[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
MISSION CRITICAL: ASSESSING THE TECHNOLOGY TO SUPPORT COMMUNITY CARE
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, APRIL 2, 2019
__________
Serial No. 116-3
__________
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
38-953 PDF WASHINGTON : 2021
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Tuesday, April 2, 2019
Page
Mission Critical: Assessing The Technology To Support Community
Care........................................................... 1
OPENING STATEMENTS
Honorable Mark Takano, Chairman.................................. 1
Honorable David P. Roe, Ranking Member........................... 2
WITNESSES
Dr. Richard Stone, Executive in Charge, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 4
Prepared Statement........................................... 31
Accompanied by:
Mr. James Gfrerer, Assistant Secretary for Office of
Information and Technology/Chief Information Officer,
U.S. Department of Veterans Affairs
Dr. Melissa Glynn, Assistant Secretary for Enterprise
Integration, U.S. Department of Veterans Affairs
QUESTIONS FOR THE RECORD
House Committee Members To: Department of Veterans Affairs (VA).. 33
MISSION CRITICAL: ASSESSING THE TECHNOLOGY TO SUPPORT COMMUNITY CARE
----------
Tuesday, April 2, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 2:03 p.m., in
Room 2360, Rayburn House Office Building, Hon. Mark Takano
[Chairman of the Committee] presiding.
Present: Representatives Brownley, Rice, Lamb, Levin, Rose,
Brindisi, Cisneros, Lee, Underwood, Cunningham, Luria, Pappas,
Allred, Peterson, Sablan, Roe, Bilirakis, Radewagen, Bost,
Dunn, Bergman, Banks, Barr, Meuser, Watkins, Roy, and Steube.
OPENING STATEMENT OF MARK TAKANO, CHAIRMAN
The Chairman. Good afternoon. I call this hearing to order.
Today, the House Committee on Veterans Affairs is gathered to
assess the implementation status of the community care
requirements under the MISSION Act, including the technology
that will support the program.
The impetus for this hearing is a report prepared by the
U.S. Digital Service at the request of Dr. Melissa Glynn of the
Office of Enterprise Integration. Before we discuss the report,
I want to establish a few items for the record. First, I had
hoped that the U.S. Digital Service would be here today to
discuss both, the work that it is doing at VA in general, and,
specifically, its work on this report.
I want to be clear that I believe USDS is doing good work
at VA and in other Federal agencies. USDS is filled with very
talented individuals who have heard the call of public service
and are tempting to help fix very challenging technology
problems.
Although the administrator of USDS was invited, it appears
that the Office of Management and Budget, OMB, had a role in
Mr. Cutts, or his staff, not being here today. I have to say
that I am disappointed in this result, and I urge OMB to
reconsider whether its bureaucratic internal processes are
actually serving the government and the taxpayer well. If
Congress is prevented from conducting legitimate oversight
because of unnecessary bureaucratic hurdles, then it is a real
problem. I hope we will have an opportunity to hear from USDS
at a future hearing and to learn more about the work the
digital services team is doing at VA.
Second, I understand that there are sensitivities involved
in USDS's role in advising agencies on technology. We want
agency staff to speak freely to USDS and for USDS to be able to
provide unvarnished advice because we want agencies to succeed
at their technology projects. We want agencies to have the room
to fix known problems before it endangers an entire program.
The Committee understands that this report was not meant
for the public, but it is now in the open. And as the Committee
responsible for overseeing the implementation of one of the
most significant pieces of veterans' legislation, we are
compelled to ask questions about it. This is what brings us
here today.
Third, I want to be clear that this is a fact- finding
hearing. We have invited VA leadership here in order to
exchange information and to have a robust discussion about that
state of implementation. I want you to understand, Dr. Stone,
Dr. Glynn, and Mr. Gfrerer, that I want to have an open and
honest conversation, and if there are things that the Committee
needs to know about, such as resources, implementation
timelines, or the real state of the technology, this is the
time to share that information. We want transparency. Veterans
expect and deserve transparency.
And this is because when we talk about technology at VA, we
are talking about more than technology. Information systems at
VA support the very backbone of the mission of VA. These are
systems that directly impact veterans' lives, their health, and
their ability to access the benefits they have earned.
The MISSION Act is a big mandate and we need to get it
right. If the technology experts say that VA should cease
development on the Decision Support Tool and for VA to rethink
its approach to implementation, we want to understand those
recommendations and what VA is doing about them. If a veteran-
centric vision is not guiding this implementation, then we need
to figure out what needs to change. Our veterans deserve
nothing less.
So, I want to thank the witnesses for being here today and
I look forward to their testimony. And with that, I now
recognize Dr. Roe for his opening statement.
OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER
Mr. Roe. Thank you, Mr. Chairman. I welcome the opportunity
to be here this afternoon to discuss the implementation of our
new MISSION Act Community Care Program. That program is
intended to take place of many disparate Community Care
programs that the Department of Veterans Affairs uses today and
create a streamlined process for veteran patients to be
referred to community providers.
The MISSION Act requires that the Community Care Program to
begin on June 6th, just a little more than two short months
from now. I know that Secretary Wilkie and his team are working
hard to meet that deadline; however, United States Digital
Service, USDS, issued a report last month that was highly
critical of VA's implementation of the law to date and called
into question, VA's ability to ensure timely access to care for
veterans using authorities Congress provided under the MISSION
Act.
Some of the media reports, especially the headlines about
the report, were down right alarming. Unfortunately, alarming
reports about the readiness of major VA modernization efforts
are nothing new. We have seen VA stumble too many times because
of inadequate IT solutions, poor communication, failure to
properly train clinical and sports staff, contract problems,
and more. This Committee has done a deep-dive work into all of
those areas in the past and I am sure that we will continue
this moving forward.
But in the meantime, veterans are counting on us to
deliver. You heard me say before, and I will say it again, that
I believe in taking the time to get things right, not just get
them in a hurry. I said it in December when I chaired the first
oversight hearing regarding MISSION Act implementation, and I
will say it again now: I would rather postpone--VA postpone
implementation of this program than to rush to implementation
in name only and have veterans pay the price for it.
I do not want to repeat the mistakes that were made with
respect to the G.I. Bill last year. As such, I am taking the
additional service findings seriously and I am focused on
solutions. The way I see them, they fall into three general
areas. First, there are concerns about Decision Support Tool,
the eligibility-determination software underdeveloped to
support the Community Care Program. Second, there are various
critiques of this, strategic decisions VA made with regard to
the Community Care network contracts. And, thirdly, there are
continued alarms that VA needs to institute better
interoperability capabilities with community providers right
now.
I think the Digital Service recommendations are right on
target with respect to interoperability and the need to use
data standards in what are called ``application program
interfaces'' or APIs to jump-start interoperability with
community providers' electronic health records. Certainly, it
will undoubtedly improve interoperability, but the nationwide
rollout is 9 long years away and we are 60 days from getting
started. We are working on legislation that would create a
competitive interoperability strategy to make sure we resolve
this problem as soon as possible. I look forward to discussing
that bill in a future hearing.
As for other concerns detailed in the report, there is no
doubt that the rollout of the new Community Care Program will
bring with it, its own set of complications that VA will have
to overcome. The same could be said of any new endeavor.
Transformation is never easy, especially for an organization as
large and complex as VA.
I want to hear today how VA is preparing clinical and
support staff on the front lines for the rollout of this new
program, how they are training them on the new processes,
procedures, and systems, that they will need to work with and
how VA will mitigate any setbacks that may occur to prevent
disruptions to veteran care.
As to DST, my understanding is this new system is meant to
create an automated system to replace a manual process that is
been used for a number of years. If done well, the DST would
make processing veterans' eligibility more efficient, but its
failure or delay means continuation of the status quo, not the
falling off of some sort of cliff. The Digital Service report
raised the possibility of a worst-case scenario that the VA's
daily appointment capacity nationwide could be reduced by
75,000 if DST usability issues are as severe as the report
suggests.
I want to be sure that we leave this hearing today
absolutely clear on what would have to happen for the worst-
case scenario to come to pass. My understanding is it would
entail rushing DST into use after inadequate testing, that only
doctors are permitted to use the DST, rather than nurses or
medical-support personnel, and that VA employees try to use DST
with web browsers other than Google Chrome, and that a glitch
between those other web browsers and VA's EHR cannot be fixed.
I wanted you all to know this is not an infomercial for Google,
but it sounds like it would be a good idea for everybody at the
VA to download Chrome.
Now that we have this report out in the open and we are
discussing these issues, my sincere hope is that we can help VA
work through them, rather than arguing about them later about
what happened.
With that, Mr. Chairman, I yield back.
The Chairman. Thank you, Dr. Roe.
Before I recognize--not recognize myself yet--Dr. Stone,
you are recognized for 5 minutes.
STATEMENT OF RICHARD STONE
Dr. Stone. Good afternoon, Chairman Takano, Ranking Member
Roe, and Members of the Committee. Thank you for the
opportunity to discuss the implementation of information
technology systems that will support the new Veterans Community
Care Program under the MISSION Act.
I am accompanied today by Dr. Melissa Glynn, assistant
secretary for enterprise integration, and Mr. James Gfrerer,
assistant secretary for information technology, and our chief
information officer.
The MISSION Act is an unprecedented opportunity to increase
veterans' empowerment over their own health care and to drive
the entire health care industry on behalf of those that we
serve. Under the MISSION Act, veterans and their families will
be able to choose the balance of VA-coordinated care that is
right for them.
Our job in VA is to ensure that the VA health care system
is so exceptional that it earns the trust of America's veterans
and they, therefore, choose VA. We know that veterans who are
given the opportunity to choose their care from VA or from the
community will typically choose to stay with the Veterans
Health Administration. That is because research has shown that
the VA provides care that is as good as or better than what
veterans can receive in the community.
While we increase veterans' empowerment and choice with
Community Care, we are continuing to invest in our direct care
delivery system and will use tools provided under the MISSION
Act to ensure that high-quality, direct VA care is readily
accessible for veterans who choose it. VA's recent achievements
in expanding access to care are supported by new authorities
under the MISSION Act that focus on underserved facilities,
recruitment, and retention of health care providers. We are, in
fact, the only health care system in this industry to make
information about quality and access to VA health care fully
transparent to our patients and we will continue to increase
that transparency.
While our vision is to ensure veterans choose VA for their
care, we are committed to successfully implementing the
expanded Community Care options under MISSION Act. VHA
Community Care has partnered with information technology staff
to design technology improvements that will streamline the
process of identifying which veterans are eligible for
Community Care.
Because of the importance of the MISSION Act, VA has
welcomed broad input on how best to implement these major
programmatic changes. That is exactly why we asked U.S. Digital
Services to review the development of the Decision Support
Tool. Digital Services has offered VA in past initiatives.
While I acknowledge the draft report, I reiterate that VA will
be ready to offer veterans Community Care under the MISSION Act
on June 6th.
Once it goes live, the Decision Support Tool will improve
efficiency for VA providers, making referrals by helping to
simplify decisions about Community Care eligibility. But the
tool is not essential for implementing any of the new
provisions of the MISSION Act. VA is planning to develop tests
and deploy the Decision Support Tool by June 6th. In the event
that any technical challenge occur, VA will be able to make
eligibility decisions, using existing and enhanced methods and
tools. Veteran care will not be disrupted.
