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25–124 2017

CHOICE CONSOLIDATION: LEVERAGING PROVIDER 

NETWORKS TO INCREASE VETERAN ACCESS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

TUESDAY, MARCH 22, 2016 

Serial No. 114–61 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

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. 

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(III) 

C O N T E N T S 

Tuesday, March 22, 2016 

Page 

Choice Consolidation: Leveraging Provider Networks To Increase Veteran 

Access .................................................................................................................... 1 

OPENING STATEMENTS 

Honorable Dan Benishek, Chairman ..................................................................... 1 

Honorable Julia Brownley, Ranking Member, Subcommittee on Health ........... 2 

WITNESSES 

Billy Maynard, President, Health Net Federal Services ...................................... 3 

Prepared Statement ......................................................................................... 32 

David J. McIntyre, Jr., President and Chief Executive Officer, TriWest 

Healthcare Alliance .............................................................................................. 5 

Prepared Statement ......................................................................................... 35 

Baligh Yehia, M.D., Assistant Deputy Under Secretary for Health for Community Care, Veterans Health Administration, U.S. Department of Veterans 

Affairs .................................................................................................................... 7 

Prepared Statement ......................................................................................... 46 

Accompanied by: 

Gene Migliaccio, Dr.P.H., Deputy Chief Business Officer for Purchased 

Care, Veterans Health Administration, U.S. Department of Veterans 

Affairs 

STATEMENTS FOR THE RECORD 

The American Legion .............................................................................................. 49 

Veterans Choice in Health Care Factsheet ........................................................... 52 

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CHOICE CONSOLIDATION: LEVERAGING PROVIDER NETWORKS TO INCREASE VETERAN 

ACCESS 

Tuesday, March 22, 2016 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

Washington, D.C. 

The Subcommittee met, pursuant to notice, at 10:00 a.m., in 

Room 334, Cannon House Office Building, Hon. Dan Benishek 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Benishek, Bilirakis, Roe, Huelskamp, 

Coffman, Wenstrup, Abraham, Brownley, Takano, Ruiz, Kuster, 

O’Rourke, and Brown. 

OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN 

Mr. BENISHEK. Good morning. The Subcommittee will come to 

order. Thank you all for joining us for today’s Subcommittee hearing, Choice Consolidation: Leveraging Provider Networks to Increase Veteran Access. This is our third in a series of hearings on 

different key aspects of the Department of Veteran Affairs’ plan to 

consolidate care in the community programs under a new and improved Choice Program. 

In February, we discussed eligibility for care and billing and reimbursement under the consolidation plan. Today we will discuss 

provider networks. VA’s consolidation plan proposes a tiered provider network composed of a core and external network of providers. 

The so-called core network would be managed by VA and consist 

of federally funded health care entities from the Department of Defense, the Indian Health Service, tribal health programs, and federally qualified health centers, as well as academic affiliates. 

The so-called external network would be managed by third-party 

contractors across four distinct regions and consist of commercial 

health care providers from the private sector who would be divided 

into a preferred network of providers who meet certain quality and 

performance metrics, and the standard network of providers who 

meet minimum standard criteria. 

I understand the advantages of a tiered network. Namely, that 

it allows the VA to organize and differentiate between providers by 

type and quality. However, I am concerned that the tiered network 

the VA has proposed will hold government and academic affiliate 

providers to a different, perhaps a less stringent, standard than 

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private sector providers will be held to. That is fundamentally unfair; it is also unnecessary. 

Government and academic affiliate partners have existing relationships with VA that are longstanding, unique, and important 

that already put them at a significant advantage when compared 

to private sector providers who, for far too long, have been held at 

arm’s length by a department who did not want to treat them like 

peers and partners in providing high-quality care to veteran patients. 

What’s more, government and academic affiliate providers are 

fully capable of competing with private sector providers using the 

same quality and performance criteria that VA has proposed, and 

they should compete. Some government health care entities and 

some academic health care entities are world-class, best in show 

providers. But some are not. We need to know the difference between the two, and more importantly, our veterans deserve to 

know the difference between the two, and to be referred for care 

accordingly. 

I also want to ensure that under the VA’s tiered network proposal and individual veteran’s choice in who to receive care from 

will still be preserved. Our veterans have earned their health care 

benefits in many cases through blood, sweat and tears. The least 

that they deserve in return is a choice. 

Finally, I want to make sure that the significant infrastructure 

that has been built, largely with taxpayer dollars, since the current 

Choice program was created in 2014 is not lost as the VA transitions to a consolidated approach. Implementation of the current 

Choice program has not been a smooth or as easy as any of us 

would have hoped. Indeed, setting up a program of such magnitude 

under such time constraints never is. 

I have heard complaints from providers in northern Michigan, for 

example, that report having to spend significant amount of staff 

time on the phone resolving authorization, scheduling, and payment issues. It is far from ideal. I would encourage the VA and 

both of the third-party administrators to continue to work to resolve issues as they arise and make Choice work better, faster, and 

easier for veterans and community providers. 

However, a lot of gains have been made, a lot of lessons have 

been learned, and a lot of relationships have been built in the last 

year and a half around the current Choice program. As we move 

forward, we have to ensure that those gains are not needlessly sacrificed in pursuit of the new, which is sure to carry unforeseen 

problems all its own. 

I look forward to hearing from all of our witnesses this morning, 

and thank you all for being here. And I will now yield to Ranking 

Member Brownley for any opening statement that she may have. 

OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman. And thank you for 

calling this hearing on VA’s future plan to provide safe, quality 

health care to veterans by implementing a high-performing network in partnership with Federal partners, academic affiliates, and 

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the community. VA believes veterans will exercise their choice 

when it comes to where and when they receive health care. 

This is the third in a series of hearings held by the Subcommittee to examine details of the care consolidation plan, which 

was submitted to Congress in October of last year. Last month we 

heard from stakeholders on eligibility criteria and VA’s plan to improve community care billing and reimbursement. Today, we will 

receive testimony on the very important provider networks. 

I understand the VA’s plan is to build a high-performing network 

that will consist of three separate tiers, with tier 1 being with our 

Federal partners and academic affiliates. Tier 2 will consist of toprated community providers. And tier 3 will be the community providers who meet standard criteria. 

VA’s objective is to ensure veterans will have the ability to 

choose which provider he or she would like to see for care. According to the VA, the tiered network structure will allow VA to provide the veteran with information to make an informed choice 

about the right provider to see. The goal is to reduce confusion for 

the veteran on where to seek high-quality health care by streamlining the transition from a VA facility to a community facility. 

We are all aware that the devil is in the details. When the plan 

was first received, the implementation of a high-performing network was somewhat confusing and unclear. I hope the VA today 

will shed more light on their plan regarding how this network will 

be built and how veterans will, in fact, be able to choose their provider. Continuity of care and the quality of care provided through 

this network should be first and foremost the top priority of VA. 

Additionally, we must ensure that lessons learned from the past 

programs such as PC3, ARCH, and the current Choice program will 

be considered as we move forward with a new veterans choice program. I appreciate the testimony we have received, and I look forward to hearing from all of our witnesses today. So thank you, Mr. 

Chairman, and I yield back. 

Mr. BENISHEK. Thanks, Ms. Brownley. Joining us on our first 

and only panel this morning is Billy Maynard, the President of 

Health Net Federal Services; David McIntyre Junior, the President 

and CEO of TriWest Healthcare Alliance; Dr. Baligh Yehia, the VA 

Assistant Deputy Under Secretary for Health for Community Care, 

who is accompanied by Dr. Gene Migliaccio, the VA Deputy Chief 

Business Officer for Purchased Care. Thank you all for being here 

today, I am looking forward to this discussion. 

Mr. Maynard, we will begin with you. Please proceed with your 

testimony, and you have five minutes. 

STATEMENT OF BILLY MAYNARD 

Mr. MAYNARD. Thank you, Chairman Benishek, Ranking Member Brownley, and distinguished Members of the Subcommittee, 

thank you for the opportunity to participate in this hearing. 

Health Net Federal Services is proud of our work leveraging private sector best practices to supplement and complement Federal 

agency capabilities. To this hearing, we bring the perspectives and 

lessons learned from throughout our nearly three-decade history 

supporting government health care entities at the intersection of 

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their care capacity and their need to support their beneficiaries, in 

this particular case, eligible veterans with care in the community. 

My commitment to VA health care is personal. I am a veteran 

myself. I served in the U.S. Army for ten years. I am the son of 

a Navy retiree, born at Portsmouth Naval Hospital, and I am the 

grandson of a World War II combat veteran who benefitted greatly 

from the services of the VA following his return from that conflict. 

I take the mission of the Choice program to heart and in this 

vein, I offer comments informed as much by the spirit of service, 

the spirit that led me and many members of my family to service, 

as by our business experience. 

I want to thank this Subcommittee, and the Committee as a 

whole, for your leadership on the issues at hand. This Committee 

acted decisively in response to the revelations of extensive wait 

lists at some VA facilities. In Choice, you have created the foundations of a program that can serve as a viable model for the integration of VA’s direct care capacity and care in the community as we 

look forward. 

I also want to express my thanks to senior members from the 

VA, who from Secretary McDonald on have worked tirelessly over 

the past year to make the current Choice program work. In particular, Dr. Baligh Yehia and Gene Migliaccio, both of whom are 

here, have led key efforts to evolve the initial program and 

proactively address issues that have hindered program effectiveness in its initial implementation. 

Today, over 2400 Health Net Associates located throughout the 

regions we support, and the Nation as a whole, directly support the 

Choice program, and it is a great honor for us to do so. Working 

with their VA counterparts, our associates have accomplished 

much. We have fielded some 2.5 million phone calls from veterans 

and community care providers as well as veterans’ affairs staff; appointed what is rapidly approaching half-a-million individual veterans to community providers who might otherwise have remained 

on a VA wait list, and we have built a registry of nearly 250,000 

participating providers located throughout the VA regions we support. 

While there is still much to do, real progress has been and is 

being made towards the kind of public-private partnership through 

contracts upon which the effective delivery of health care for our 

Nation’s veterans now depends. 

A few points specific to the topic of this hearing. First and foremost, we believe all health care provided in support of veterans is 

VA care, whether delivered directly by the VA, by its close affiliates, or by community providers. Seamless integration of that care, 

therefore, is key, particularly at the intersection of the VA’s capacity and community care. 

Based upon our years of experience, we believe the only way all 

care will be seen and received by veterans as VA care is through 

mutual accountability in the framework of a public-private partnership contract structure. 

Second, it is now clear, based on eligible veteran demand, that 

significant and continuing access to community-based care will be 

absolutely necessary to support veterans’ health care needs in the 

future. Standardization in consolidation and the development of 

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clear and comprehensive policies addressing the full range of community care eligibility and programs is, therefore, vital. This was 

a central point in the independent assessment, and it has been a 

lesson learned in the initial implementation of Choice. 

Third, we believe the preferred, also often referred to as a tiered 

provider, network construct that is part of VA’s plan for the future 

can effectively deliver the necessary access to care in the community going forward. While there are other approaches, given VA’s 

significant direct care mission and capacity, a tiered approach will 

ultimately be the most effective way for VA to optimize and integrate care while extending VA’s ability to better focus on its core 

competencies. Of course, throughout that development, veteran 

choice must be extended and preserved. 

