, we have a PCMH standard on query of prescription drug
monitoring program we could add to PCSP to align with the MISSION Act
provision on monitoring opioids. We also could make optional criteria
like same-day access and measuring patient experience must-pass to
fully align PCSP with other MISSION Act provisions.
Conclusion: NCQA for nearly three decades has worked toward our
mission to improve quality, access and patients' experience of care in
ways that closely align with the VA MISSION Act. We believe our
extensive experience, consensus-building approach and market leading
products that track MISSION Act requirements can add real value to your
efforts. We stand ready and eager to help any way we can, including
tailoring our work to best meet the VA's unique needs and challenges in
implementing the MISSION Act.
Thank you again for the opportunity to submit this statement for
the record. We welcome the opportunity to discuss these ideas in
greater depth. Please contact Paul Cotton, Director of Federal Affairs,
at 202- 955-5162 or [email protected] if you have any questions.