VA's actions to modernize our systems and leverage the
opportunities in the MISSION Act will place VA at the leading
edge of health care evolution. We are committed to building
both, the trust and health of our patients, and will continue
to advance options that empower them to receive care when and
where they need it.
Your continued support is essential to providing this care
for veterans and their families. Mr. Chairman, this concludes
my oral testimony. My colleagues and I are prepared to answer
your questions.
[The prepared statement of Richard Stone appears in the
Appendix]
The Chairman. Thank you, Dr. Stone.
Dr. Stone's full written testimony will be included in the
hearing record.
Before I recognize myself for questions, without objection,
I will enter the report from the U.S. Digital Services into the
record.
The Chairman. I now recognize myself for 5 minutes. So, I
wanted to begin with Dr. Glynn. Dr. Glynn, why did you request
that the U.S. Digital Service conduct a discovery sprint of the
VA's preparations to implement Section 101 of the MISSION Act?
Ms. Glynn. Thank you for the opportunity to be here today.
Well, I joined the VA coming from the private sector and it's a
common leading practice when you have a milestone, a priority
to enlist all of the expertise that we have at our disposal and
certainly believe that our veterans, you know, the best value
that we can bring to them is bring forward that level of
expertise. Digital Service represented that level of expertise,
especially around digital technology and pushing the envelope
on technology. So, we sought an independent perspective on our
implementation efforts and that was the impetus for the
request.
The Chairman. Did you have any particular concerns about
the implementation?
Ms. Glynn. There were no particular concerns, just making
sure that we were doing everything in our power to make sure
that the implementation would go smoothly, that we had thought
of every kind of pitfall, and we had thought of how to mitigate
the situation from an implementation standpoint.
The Chairman. Were there any other reviews or assessments
conducted about preparations prior to the discovery spread?
Ms. Glynn. No, there were not, sir.
The Chairman. This is really just your general standard
practice when you come onboard and are trying to--
Ms. Glynn. Yes, my responsibility is to make sure that we
deliver, and this was the path we took.
The Chairman. Okay. Thank you for that.
We understand that the U.S. Digital Service held a
discussion with VA after it prepared its report. Who from the
VA was present for that discussion; do you recall that?
Ms. Glynn. I know I was present. I'm trying to think of--I
would have to go back and look at the attendee list. There were
members of our working team, but there not broad representation
from some leadership. I would have to go back and check our
attendance to give you names.
The Chairman. Okay. If you would, I would appreciate that,
if you could provide that to the staff.
As you know, we have been concerned about access standards,
as currently contemplated. The criteria needed to develop the
tool adds further complexities and exposes the ambiguity in the
standards. The United States Digital Service requires a
simpler, technical approach to attempt to avoid inconsistent
and unfair results from this tool.
Do you agree with the USDS' recommendation?
Ms. Glynn. I believe I understood the recommendation that
in order to make sure that there was consistency that we would
have to put policies in place to support the fielding of the
tool and I believe that we can deliver that level of
consistency with the policies that are drafted currently.
The Chairman. All right. So, what is VA doing to establish
clear standards--I mean, you just mentioned the policies in
place--
Ms. Glynn. Yes.
The Chairman [continued].--and veteran-centric guidelines
to address the discrepancies due to data variation?
Ms. Glynn. So, we're working internally to make sure, I
think as Dr. Roe and yourself had mentioned, it is critical
that we are ready for June 6th, so we are working internally on
implementation planning and the rollout process, which includes
training, policies, all of those tools that will make sure that
there is consistency for the veteran working on communications
that are directed specifically for the veterans and their
family and support teams to make sure that there is
understanding of how we can implement these access standards.
The Chairman. Yeah, you know, as I was reading through the
U.S. Digital Service report, I am trying to remember some of
the particular--I mean, some of the particulars of just how--
some of the examples that they gave for how the tool could be
inconsistent. Of course, what we are concerned about is
veterans thinking that they should qualify and veterans not
qualifying, people comparing notes and finding out that they
are not qualified to go into the community and that this tool
was potentially a source of a lot of inconsistency.
But do you feel that you can get these policies in place in
time for--
Ms. Glynn. I personally feel, and my colleagues will
certainly join in and provide their perspective from technology
and from the leadership from the Health Administration, but
overall, I feel that the tool will actually help us drive
consistency and certainly drive more consistency. It is the
sort of front-facing dashboard, which will help everybody have
the same kind of perspective and see the same kinds of
information every time they have that opportunity to look at
whether they are going to receive care in the community or not.
The Chairman. That is great. My time is up.
I want to now recognize Dr. Roe for 5 minutes.
Mr. Roe. Thank you. I was sitting down for dinner last
night about 8:30 and my phone rings and it is a veteran who had
been in the hospital at our local hospital, which is about a
quarter mile from the VA medical center. So, he calls me up to
get his record transferred from--he can't get the record
transferred between his 7 days he had spent in the hospital, so
that when he sees his doctor over at the VA. We are having that
problem now 2 months from--so, how are we going to make sure
that there is a seamless flow of information--anybody can take
this--between the outside providers?
Because if this doesn't work, then the whole system won't
work. It will defeat what we are trying to do if we can't do
that one simple thing, is get that information from me on the
outside, back to the VA and vice-versa. That happened last
night.
Dr. Stone. So, certainly this is exactly the problem that
we have dealt with for decades across medicine and one of the
things that we are doing--and one of--there are 11 separate
information systems that we are implementing as part of the
MISSION Act. Some are out there already. Some are in further
development, but the ability to move medical records right now
is dependent upon the participation of various community
providers in our health information exchange.
One support we could get from the Committee, we would hope,
is that good discussion with the community providers about
participating in our health information exchanges so we are not
forced to either fax or hand-carry records back to the VA from
community referrals.
Mr. Roe. And this is for you, Dr. Stone, you said this, but
I want to make sure that we get it on record. How confident are
you that the VA is on track to enact the MISSION Act Community
Care Program on June 6th, as required by law? And the second
part of that question is: You mentioned something in your
testimony, if it didn't work by the--if the digital system, new
system didn't work, that existing and enhanced tools could be
used. What does that mean?
Dr. Stone. So, let me answer the second half of that first,
sir. We fielded last October, a provider-listing software
system. That provider-listing software system included 30- and
60-minute drive time calculations. That is been in use since
last October.
Now, since at least 2013, under the PC3 Program and then
under the Choice Program in 2014, our providers and our
provider care teams have been working hard to adjudicate 40-
mile distances for veterans, as well as wait times of 30 days.
What you have asked us to do under the MISSION Act is to
take some different access standards in order to adjudicate
whether the patient is eligible to go out. That work is going
on every day today.
What the Decision Support Tool does is automate it. So, if
I am seeing you as a patient and make a decision to send you
out for orthopedic care, that when I make that decision in
VistA or CPRS, our current electronic system, a pop-up comes up
that I need to use the Decision Support Tool. When I click on
that, the whole thing pops up and gives me all the information
I need on a single screen.
But if that fails or that system is just not at the point
that it should be, all of the software systems that are
necessary to support the referral of you to a patient--or to an
outside provider are in place.
Mr. Roe. Okay. And you feel comfortable that you will be
ready to go?
Dr. Stone. I do, sir.
Mr. Roe. And how will the experience of a veteran patient
who is seeking Community Care referral and VA employees, who
will be authorized Community Care referrals differ on June the
5th before the MISSION Act Community Care Program is
implemented and on June 7th after the MISSION Act Community
Care Program is--what difference will they notice, if any?
Dr. Stone. The mainstay of VA health care is the patient-
aligned care team, and what I mean by that is the physician,
the nurse, the assistance, the schedulers that all work with
that provider and that veteran in order to provide care. On
June 6th, just like on June 5th, the veteran will be
interacting with their care team in order to make decisions
ongoing forward.
So, although, I would not underestimate the fact that there
are multiple criteria that are included in the Act--and this is
complex work--for the veteran, it is not going to look terribly
different in their approach to getting care.
Mr. Roe. So, that pop-up screen is going to be the same
then? They won't notice a difference.
Dr. Stone. I think--with your permission, sir?
The Chairman. You may.
Dr. Stone. For you and I, as clinicians, we have spent our
whole career with people calling us up saying, what do I do?
All of us, when we get symptoms, and especially lay personnel,
when we have symptoms, you don't want people out just Googling
those symptoms and figuring they have got some sort of awful
thing and end up in the emergency room.
What you really want is them interacting with their
provider and making decisions together. We are not going to
abandon the American veteran on June 6th; they are still going
to be interacting with their care team, making decisions on
what is best for them.
Thank you, Mr. Chairman.
The Chairman. Mr. Pappas, you are recognized for 5 minutes.
Mr. Pappas. Thank you, Mr. Chairman.
I appreciate your comments. And, you know, my concern is
with the end user here and the veteran and their teams. I am
just wondering on Page 5 of the report, the quote is, ``Little
research has been done in the field to understand how veterans'
physicians and clinical staff are currently providing and
receiving care in the community through the VA before a new
process is established.''
And I am just wondering if you could talk a little bit more
about the field research that was done as part of the IT
rollout.
Dr. Stone. Yes, I can, and I appreciate that question. As
you are well aware, sir, we have been buying care since 1945.
We have been through 6 major transitions in care. I talked
earlier about the 2013 change in PC3 and the 2014 Choice Act
and now the MISSION Act. But, literally, since 1945, we have
been buying care in the community.
On any given day, we decide to buy care about 50,000 times
and we will see about 323,000 patients today. About 50,000
additional patients will go out to the community.
The Decision Support Tool was designed by our clinicians in
the field, and, literally, a field clinician designed this and
said, you know, what do I need today and what would be nice if
I had that all in a pop-up screen? And there are 6 major
information systems that connect to the Decision Support Tool
that provide a single screen.
And I have had an opportunity to see the prototype of it;
it is pretty impressive. I sat with other clinicians from the
field looking at it, and so the research, although, I would
guess I would refer to it as anecdotal because we drew in
people, it was all from actively practicing clinicians.
Mr. Pappas. And, you know, if there are delays in further
development or deployment of the new IT systems, I guess, do
you have contingency plans of how to stay on track and do you
potentially anticipate any further funds-transfer requests to
make sure things hit their mark and they are on schedule?
Dr. Stone. I think that the contingency plan is the
fielding of the other 10 software systems with the Decision
Support Tool as sort of being the icing on top that brings
everything together. Should the Decision Support Tool not be
effective or hit a technology glitch, then we will be working
just about the same way we are working today as we go through.
We do not anticipate large movement of patients into the
system. I don't think the MISSION Act is going to force
somebody that trusts their doctor to leave their doctor and
come to the VA. By the same token, I don't see patients that
trust their doctor in the VA leaving in large numbers to go out
someplace else. Now, there may be transactions of care, and we
monitor this, as I have said, on a daily basis.
The second question you asked is about funds transfer. As
you all are well aware, the MISSION Act was passed without
appropriation as we looked at the one-year implementation, as
we have moved our way through the requirements, as well as then
getting the feedback from the comment period on those
requirements for access, and as we then began to design these
systems and move forward. That is a lot of work to do in 12
months.