Whatever geographic or provider network development approach 

VA takes, we feel it is necessary that VA partner with single thirdparty entities within each geographic area to administer all community-based aspects of the program. TRICARE is a good example 

of the lessons learned from attempting to do otherwise, as learned 

in the early days of their journey to the integration of community 

and direct care. 

The seamless integration of community care is vital for the provider and veteran experience, and without seamless integration, 

neither providers nor veterans will ultimately want to participate 

at the levels necessary to ensure all eligible veterans are cared for. 

In closing, let me say that in a program like Choice, veteran and 

provider experience is paramount. The success of any future program will depend, in large measure, on three interrelated imperatives. First, strengthening VA’s capacity planning and optimizing 

their capacity in the face of veteran demand through Choice so that 

community care can be tailored to ensure ready access in every location. 

Second, making the provider experience as consistent with community standards as possible, while respecting and recognizing the 

VA’s need for visibility and access to veteran health care information. 

And, third, streamlining the veterans’ and provider experience so 

they are better able to control the process and receive and deliver 

care when and as necessary. 

Health Net is proud to stand as a partner with the VA and this 

Congress in helping deliver care to our Nation’s veterans. Thank 

you, Mr. Chairman and Committee for this opportunity to present 

our views. I look forward to answering any questions you may 

have. 

[THE PREPARED STATEMENT OF BILLY MAYNARD APPEARS IN THE

APPENDIX]

Mr. BENISHEK. Thank you. Mr. McIntyre, you are recognized. 

STATEMENT OF DAVID J. MCINTYRE, JR. 

Mr. MCINTYRE. Chairman Benishek, Ranking Member Brownley, 

and distinguished Members of this Subcommittee, it is a privilege 

to appear before you this morning on behalf of our company’s nonprofit Blue Cross/Blue Shield and University Hospital System owners, and our 3,600 employees, most of us who are veterans and vetLeonard.horne on VACREP0180 with DISTILLER

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eran family members, to discuss how the Choice program is evolving in our 28-state geographic area responsibility. I am going to 

focus on the current, and I am going to focus on the journey we 

have taken. 

Mr. Chairman, Janet Van Hagen is an Army veteran who lives 

in rural America. Before you passed the Choice Act, she used to 

drive four hours each way for health care. Now, thanks to you, she 

receives her health care close to home. Janet’s doctors, joined by 

more than 180,000 providers in our geographic area, that are leaning forward in at the side VA, to make sure that those who are in 

the 28 states, that we are responsible for supporting—receive the 

care that they need when VA is unable to deliver it directly. 

Yesterday, as is the case every day, more than 5,000 veterans in 

our area received care from this consolidated network, accredited 

by your Act. That is up from 500 a day a year ago. Of course, you 

might ask if things are happening as result of Choice, why am I 

hearing complaints from my constituents? That is a fair question. 

I would like to be candid with you. 

In spite of the early successes of standing up the program, there 

has, and remains work to be done. You have modified the law that 

was originally passed. We and VA together have been modifying 

the tools and the processes to make the program as you would have 

expected it. I would submit, however, that a 90-day implementation 

period is extremely short. And at the end of the day, those of us 

in the private sector had a little more than 30 days to do our part 

of that work. 

If you look at the comparative of TRICARE, and I was there 20 

years ago at the beginning, they had more than three years to design the program and implement it. And it did require adjustments 

as we went forward. I know it is probably not positive or popular 

in some quarters, but I believe that this was a good thing for you 

all to do. I think it was the right answer in response to the challenge that came out of Phoenix and the other areas, and Janet Van 

Hagen would agree with that. 

I have been impressed with the courage and the uncommon intensity with which the VA has acted. Just like you, their focus remains sharp. And the sustained pace and intensity at which we all 

continue to operate is daunting. However, if you look at our geographic area of responsibility, I believe that we in VA are gaining 

on it. 

This month, we will field more than one million phone calls, with 

an average speed of answer of less than 16 seconds, and an abandonment rate of less than 2 percent. More than 100,000 veterans 

in our part of the country will receive care closer to home; a long 

way from the 2,000 served in the first month of this program. And 

our claims processor will pay more than 97.5 percent of clean 

claims within 30 days. And we have now processed more than 1.8 

million claims for providers. 

Is our work finished? Not at all. We all have a lot of work to do. 

The topic of this hearing gets to the next generation, but we have 

work to do in our current generation. Our network is finished, it 

is tailored to the demands of the VA medical centers that we support. It includes the federally qualified health centers, and it includes most of the academic medical centers. 

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It is ready to be leveraged to have a tiered network in our area. 

And most of the network is at market rate, which means that we 

extend the buying power of the taxpayer in support of the VA with 

any discount accruing to the budget of the VA. And our turnover 

in network is less than 2 percent. It includes specialty, primary 

care and behavioral health. And less than 1 percent of the appointment requests that we have require us to go outside of our network 

looking for another provider. 

Second, getting to scale is a challenge. We now have ten sites of 

operation, 3,600 employees. On Friday, I was privileged to be in El 

Paso to roll out the final operations center, which is now serving 

our area. 

Chuck Byers is a Vietnam veteran. Chuck Byers asked me to 

convey to you his gratitude. Chuck Byers has cancer. Chuck Byers 

was in a line to get care. And he was in a line to get care not because people don’t care, he was in a line to get care because the 

number of providers available to deliver care in the VA, in the market in which he resides, was not sufficient enough to meet his 

needs. 

Chuck Byers saw a cancer specialist in our network. Chuck 

Byers is alive today. There are many Chuck Byers, and there are 

many Janes across our area. We are on a pathway to improvement, 

we are on a pathway to refinement, and we have work to do. 

I believe that the leadership of the two gentlemen that are on 

this panel, the Secretary, the Deputy Secretary, the Under Secretary Shulkin, and this Committee, and Subcommittee, and those 

on the Senate side are going to allow us to achieve the success that 

we all desire. And that is that the Chuck Byers of this world, who 

served our country with distinction, have the opportunity when 

they have a need to have that need met, whether it is met in the 

VA directly, at an academic facility, a DoD facility, or in the community. Thank you for the privilege of being here today. Thanks 

for the privilege of supporting this population. And we, and our 

3,600 employees, and 180,000 providers are privileged to lean forward at the side of those that served in the VA. Thank you very 

much. 

[THE PREPARED STATEMENT OF DAVID J. MCINTYRE APPEARS IN

THE APPENDIX]

Mr. BENISHEK. Thank you. Dr. Yehia, you are recognized. 

STATEMENT OF BALIGH YEHIA, M.D. 

Dr. YEHIA. Good morning, Chairman Benishek, Ranking Member 

Brownley, and Members of the Subcommittee. Thank you again for 

the opportunity to testify today regarding the Department’s plan to 

consolidate community care, specifically to further discuss our community care network. I am accompanied today by Gene Migliaccio, 

who is a Deputy Chief Business Officer for Purchased Care. 

Establishing a robust provider network is critical to increasing 

access to quality care for veterans. Our proposed network emphasizes veterans’ choice, access to care, and quality by partnering 

with community providers. Let me be clear. Veterans will have a 

choice in our network. 

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First, they will choose whether they want to access community 

care at all. Second, for those who choose to access community care, 

they will be able to select a provider that best suits their needs and 

their preferences. 

Over the last couple of weeks, I have had a number of meetings 

with folks on the congressional staff to discuss VA’s proposed community care network. During those conversations, it became apparent to me that tiered networks has a different meaning for different people. Some think of having to pay a different cost share 

for providers in different tiers, others think of a narrow network 

that limits the numbers of providers or restricts choice. And when 

it comes to distinguishing between providers, some people describe 

tiered networks as emphasizing cost over quality. This is not how 

VA wants to set up our community care network. 

First, there will not be any difference in VA copayments from 

provider to provider in the network. If a veteran does not pay a copay in the VA, they will not pay a co-pay in the community. 

Second, we understand that some health plans distinguish providers as preferred based on their ability to control costs over quality. We want to flip that on its head by placing greater emphasis 

on performance metrics that are related to quality and satisfaction 

over cost. That is why we are working hand in hand with industry 

to determine which quality and satisfaction metrics are most appropriate and also commonly used in the community. 

Last, some networks are often narrow, meaning there is a—they 

have a limited number of providers. That will not work for our veterans. We have veterans in every community across the United 

States and abroad. Therefore, we want to partner with as many 

providers as we can. 

At the heart of it, a community care network is simply a way to 

organize our community partners and identify and reward highperforming providers. This structure will provide veterans with 

easier access to information so they can make informed decisions. 

Veterans who are eligible for community care will have the ability to decide whether they prefer to receive care at a local VA or 

in their community. And if they choose to receive care in the community, they will have the ability to choose a provider. However, 

just giving them a list of providers is not enough. In my experience 

as a clinician, patients look towards us to help them navigate the 

health care system and their options. That is why it is critical for 

our network to identify quality providers which will ensure that 

veterans are able to make an informed choice. 

We also want to be better partners for our community providers. 

Just this month, I sat down with a roomful of providers ranging 

from small practices to large health care systems in Florida. They 

were direct about what works and what doesn’t work with Choice, 

and the changes they would like to see in the future. 

Their comments mirror the more than 600 responses received 

from the private sector and 300 responses we received from our 

own employees on our draft community care network performance 

work statement. We are actively engaged, and this important feedback is being used to draft the next step of our contracting process, 

which is a draft request for proposals. 

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As we continue to move forward toward consolidating community 

care, it is important to maintain our relationships with Federal 

partners like DoD, and also our academic affiliates. For decades, 

they have served as a foundation of our community care network, 

and over time, these relationships have led to the delivery of high 

quality care and also robust care coordination. 

Growing them will ensure that veterans continue to have access 

to not only quality care, but in many circumstances, state-of-theart care while ensuring that we continue to train the next generation of clinicians that will serve veterans. Therefore, we want to 

make sure that these valued partnerships are supported by the 

consolidation of community care programs. 

In summary, we want to empower veterans to make informed 

choices and improve their health outcomes. We also want to ensure 

that we set up a program that aligns with the private sector and 

encourages collaboration between VA and community providers. 

Mr. Chairman, I appreciate the opportunity to appear before you 

today, and we are prepared to answer any questions you or other 

Members of the Subcommittee may have. 

[THE PREPARED STATEMENT OF DR. YEHIA APPEARS IN THE APPENDIX]

Mr. BENISHEK. Thank you, Dr. Yehia. I will now yield myself five 

minutes for questions. And there are so many things I want to talk 

about because I don’t really understand the different tiers, to tell 

you the truth, and how it all works. But I guess the key question 

that comes to my mind is, is a veteran going to be able to call and 

get an appointment for themself? 

I mean, it seems to me that a huge part of the problem in getting 

an appointment is somebody is making the appointment for the 

veteran. Are you going to change this? When I, as a physician, I 

refer the patient to somebody, I tell the patient who I am planning 

to refer them to, and then they make their own appointment. So 

is that going to happen now in this new community care program? 

Dr. Yehia, can you answer that? 

Dr. YEHIA. I can. So let me—I think that is an excellent question, 

and we want to move more and more towards—in that direction. 

Mr. BENISHEK. I think that maybe they can’t hear you. 

Dr. YEHIA. Okay. 

Mr. BENISHEK. Okay. 

Dr. YEHIA. Is that better? 

Mr. BENISHEK. Yes. 

Dr. YEHIA. Currently what we do is, we do outbound calls. So 

once a veteran is eligible, we send the phone number—their information to our contracting partners and they reach out to the veteran. But just as you describe, some patients want to coordinate 

their own care. 

Mr. BENISHEK. Like most patients, I would say. 

Dr. YEHIA. A lot of patients, yes. In our future state, where we 

are hoping to move towards, is VA would be more in the center of 

customer service and care coordination. I think for veterans that 

want to make their own appointments, we want to be able to provide that option. However, we want to make sure that we can connect the dots. And so we don’t want to just say, here, go see your— 

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make your own appointments, we want to figure out a way to get 

that information back, so when they do come back to the VA if they 

have to see another doctor, we have the clinical information from 

that community provider. 

And, as you know, some veterans have a lot of comorbid conditions or complicated social circumstances, and they want the VA to 

help them with— 

Mr. BENISHEK. Yeah, I know, but that is sort of a internalistic 

viewpoint, in my opinion. 

Dr. YEHIA. I think what I was getting at is that we want to give 

them choices. Some folks want to say I want to make my own appointment. And with that, we say great, we want to make sure that 

we have the right process to get the information back. 

Mr. BENISHEK. Well, can’t the appointment be made right at the 

time that the patient is referred, right there so the patient can participate? The problem is that the appointment is made without the 

patient’s awareness, so then they find out he is not available when 

the appointment was made. 

Dr. YEHIA. Yeah. We definitely don’t want to do anything that 

you are describing, which is more blind scheduling. So the way that 

we work now, it is more of we get the veteran’s preference, and 

then we contact the community provider, and we link the two up. 

But in some circumstances like you are describing, a lot of patients 

say, hey, I will just make my own appointment. And I think that 

is great, we just want to make sure that we are able to track that, 

yes, they were able to get in to see a doctor, and that we were able 

to get the health information back from that visit. 

Mr. BENISHEK. So the other question is, I guess I don’t understand the difference between why are there separate tiers? I mean, 

why is there a core provider and then there is a preferred provider? 

And what is that all about? I don’t understand that. Why isn’t 

there one set of providers? 

Dr. YEHIA. Yeah. So over the last couple of months I have been 

talking more and more about this. And the way that we present 

it in the plan is just a way to organize providers. So from the veterans’ perspective they will not see tiers, they will see a directory 

of providers. And those providers, as best as possible, will have information about where they are, what specialty they are, their affiliations, their quality, satisfaction. 

So it will be—this is kind of behind the scenes stuff. It is, now 

we organize ourselves so that we can make sure that we know that 

like providers are grouped together. For example, we talk about 

DoD and Indian Health Service. We work with them in a completely different way than the private sector. We don’t use Medicare rates. We pay Indian Health per person. So the way that we 

actually interact with them is different. That is why they are 

grouped together. And then we want to be able to distinguish and 

reward those top quality providers, and they are another group. So 

to the veteran, they won’t see tiers. They will see information about 

different providers. But for the VA and for the provider community, 

we will be able to organize ourselves so we can—we know the different types of providers in a network. 

Chairman BENISHEK. So the top tier providers are incentivized 

some way than some other providers? 

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11 

Dr. YEHIA. No. The way that the incentives will work, the incentives of giving no value-based payments is independent of the 

structure of the network. So we want to group like providers together. So if you are delivering excellent quality, other veterans are 

recommending you, they are giving you high satisfaction scores, 

somehow, we want to say that we are measuring those, and we are 

providing the information for the veteran to make a choice. 

Based on those metrics, you will be able to get, as we move more 

and more towards value-based payments, you will be able to get rewarded for delivering excellent quality care. 

Chairman BENISHEK. I am out of time. Ms. Brownley, you are 

recognized for five minutes. 

Ms. BROWNLEY. Thank you. Well, just to follow up on that line 

of questioning, so I understand in terms of the tiered process, the 

veteran will not know the different tiers, in essence. It is for internal use. 

But it seems to me, I still, you know, in terms of the second and 

third tier, you know, a preferred, well-qualified doctor compared to 

a adequate doctor. And it seems as though, quite frankly, we would 

want, you know, the best qualified doctors for our veterans. And to 

make a distinction between two qualifications seems odd to me. 

Dr. YEHIA. We, because we serve veterans in every corner of the 

United States, we need as many as providers to partner with us 

as possible. And so I think, at minimum, we want to set the standards. You have to have a license. You have to be able to practice 

in that state. So we will set a bar so that we make sure that the 

veterans, when they see community providers, they are 

credentialed, and they are able to serve them. 

But just by setting one bar and not being able to reward those 

providers that perform really well, I don’t think that goes far 

enough. And so the idea is, we would love to have every single one 

of our providers preferred. It is not like we are going to set, like, 

a percentage of all the providers will be preferred. If you meet the 

quality and the satisfaction metrics of the VA, anyone can become 

a preferred provider. 

So it is not like we are limiting who can enter that group. It is 

just based on your performance. 

Ms. BROWNLEY. Okay. 

Dr. YEHIA. We want to make sure that those performance 

metrics align with industry. A lot of folks are already reporting on 

those today. So we are not going to create some new measures that 

don’t exist. We want to use existing data sets. 

Ms. BROWNLEY. So to Mr. McIntyre and Mr. Maynard both, I 

think the VA just testified that they had had interviews in Florida 

in terms of their network providers, to ask what works and what 

doesn’t work. I wasn’t there for that process, so I would ask you 

the same question in terms of your experience so far. What do you 

think is working, what is not working, where improvements should 

come from? 

Mr. MCINTYRE. We have done interviews with providers in our 

network for the last nine months to determine what changes needed to be made in our processes. And we have implemented those 

changes. We put the provider first from that standpoint, because 

if the provider engagement doesn’t work, nothing else works at the 

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12 

end of the day. And we are in the process of finalizing what we call 

Provider 2.0. 

I will tell you as part of that, and a follow-up to the question on 

tiering of networks, we set up our systems at the beginning of 2014 

with the adoption of PC3 to actually give our appointing staff the 

ability to tier the networks. And so among the best providers in our 

communities, they are the first that we go to for appointing. 

So if we know, for example, there is a neurology appointment 

need in a particular community, or there is a urology need that is 

very specific, we will seek the top urologists out of our network, 

and they will end up in our systems in the front of the appointing 

staff first. That is not an uncommon strategy, and we have been 

using that from the start. 

Ms. BROWNLEY. So in terms of providers and—I understand that 

you are interviewing. You are hearing from them. You are making 

improvements, you know, daily as you have moved forward to kind 

of perfect the system— 

Mr. MCINTYRE. Yes, ma’am, it is— 

Ms. BROWNLEY [continued]. —and within the network, and are 

there any outstanding issues that you have limitations, where you 

are hearing from the provider, but because of VA and regulations 

that are limitations to you to improve it, do you have full authority 

to make all of those improvements? 

Mr. MCINTYRE. Yeah, great question. The first set of things we 

brought back to Congress. Because there were limitations in the 

original law that was passed, and you all have acted on those now, 

and the VA has acted on them policy-wise and pushed them over 

to us operationally. 

The set that we are working now, and we are down to the lower 

part of that list, we in the VA, particularly these two individuals 

that are leading the effort internally to VA, are working those last 

remaining mile issues to make sure that we have worked through 

what needs to be done to make the provider engagement better in 

our geographic space. 

Ms. BROWNLEY. Thank you. And Mr. Maynard, do you have anything to add? 

Mr. MAYNARD. Yes, if I could just add one thing specific to the 

questions both you and the Chairman have asked on this issue. If 

there is a remaining challenge as we look forward, I think it centers on the concept of eligibility and the parameters of authorizations under which eligible veterans are seen. 

And this begins even at very routine levels. I know there are 

many doctors here on this distinguished panel. But even at the primary care level you have providers that are looking at a presenting 

patient who presents with a variety of conditions that may, in fact, 

go beyond the boundary of the eligibility. Many of the challenges 

in delivering care begin right then and there around the boundaries of the authorization or the eligibility and what presents itself 

as medically necessary. 

So we continue to work with the VA around the definitions of 

those eligibility parameters, particularly at levels like primary 

care, where patients present and may actually need to be expedited 

directly from there to a specialist or to some further care beyond 

the boundary of the original eligibility. 

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13 

I think the more that we can do to expedite that and ensure that 

providers are not prohibited from addressing what is medically necessary while they are there as the veteran presents, and that from 

there, the path to whatever follow on care is itself expedited, the 

more we are focused on those issues, the more the program will improve in support of veterans. 

Ms. BROWNLEY. My time is up. I yield back. Thank you. 

Chairman BENISHEK. Dr. Roe, you are recognized. 

Mr. ROE. Thank you, Mr. Chairman, and thank you and the 

Ranking Member and the staff for putting this together. And I certainly appreciate the fact that this is not easy. To put a network 

together across the country is a big bite of the apple. 

And I think consolidating all of these, certainly into tiers, I don’t 

have any particular problem with that. The real question that I 

have are more about function. I have a health care card here. I 

know exactly where I can use it, what it is good for. Does a veteran 

actually have that? 

And the example I am using here is, like with Dr. Benishek was 

trying to get to it a minute ago, if I go in and I don’t think I am 

getting the care that I need—and Mr. McIntyre presented a very 

compelling case of a veteran who did get the care they need, I can 

tell you one who didn’t, who last April went to a VA, got a FIT test 

for colon cancer screening, because they don’t do routine colon cancer screening. 

He had some bowel changes. Came back in August of this past 

year. Had a positive FIT test. His colonoscopy was scheduled for 

April 5th of this year, 2016. Went to the Choice—finally got to the 

Choice program after having X-rays done. That was in November. 

He finally got his colonoscopy in January, and he has Stage IV 

colon cancer. 

So those stories can be told over and over. That was a failure. 

The question is, does the veteran actually have a choice when, 

what Dr. Benishek was saying, when I go in there, if I don’t like 

the care I am getting, can I go take my card and make an appointment and see a doctor that I want to see? Because I think that is 

how the VA gets better and, certainly, we can credential easily. 

I mean, I look at our local system—at our hospital system—if 

you are credentialed to do surgery at the hospital, your license is 

good in the state, that can be done fairly expeditiously, because the 

patients go back and forth between those hospitals anyway. 

So that is not a hard thing to do. Maybe in rural areas it is a 

little harder, but in most areas of the country now, we have primary care people and specialists. Can the veteran actually take 

this card and go see a doctor that they choose? That is a question 

I am asking. 

Dr. YEHIA. In part. I mean, that—what you are asking—what 

you are describing is the way that typical health insurance plans 

work, which is, you have a health insurance—you go—you look at 

the network, go to whoever you want. But VA’s community care 

network is not a health insurance plan. It is an integrated system 

with the direct care and the community. 