When we found ourselves without appropriation, IT
leadership came to me and said, Gee, we need some help. Now, IT
has committed funds to this, but we are able, because of the
generosity of all of you and how you funded us over the last
few years, that we do have the funds in order to support this
until appropriate appropriation occurs.
And, Jim, I don't know if you have additional comments?
Mr. Gfrerer. I guess from a technical perspective, the only
thing I would offer additionally is I think there is a lack of
understanding broadly around what the tool does. It is actually
pretty simple. It goes out. It looks at the master veteran
index. It then establishes some level of eligibility. It looks
at the provider database and it makes a determination around
drive and wait-time eligibility.
The other, I think, misconception is the tool does have the
opportunity to what is called in software ``fail elegantly'';
in other words, if any one of those steps, if there is an
interruption in the data query from the system, it can come
back with a null and continue on with the process. So, it is
not an all-or-nothing proposition.
Mr. Pappas. Okay. Thank you. I yield back, Mr. Chairman.
The Chairman. I now recognize Mr. Banks for 5 minutes.
Mr. Banks. Thank you, Mr. Chairman.
Once again, as I have said before, we really may be
whistling be past the graveyard with the access standards
debate. I understand that there is a lot of pent-up political
energy anticipating the release of the standards, but they
don't appear to be radically different than the existing
standards.
My concern is that the MISSION Act actually fixes Community
Care, that the situation actually improves. That we don't just
wind up with different programs with different names with the
same old problems. Claims processing has been far and away, the
worst problem.
Dr. Stone, the Digital Service recommends scrapping the new
Community Care network contracts. VA has a new claims system
called eCAMS used to pay the network administrators, but it is
my understanding that VA is expecting these contractors to
provide the new claims system that is actually used to pay the
providers' claims.
Is getting rid of the contracts realistic and what would it
mean to claims processing?
Dr. Stone. I don't find, sir, that getting rid of contracts
is realistic. I think we are going to need a third-party
administrator.
Let me talk a little bit about the standup of the Choice
system and, certainly, across the Nation we ran into very
substantial problems paying our bills, as well as the fact that
we needed to change out one of our third-party administrators
partway through that. We have done two things. Number one, we
have gone to a nationwide safety net under a third-party
administrator while we get our additional contracts out for
Community Care. Secondly, we have moved from processing from
about 140,000 claims a month to 1.7 million claims in the month
of March in paid claims. So, we have dramatically increased the
amount of claims that we are paying.
We will still need a third-party payor. We have two systems
coming online. One is eCAMS, which you talked about, which our
non-network providers will be paid from. The second something
called the Community Care Reimbursement System, CCRS, which
will literally pay our third-party administrators and monitor
their work. Those two systems are--the first, eCAMS is in
production in VISN 19 and will expand in the next few weeks
over the entire system. It is operating very well. The second,
the Community Care Reimbursement System is a new system that
will be completed in the month of May.
Mr. Banks. Okay. Let me move on.
Dr. Stone and Mr. Gfrerer, it is very important to me that
the claims-processing system improves. I never want to hear
from another veteran being hounded by a bill collector because
the VA or its contractors failed to pay a provider. VA is
asking the new network contractor to walk in the door with a
claims system that meets all of VA's requirements, meaning it
can handle all the EDI transactions that VA uses.
First of all, can anyone tell me what claims system the
company, I believe it is call Optum, uses? Dr. Stone? Mr.
Gfrerer?
Dr. Stone. I certainly cannot tell you, except that I have
had--I do a monthly meeting with Optum talking about problems
and this is--
Mr. Banks. If you don't know, maybe you can take that for
the record and get back with us?
Dr. Stone. I would be happy to do that for you.
Mr. Banks. Okay. So, Dr. Stone and Mr. Gfrerer, VA also set
out 14 requirements for how the contractor system will
adjudicate claims. Does the system already do those things, or
would the company need to modify it to meet VA's requirements?
Dr. Stone. We will take that for the record, also.
Mr. Banks. Okay. Mr. Chairman, Dr. Roe, I think that we
should keep an eye on both of these issues--they are very
important--I know it is a big lift.
And Dr. Stone, just as a follow-up to that, the VA also has
to provide a company with the correct fee schedules for every
type of claim. As you know, VA personnel have had a hard time
picking the right fee schedules to pay their own claims. Has
this problem finally been solved, and if so, how did you solve
it?
Dr. Stone. I believe it has been solved because it was part
of the contractual bid of the winning bidder that proposed a
fee schedule as part of it.
Mr. Banks. As simple as that?
Dr. Stone. Yes, sir.
Mr. Banks. Okay. With that, I yield back.
The Chairman. I now call on Ms. Brownley for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman.
Thank you all for being here and, you know, we, obviously--
this piece of it for implementation of the MISSION Act is
critically important and it was certainly concerning to all of
us here on the dais to read this USDS report. And just, you
know, in the executive summary it says really right up front,
it says, ``To stop the development on DST as it is currently
implemented.'' And it goes on to talk about the
interoperability with the 6 legacy systems and then goes on to
say, you know, ``adding this eligibility work to the already
time-constrained physician in a worst case could increase each
appointment by an estimated 5 to 10 minutes forcing physicians
to see approximately 3 fewer veterans each day and ultimately
decreasing the VA's nationwide capacity by approximately 75,000
appointments daily.''
That is a concern for me. When I read that I think--and,
particularly, we have an oversight responsibility to say we
should stop right here and now until we can get some assurances
and not just trust, but real honest-to-God assurances that we
are moving ahead, understanding some of these recommendations
that are coming out from this report and moving down a path of
success.
And so, I guess my question, Dr. Stone, you had said that
this was all designed, but with the input of practicing
physicians, but then the report gives some quotes from various
physicians and one of them says, These people are out of their
minds; they aren't housekeepers, door keepers, or garage men,
saying, you know, really, you are going to ask me to do all of
this, you know, sort of enforcement, who is eligible, who is
not eligible.
So, it raises my concerns. We don't have a great reputation
when it comes to IT within the VA, and so I guess my question
is, you know, how are you going to give us assurances that you
are traveling down the right road and at the same time, able to
meet these deadlines? It seems to me that if you have a way of
interacting, if you don't meet the June 6th deadline, you have
said that you have a way of addressing that, that you will do
it the way that you are doing it now and interacting with a
physician team and making, you know, good, solid clinical
decisions down the road. But if we don't meet that deadline, we
can do that, so I understand that there is a backup here, but
should we just be doing that now and taking a deep breath,
doing it as we are doing it and taking a deep breath and making
sure that we are doing this properly to ensure that we are
going down a road to success? It is a long-winded question, I
understand, but--
Dr. Stone. Congresswoman, it is exactly the question. This
is complex work that you have asked us to do and I wouldn't
underestimate it in any way. There is a lot of new
requirements. There are a lot of new pieces to it, and in
essence, every single veteran that we are seeing needs to have
adjudicated, are they eligible to go out.
And so, I would say, are we concerned? Yes. Do I think that
the Decision Support Tool will make life easier when it comes
into fruition? Yes.
That said, the Choice Act expires on the 6th. I have no
ability to buy care if we don't go forward. We must go forward
with the MISSION Act on June 6th. And that said, I think your
expectation of me is to be transparent, especially when I am
concerned.
What I have to say to you is that I am very, very pleased
that the team has been working closely with IT. That we have
gotten a third party to take a look at us, that has given us a
really hard look, hence we are sitting here, but--
Ms. Brownley. And I applaud you for doing that, too.
Dr. Stone [continued].--most importantly, it was a chance
to take a good hard look at ourselves. And so, are we concerned
about the complexity of work? Absolutely, but I am optimistic
that we are going to get this done.
Now, that optimism is not a blind optimism. It is an
optimism by the fact that we have gotten our provider-
automated system out into the field last October and our
providers and our care teams that I referred to earlier are
using it today and they could call up the 30- and 60-minute
drive time today.
Ms. Brownley. Well, I thank you for that, and I appreciate
your confidence, and, you know, I hope that we can interact
more frequently as we move forward in the next couple of
months. I apologize that I am over my time, but I hope that we
can, you know, communicate closely over the next few months to
keep us informed of the progress.
So, sorry, Mr. Chairman. I yield back.
The Chairman. Thank you, Ms. Brownley.
Who is next? Ms. Radewagen, you are recognized for 5
minutes.
Ms. Radewagen. Thank you, Chairman Takano and Ranking
Member Dr. Roe for holding this hearing.
I want to thank the panel for being here. I also want to
welcome my constituent, Ms. Lisa Tuato'o, who is all the way in
from American Samoa on Homeland Security business.
I appreciate everyone's work here to ensure that the
MISSION Act implementation is going smoothly. And as I have
mentioned in previous hearings, I also appreciate that the VA
is really making an effort to meet the unique needs of those in
rural areas, as well as the U.S. territories through the
Community Care contracts.
So, my question is for anyone on the panel who can answer:
What is the status of the Community Care network contracts and
what are you doing to ensure that the transition from the PC3
Choice contracts to the CCM contracts will be as seamless as
possible for veterans, community providers, and VA staff? And,
also, what do you any are the major differences between the
current PC3 Choice contract and the CCM contract that members
should be aware of?
Dr. Stone. So, the status of the contracts are as follows:
Region 1 in the northeast part of the United States is in the
process of implementation with Optum, as you heard previously.
The major difference in that contract is a stable payment
levels tied to Medicare, and so I think that is the major
change, as well as probably about 140 other data points that we
have locked through with the vendor as we have gone forward in
improvements and how we interact with each other, and we would
be happy to lay those out for you in separate session.
Region 2 and 3 are under protest. They were awarded and
then protested. We anticipate in the month of May, they will
come out of protest, and, certainly, I would not suppose what
the effect is of the protests, but we are hopeful.
Region 4 will award in the next few months. Those bids are
back in. That is the western half of the United States. Those
bids are all in and being evaluated, and I probably should say
nothing more about that at this point.
Region 5, Alaska, we just finished tribal consultations and
will implement the further either RFIs or RFP over the next
year.
And then Region 6 will also--we have consultations, an
industry day actually tomorrow in Region 6 that we will begin
to look at what the questions of the provider community are in
providing care in the Pacific.
Ms. Radewagen. Thank you. USDS alleges that the additional
administrative burden of continuing to pursue the new contract
arrangements outweigh their benefit. Do you agree? Why or why
not?
Dr. Stone. So, I do not agree, and as a matter of fact,
they refer in their report to maybe we should use Medicare.
Please remember that Medicare uses third-party administrators.
Medicare does not deliver care directly.
I spent most of my career in the upper Midwest. I dealt
with Blue Cross of Illinois as the Medicare adjudicator of
payment of claims. So, I think that criticism reflect a failure
to understand Medicare and how it reports. And I am not being
pejorative in any way towards U.S. Digital Services, but that
concept just didn't bear fruit.
I think the second thing they suggested is maybe we have to
use TRICARE. And please remember that I spent 25 years in
uniform, so I know a little bit about TRICARE and certainly
have been a consumer of TRICARE services over my family's time
and service and even today.
The problem with the regional delivery systems with TRICARE
is they are centered in areas of the country that just are not
broad enough in order for us to take care of the dispersed
veterans as we look in the Pacific, as we look in Alaska, and
in the rural areas of this country. Forty-five percent of our
veterans are out in rural areas, well away from TRICARE
delivery networks.