So who can do—there are some folks that could do that, so our 

40-milers today. If you live more than 40 miles’ driving distance 

from a facility, you can take that card, and you can go to someone 

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14 

in the network and receive care. But the other criteria of how you 

access community care is from being—not offering the services of 

the VA or a wait time. So it is harder for someone to just walk— 

without knowing if you are actually waiting on a list to know if you 

can actually access community care. 

Mr. ROE. See, I think that is a mistake. I think what we need 

to do is, the veteran needs to be in charge of their health care, and 

we as providers, both the VA and the community, need to provide 

that care for them. 

Many veterans will very much like the care they get at the VA 

at home. 

Dr. YEHIA. Yeah. 

Mr. ROE. They love it. I mean, I have to say that they have very 

high marks. I meet very few people who don’t. There are some, but 

for the most part, I think if you surveyed the folks in our area, 

they would say the VA does a great job, and there would be no 

problem. In other places that is not true. 

And so I think the veteran should be able to have a choice, a real 

choice, and not get hung up like this particular—and hundreds or 

thousands of other veterans—are tied up in the system. 

And as Dr. Benishek was also saying, that the absolute simplest 

thing I ever did in my practice—I have said this until I am blue 

in the face—is to make an appointment. And if I saw someone, I 

would walk them out or send them out to the front desk, make an 

appointment with Dr. Jones. My staff would pick the phone up and 

call and get an appointment with Dr. Jones. If it had to be urgent, 

I might even get on the phone with Dr. Jones. That is how it 

works. And it works really well. 

Dr. YEHIA. Yeah. 

Mr. ROE. And what we have done with the VA has complicated 

this with so many layers of bureaucracy. We have made something 

that is complicated, that is not. So I think the choice needs to be 

the veterans’. And they should be able to have that appointment 

when they leave the VA. If they see a VA provider that day and 

that VA provider says, ‘‘Well, you need to see so-and-so, and he is 

not available here at our VA,’’—maybe it is a back issue, hip, whatever—before they leave that VA that day, that appointment should 

be made. 

And what I was told when I went home and talked to the providers that a primary care provider has a registered nurse, an 

LPN, and an assistant. I never had anywhere near that kind of sophistication. If four people like that could not make an appointment that day, you need to re-evaluate your processes, I think. 

Dr. YEHIA. Yeah. 

Mr. ROE. You agree with that? 

Dr. YEHIA. No, I agree. I think that, you know, I was just in clinic last Friday, and I did the same thing. I had a patient that needed to be seen by a specialist, and I picked up the phone, and I 

called them and got them in for next week. So I think that is how 

a lot of people— 

Mr. ROE. That works. 

Dr. YEHIA [continued]. —practice. I think that is the intent why 

we are here today, is to consolidate and improve care. There is a 

part of the plan that we talk about, this referral and authorization 

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15 

process, that is so clunky right now. And there is the eligibility criteria that we have been talking about. There is so many variations 

on it. 

If we get to very crystal clear, if you are eligible or you are not 

eligible for community care, then I think we can move up when you 

can—an appointment to the time when you are leaving the clinic. 

We have to get there first, because right now we have to double 

check and triple check— 

Mr. ROE. Yeah. 

Dr. YEHIA. —if they meet this, if they meet that. And that requires people. And the scheduling clerk sometimes can’t do all that, 

which is different than what it is in the private sector. 

Mr. ROE. Sorry, my time has expired. But just, your motivation 

when you saw that patient last week was to get their care given. 

Dr. YEHIA. That is right. 

Mr. ROE. And all that other stuff in between, you weren’t interested in. And all the patient was motivated was to get the care. 

Dr. YEHIA. Yeah. 

Mr. ROE. That is what we need to simplify. Yield back. 

Dr. YEHIA. I agree with that. 

Chairman BENISHEK. I now recognize Ms. Brown, the Ranking 

Member of the full Committee. 

Ms. BROWN. First of all, I want to thank both of you all for letting me sit in on this meeting, and I am going to be really quick. 

But I have two people there from my area, Dr. Yehia, and I want 

to follow up. And also, I have a statement from Action News Jacksonville Investigation, and I want both of you, one from Jacksonville and one from Gainesville University of Florida, we are very 

happy. 

But following up with Dr. Roe’s question, because I understand 

the card, but the main thing is that patient has to have prior approval in order to get paid. And Dr. Roe would be very upset—and 

I have heard lots of discussion in this Committee about people not 

getting paid and why they are not getting paid, and so their practice is closing or something. So you have to address that. 

And then the person, Madeline (?), who attended school in Jacksonville, the same school my daughter attended, Sandalwood, I 

need you to talk about this Action News investigation of the VA in 

my area, because I am the Ranking Member, and there is a serious 

wait time, or not happy with Choice. So those are my two questions. I met with all of you all before, had hearings in my area. So 

can you please address it? 

Dr. YEHIA. Sure, why don’t I start? 

Ms. BROWN. Yes, sir. 

Dr. YEHIA. Thank you so much for that question and for representing your area so well. We have to be good partners to community providers. It is how you build a network, and one of—the 

most critical thing, probably, is making sure that we pay timely 

and accurately, 100 percent. 

And I think right now there is three areas that we have to improve on. Number one is the eligibility criteria that we just talked 

about with Dr. Roe, is some veterans will take their Choice card, 

and they will just walk right up to a community provider and they 

will deliver care. However, that is not how the law was written. 

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16 

There is certain criteria that you have to meet in order to receive 

that health care. 

So when we get a bill, we can’t pay that bill. Even though we 

would like to pay it, we can’t pay it, because that veteran did not 

meet criteria that were established. So getting to a simple set of 

criteria that makes sense to the veteran and that we clearly communicate to everyone so they know who is eligible and who is not, 

will be very important. 

Number two—and this is something that we fixed about a month 

ago—is that we were requiring medical records before we actually 

paid the bills. And as a clinician, I want the medical records back. 

It is very important. And we still want them back. But we don’t 

have to tie it to payment, and remove that, and the payments have 

become better and better and better on both sides of the United 

States for Health Met and TriWest. 

Ms. BROWN. Is that retroactive so those physicians will get their 

pay. 

Dr. YEHIA. I—is that retroactive, do you know? I would have to 

check. 

Mr. MAYNARD. Yes. Coupling with the medical bills. 

Dr. YEHIA. Yes, it is. Thank you for that. 

Ms. BROWN. Okay. 

Dr. YEHIA. And then lastly is, we want to provide more transparency for the doctor. So the doctor right now sends a bill, and 

they don’t know where it is at. And I think on both our partners, 

Health Met and TriWest, are taking action so that we can improve 

the visibility into the system, because many times, you just want 

to know did I get—did they receive the bill? Do we have to send 

them another one? When am I going to get my check? And that ambiguity, or lack of information, creates anxiety. And so we want to 

be able to improve that. And that is some of the things that we are 

doing over the last couple weeks. 

Ms. BROWN. Thank you. 

Mr. MAYNARD. Yes, ma’am? Good to see you again and good to 

meet with you earlier this morning on some of these issues. 

First of all, I would just like to state that any shortcoming or inability to facilitate health care in support of eligible veterans is, obviously distressing and requires attention, every single individual 

one, even in the face of the increasing demands and the volumes 

that are there. 

I think it was particularly unfortunate—you know, we have been 

reaching out in Jacksonville to the press outlet, in particular, about 

the specific issue, and I think it is quite unfortunate that both the 

personnel from the provider offices where veterans were involved 

chose to remain anonymous, which makes it very difficult to find 

exactly the specific instance that they are addressing there. Nevertheless, it is something that we take quite seriously. 

I think as Dr. Yehia addressed in a previous response just a few 

minutes ago, real progress has been made, but there have been 

challenges around some of the—and I think he used the word 

′′clunky′′—procedures of referrals and particularly incidents that 

began where a veteran was seen and required further care, does activate a loop going back through from that provider or veteran back 

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17 

into the VA and back out through our processes to authorize that 

care and actually get it appointed again. 

I think as this Committee has been rightfully focused on, that is 

not directly in accordance with all the commercial best practices 

that could be applied, and I do believe that not only the improvements that we have seen, as you and I discussed, we are appointing some 800 to 1,000 veterans just within the Jacksonville domain 

itself, not counting all the way down to Gainesville, more than 90 

percent of those are being appointed well within the five-day standard. There is plenty of access within the network. 

Nevertheless, as veterans need to be seen, secondarily or subsequently, there is much that we can continue to do, and will continue to partner on with the VA to expedite that care as it presents 

itself to providers and as it develops. 

And just on the provider payment issue, quickly to follow up to 

Dr. Yehia, I want to, again thank the Department’s very close collaborative work with both Dave McIntyre and my company over 

the past three to four months to evolve and modify the contract. 

I think we are all very convinced and already have evidence that 

those providers that were challenged by the more complex payment 

methodologies are already seeing a very significant relief in the 

first three weeks after that modification. I think we expect all providers to be current very expeditiously as we move into the spring. 

Ms. BROWN. Well, thank you all for your service, and thank you 

all for letting me sit in. 

Chairman BENISHEK. Dr. Abraham, you are recognized. 

Mr. ABRAHAM. Thank you, Mr. Chairman. I want to kind of reflect on what Dr. Benishek and Dr. Roe started the discussion on. 

I am just a country doctor here, private care. I have practiced for 

many, many years. And, yeah, it is a big bite of the apple to institute this. But I don’t think it is that big of a bite. I mean, this is 

what you two guys do for a living. I mean, you enroll people, and 

this is you all’s forte. You all are experts in your field. 

And like Dr. Roe said—again, maybe I am making it over simplistic—but have the card, get the providers accredited. And, again, 

we keep having the same discussion over and over about accreditation. Well, if they come from an accredited medical school, if they 

are licensed, and they don’t have any criminal investigations, well, 

why not put them in the network and see how they do? 

And I know you need your records back. Well, let them have access to the EHRs or put the onus on the private physicians to either fax or email you a copy of that office visit. Again, I am the 

private practice guy, and I am the primary care guy here. 

I guess my question to you Dr. Yehia first, what is a veteran 

going to see? You say these objective datas, these quality measurements, are internal. What is that veteran going to see that will 

steer him or her to a tier 2 or tier 1 provider as opposed to a tier 

3 provider? 

Dr. YEHIA. So what we want to do is provide them with information. So they won’t even see a tier 1 or tier 2. That won’t be a term 

that— 

Mr. ABRAHAM. No, I understand, but— 

Dr. YEHIA [continued]. Yeah. The way that— 

Mr. ABRAHAM [continued]. —how are they going to know— 

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Dr. YEHIA [continued]. Exactly. 

Mr. ABRAHAM [continued]. —whether it is a tier 2 or tier 3 based 

on just, you know, pixie dust, basically, if you are going to say, 

well, it is tier 2 or tier 3. But what is a veteran going to see, he 

or herself— 

Dr. YEHIA. Yes. 

Mr. ABRAHAM [continued]. —that will actually—this is why this 

is a tier 2 or a tier 3, or a tier 1 provider? 

Dr. YEHIA. So they will be able to choose whoever they want. 

What we are going to be able to do is give them information to 

choose what they want. So first there will be basic information 

about the provider, where they are located, their specialty, what 

they do. That is, kind of, that is set. And then using, kind of, private sector metrics, so things that are already agreed upon that 

CMS uses— 

Mr. ABRAHAM. Do— 

Dr. YEHIA [continued]. —such as—I was going to— 

Mr. ABRAHAM. And let me interrupt you. 

Dr. YEHIA. Yeah. 

Mr. ABRAHAM. Do you already have that objective check box formulated for the VA as for those metric measurements that will distinguish between a tier 2 and a tier 3 provider? 

Dr. YEHIA. We have—we don’t have that today in our community 

care program, but in the draft request for proposals that we are developing, we are putting a list of different quality metrics that we 

want to measure. And so those get to—like do you have—is your 

hemoglobin A1C in control? 

Mr. ABRAHAM. Right. 

Dr. YEHIA. Are you asthmatic and do you actually have an inhaler? So they are not—we are not talking about things that are 

so off the wall. These are basic things that a lot of your providers— 

Mr. ABRAHAM. And I guess that is my point. These metrics— 

Dr. YEHIA. Yeah. 

Mr. ABRAHAM [continued]. —are already in any electronic health 

record— 

Dr. YEHIA. Yes. 

Mr. ABRAHAM [continued]. —I have ever accessed. 

Dr. YEHIA. Yes. 

Mr. ABRAHAM. And I have seen my share of them, I am sure. 

And, again, you check the box. It is a matter of hitting the key— 

Dr. YEHIA. Yeah. 

Mr. ABRAHAM [continued]. —and the computer picks it up. And 

then it is part of the record. I guess my other concern is, as a family doc—like, Dr. Roe was saying, like you were saying—when you 

had your patient the other day and you immediately went and 

made a referral, if I need—if I have got a patient with hematuria, 

blood in the urine— 

Dr. YEHIA. Sure. 

Mr. ABRAHAM [continued]. —and going back to your urologist example, and I need a urology appointment, am I going to have to 

go back to the VA to get that specialist, or can I walk out to my 

receptionist and say, ‘‘Go to Dr. Smith right down the street, the 

urologist?’’ Again, if I have to go back to the VA for that specialty 

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19 

care, then I worry what—all of a sudden the cycle starts again, and 

it may be 30, 60, 90 days before he or she can be seen. 

Dr. YEHIA. No, I think you have a great point. So if you are being 

seen in the community for urology and let’s say you discover that 

someone has diabetes and you can’t just directly refer them to the 

endocrinologist because we didn’t authorize that care. However, the 

way that they would do is, they would call the VA and they say, 

‘‘Hey, this person who I figured out has diabetes, is there a diabetic 

specialist that could be seeing him timely?’’ If not, then we will— 

then they can access the network for that. 

Mr. ABRAHAM. And I guess that is my rub, is that call that I 

have to make that interrupts my patient care, because then I lose 

that patient back to the VA and may or may not get those records 

back, if I don’t have that access to the electronic health record. So 

it is just that continuity of care that I worry about. 

Dr. YEHIA. I am agreeing with you in that spirit is that we have 

to find better ways to share information. You made my point for 

me, which is a lot of those things are in the EHR. The only thing 

that we want is to be able to get that information and present it 

to the veteran. 

And so it is not asking for the community provider to take something more onersome than what they normally do. And to be able 

to report this information will be voluntary. It won’t be a requirement for them to share that with us. So for those that have—that 

feel inclined, will be able to take that information and share it 

with—for the veteran, so they can make decisions. 

What we are working on doing is, how do we get to a place where 

they don’t even have to fax us anything? 

Mr. ABRAHAM. Exactly. 

Dr. YEHIA. Like, we can actually start sharing information. 

Mr. ABRAHAM. Right. 

Dr. YEHIA. This is something that I think all of health care is 

struggling with now. So it is not just the VA, because I don’t think 

anyone has, you know, figured it out completely. When you are in 

an internal health care system, it is easy to share records. But 

when you start going from one health care system to the other, it 

becomes harder. 

So I think we are going to continue to evolve as health care 

evolves there. 

Mr. ABRAHAM. Okay, thank you. 

Dr. YEHIA. Thank you. 

Mr. ABRAHAM. Thank you, Mr. Chairman. 

Chairman BENISHEK. Mr. Takano, you are recognized. 

Mr. TAKANO. To follow up on these concerns, I would just take 

my own—the kind of questions that Dr. Abraham was asking and 

Dr.— 

VOICE. Roe. 

Mr. TAKANO [continued]. —Dr. Roe—excuse me I was blanking 

on his name—Dr. Roe is asking about patient choice, I think we 

face in the private sector health care the same anxieties. But the 

stakes can even be even higher, right? 

If I go out of network, I can pay 50 percent more for going out 

of network. And it is on me to find that out. And I don’t know that 

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20 

dealing with my private sector health care folks are any easier getting through on that customer service line. 

So I don’t know that, you know, putting these expectations on 

the VA, which is not an insurance plan, right? Well, you were not 

set up as an insurer. You are having to do a whole new thing in 

terms of creating payment plans. 

I mean, the concerns of my colleague from Florida, our Ranking 

Member, about making sure providers get paid, you are trying to 

simplify and consolidate all the different care in the community. In 

other words, care in community means—care in community means 

are non-VA private sector providers out there who are under all 

these different plans, right? 

So my question is for Mr. Maynard and Mr. McIntyre. Do you— 

are you optimistic that this consolidation plan under the VA is 

going to make it far more easier for you to recruit people into your 

networks if providers can be assured that they are going to be paid 

timely and there is a simplified process, do you think that is going 

to really enable you to provide robust networks? 

Mr. MCINTYRE. I think that the consolidation makes a lot of 

sense. It is confusing to everybody that is involved in this process 

when you have got multiple plans that pay at different levels, that 

have different requirements, and require different types of management. And the VA is to be commended for taking a look at how do 

they bring those pieces together? 

As it relates to recruiting itself on the provider side in the area 

that we are responsible for, we have been able to successfully reach 

out and bring providers into the network in the areas where we in 

the VA believe that they are necessary. The one thing that I would 

say is that, you know, these things take a while to refine. 

And back to the issue of tiered networks, the Defense Department has a term called ‘‘right of first refusal.’’ And the objective 

there is to make sure that the Federal footprint that has been paid 

for by the taxpayers is maximally leveraged. And what we did in 

TRICARE during the term that we were involved in that, was to 

actually profile each facility and determine what kinds of services 

were available and in what supply. And those were the only ones 

that we went back and determined whether there actually was the 

ability to push that specialized patient back in. 

So I think this—I think you are on the right path. The VA’s on 

the right path in terms of trying to move these pieces. 

Mr. TAKANO. Well, let me ask this. So Dr. Yehia, from the point 

of view of the veteran, they are just going to see whether the doctor 

is in network or out of network, right? They just—it is—they will 

see if the VA provider they want to go to is eligible and that is, 

kind of, a point one, but not every veteran will be eligible to see 

certain practitioners; is that right? 

Dr. YEHIA. They will not see in and out of network. They will 

just see one network, and that network will have all the VA facilities and the community providers. So there is not an out-of-network benefit. 

Mr. TAKANO. So it is much, so from a standpoint of veterans, 

much simpler than the task I have, right? 

Dr. YEHIA. Yes. 

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Mr. TAKANO. Because I have to figure out who is in network, who 

is out of network— 

Dr. YEHIA. Exactly. 

Mr. TAKANO [continued]. —where I can—and who is going to be 

paid, which facility, which emergency room will take me. So for the 

veteran, it is potentially a lot simpler. 

Dr. YEHIA. That is right. And I think you made an important 

point, which is, I think some folks think of the community care network, or the community care program, as an insurance plan. It is 

not. It cannot stand alone. If there was no direct VA care, that program cannot stand alone to provide all the health care needs of veterans. We have to think of it as an integrated system where together internal VA care, community care, now that actually forms 

the health plan, that actually forms what is called, you know, minimal essential— 

Mr. TAKANO. So if you are a provider, if you get everything in 

order, all your ducks in order, the payments, and you attract a lot 

more physicians, a lot more partners, the veteran could probably 

have a lot more choice than someone like me potentially. 

Dr. YEHIA. They probably will. Yeah, I mean we have a—not only 

that, because of some of our specific relationships, they all have access to some services that people in the private sector don’t have 

that don’t have access to. Let me give you a quick example. In my 

practice, in Philadelphia, we were doing—across the street at the 

university we had clinical trials that no one else had access to except for our veterans. And so our veterans were getting access to 

some of the new hepatitis C medicines before they came on the 

market. And so I think our network and what is part of our network, not only delivers good quality care, but access to some state 

of the art care that other folks don’t have access to. 

Mr. TAKANO. Well, I don’t have time to get into the cost, but potentially, even the cost at below what some of—and in the private 

sector as well, because you negotiate the drugs and all that sort of 

stuff. So access to the latest drugs at better costs, so potentially the 

choices are even better for the veteran under the track you are 

going. 

Well, thank you. I yield back. 

Mr. BENISHEK. Dr. Wenstrup? 

Mr. WENSTRUP. Thank you, Mr. Chairman. So my thought is that 

I would like to see the primary care doctors be the gatekeeper for 

the referrals. That is the doctor you have a relationship with, that 

is what you just did in the example you gave. And I would even 

like to see it, whether there is an option, you know, of the 30 days 

or 40 miles. This is whether—even if someone is available within 

the walls of the VA, but you know that the doctor down the street 

is probably the better one for this patient for whatever reason, 

shouldn’t the primary care doctor have that authority? Do we need 

to grant that authority on this level? How can we help here? 

Dr. YEHIA. So actually in our plan, because I believe the heart 

of care coordination is the veteran-primary care doctor relationship. 

Mr. WENSTRUP. Agreed. 

Dr. YEHIA. And we talk all about that here. And I also agree that 

they are the heart of the referrals. And for—if you have a primary 

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22 

care doctor within the VA, they will be the ones that coordinate referrals. Some referrals will go inside, some referrals will go outside. 

Mr. WENSTRUP. Uh-huh. 

Dr. YEHIA. That is true. I think it becomes a little bit harder 

when you have a primary care doctor outside. 

Mr. WENSTRUP. Uh-huh. 

Dr. YEHIA. The only thing that, but I think we can improve on 

that. The only thing that we want to do is provide more visibility 

to the community primary care doctor about what services are offered at the VA— 

Mr. WENSTRUP. Uh-huh. 

Dr. YEHIA [continued]. —because traditionally, most of the veteran—the patient they see they would send to their friend down 

the street, or someone— 

Mr. WENSTRUP. Right. 

Dr. YEHIA [continued]. —else in the community, partly because 

they don’t know what is offered. And I think if we can give more 

visibility on, oh, actually we have really good, you know, diabetes 

doctors here, and really good, you know, cardiologists at the VA, 

they can start referring things back in an appropriate fashion. So 

I agree with you, the center relationship is that veteran with the 

primary care doctor. 

Mr. WENSTRUP. Yeah, and you are right, I mean it just becomes 

an awareness of who is at the VA and who is available, because 

they are not the person you have traditionally referred to. 

Dr. YEHIA. Yeah. 