Ms. Radewagen. Thank you, Mr. Chairman. I yield back the
balance of my time.
The Chairman. Thank you, Ms. Radewagen.
Mr. Lamb, you are recognized for 5 minutes.
Mr. Lamb. Thank you, Mr. Chairman.
Dr. Stone, if we could just step back for a second, the
MISSION Act and Choice before that were all done before I
arrived in Congress, but my understanding of them is that the
expansion of Community Care was motivated by what is good for
our veterans, right?
Dr. Stone. Absolutely. I think all of the work going back
to 1945, has been what is good for veterans.
Mr. Lamb. And we have kind of reached a shared
understanding at this point that one thing that might be good
for them would be to give them more choice in where they could
get providers; again, for their own sake, not for anybody
else's sake, but so that they could feel like they had some
choices for things that were closer to home, for simple
conditions, they wouldn't have to go all the way to the VA;
that was the idea, right, to do something nice for veterans?
Dr. Stone. Sir, I would not suppose to think or to suppose
what Congress thought as they passed it, but as I read it, I
think this is law that is good for veterans.
Mr. Lamb. I agree. I guess my point is just we didn't do
this to make things easier on the VA or to give Congress
something good to talk about. We did it because veterans wanted
it and we thought it might be a better way to get them health
care; would you agree with that?
Dr. Stone. Yes.
Mr. Lamb. Now, does this Decision Support Tool that we are
talking about here, does it allow veterans, themselves, to use
it?
Dr. Stone. It does not.
Mr. Lamb. Okay.
Dr. Stone. It is a provider-facing, patient-aligned care
team facing tool.
Mr. Lamb. So, it does not provide a tool for the veterans,
themselves, before they go in to the VA to determine if they
are eligible for Community Care?
Dr. Stone. It does not, although, that is something that
Digital Services suggested, and we are respectful of that.
Now, the complexity of delivering care to America's
veterans has to reflect how complex their disease processes
are. This is not about giving them a Google site to go to and
then make decisions. Those decisions are best made in
conjunction with their provider care team.
Mr. Lamb. And I appreciate that, and that is a mission that
we have given you and that you are trying to execute, so I
totally understand that.
But as a result of the way that this Decision Support Tool
was developed, the discussion and decision is going to have to
take place during the appointments, right?
Dr. Stone. No, not at all. Certainly, the patient can call
for their care team as they do today. They can call for an
appointment and say, Gee, am I eligible to go out? And all of
this can be done with the patient-aligned care team scheduler
or the nurse. Usually, we do involve either the nurse or the
physician in that discussion just because of the complexity.
I referred earlier to, gee, if I want to refer you to out
for an orthopedic visit, well, if you are on a blood thinner,
just me referring you out to an orthopedic surgeon will create
a disconnect in care and potential risk if you are not talking
to your care team.
Mr. Lamb. Right. Absolutely.
So, do you accept the finding or suggestion of this report
that this will probably result in fewer appointments a day
systemwide because of the additional time that it is going to
take from the care teams?
Dr. Stone. I do not.
Mr. Lamb. Okay. And that is a fair disagreement.
I am trying to think of how I want to ask this. Given what
we have happening right now is the risks presented in this
report, one of which, for example, is that--I guess I want to
back up. The report suggested that several primary care
providers told the authors of this report that veterans often
are not presented directly with a choice for a veteran's care
if they don't ask about it from their care team or don't ask
about it with the providers. Have you heard that before, as
well?
Dr. Stone. Just in the report.
Mr. Lamb. Okay. Do you accept that as a possibility? I
mean, that has, obviously, been said to these authors.
Dr. Stone. Certainly, I would expect all of our providers
to act in an ethical and honest manner with their patients. I
think that is how you earn future trust.
Mr. Lamb. Sure.
Dr. Stone. And I would expect everyone to discuss exactly
what is in the best interests of the veteran.
Mr. Lamb. Okay.
Dr. Stone. And that is actually in the law as part of the
statute, that if it is in the best interests of the veteran,
even if they don't qualify to be referred out because of wait
times or drive times, that if it is it in their best interests,
they should be referred out.
Mr. Lamb. Sure. And that part I understand. I guess it is
just coming back to my point that what we are supposed to be
doing here is presenting our veterans with an actual choice
that they get to make, obviously, in conjunction with their
care team. But we have created a tool that they are not able to
use. They have to know to ask about it in some cases from their
care team. They may have to call. They may have to do it in an
appointment, which slows it down. They may reduce the number of
appointments systemwide, and that seems, to me, to not
accomplish the mission of giving them more actual choices.
Given all of that I just--and I am out of time--I just urge
you to consider slowing down on this and doing a less- complex
version of it on June 7th. I understand that you are under the
gun timewise, but this seems rushed in a way that does not
reinforce the actual choices that our veterans get to make.
And, Mr. Chairman, I yield back. I apologize for going
over.
The Chairman. All right. I thank the gentleman.
I would like to move on to asking Mr. Barr, you are
recognized for 5 minutes.
Mr. Barr. Thank you, Mr. Chairman.
Dr. Stone, good afternoon. How are you? That is okay. Dr.
Stone, last year my office assisted a veteran from our district
who, after receiving two hip replacements from the same Choice-
approved doctor through TriWest, was told at the desk of the
doctor's office when he showed up for an appointment that he
was no longer eligible to see that doctor under the Choice
Program. After looking into my constituent's case, it was found
that due to a VA system glitch, my constituent's distance
eligibility was erroneously terminated under no fault of his
own.
How is the VA going to ensure that veterans are not going
to be arbitrarily kicked off of the eligibility rolls for the
Community Care Program, particularly, with the issues being
highlighted by the rollout of the Decision Support Tool?
Dr. Stone. So, I think this is exactly what I was talking
about in the Provider Profile Management System that we rolled
out 6 months ago, and have begun to look at that getting ready
for June 6th. That is a generally used tool across at least 13
states and 20 health care systems in that 30- and 60-minute
time.
We have got really good data that we currently have on our
wait times on the 20- and 28-day wait time that the secretary
has ordered as part of the access standards and the eligibility
to go out. What we don't good data yet is the wait time in the
community; it is just not as transparent as we are in VA.
Now, in the Decision Support Tool, when we looked at the
prototype, it pops up our wait time, as well as any information
on the distance from the home address for the veteran in the
30- and 60-minute software system, as well as any information
eventually when we accumulate it on wait times in the
community. So, in essence, that provider team scheduler will
need to make a phone call with you, the veteran, in front of
them, to find out what--how long it is going to be before we
can get you in before you leave the office.
Mr. Barr. And this DST is an automated system, and I think
my veterans would want to know the role of human beings in
checking the system. And so the next question I have is, you
know, what role will VA personnel play in reviewing the
accuracy of these determinations and then also when there is a
change in a veteran's Community Care eligibility?
Dr. Stone. So, I think we are comfortable with the work and
transparency that we have been doing for a number of years on
wait time--how many days' wait there is inside of our system
and the accuracy of that data. It appears that the 30- and 60-
minute tool is going to be solid just because it has been used
for many years in the commercial space.
But your question really relates to how are we going to
manually override that and check it?
Mr. Barr. Well, so, in other words, if the veteran is
pretty confident that he or she would meet the criteria and for
whatever reason the digital tool, the Decision Support Tool,
rather, makes an alternative, a different determination, you
know, how can there be an appeal? How quickly can the veteran
question that automated determination?
Dr. Stone. So, that automated determination is also going
to be overseen by your provider care team, and your provider
care team then will decide if it is in your best interests. And
if you are convinced that because of some other health problem
or transportation problem, you ought to be someplace else for
your care, then the beauty of this law is it says, if in the
best interests of the veteran, that can all be overridden right
at the point of care, at the point of scheduling.
Mr. Barr. As you know, one of the flaws, with respect to
the implementation of the Choice Program was a failure to
properly communicate with trained VA staff regarding
expectations, processes, procedures, et cetera. What is the
status of that work for the MISSION Act Community Care Program,
and can you ensure that the VA staff on the front lines will be
ready, willing, and able to effectively administer care under
this new program on June 6th, again, speaking to the issue of,
you know, human beings ultimately being accountable, Dr. Stone?
Dr. Stone. So, we have automated all of this training and
both, web-based training and e-training. We have got at least
two dozen training modules out even for our community providers
and Web sites and I would be happy to go through that training
with you. But this has all been done through automated training
that does not require the provider to go to anyplace.
Mr. Barr. Thank you. I yield back.
The Chairman. I knew call on Ms. Lee for 5 minutes.
Ms. Lee. And I am down here. Thank you all for coming out.
And, clearly, this is an incredibly complicated task with, you
know, very far-reaching and potentially grave consequences if
we don't get it right.
And, Dr. Stone, I wanted to ask you, you made a comment
earlier, you know, this, obviously, is dictated by the MISSION
Act. There is a June 6th deadline. And I wanted to ask you,
like, waving a magic wand, if we did not have this June 6th
deadline, what would you be doing differently?
Dr. Stone. I think the ability to move--first of all, the
ability for me to buy care in the community expires on June
6th. What I would be doing differently is trying to figure out
how to go back to a system that preceded 2013 that didn't work
very effectively.
I think all three pieces of legislation could have been
implemented slightly differently, but it is good legislation,
and I think it brings us from 6 or 7 different ways of buying
care to 1. That is good for the veteran. The veteran will now
be able to understand from a single methodology how decisions
are made, instead trying to figure out which program they are
eligible for.
I wanted to ask, you know, the MISSION--and I am sorry if
this was asked earlier, but the MISSION Act emphasizes the need
for efficiency, potential consolidation for the provider
network. The USDS recommended that the VA discontinue its
efforts to create its own payer network and explore--perhaps
explore partnering with another existing network. What is the
response to this--the VA's response to that recommendation?
Dr. Stone. Congresswoman, we did go over that previously.
Let me say to you that the two recommended systems that they
suggested were Medicare, one. Medicare does not run its own
delivery system. That is done through fiscal intermediaries out
in the commercial space. The second is TRICARE. And the problem
with TRICARE is it is just not broad enough because of the
rural nature of many veterans. Forty-five percent of veterans
are in rural space.
Ms. Lee. Are you exploring any other opportunities?
Dr. Stone. Certainly. We are exploring a number of other
opportunities. Number one, we have given priority to our third-
party administrators to the federally disadvantaged clinic
system. We have over 900 providers that are in the federally
disadvantaged clinic system that participate with us. In fact,
we will buy this year almost three quarters of a billion
dollars' worth of care through those Federal clinics.
Secondly, we continue to work in innovative methods with
the Department of Defense, as well as Indian Health Service, in
order to buy services through them as preferential partners.
Ms. Lee. And finally, the USDS also recommended using
resources to have like a concierge approach to managing care,
essentially closing the loop with the veteran-centric approach.
What is your response to that recommendation?
Dr. Stone. I think that is exactly what we are trying to
move to. I think by--if you were seeing me as your provider,
you would get me involved in a concierge approach of what is
best for you, what are the nuances and difficulties of care.
Because of the extraordinary amount of pain we deal with
across the veteran population in chronic pain, degenerative
diseases of the spine, hips, and knee, it requires a concierge
approach to every one of our veterans. And I think this goes
back to Congressman Lamb's question of what you want is a
veteran-centric approach to this care.