Mr. MCINTYRE. That is exactly what we did in TRICARE with 

that concept I was talking about in terms of right of first refusal. 

And then you want to map out what is available facility by facility 

so that you are not posing a challenge to someone when they are 

trying to find care that needs to be delivered. In our network, there 

are 50,000 primary care providers stretched across every zip code 

in the 28 states. And so if you are outside of 40 miles, you have 

the ability to go and see a primary care provider if we are able to 

put that in place. 

Mr. MAYNARD. If I could just add one point to that. I think that 

is why it is very critical that if we are going to actually have veterans’ choice, veterans’ choice really needs to begin with the choice 

as to where to be linked from a primary care perspective, to be 

linked within the VA directly, or to choose to be linked for primary 

care purposes in the community so that then the processes can proceed from there, and that gateway that you spoke to will actually 

be established. 

Mr. WENSTRUP. Is there anything we need to change from the 

legislative end to make that more workable? 

Dr. YEHIA. I think there is—I think to be able to highlight that 

relationship would be important, and we can chat more offline 

about some options. 

Mr. WENSTRUP. Okay. 

Dr. YEHIA. Thank you. 

Mr. WENSTRUP. Thank you. I yield back. 

Mr. BENISHEK. Ms. Kuster, you are recognized. 

Ms. KUSTER. Thank you, Mr. Chair, and thank you to the panel 

for being with us. 

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I have a question on the academic medical centers. And in New 

Hampshire, where I am from, we have a top-rate academic medical 

center, Dartmouth Medical School, and a close relationship with 

the VA. Dartmouth is also affiliated with a very, very, large medical center, one of the rare rural tertiary hospitals in Lebanon, New 

Hampshire. And also a series of clinics around the state, including 

my district. And my question is, when you talk about including 

academic medical centers, are you also including their network of 

care in a situation like this where they run clinics all around the 

state? 

Dr. YEHIA. Yes, we want to sign up as many providers as possible. When we talk about the specific partnerships with academics, 

we focus on those teaching relationships where we actually have 

residents and fellows that go back and forth. And so I think that 

there was a point that the Chairman made about making sure that 

they have the same standards as everyone else. And we want that 

to be the case. So we are not going to like carte blanche, just because you are an academic, we send you all our business. There are 

specific relationships where we send trainees back and forth, and 

there is a volume need. So they need to have a certain case mix, 

you know, in surgery, to be able to actually have an accredited residency and to be able to support trainees. So it is only in those circumstances that they are considered core providers. If we don’t 

have a relationship, let’s say we don’t have any residency in dermatology, they would compete and be on par with everyone else in our 

commercial sector tier. 

Ms. KUSTER. Okay. I understand that from your perspective; I 

want to understand it from the veteran’s perspective. Is your answer meant to lead to the veteran being able to access the care in 

their community through these clinics? 

Dr. YEHIA. Yes, I think from the veteran’s perspective and the 

community provider’s perspective, we are interested, and I am sure 

Dartmouth is an excellent institution, we would love to sign up 

every single one of the providers. And so from the community provider perspective, we want them all to join the network. That 

means more choice for the veteran. 

Ms. KUSTER. And along the lines of the indicators of quality, I 

just want to make a point, Representative Kaufman came to New 

Hampshire for a regional field hearing on our heroin epidemic, 

which we now know that four out of five heroin users started on 

prescription medication. And we have now uncovered that part of 

the problem is an inadvertent use of quality indicators in Medicare 

that is leading to reimbursement decisions being made on the basis 

of pain surveys, which is leading to the unintended consequence of 

over-prescribing of opiates. And we have a bill, Representative 

Mooney, our colleague from West Virginia, and myself, have a bill 

to change that. But I am concerned, and I want to put this on the 

record right up front, that that not be used as a quality indicator 

in anything that you may be doing, because veterans have had a 

very challenging experience with this. 

Dr. YEHIA. Yeah, and I would agree with that. I think there is 

some, this is one of the things that we distinguish ourselves from 

the private sector. I think they probably had a well-intentioned 

reason to do those satisfaction surveys, but I have seen many of my 

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24 

colleagues that are excellent clinicians and they are doing the right 

things, and that may mean not prescribing an opioid, but maybe 

physical therapy or acupuncture. And because the patient didn’t 

walk out with a prescription, they give them a bad score, but they 

are actually excellent doctors. So we have to be very clear about 

the metrics that we use. I definitely would agree with that. 

Ms. KUSTER. Yeah, and if we could just say that right up front, 

that any type of—you have to think through what might happen 

in using these different metrics. 

And then the last question has to do with one that frequently 

comes up when we are talking with the Secretary and the VA, and 

that is the issue of co-pays, out-of-pocket expense to the veteran. 

I know that we want to keep that as low as possible, but I am concerned, just given that the taxpayers are at the other end of this 

equation, that we are not sort of incenting people to use the VA 

when they have perfectly good health insurance from another 

source that might be more appropriate. And for this I am talking 

about not the veteran experience related, and I think I may be 

going over my time, but if we could submit that for the record. 

Thank you very much. 

Mr. BENISHEK. Mr. Bilirakis, you are recognized. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it very 

much. Thanks to the panel as well. 

With regard to the costs, I have a question. Of course quality of 

care, veterans deserve the best. No question, that is imperative. 

But do you have any metrics as to—are you tracking what the costs 

would be within the VA and also outside the VA under the Choice 

program? 

Dr. YEHIA. Yeah, we are monitoring the spend on the Choice program very closely. We have a set limit that was provided by Congress, and so we monitor that very closely. So we do have that. 

Mr. BILIRAKIS. Can you give me some answers? 

Dr. YEHIA. Sure. So we spent last fiscal year, we had about $3.5 

billion that we used out of Choice funds to deliver care to veterans. 

This year we are anticipating kind of something similar, about $3 

billion to $3.5 billion. So that gives you a little bit of a sense of— 

at least just from Choice, that is only Choice care that we spend 

financially. 

I think to your point though, I think what you are getting at is, 

as we continue to make the program better, more and more people 

are using the program. And that is something that we have to be 

very cognizant about, because as we make a product that people 

want to use, there comes—there is a cost that is associated with 

that. And as we start considering developing new legislation that 

will consolidate community care and create a new program, how do 

we make sure that we have the right resources to actually deliver 

that benefit? We are seeing more and more people using the program than ever before. 

Mr. BILIRAKIS. How are you getting the word out? I know we are 

doing our job here to get the word out, with regard to the program, 

the eligibility requirements, what have you. Tell me that, and also, 

how are we getting the word out to the providers or potential providers that want to participate in the program? 

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25 

Dr. YEHIA. So we have done a number of outreach for both veterans and community providers, you know, including, we have a 

website, that website specifically has an area just for providers, an 

area just for veterans. We have issued letters to all of our community providers that we were working with before Choice, encouraging them to join Choice, similarly to veterans, mailers, so we 

kind of, are trying to use different avenues to reach more people. 

I will say probably the biggest thing that we do is really word of 

mouth, which is the local medical center talking to their veterans 

in town halls and their local providers, ask them to sign up. And 

as Dave and Billy can attest to, we have seen a big increase in the 

number of providers that have joined both of the networks. 

Mr. MCINTYRE. And on our end, we had the Blue Cross/Blue 

Shield plans and universities that own our company that are indigenous to the 28 states reach out to their networks across their 

states to be able to give them the sense that this was there, and 

how they would sign up. And we are signing 300 to 500 doctors up 

a day. 

Mr. MAYNARD. And it is the same with us and both Dave’s organization and mine also had deep foundations in the TRICARE program, and were able to approach all of the participating providers 

there who also were reimbursed under Medicare and have been 

very receptive to expanding access and support of veterans as well 

under this new program. 

Mr. BILIRAKIS. With regard to dental care, those who are eligible 

under the VA, are they also eligible under the Choice program? 

Dr. YEHIA. Yeah, yes, sir. So if you meet the eligibility criteria 

for dental, which are pretty high— 

Mr. BILIRAKIS. I know that. 

Dr. YEHIA [continued]. —there is a number. And we can’t—either 

we don’t provide dental care at the VA, or there is a wait issue, 

they can get that care in the community. Also, we know that a lot 

of the dental care is already delivered in the community today. We 

don’t have dental practices at most VAs, so most of that benefit is 

delivered in the community already. 

Mr. BILIRAKIS. Very good. 

Dr. YEHIA. Thank you. 

Mr. BILIRAKIS. Okay. Anyone else want to comment on that? 

All right. Thank you very much. I yield back, Mr. Chairman. 

Mr. BENISHEK. Mr. O’Rourke, you are recognized. 

Mr. O’ROURKE. Thank you, Mr. Chairman, and I would like to 

thank everyone who has testified today, and thank you also for 

your answers to our questions. 

Mr. McIntyre, you mentioned being in El Paso on Friday. Thank 

you for being there, for making the commitment to our community, 

and we really appreciate TriWest having an operation center that 

is hiring veterans in El Paso. And Dr. Yehia, through you, I want 

to thank Mr. Joe Dalpiaz, VISN Director for Texas, who was also 

there, for his commitment to the community, and for everything 

that you all are doing. 

I have two questions, I think, on this subject. We were told by 

Dr. Clancy last week, that while we thought we had 41,500 authorized funded but unfilled positions at VHA, the number is now 

43,000. Given this consolidation, this admission that the VA will 

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not be able to provide all things for all veterans within the walls 

of the VA medical facilities, this excellent article by the Under Secretary Shulkin in the New England Journal of Medicine last week, 

to that same end, a couple things. One, can we dispense with the 

fiction that we will ever hire, or maybe even need to hire, those 

43,000? 

Related to that, number two, Dr. Shulkin mentions in the article 

the need for the VA to focus on those conditions and disabilities 

and illnesses that are connected to military service and to combat. 

And I think of post-traumatic stress disorder, traumatic brain injury, military sexual trauma, traumatic amputation, those things 

that you generally are not going to see in the civilian population. 

And should there not be sooner, I hope, rather than later, some 

kind of behavioral health dividend related to those conditions, 

where if we are not focused on hiring all 43,000, we are going to 

really focus on those specialties like mental health that we really 

need that will prevent veteran suicide and do a better job for all 

of our veterans? 

And then the second question, if you can get this in, in the time 

remaining, I held a veteran town hall on Saturday, 28 veterans approached the microphone to share their experiences at the VA. 

Thirteen of those 28 mentioned that their primary care physician 

left the VA in El Paso, they were never notified. They only found 

out when they went to refill a prescription and couldn’t, or were 

waiting for a referral that never came through. High level person 

at the El Paso VA medical center said there is actually a problem 

right now where we cannot refer somebody to community care. We 

first have to have 30 days to demonstrate that we couldn’t get it 

done in here. We need the flexibility to recommend right away. I 

know this has come up in other questions. Could you just address 

that specific to those dropped veterans who have lost their primary 

care physician and don’t know what to do, and wait months to get 

an answer? 

Dr. YEHIA. Yeah, and thank you so much, Congressman. This 

gets back a little bit to the eligibility criteria. And the way that I 

describe those eligibility criteria is three areas: wait time, geography, and availability of service. And so I think at El Paso there 

is a number of things that are not available there. So by definition, 

we automatically partner with the community to deliver that. Geography, if they live more than 40 miles away. And then wait time, 

the 30 day criteria. 

That is only—the way that I think of it, that is only the floor. 

So that is a minimal set of eligibility criteria. We need to make 

sure, and this is something that I think Congress can help us with, 

is make sure that there is adequate flexibility so that if there is 

a special circumstance, if I am seeing someone in my clinic that I 

think has to go out of the community, even though we don’t have 

a wait in that area, we have some of that flexibility to do that. And 

some of that was afforded to us when the most recent iteration of 

the Choice law was passed over the summer. So I think keeping 

that front and center is important so that it is not so rigid to just 

those three areas, but there is some flexibility so that the local VA 

can work with their veterans if someone needs to go in the community. 

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I don’t know specifically about the issue in El Paso and the primary care providers; however, if there is a wait for primary care, 

they automatically are eligible for Choice, and so that is something 

that we can make sure that they are aware of that option, and they 

can offer that up to their providers—or to their veterans. 

Mr. O’ROURKE. And then the other question is, you know, I 

would like to get into the specifics of that offline, but the other 

question is, can we now tighten our focus on hiring mental health 

providers, and if that means increasing what we pay for them, just 

having the attention to that, prioritizing that over other conditions 

that might be more better served by a network that they can refer 

out to, what are you seeing towards that? I am out of time, so I 

may need to get your answer for the record, but we are acutely interested in that right now. 

Thank you. 

Mr. BENISHEK. Mr. Coffman, you are recognized. 

Mr. COFFMAN. Thank you, Mr. Chairman. First of all, if I understand this right, Dr. Yehia, under your—this VA’s proposal, it is 

the VA that will do the scheduling for the third-party providers or 

administrators? 

Dr. YEHIA. Yeah, in our proposed plan, we want to be more of 

the face of customer service and scheduling. That could mean, as 

we talked about before, just saying to the veteran, ‘‘you are eligible 

for community care, here is your options, do you want to schedule 

your own appointment?’’ But we would be more the ones that 

would be having that conversation, rather than the contractors. 

Mr. COFFMAN. Yeah, I am very concerned with VA doing the 

scheduling, and let me tell you why. The whole reason for the 

Choice program was that there was a scandal in the VA on scheduling, that the level of corruption, systemic corruption across the 

VA in scheduling, driven by cash bonuses in order to bring down 

the wait times, and they created these secret lists. And now what 

you want to do, and what the VA wants to do, is let’s give it back 

to those same people. 

Dr. YEHIA. So first of all, the reason why we want to do this is 

because we have heard from veterans and community providers. 

Mr. COFFMAN. Yeah. 

Dr. YEHIA. So when I—and in all the town halls that I have, and 

that I sit down and talk to folks, they say, ‘‘why is there a middleman— 

Mr. COFFMAN. Yeah. 

Dr. YEHIA [continued]. —in the scheduling?’’ And the folks that 

actually do the scheduling for community care are different than 

those that do the in-house. 

Mr. COFFMAN. We need to get the system to work. But we need 

to get it to work without getting VA back into the system that got 

us to where we are today. I mean, unbelievably incredible, that— 

and I got to tell you, those who have been responsible have not 

been held accountable. We don’t even have a mechanism, and the 

Secretary doesn’t support one, to claw back bonuses for people that 

fraudulently got them on this scheduling scandal. And yet we want 

to move it back? I mean, I just think that that is absolutely incredulous. And that is truly an exercise in poor judgment. And let me 

tell you, this Member of Congress will be in a blocking position, if 

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you are familiar with that term. I don’t know if you served in the 

military. 

Dr. YEHIA. I didn’t, sir. 

Mr. COFFMAN. The blocking position, well, take it from a Marine 

Corps officer, infantry officer, that is to stop you from doing that, 

because I think that that is an incredible exercise, again, in poor 

judgment. You know, and I think you are reluctant to let go, I 

think the VA is reluctant to let go of this and so creating an excuse 

rather than fixing the system, let’s give it back to the VA. And, 

again, I think that that is an incredible mistake. 

Mr. Maynard and Mr. McIntyre, both Health Net and TriWest 

have experienced managing care networks with TRICARE. Based 

on your experiences with both DoD and VA, where can VA learn 

from the methods and practices employed by DoD with TRICARE? 

Mr. MAYNARD. I think there are a couple of key points that 

would really facilitate, that even though the benefit or eligibility 

structure is different, are still there as critical lessons learned. I 

think one of them is really clear: eligibility criteria, linked with 

standardized reimbursement. The more we standardize reimbursement around Medicare, there is sufficient provider support in the 

community to largely accept Medicare reimbursement in support of 

eligible veterans. That represents a savings itself from commercial 

rates, but it standardizes and simplifies and streamlines a good bit 

of the provider relationship. 

The other, I think, is continuing to remove the very points that 

you have been emphasizing, that impede ready access. I think—I 

myself believe that scheduling going forward, while it started as a 

critical and well-intentioned component of the initial Choice program, really did have an unintended consequence of obstructing a 

bit the ready flow in terms of the way the facilitation of health care 

works. I think as we look forward, that scheduling service should 

be a secondary or tertiary availability to veterans who individually 

need help. But to the point that you raised, there are very sophisticated and increasingly capable commercial sector capabilities, including, for example, our own relationship with 1–800–DOCTORS 

that has auto-adjudication and auto capabilities to link into community care hospital and provider systems to automatically schedule necessary appointments. So I think keeping an eye on the evolution of the way that customer services are delivered, ensuring 

that industry is not impeded from bringing best practices to the 

support of veterans are critical concerns as we look forward to serving veterans into the future. 

Mr. MCINTYRE. I would agree with Billy. I would add, though, 

that I think there is the opportunity to take advantage of the first 

right of refusal process so that when we have got veterans that are 

far out, making them aware of what is actually accessible in the 

VA would be a good idea, but not force them to go there. 

Secondly though, as it relates to rate structures, two-thirds of 

our network is actually built at market rate. And it is a full passthrough to the VA budget. And what that means is we have doctors 

and hospitals all over our 28 states that said, ‘‘You know what, we 

will give you up to Medicare, not Medicare.’’ And you don’t want 

to lose that, because it is built into the base of the budget. 

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Mr. COFFMAN. I just want to, again, just—oh, I am over my time. 

Mr. Chairman, I will yield back. 

Mr. BENISHEK. Mr. Huelskamp, you are recognized. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. I apologize for being 

late. I had another Subcommittee hearing, Small Business Committee, also talking about health care. But I appreciate the questions of Mr. Coffman. I do have my assistant here, my youngest 

son, Alexander, on spring break. This is exactly what every nineyear-old likes to do on spring break, I must admit, so. But thanks 

for—Alex for joining me. 

I would like to follow up with the questions from my colleague 

to the west about scheduling and he already stole my question 

about how can we learn from TRICARE experience as well. But 

under TRICARE, does the DoD schedule the appointments? 

Mr. MAYNARD. No. There are no scheduling services. Originally, 

there were various services. There are a few military treatment facilities, or MTFs, that maintain some appointing support for their 

own appointing, but not outside the walls, and neither has it really 

proven a critical issue at all in terms of the facilitation of care on 

behalf of TRICARE beneficiaries. 

Mr. MCINTYRE. You would have to go back a decade to find that. 

And it took a bit of refinement, just like this is doing, to get it 

right. And you know, part of the challenge, I think, in the scheduling space was, we stood this program up in a little over 30 days, 

because you were responding to a crisis, and appropriately so with 

the right kind of intensity. And how we are doing scheduling now, 

in our area, is vastly improved over the first couple of months of 

what we were doing it. And part of that is, we took the geography 

and broke it down into segments. So now we are not serving people 

out of one or two geographic areas; we have ten operations centers. 

We stood them up since the summer. Went from 400 staff to 3,600 

as of last Friday. And so we built a hub and spoke environment. 

That is what you have to have. You have got to have a relationship 

with the providers in the community. And it takes a little while to 

get that refined. At the end of the day, I do believe there are areas 

where it makes a lot of sense for the VA to be absolutely at the 

nuclear center of scheduling. And Alaska is one of those examples. 

Far too complicated for everybody than to be having a third party 

involved in that process. But in many parts of our environment, 

that is not the case anymore. And we are not getting the negative 

feedback from the providers that we were getting even six months 

ago. 

Mr. HUELSKAMP. I would agree, and prompt payment helps lessen feedback, and I appreciate the VA announcing some of the reductions in paperwork that is making that happen, still have some 

pushback, but the idea we would go back. I had a local VA clinic, 

or maybe, I guess, maybe this wasn’t local, it certainly wasn’t local 

VA clinic, but they wanted to do some scheduling for a veteran, 

and I think they scheduled, said, ‘‘well, the nearest provider is five 

states away.’’ They misunderstood, they were looking at the city, 

and didn’t recognize they were states away. I mean, I think that 

was online with the VA. You hear that again, but it might be different, Doctor, maybe in an urban area, but in my district, they 

know the hospital. You know, and don’t forget, these veterans, this 

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30 

is not their first rodeo to go to the local hospital. Most of them are 

already going to the local hospital. And that was the fear that 

somehow they would overwhelm the VA system as they rushed in. 

All we are saying is let them keep going where there are going, in 

many cases, and they don’t need the VA calling the local doctor 

they saw at church on Sunday. 

And again, it might be different in an urban area where you 

have got the VA hospital a couple miles away and you have been 

waiting your 30 days. But for our rural areas, if we went back and 

centered scheduling, we would have even more problems than before. We would have even more complaints. The robustness of this 

network is developing, and I think is continuing to improve, and 

the providers I talk to, they are signing up just to make sure that 

they get paid on time. But, again, let’s not envision this as a veteran that is getting 100 percent of their health care. It is the case 

sometimes they are starting to drop in, and then say ‘‘Hey, can we 

get this taken care of,’’ if this is going to work. So we will hopefully 

see this continue to develop and work with the folks that have experience in other networks. 

And again, don’t forget that you have a veteran that may be a 

senior officer, he has served alongside as TRICARE for life, he 

served four years, ‘‘Why can’t I go to my local hospital,’’ but the guy 

that has long-term benefits the rest of his life, you know, he gets 

to go to the local hospital, but I got to drive 200 miles. Obviously, 

we want to avoid that. So let’s continue to work and develop that 

network. I know in western Kansas, central Kansas, they are ready 

and waiting, they are slowly adding providers, actually quickly, 

and I have got 70 community hospitals, you know, unlike some of 

the other areas, they are begging for patients, you know, and they 

are hopefully getting the veteran once. They might even get his 

wife and get his kids as well and it is these kind of things that develop. 

My concern as well is that the temporary nature of the language, 

and I know the Secretary has promised that he wants to make this 

permanent, but the sooner we can make this permanent, the sooner 

we can make these relationships more long term, and for the veterans as well as for the providers, Mr. Chairman. So I appreciate 

the timeliness of this topic. I yield back. 

Mr. BENISHEK. Thank you, Mr. Huelskamp. 

Does anyone have any further questions? I know there is lots 

of— 

Ms. BROWNLEY. Just quickly? 

Mr. BENISHEK. Yeah, sure. 