Ms. Lee. Thank you. I yield.
The Chairman. Dr. Dunn, I recognize you for five minutes.
Mr. Dunn. Thank you very much, Chairman Takano. Dr. Stone,
it is good to see you again. I want to describe my district
briefly to you, so you understand my situation. I have 19
largely rural counties, a couple of CBOCs, one VA hospital. The
vast majority of my veterans--there are 70,000 veterans living
in my district--the vast majority of them per force meet all of
the choice requirements. I mean, you just know they aren't
within an hour's drive of specialty care. So and it is the
specialty care, specifically, I would like to address.
We saw--we never turned away a veteran in my offices, but I
will say that our accounts receivable with the VA habitually
were in the 180 day plus range. There are a lot of physicians
who will not tolerate, that can't tolerate that really in their
offices. And so the reimbursements become the problem. And the
choice of provider goes away if there is no reimbursing the
other specialty providers there in the district.
And so what I would like to know is what are we going to do
to make sure that this problem ends, so that we don't have the
problems with the veterans going out, seeking care, and there
is no reimbursement?
Dr. Stone. Congressman, first of all, your district is one
of the most rapidly growing areas we have in the country when
it comes to veterans. Veterans are seeking that area of the
country and--
Mr. Dunn. We are nice to our veterans. We like them down
there.
Dr. Stone. Thank you, sir. Secondly, the primary corporate
structure of the physicians providing care to veterans in your
district and many areas of the country is small businesses.
They cannot carry 180-day accounts receivable. So for that
reason, community care has been working hard to increase the
number of claims that they are processing on a monthly basis.
And I monitor that on a weekly basis of where they are at.
And I am pleased that we have moved, and I have said
earlier from 140,000 claims a month to over 1.7 million. We
will approach 2 million claims processing a month and begin to
exhaust this backlog.
As this system grows, we will need to continue that growth,
and therefore I have authorized the expansion into a third-
party claims payer that will move us towards the goal of at
least 90 percent of claims paid within 30 days.
Mr. Dunn. We would be very grateful for that. That would
certainly be a change that we would experience. And I would
like to know that we have some recourse offline. We will talk
to your office. Some recourse to talk to when I do get
complaints from my district from the care providers on the
civilian side. And we can talk about that offline.
Dr. Stone. I know that wasn't presented as a question, but
please understand that we recognize the fact that unless we
have credibility as a payor, we cannot maintain a delivery
network. And our providers in the community deserve better than
that.
Mr. Dunn. We understand each other. Let me ask you also if
you will nail something down for me. I am a little fuzzy on
this. Is it only the physicians who are using the DST, or is it
your mid-levels, nurses, administrative personnel, contracts,
who gets to use the DST?
Dr. Stone. You are exactly correct, sir. It is entire
patient aligned care team. So it could be the--
Mr. Dunn. Okay, so not the veteran, but anybody else in the
VA, basically, who does patient care?
Dr. Stone. Exactly. This is not unique. It could be the
telephone scheduler. It is not just the physician. So if I, as
a physician, make a decision to refer you out for some sort of
episode of care, it may be that the nurse that is working with
me that day, the physician extender that is working with me
that day will pick that up and finish that work. This is not
simply the physician who needs to do that.
Now, we have talked to a number of physicians that enjoy
doing all of that work, right up to the point of picking up the
phone and calling the referring office for an appointment.
Mr. Dunn. We don't have a lot of those. Thank you very
much. I appreciate your reassurances, Dr. Stone. I look forward
to working with you. Mr. Chairman, I yield back.
The Chairman. Thank you, Dr. Dunn. I now recognize Mr.
Bilirakis for 5 minutes. He is not here. I now recognize Mr.
Watkins for 5 minutes.
Mr. Watkins. Thank you Mr. Chairman. I have the honor of
representing eastern Kansas, rural communities. I think
communities 3,000 people and less. So the MISSION Act is very
important to us. Thousands of rural veterans in eastern Kansas
live outside the VA medical facility areas. They need community
care options and the MISSION Act is imperative.
So Dr. Stone and Mr. Gfrerer, which IT systems do you
consider critical to implementing the MISSION Act by June 6th
and which IT systems are not?
Dr. Stone. So all of them help. All of them help, right
down to those systems and program integrity for us to detect
fraud. So all of them help and together, they make our life a
lot easier. In order to do this, none of them can we operate
without. Now, it just makes it a more inefficient system.
And this is where we acknowledge digital services concerns.
I think you bring it all together, and you lay DST over the top
of it, it all works pretty well. But every one of them, we are
still going to be delivering care on June 6th if every one of
them failed.
Mr. Watkins. Thank you very much, Mr. Chairman. I yield my
time.
The Chairman. Thank you. Mr. Meuser, you are recognized for
5 minutes.
Mr. Meuser. Thank you, Mr. Chairman. Thank you all very
much for presenting here today and discussing this complicated
and difficult initiative. I have had experiences in
implementing IT systems in the private sector, as well as for
the Commonwealth of Pennsylvania, when I served as Secretary of
Revenue. Something we called a tax integration system and
modernization act.
The moment I reviewed when I entered as secretary, after
the--it went online or began to be implemented a few months
earlier and contracted, after about 3 months, I realized that
everything was going to be about 6 or 7 months delayed from the
initial--from the get-go.
So I certainly can understand a system like this and
running into some shortcomings and some--particularly from
contractors, then perhaps overstating what can be done in a
perfect scenario. I also recognize very clearly the backgrounds
of all of you, just incredibly impressive. Thank you for your
service and thank you for what you are doing now, Dr. Stone,
Assistant Secretary Gfrerer.
Mr. Gfrerer. Gfrerer.
Mr. Meuser. Gfrerer. All right, and Dr. Melissa Glynn. I
won't go through your resumes. You probably did that before,
but incredibly impressive and clearly you are the right people
to be handling this very challenging task, which is very
important to all of us.
I, as well in my district, Pennsylvania Ninth, I have
80,000 plus veterans. We really--we have two Vas: one in
Lebanon VA, which does a terrific job for our veterans, as well
as the Wilkes-Barre VA. So again, very appreciative and
understanding.
Now, the USDS assessment did point out three areas. Number
one, it says your IT systems to automate veterans' eligibility
determinations for community care. That is clearly important. I
will leave it open to whoever would like to respond to that.
And maybe you did earlier. My apologies. But where do you think
you are versus their assessment or just honest--your honest
look at where things are right now? And when do you think you
will get to where you would be satisfied?
Mr. Gfrerer. Congressman, as I came on in January, the
decision had been made that, you know--as you know probably
from your experience, you have to manage a program according to
a certain set of risk parameters, cost schedule, and
performance. This one was clearly falling into the schedule
bucket. As you said, too, with the delays that you have seen in
IT systems, you know that information technology serves to
automate and support a business process.
And so when you look at one year to accomplish everything
that is in a very complex statute, and then all of the
activities that have to occur from the regulations, to
eliciting user requirements, to--from there on forward. That is
quite a lengthy flow if you are going to get it right.
And so I would tell you that I am confident we will have
the functionality by 6/6 for the decision support tool. I think
when you look in the report, you are sometimes left with
choosing--making a binary choice. We talked about the ability
of the system to fail elegantly across the different criteria
that it is going to look at, so it doesn't just blow up and
cease.
Alternatively, I would say as well that we certainly looked
at and within VA, we are going to an application program
interface architecture, right? Applications are the wave of the
future. We are going to the cloud, again, managing that program
to risk. We just couldn't get there fact enough from January to
June 6th.
Now, that said, there is a parallel development team that
is taking those requirements around that Legacy architecture
and developing it on an API basis. So it is really not an
either/or, it is an and. It is just, again, managing the
program to a schedule risk.
Mr. Meuser. All right. Very good. I'm going to jump to the
third that they mentioned here regarding health record exchange
with the community providers. That certainly sounds like a bit
of a challenge. Maybe you could just address that in the
remaining seconds.
Mr. Gfrerer. I know at the HIMSS Conference in Orlando in
January; the entire medical and health care community really
looks to the VA to be a leader in this area. So we are, again,
via our API approach, we are rapidly, and we are a leading
adopter of the fire standard, you know, the fast health care
interoperability resource standard. Again, the entire market is
looking to the VA to develop that and kind of put its weight
behind it, because I think, again, as someone that has served
in uniform for 28 years and then migrated to VA with putting my
paper records over, and you know, no one thinks that that is a
vision of a future that we all want to be a part of.
And so whether it is--those health information exchange
opportunities and those standards are things that we are
rapidly adopting. And as Dr. Stone sort of alluded to, bringing
our community care partners into that. And part of the reason
for that, too, is around the proliferation of electronic health
record systems.
Someone corrected me a couple of weeks ago. I thought I was
on over about 80 systems and I said--they said, ``No. It is
about 400 different electronic health record systems.''
Mr. Meuser. Well, thank you. You have many veterans
counting on you. Let us know how we can help. And I yield back,
Mr. Chairman.
The Chairman. Mr. Bergman, you are recognized for five
minutes.
Mr. Bergman. Thank you, Mr. Chairman. And thanks to all of
you for being here. Now that Mr. Gfrerer, right? Colonel
Gfrerer, retired.
Mr. Gfrerer. Recovering.
Mr. Bergman. Recovering. Well, that is--there is no such
thing as a recovering Marine. Maybe retired. We know that one
of the challenges that we have in any system, but especially,
let's say as related to United States military, the challenge
of balancing, maintaining Legacy systems while we overlap and
implement Next Gen systems. So now that you are in the VA
system, I am hopeful that you will bring that tenacity that you
had as a Marine to the urgency to truly seek a balanced
blending of the Legacy with the Next Gen, whatever it is we are
trying to do, and not look at life just linearly: we are going
to do A, then B, then C. We are probably doing all three of
them at the same time. We are just running at different speeds.
So let's take, for example, here as to the two community
care network contracts that are under protest currently. Why
has the secretary not exercised his authority to allow the
contractors to proceed with their work while the protests are
being resolved? To me, that sounds linear. How can we keep the
ball moving forward while we deal with protests?
Dr. Stone. I would need to defer that to counsel. Counsel
made the decisions on how to proceed with this, and advised the
secretary, and I would ask to take this one for the record.
Mr. Bergman. Well, please do, because the--again, the--we
all have our roles to play and while we need to make sure we do
everything legally, we can't let the battlefield just lay, if
you will. In this case, the battlefield is the implementation
so that we can move it forward. So I appreciate you taking that
for the record. And because if there is a way possible, let's
keep the inertia going.
Next question. What abilities will the VA have to improve
these IT systems over time, again. Okay. We are going to go
from Legacy to Next Gen. But that Next Gen is going to be
Legacy at some point. And how do we keep a--because I think in
somebody's resume here, I saw Lean Six Sigma certifications.
How do we keep that system updated over time, future updates,
what is the plan?
Mr. Gfrerer. Congressman, I would start by saying that part
of the job of the Chief Information Office is to constantly
partner with the business and find ways to increase
effectiveness, contain cost, but also drive innovation, right?
And so sometimes that innovation responsibility of the CIO is
really kind of top of mind. I know it is something that I have
prioritized. While I have all of the, you know, kind of keeping
the lights on activity, I can't just be maintaining, as you
would say, the Legacy systems. I have to be looking to the
future.
I would point to a few things that specifically--certainly,
our migration to an electronic health record. I am spending a
lot of cycles on that with our partner, Mr. John Windom in that
office, and Dr. Stone. Certainly our movement to the cloud. We
have an entire enterprise cloud strategy where we are moving
applications and there is a lot of really good use cases around
that, about increased functionality.
You know, one of our team told me about recently was right
before Hurricane Harvey, the decision was made to move some
benefits applications into the cloud, along with that
associated data. And as soon as Harvey rolled in and the on-
premise data centers were shut down, because it had been
migrated to a cloud, the rating officials were able to continue
their business.
Mr. Bergman. Okay. Well, and I know my time is running
short and I appreciate that because there are sometimes you
cannot predict, stuff happens. Life happens around you. But it
would, I think it would be helpful for all concerned,
especially as Congress, as we continue to give money to the VA
for projects, that if there is a way on some kind of a scale
for all of you to say, ``Well, we think at this point, 2 years
from now, or based on whatever it is, it could be a guess, but
let's see how close we get.'' Because without any kind of
predictive nature, we are going to have surprises. Let's face
it. That is just the nature of the world. If we could predict
and see how close we get to some of these surprises, then it
would help us long term to have better planning, and I yield
back, Mr. Chairman.
The Chairman. Thank you, General Bergman. Mr. Cisneros, you
are recognized for 5 minutes.
Mr. Cisneros. Good evening. Thank you all for being here.
Or I should say good afternoon. Thank you all for being here
today. You know, in my--I'm from California, 39th Congressional
District, and unfortunately, we don't have a VA health center.
My veteran constituents need to travel at least 30, 40 plus
miles in about two hours of traffic to get to the VA care,
which depending on the time of day, like I said, could be
anywhere from an hour to two hours.
This is something I am very mindful of when thinking of VA
services for the veterans in my district, as traffic congestion
is a way of life for many constituents in Los Angeles and
Orange County area. And although the MISSION Act has expanded
the community care access standards to include drive time,
there are major concerns that neither the law nor the draft
regulations specify to an adequate level of detail how the VA
should calculate drive time and wait times to make eligibility
determinations leading to unreliable and inconsistent
calculations.
Additionally, the USDS report finds that much of the data
necessary to determine eligibility is currently housed across
several VA systems that don't interoperate. However, the VA
only gave itself 12 weeks to develop the decision support tools
meant to address this. It is a big concern of mine.
So where is the VA in the development of tools veterans
makes access on the development Web site to determine the drive
time associated with their local facility? And is the VA open
to adopting a people-centered approach in this field, providing
that most liberal interpretations possible for eligibility
criteria as recommended by the USDS report?
Dr. Stone. Congressman, we appreciate the nature of the
drive times in that area of the country. There are many areas
of the country that we have struggled with drive times and
various different drive times at different times of the day or
different times of the year.
We struggled mightily with the 40-mile limit, just because
of geography that 40 miles in an area like the Pacific
Northwest may be just completely untenable. Whereas, in
Montana, it may be fairly acceptable in an area that is-- that
you are able to get through.
So as we adjudicate this, and as we work these, the actual
30- and 60-minute drive time is a commercially available system
that has been linked to one of our programs and is in current
use today. So we are comfortable at its accuracy because it has
been used for many, many years, including in the State of
California to assess the adequacy of the Medicaid system. And
so the California Medicaid system uses the same software
system.
So we are comfortable with its accuracy, but remain
respectful of the fact that different times of the day are
pretty tough to get around the area that you represent.
Mr. Gfrerer. Congressman, I just wanted to address your
technical concerns and I think this was before you stepped in,
potentially. There are certainly three systems that are at the
core of what the decision support tool has to reference in
order to help the clinician and the veteran reach this best
medical interest decision. One is the master veteran index; one
is the enrollment system; and the other is the provider
database. So there is just kind of no getting around. Those are
three very discreet and differential databases.
And I know in the report, one of the things it talked about
was the brittleness of the architecture, really referring to
could the data calls on these three systems handle the
additional load that would potentially occur, even with say a
50,000 to 75,000 patient a day referral. And I can tell you
that we have done the sufficient stress test to show that it is
orders of magnitude more capable of handling that increased
load.
Mr. Cisneros. On another--just kind of changing the subject
a little bit. The overachieving findings of the report also
said the need for a veteran-centric vision for implementation.
For technology implementation, this translates to user-based
approach. In this case, the user is both the care team that has
to manage the eligibility determination and the veteran whose
care is at issue. Do you agree or disagree with the assertion
that the VA leadership has to define what community care should
be from a veteran's perspective?
Dr. Stone. Congressman, I think that is exactly what we
have done. The VA's foundational service is to be veteran-
centric and to recognize the nuances of service and the
injuries that it causes, even injuries that can't be seen. And
the reason this system was designed in this manner is because
of that belief in the integration of care between the provider
team and the veteran.
This is not simply a system that you can go out and say to
a veteran, ``Well, get on the Web site and decide if you are
eligible to go out or not.'' That doesn't at all recognize how
many of our patients suffer from mental health diseases, as
well as the amount of even--I could just focus on military
sexual trauma. The real importance of this as a health care
system is about our ability to integrate care and not just
simply send people out to a Web site in order to make a
decision on care.
Now, that is the same as people have in the commercial
space, and the frustration of trying to figure out what doctor
to go to. What we do is partner with the veteran and make this
a veteran-centric system.
Mr. Cisneros. I yield back my time.
The Chairman. We have an option for a second round of
questions. I will recognize myself for the first 5 minutes. Dr.
Stone, you mentioned the participation of community care
providers in the VA's health system as a concern of yours. Can
you tell me what --
Dr. Stone. Sir, I--
The Chairman [continued].--that they may or may not
participate. Is that the--
Dr. Stone. There are areas of the country where Medicare
participation is very low: Alaska. As we begin to work our way
through and effectively recover from a period of years in which
we were slow to pay bills, as you heard from your colleagues,
we need to regain the trust of the providers in America. And so
I do worry about the willingness to participate in our system
as we regain that trust.
The Chairman. Okay. So that wasn't about the Health
Information Systems? The--
Dr. Stone. That was not.
The Chairman [continued].--ELH, so that was, okay.
Dr. Stone. No, that strictly related to the fact of are we
paying the right rates to earn your trust, and are we paying in
a timely manner, and are we giving you a bundle of care that
is--
The Chairman. I understand now the issue. Okay. I want to
ask you about the Patient Aligned Care Team initiative within
the VA and the workflow that that entails. And there was--on
page five, there was some pull quotes from actual VA
physicians. One said--one of the pull quotes says, ``There was
a misconception that the primary care provider,'' i.e., the
provider within the VA, ``will co-manage community care.''
And there is a sense of, like, resentment about that. And
it says, ``I will instruct every one of my primary care
providers not to do this.'' And I believe that is coming from a
place of the concern within VA among the primary care providers
that the way MISSION is going to be implemented is not really
taking into consideration about the workflow and the potential
disruption of the workflow. Can you respond to that?
Dr. Stone. I can. And it certainly is a concern. And what
it reflects the fact is we need to do more training. We need to
do more communication. And as we have come out of the period of
comment on the regulations on access standards, we have begun
communicating more effectively, I think, with our providers.
Our providers are nervous. Our providers are concerned
about the change. And our providers are concerned about
privatization. They read about privatization all the time and
they are concerned of, ``Are we going to do that?'' I would
hope that from my comments today, and my previous testimony,
and the secretary's testimony, you would recognize that the
fact that we are not privatizing, the future of the VA's health
care system is in the hands of the American veteran. And just
like you and I get to choose sort of where we are going for our
health care, the American veteran will choose, and they will
determine our future.
The Chairman. Well, I will remind you that it is a pretty
limited choice. I mean, depending on which health care plan we
belong to. We stay in network, or out of network, and we pay
our price if we go out--I mean, this idea that choice is being
extended willy-nilly to all veterans, I think no American seems
to have that unless you are super wealthy and can--it is no--
price is no consideration, right?
Dr. Stone. Yes, sir.
The Chairman. So it is--I mean, I want to be careful about
the language we are using because I think people in the
leadership of the administration often throws it out there and
I think it is misleading, because we are not looking at
unfettered choice here. And to create a sense of--like the
charter school movement. I mean, that is also--I also have
problems the way we talk about choice in that context as well.
So I hope that we are retaining the coordinating role of
the VA and it is not sort of being outsourced to some sort of
technological formula that we are looking all--I mean, I am
concerned about how much--we don't even know how much all of
this is going to cost in terms of what these access standards
will do to the cost of care.
And that is, I think, the concern is that will it raise
cost so much in private sector care that it is going to hollow
out existing internal capacity?
Dr. Stone. Sir, I appreciate your comments and that is
exactly right. I think all of our intention is to have the VA
remain as the centerpiece of the decision process for America's
veteran. And as America's veterans go through these decisions,
it is our intention to remain the integrator of that care.
The Chairman. Thank you. I recognize Dr. Roe for five
minutes.
Mr. Roe. Thank you, Mr. Chairman. Obviously, and briefly,
so look, I am a veteran and I have been a patient. And like any
other veteran or patient, civilian or not, I am going to seek
out the best care that I feel for me and my family. That is
what I am going to do, and I think that is what veterans will
do. And you started out, Dr. Stone, VA care in most places is
as good or better than the community. And I think that sale
itself will keep people in the VA.
Where I live, the veterans are very happy with it. We are
very fortunate where we live. But that is not the case in other
places. And so we tried to create a MISSION Act that was good
from east coast to west coast. And I think we have succeeded if
it is implemented properly and doing just that to meet most--
you can't meet every need, but most veteran needs.
And we know that VA can't be everything to everybody, just
like the private sector sometimes has to--we have a very
sophisticated center at home, but we have to occasionally send
some out for a super specialist somewhere that we can't handle
at home. So having said that, just a couple three real quick
questions.
One is still making sure that our doctors out there in
network can access VA data. That is extremely important for me
when I see a patient to have all necessary information, and
will that be live come June 6th? Can we get to it? Number two,
it is amazing you processed 1.7 million claims, but did the
payment go out on time? Did we process those claims that were
clean claims and got the check out the door for those folks?
Because I talk to people all the time. They have hundreds
of thousands of dollars of back claims to VA.
Dr. Stone. First of all, the community care referral and
authorization system allows us to move data to the community
providers.
Mr. Roe. Okay.
Dr. Stone. So to your first question, yes. I think one of
those software systems of the 11 I talked about moves data out
in an effective manner to--
Mr. Roe. That's great.
Dr. Stone [continued].--you as a provider if I am sending
somebody to you.
Secondly, it is my understanding that the 1.7 million last
month was not only authorization but also payment of claims.
Mr. Roe. And thirdly, we need to know the status of the
clinical networks because--and we asked VA in 2014 to do
something no organization can do, which is to put up a
nationwide network together in 90 days. We also asked MISSION
in 365 days to put this network out. And the contracts are just
now going out. Are your partners that have gotten these
contracts now, and I know there are two that are being held up
right now, is that network going to be ready to go? Because
once again, if that network is not ready to go, it won't work.
Dr. Stone. So this is exactly why when I came last summer
to this position, we stood up the Triwest nationwide system as
a safety net, to begin building across the Nation a delivery
system as our other vender went away. And then to hopefully use
that provider network as our next generation of community care
comes on board to actually facilitate a rapid and smooth
transition.
The other thing that digital services did in their report
is they actually questioned continuity of care. Please
understand that we have been through this a number of times,
including as Health Net stepped away. And we will not disrupt
the care if we have authorized a bundle of care for somebody
that has got ongoing chemotherapy or ongoing dialysis. We are
not going to disrupt that care.
Mr. Roe. Because really all the patient--all the veteran
patient cares about June 7, I come down to the VA and I need an
appointment, can I get an appointment? That is all they really
care about.
Dr. Stone. That is right. And the goal, sir, in community
care and in all of VA is to take on the administrative burden
of this ourselves and to make sure it is invisible to the
veteran and we are just meeting the veteran's needs.
Mr. Roe. I appreciate it. I will yield back.
The Chairman. Thank you. Ms. Brownley, you are recognized
for 5 minutes.
Ms. Brownley. Thank you, Mr. Chair. I wanted to ask, again
on the USDS report, do you agree with what they suggest that if
the criteria model for the MISSION Act fully implemented, you
know, the regulations of 30 minutes for primary care, 60
minutes for specialty care, that the--that they expect a
significant increase from 685,000 veterans under the Veterans'
Choice Program to 3.7 million veterans under the MISSION Act.
Do you believe in that premise or--
Dr. Stone. It is my belief that they got that from our
actuaries. I am not really sure the source of the 3.7 million,
Congresswoman. But I would bet it is from our actuaries. Now,
there is something else--
Ms. Brownley. Does that mean that is good data or--
Dr. Stone. I think it is good data. I think it is good
data. I think that already today, every single veteran we are
seeing, we are looking at these criteria based on 40 miles and
30 days. We are just changing this to 20, 28 days; and 30- and
60-minute drive times.
I don't believe that if you came to me as a doctor, and I
incurred trust from you in the way I handled myself and my
professionalism, that if I looked at you and said, ``Well, you
know, I can find you another doctor 10 minutes closer, or 30
minutes closer, or even an hour closer, you are going to leave
me.'' I think very few people will leave a provider based on
that kind of convenience.
And we have actually surveyed five million veterans that
don't use us. And that is exactly what they have told us. It is
not just about convenience. So I don't see that somebody that
is seeing us, and trusts us, and our trust scores are
approaching 90 percent, about 87 percent, are going to leave us
based on the fact that we have told them that we have got
something that might be more convenient.
Now, if they have never interacted with us, I think that is
different. And I think that is a different discussion. By the
same token, I don't see people that are out in the community
already looking at the MISSION Act and saying in great numbers
that they are going to come in to see us because of something
that is in the MISSION Act. I don't think people leave your
doctor for that reason.
Now that I have said that, let me say to you that it
appears in the first 6 months of this year that we have grown
by a million visits. Not only that, 100,000 veterans have
joined us that weren't with us 6 months ago. So I think we have
got to watch it, we have got to communicate with you. I think
we owe you, as part of oversight, really predicting what the
future looks like. But I don't think there is--that 3.7 million
number we should be concerned that droves of patients are going
to leave us.
Ms. Brownley. Thank you. Thank you for that. And just one
last question in terms of the PPMS, these acronyms always just
drive me absolutely crazy. Reading all this stuff, I have to go
back and figure out, you know, what that acronym means again.
But with regards to that, so the wait time in the community can
vary day to day, week to week. So the question is how will the
VA ensure that the PPMS data is current so that eligible
veterans are able to make informed decisions about where they
obtain their health care and how frequently will the system be
updated to ensure it is providing the most accurate and up to
date data?
Mr. Gfrerer. Congresswoman, I am not--I would have to take
that one for the record. I am not in a position to tell you
exactly how those updates occur around that database and that
data element. But I can take that for the record.
Ms. Brownley. Very good. Thank you. I yield back.
The Chairman. Thank you, Ms. Brownley. All--well, I want to
thank all of the witnesses today and we look forward to working
with you, your staff, and the USDS in the future. All Members
will have five legislative days to revise and extend their
remarks and include extraneous material.
Again, I thank you all for appearing before us today and
this hearing is now adjourned.
[Whereupon, at 3:43 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Richard A. Stone, M.D.
Introduction
Good afternoon Chairman Takano, Ranking Member Roe, and Members of
the Committee. Thank you for the opportunity to discuss the Information
and Technology (IT) systems that will support the new Veterans
Community Care Program required by the VA Maintaining Internal Systems
and Strengthening Integrated Outside Networks Act of 2018 (the MISSION
Act). I am accompanied today by Dr. Melissa Glynn, Assistant Secretary
for Enterprise Integration, and James P. Gfrerer, Assistant Secretary
for Information and Technology and Chief Information Officer.
The MISSION Act, in combination with the transformative
modernization efforts underway in VA, represent a unique opportunity
for VA to lead the evolution of health care. VA is a leader in patient
empowerment: we were among the first in the industry to make health
care information and documents fully transparent to our customers; we
are building technology and programs that are inclusive of the most
important people in Veterans' lives, their families, and caregivers; we
are driving innovation and research that informs better care and
services; and we are emphasizing the whole health of Veterans well
beyond the institution. For example, the MISSION Act has strengthened
VA's ability to furnish telehealth across State lines and into
Veteran's homes, allowing VA to enhance the accessibility, capacity,
and quality of VA health care. VA has integrated telehealth technology
with the Whole Health initiative, which is an approach to health care
that empowers and equips Veterans to take charge of their health and
well-being by focusing not only on treatment but also on self-
empowerment, self-healing, and self-care. To accomplish that, VA is
combining innovative complementary treatments like yoga and tai chi
with the latest technology to allow Veterans to receive world class
treatments in their homes or local VA clinics. VA will also launch a
Whole Health app this year that will guide Veterans through the
Personal Health Inventory and resources available at VA.
Alongside the MISSION Act, VA is expanding access to care in our
direct care delivery system. VA is implementing the Improving Capacity,
Efficiency, and Productivity initiative, a collaboration among VA
offices focused on creating efficient practice solutions, including
offering extended hours (evenings and Saturdays), using telehealth and
video appointments, providing facilities with appropriate guidance for
overbooking, and adopting point-of-care scheduling.
These are only a few examples of the way VA is using its authority,
including the MISSION Act, to strengthen both the in-house and
community aspects of our integrated system, giving VA the ability to
build on its innovative legacy and drive the industry forward.
Veterans, their families, and their caregivers will now be more able to
choose the balance of VA-coordinated care-whether direct care or
community care-that is right for them, with an optimized network of
excellent choices.
MISSION Act Community Care IT Collaboration
The Veterans Health Administration (VHA) Office of Community Care
(OCC) has been developing and deploying improvements to the community
care program to improve the experiences of Veterans, community
providers, and VA staff. Work began in 2016 to develop a standardized
operating model for the community care staff working in VA medical
centers (VAMC) and in recent years tools and technologies have been
developed to support the upcoming implementation of the Community Care
Network contracts. The operating model provides a standardized way to
manage consults, referrals and authorizations, and perform care
coordination to ensure good customer service.
Even before the MISSION Act passed, OCC was working closely with
VA's Office of Information and Technology (OIT) to discuss expected IT
requirements and systems that would either be impacted by the new law
or created entirely as a result of the law. Since passage of the
MISSION Act, OCC has worked closely with OIT to develop new tools, such
as a Decision Support Tool, to aid in community care eligibility
determinations, as well to support enhancements to existing tools that
will ensure that the capabilities necessary to implement the MISSION
Act will be in place.
Deployment of many tools that will support implementation of the
MISSION Act already started and, for example, a tool known as the
Provider Profile Management System (PPMS) was deployed nationally in
Fiscal Year 2018 that provides VA staff and Veterans with a directory
of VA providers, Department of Defense (DoD) providers, and community
providers who are part of VA's network. In the coming months, VA will
be deploying a new referral and authorization system that will
streamline information sharing between VA and community providers and
expand its deployment of Electronic Claims Adjudication Management
System (eCAMS), which is a tool that will modernize our claims
processing systems and improve both timeliness and accuracy of payments
to community providers.
Enhanced community care eligibility determination capability:
Decision Support Tool (DST): This tool will help VA
identify Veterans eligible for community care, as well as the basis for
their eligibility, and will document the Veteran and provider decision.
The tool interfaces with the PPMS, enrollment system, scheduling, and
the access standard table on the use of community care. This will be
available June 6, 2019.
Enhanced referral and authorization/care coordination capabilities:
Provider Profile Management System (PPMS): This is a
directory of providers, including those in the DoD military treatment
facilities, VAMCs, and in VA's community provider network. This is
active with 1,500 VA users accessing the system 10,000 times in the
past month since it went live in October 2018. PPMS will allow Veterans
to find community providers via the VA.gov site. It also supports VA
staff in identifying community providers when scheduling appointments
for Veterans.
Health Share Referral Manager (HSRM): This is a referral
and authorization tool that includes a portal and will standardize how
VAMC staff create and share referrals with VA's network contractors,
other community providers, and with the claims payment systems (for
validation that a claim was authorized by VA). It allows for electronic
exchange of information between community providers and VA. Deployment
is scheduled to begin in April and complete in June 2019.
REFDOC: This is a Web-based tool that allows VA users to
quickly extract a Veteran's health information and compile it into a
PDF to send to community providers. This was deployed in May 2017.
Community Viewer: This allows community providers to
securely view Veteran health information via a Web browser. This was
deployed in May 2017.
Virtru Pro: This is a secure method for VA to exchange
health information with community providers using encrypted e-mail.
This was deployed in May 2017.
Enhanced timeliness of payment of claims:
Electronic Claims Adjudication Management System (eCAMS):
This is a modern, efficient, and automated commercial-off-the-shelf
product to process health care claims submitted by community providers.
eCAMS will replace the legacy system and increase our capabilities to
improve the accuracy and timeliness of payments.
VA OIT IT Development Process is Modernizing
VA recognizes that we have faced technology challenges at times.
Thus, we have made a strategic pivot in our approach to technology
implementing the MISSION Act requirements. The business and technical
elements of the organization have formed a tight partnership and
focused on improving the Veteran experience. For example, OIT and VHA
worked together on Community Care projects such as the PPMS release in
September 2018. Prior to the deployment of this system, VA staff were
required to locate provider information on spreadsheets and SharePoint
sites. This system gives VA staff the ability to do location searches
to identify nearby providers while scheduling care for Veterans outside
of the VA. The Community Care teams also released the Veterans Choice
Locator on VA.gov on December 26, 2018. This release allows Veterans
and Staff to search for approved VA providers within a search radius by
provider specialty. Prior to this functionality being available on
VA.gov, Veterans had to call their local facility to identify
providers. Our aim is for technology to be an enabler of streamlined
business functions-all of which become invisible to our customers as
they enjoy a smooth, coordinated, personalized experience of care.
U.S. Digital Services Report
VA recognizes that we needed all available talent at the table for
this shift in approach. U.S. Digital Service has been helpful in
driving differential approaches to some VA business processes.
Therefore, we recently invited them to review the development of key
systems, including the Decision Support Tool (DST). Under the MISSION
Act, DST will streamline the eligibility determination process to
improve Veterans' experiences and support our local clinicians and
field staff by improving the efficiency and effectiveness of
eligibility determinations for Veterans seeking community care.
U.S. Digital Service agreed to review the IT system and related
policies over a 2-week period. They reviewed whether VA's technical
solutions would meet the legal requirements for implementing the
MISSION Act. While we fully anticipate that the DST will be operational
on June 6, VA will still have the ability to perform the necessary
functions to support MISSION Act implementation if it is not
operational on-time. We look forward to continued engagement with U.S.
Digital Service.
Funding Transfer Request
To ensure the technology to support the MISSION Act is successful,
VHA recently responded to a request from our OIT partners for
additional funding. Despite proposing to use funding from the Medical
Community Care and Medical Services accounts, the repurposing will not
adversely affect Veterans' health care. Medical Services funds are
available for repurposing as a result of efficiencies in the hiring
process and improved ability to fill critical positions with the
correct staff, reducing the need to over-hire to meet retention
targets. VHA maintains staffing levels sufficient to provide
exceptional care to Veterans, as evidenced by improving access and
outcome measures. Medical Community Care funds are available for
transfer as a result of higher than expected medical care collections
from other health insurance for care provided in the community.
On top of the $33.56 million committed from OIT, VA intends to
transfer $95.94 million of Fiscal Year 2019 funds ($68.78 million from
the Medical Community Care account and $27.16 million from the Medical
Services account) to the IT Systems account to fund IT projects for
various MISSION Act programs, including the projects listed above. VHA
and OIT are collectively tracking the planned use and allocation of
that funding through to fruition. Currently, VA OIT is tracking all
MISSION Act investments at the program and project level where they are
being executed. All MISSION Act spend plans are tagged with a unique
identifier to allow transparency and accurate reporting of expenditures
linked to existing program performance and goals. Additionally, VA's
OIT Chief Financial Officer currently hosts weekly meetings with
program officials to discuss planned acquisitions to meet the mandate
and any foreseen risks that need to be mitigated.
Conclusion
VA's transformation under the MISSION Act, is one of the largest
such efforts the Department has ever seen. Veterans' care is our
mission. We are committed to rebuilding the trust of Veterans and will
continue the improvements we have made to Veterans' access to timely,
high-quality care from VA facilities, while providing Veterans with
more choice to receive community care where and when they want it. Your
continued support is essential to providing this care for Veterans and
their families. This concludes my testimony. My colleagues and I are
prepared to answer any question.
Questions For The Record
House Committee Members to: Department of Veterans Affairs (VA)
Questions for the Record from Congressman Mike Levin
Question 1: The USDS report quotes a Marine veteran from my
district saying, ``I don't know how they hand off records for a
consult. I'd like them to have my history, so they could understand my
condition.'' I understand the VA plans to use its new HealthShare
Referral Manager to exchange records. However, the USDS found it
unlikely that community providers will adopt a VA-specific platform,
instead opting for manual, one-off methods such as fax or secure mail.
Dr. Stone, have you considered this concern, and how do you plan to
address it?
VA Response: HealthShare Referral Manager (HSRM) allows VA and
community providers to easily upload and download medical documents
such as medical records and images. Prior to providing care to a
Veteran, community providers can download and review documents that VA
shares regarding the Veteran/patient. Following care, community
providers upload relevant patient care documentation for VA's review.
The use of HSRM eliminates faxing and emailing documentation and
greatly enhances the accuracy of patient documentation. In the
instances where a community provider does not utilize HSRM, a packet of
information that contains referral details, additional referral
information, billing and precertification information, patient details
to include relevant medical history, and standardized episode of care
(SEOC) information will be sent by the provider's preferred method to
include secure email or electronic fax. VA medical center staff will
document that medical packet was sent to a community care provider
within the VA Consult Toolbox. The use of HSRM is highly encouraged in
the Community Care Network by our contracting partners.
Question 2: Dr. Stone, in your written testimony, you state,
``While we fully anticipate that the DST will be operational on June 6,
VA will still have the ability to perform the necessary functions to
support MISSION Act implementation if it is not operational on-time.''
While I hope that the Decisional Support Tool is rolled out on time and
smoothly, I also want to be sure we're prepared if that doesn't happen,
as the USDS report anticipates. Can you explain in more detail how VA
would conduct the new eligibility determinations without a functional
DST?
VA Response: The Decisional Support Tool (DST) went live and has
been operational since June 6, 2019; however, VA has developed and
tested a community care eligibility contingency plan which requires VA
staff to access the Veteran's static community care eligibility (e.g.,
No Full-Service VA Medical Center in the State, Service Unavailable,
Grandfathered Choice, certain categories of best medical interest,
specifically Hardship) through both the Enrollment System and
Computerized Patient Record System (CPRS). These static eligibility
determinations generally will not change, as opposed to dynamic
eligibility criteria (e.g., designated access standards, remaining
categories of best medical interest, and VA medical service line),
which could result in different eligibility determinations based on the
care that is needed. VA staff will access the Veteran's dynamic
Maintaining Internal Systems and Strengthening Integrated Outside
Networks (MISSION) eligibility through Veterans Information Systems and
Technology Architecture (VistA) clinic data and the Provider Profile
Management System (PPMS).
Question 2a: Who would be responsible for making those
determinations, and how would that affect the existing workflow?
VA Response: DST went live and has been operational since June 6,
2019. In the unlikely event that DST is not available, VA's system will
allow VA clinic staff, including the provider and clinic scheduler, to
access the Veteran's static community care eligibility through both the
Enrollment System and CPRS. Clinic staff can review the Health Benefits
Plans section in the CPRS Patient Inquiry screen to determine the
Veteran's static eligibility for community care. These will be actions
that will need to be taken by the clinic staff within the appointment
workflow or when speaking to the Veteran over the phone.
The codes in CPRS will appear as follows:
CPRS Eligibility Health Benefit Plans
Veteran Plan - CCP Grandfather Grandfathered
----------------------------------------------------------------------------------------------------------------
Veteran Plan - CCP State with No Full-Service Medical No Full-Service VA Medical Facility in Veteran's State
Facility of Residence
----------------------------------------------------------------------------------------------------------------
Veteran Plan - CCP Hardship Determination Hardship
VA has also separately established a code, ``Veteran Plan - Urgent
Care,'' to reflect a Veteran's eligibility for the walk-in care benefit
under 38 United States Code Sec. 1725A.
For dynamic eligibility criteria, VA clinic and administrative
staff can access wait time for the specific clinic in which the Veteran
is to be scheduled by reviewing the appointment availability through
the approved VA appointment software, which links to VistA clinic data.
The average drive time eligibility determination can be made by using
PPMS to calculate the average driving time from the Veteran's residence
to the VA facility that can provide the requested care within the wait
time standard.
The VA provider will determine clinical need for community care
purposes by reviewing if the care is nationally available at any VA
facility; if VA does not offer this care at any location, the provider
will enter a community care consult following normal consult entry
processes as outlined in Veterans Health Administration Directive
1232(1), Consult Processes and Procedures, and the Office of Community
Care Field Guidebook. The VA provider will also need to determine if it
is appropriate to request community care for the specific episode of
care based on such a referral being in the best medical interest of the
Veteran. If the referring clinician and the Veteran agree it is in the
best medical interest of the Veteran to receive care in the community,
the provider will either utilize DST to document the best medical
interest eligibility or add the justification to the appropriate
community care consult.
Question 3: I appreciate VA launching the Veterans Choice Locator
so that veterans can identify approved community providers. I believe,
as the USDS recommends, that user-driven transparency should extend to
eligibility determinations. Dr. Stone, has VA considered developing a
veteran-facing eligibility tool?
VA Response: VA is developing several tools to help Veterans
understand and directly query their eligibility to receive community
care. The VA Online Scheduling (VAOS) tool will incorporate the new
MISSION eligibility criteria that are static, such as residing in a
state without a full-service VA medical facility; VAOS has been
available since June 6, 2019. The display of dynamic eligibility
criteria such as average drive time will be available in VAOS by
September. VA is also analyzing self-service capabilities that can be
incorporated in MyHeatheVet to provide Veterans more information about
their eligibility; there is currently no timeline for when this will be
completed. Additionally, VA has established an Interactive Voice
Response option to allow Veterans the ability to directly obtain
eligibility information about the walk-in care benefit under 38 U.S.C.
Sec. 1725A by working with the third-party administrator.
Question 3a: If such a tool isn't provided, how will VA ensure
every veteran knows and understands their eligibility status?
VA Response: Veteran empowerment is at the core of VA's approach to
the VA MISSION Act of 2018, and VA personnel are being trained to
provide the best information available to each Veteran. As outlined
above, eligibility under the VA MISSION Act of 2018 can be determined
with or without a tool. VA is also working to educate Veterans and
train Veterans Service Organization representatives on the eligibility
process.
Questions for the Record from Congressman Chip Roy
Question 1: During the hearing, the VA witnesses mentioned some new
systems, RefDoc, VirtuPro, and Community Viewer, that VA is using to
share health records with community care providers. Are these one-way
transfers of records from VA to the provider? Or is there a capability
for VA to transfer data from its electronic health record to the
provider, that provider treat the veteran, and then that provider
transfer the information back into VA's electronic health record? If
not, what is the plan to achieve that capability?
VA Response: RefDOC generates an electronically consolidated .pdf
file that contains administrative and clinical information needed to
facilitate a referral in a standardized format. Community Viewer is a
``read only'' secure Web-based application that allows community
providers to view a Veteran's entire Electronic Health Record once
permission is granted by facility community care staff. In addition,
the new portal, HSRM, has bidirectional communication functionality
that can be used by VA and the community provider to upload medical
records. Currently VA also utilizes Health Information Exchanges, which
are secure networks of trusted partners that allow VA and participating
community providers to electronically request and receive medical
information about a specific Veteran for whom they are providing care.
Direct messaging is also available, which allows the exchange of
medical information via secure email-like messaging under a trusted
network. With the implementation of Cerner, interoperability will
continue to mature with the improved seamless flow of health data
between VA and community providers.
Questions for the Record from Congressman Jim Banks
Question 1: What is the claims processing system used by Optum and
any other new CCN contractors? Please provide as much information about
these systems' capabilities as possible.
VA Response: First, Community Care Network contracts do not dictate
utilization of any specific claims processing system. Second, to the
extent that Optum has identified the claims processing system(s) that
it has elected to use to meet contract requirements, such details would
be confidential commercial information which is not typically disclosed
without going through the predisclosure notification process (Executive
Order 12600, 38 Code of Federal Regulations (CFR) 1.558).
Question 2: In the CCN contracts, VA also set out 14 requirements
for how the contractor's system will adjudicate claims. Does the system
already do those things, or will the contractor need to modify the
system to meet VA's requirements?
VA Response: The 14 requirements for how the contractor's system
will adjudicate claims include VA-specific requirements such as
incorporating VA's fee schedule and adjudicating claims for emergency
services under 38 CFR 17.4020(c). Therefore, the contractor is
modifying its systems to meet VA's claims adjudication requirements. VA
has been working closely with Optum to ensure Optum's claims systems
are configured to meet VA's requirements for claims adjudication.