Ms. BROWNLEY. If you don’t mind. Thank you, just quickly. I 

have just a couple of quick questions, and hopefully they are just 

all yes answers. But so in my district we are still having issues 

with regards to inappropriate billing, when a patient, a veteran, is 

seeing a community doctor. And we have a particular issue, casework that we have not been able to resolve for one of our veterans 

that saw an orthopedist, was very satisfied with his care there. He 

stepped on a landmine in Vietnam, ended up getting two splints 

that he needed, but he is being billed $500 for those splints. And 

we have worked really hard in our district office to resolve this 

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31 

problem. If you could help us resolve it, I would appreciate it very, 

very much. 

Dr. YEHIA. If you give us their name, we would be happy to work 

it out. 

Ms. BROWNLEY. Terrific. 

And in terms of just following up on Mr. O’Rourke’s question 

about staffing. If you are going to send him information, I would 

be interested, you know, in the same information as well. 

And the last question I had is, if you have wait time data for veterans who are using the Choice program, and if you have any analysis of comparing that nationally, in terms of wait times, compared 

to what the VA is providing with regards to wait times. 

Thank you. Thank you for your indulgence, Mr. Chair. 

Mr. BENISHEK. Oh, no problem. 

I am sure there may be other questions that we come up with 

as you are developing this program, and I look forward to that dialogue. But other Members may want to submit some questions for 

the record even yet. So thank you all for being here today. It has 

been an education, and I am sure it will be as we go forward. 

I ask unanimous consent that all Members have five legislative 

days to revise and extend their remarks and include extraneous 

material. And without objection, so ordered. 

This hearing is now adjourned. 

[Whereupon, at 11:35 a.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Mr. Billy Maynard 

BIOGRAPHY OF BILLY MAYNARD

Mr. Billy Maynard has been the President of Health Net Federal Services, LLC 

since May 1, 2015. Previously, in addition to holding a variety of defense sector positions, he was a partner at the management consulting firm InfiniTek for 12 years. 

At InfiniTek, he specialized in federal health care strategy and provided strategic 

business planning and organization development support to Health Net and other 

leading government sector health care service delivery and technology companies. 

A veteran of the U.S. Army, Mr. Maynard was Executive Assistant to NATO’s Supreme Allied Commander, Europe, from 1983 to 1990. During this period, he was 

twice decorated with the Defense Meritorious Service Medal for contributions in 

support of the NATO Alliance. Mr. Maynard is a graduate of the U.S. Army Institute of Personnel and Resource Management (Adjutant General Corps); studied 

business administration at the University of Maryland University College Europe; 

and holds a postgraduate certification in organization development (strategic planning and change leadership) from DePaul University. 

A HISTORY OF PARTNERSHIP

Chairman Benishek, Ranking Member Brownley, and Members of the Subcommittee, thank you for the opportunity to participate in this hearing on provider 

networks under the Department of Veterans Affairs (VA) plan to consolidate Community Care programs. Health Net Federal Services (Health Net) is proud to be one 

of the nation’s largest and longest serving health care administrators of publiclyfinanced government and military health care programs. To this hearing, we bring 

the perspectives and lessons learned throughout our nearly three decade history 

supporting government health care entities at the intersection of their care capacity 

and their need to support their beneficiaries with care in the community. Today, 

Health Net and its affiliates, through health plans and government contracts, provide health benefits and related beneficiary services to more than five million eligible individuals across the country through VA, TRICARE, Medicare, Medicaid, 

group, and individual programs. 

For more than 25 years now, we have served as a partner to the Military Health 

System (MHS) as a Managed Care Support Contractor (MCSC) in the TRICARE 

Program. Health Net was the original CHAMPUS Reform Initiative (CRI) contractor, the predecessor contract to TRICARE. Currently, as the TRICARE North 

Region contractor, we facilitate the community-based delivery of nearly $3 billion in 

spending to support the health care needs of nearly 3 million active-duty service 

members, military retirees, guardsmen and reservists, and their dependents in 22 

states and the District of Columbia. 

We also deliver a broad range of customized behavioral health and wellness services to military service members and their families, including those in the National 

Guard and reserves. These services include the Military and Family Life Counseling 

(MFLC) program, which provides non-medical, short-term, problem solving counseling; rapid-response counseling to military units; and reintegration counseling. In 

support of MFLC, we have more than 700 professionals deployed with the military 

worldwide, including professionals embedded in support of special operations forces 

in various theatres. 

As an established partner of VA, Health Net has collaborated in supporting veterans’ physical and behavioral health care needs through Community Based Outpatient Clinics (CBOCs) and the pilot Rural Mental Health Program. We also have 

supported VA by applying sound business practices to achieve greater efficiency in 

claims auditing and recovery and, previously, through claims repricing, both of 

which resulted in increased funds available for health care services delivered by VA. 

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Our singular mission in all these endeavors is to enable government agencies, 

such as VA, to leverage private sector best practices in order to supplement and 

complement their in-house capabilities through an effective public/private partnership. Our focus on supplementing and complementing is important because our 

work as a private sector company focused on organizing and facilitating communitybased capabilities and services begins where the direct care capacities of the agencies we support ends. The shared goal from that point is not only to ensure ready 

access to care but also to enable our government agency partners to continue to provide the high-quality and often highly-specialized services that constitute their core 

mission. 

Our commitment is not just professional; it is personal as well. I am a veteran; 

I served 10 years in the U.S. Army, including as the Executive Assistant to NATO’s 

Supreme Allied Commander, Europe. I am also the son of a Navy retiree and grandson of a WWII combat veteran who was one of a family of brothers who all saw 

combat and were supported by VA upon their return home. The mission of health 

care integration in support of our nation’s eligible veterans is one I take to heart 

personally. That is true of our other associates, as well. Many of the top leaders in 

Health Net are veterans, military retirees, or military spouses. Several of our 

younger leaders are still serving as reservists. We take pride in our commitment 

to our comrades in arms and our fellow veterans. We take our work personally because we have friends who use the services we provide. My remarks are informed 

as much by the spirit that led me and so many of my colleagues to service as by 

my business experience. 

It is from this long-standing commitment to supporting the military and veteran 

communities that we offer the following perspectives on provider networks under 

VA’s plan to consolidate Community Care programs. 

COMMENTS ON BUILDING A HIGH-PERFORMING NETWORK

First and foremost, we believe that all health care provided in support of eligible 

veterans is VA care, whether delivered directly by VA or its affiliates or community 

providers. Therefore, care must be designed and delivered in ways that care in the 

community is understood and considered as VA care by all involved, most especially 

eligible veterans and health care providers. For this to be achieved, the approach 

to delivering care must be as seamless and integrated as possible - especially at the 

point of intersection between VA’s capacity and care delivered in the community. 

Based on our years of experience, we believe the only way all care can truly be seen 

as VA care is through the establishment of mutual accountability within the framework of a public/private partnership. 

Second, we strongly agree with the Independent Assessment of the Veterans 

Health Administration (VHA) released on September 18, 2015. Specifically, that report highlighted the challenges of VA’s current approach to purchased care through 

the seven programs already in place or in development. This report concluded that 

the programs’ ‘‘sheer multiplicity suggests the drawbacks of a piecemeal approach, 

absent a guiding orientation and strategy for VHA’s purchased care enterprise as 

a whole.’’ We strongly support standardization and consolidation across the full 

range of Community Care programs. 

Turning attention to VA’s plan to build a high-performing network composed of 

a Core Network of federal partners and academic affiliates and an External Network of community providers: in principle, we support the concept that a preferred 

provider network construct could deliver the significant community-based access to 

care that will be necessary to support eligible veterans and to enable VA to fulfill 

its mission in the future. While there are other approaches, given VA’s significant 

direct-care mission and capacity, a preferred provider approach - sometimes referred 

to as a tiered network approach - will be the most effective way for VA to optimize 

and integrate care delivery. 

We believe that whatever geographic or provider network development approach 

VA takes, whether that be tiering or some other preferred provider design, it is absolutely essential that VA partner with a single, third-party entity within each geographic area to establish and administer all community-based aspects of the program. 

Like VA care, the TRICARE program also depends on the effective integration of 

health care at the intersection of a large direct care system and supplemental community-based capabilities. After 28 years of experience, there is perhaps no more 

important lesson learned than that the only way to ensure consistency and clear 

lines of authority and responsibility across the program is through the responsibility 

of a single contractor, on a geographic basis. This approach is the most effective solution for veterans, providers, and VA. It is also the only proven way to actually 

succeed in standardizing a national-level initiative such as the ‘‘new VCP’’ and makLeonard.horne on VACREP0180 with DISTILLER

34 

ing it operational in all locations. A single, third-party entity by geographic region 

will also be the most fiscally responsible method. 

The effective implementation of any future version of the Veterans Choice Program is contingent upon optimizing the capacity of VA (including VA Medical Centers and local community-based outpatient clinics); making the provider experience 

as consistent with community standards as possible; and streamlining veterans’ experiences to enable better control of their health care experience. All this can be 

done while maintaining care in the community as a complementary capability within the broader context of VA health care. We believe this can be done in ways that 

will preserve and extend the very important relationships VA maintains with DoD 

and its academic affiliates. 

DISCUSSION OF THE DRAFT PERFORMANCE WORK STATEMENT

Turning attention to VA’s Draft Performance Work Statement (PWS) for Community Care Networks, we support the comprehensive nature of the requirements outlined and believe it to be a good start toward future procurements that the managed 

care industry can effectively support. 

The Draft PWS requires contractors, within newly defined health care regions, to 

develop the community-based elements of a High-Performing Network that would 

provide a full complement of services in support of the consolidated new Veterans 

Choice Program (‘‘new VCP’’), including: network management, credentialing, medical management, call centers, and claims processing. 

In the process, VA has defined a draft baseline that is much more TRICARE-like 

and incorporates a substantial number of industry recommendations made during 

the market research phase of the acquisition development process. That said, it is 

important to note the Draft PWS suggests that VA will retain initial appointing and 

appointment scheduling responsibilities, which is a significant change from the current Choice Program. 

The future success of any program, even one based upon an existing program, is 

laying the appropriate foundation. The transition period for the ‘‘new VCP’’ should 

have a baseline transition period of at least 12 months from contract award to the 

start of health care delivery. This will allow the program to ‘‘go live’’ with fully developed and tested networks and operating processes based on lessons learned. 

Among the lessons learned in Choice, and similar to those learned in the early 

TRICARE experience, is that a vital element to the smooth operation of any health 

care delivery program is a set of standardized written policies and procedures. 

These policies must answer the ‘‘who, what, when, and why’’ of delivering care. We 

commend VA for starting this process by releasing the beginnings of an operations 

manual with the Draft PWS. Much of the friction in the current Choice Program 

has come as VA tried to implement the intent of Congress and this friction translated to the veteran and provider experience. Having a clear set of guidelines before 

a complicated question arises, such as how to compute eligibility or what defines 

an episode of care, is vital to the veteran and provider experience. A thorough transition period will allow for the development of consistent, standardized written policies and procedures. Clear guidelines will also speed any adjudication processes and 

result in a better experience for veterans and providers through faster responses. 

Even with a clear operations manual, however, the veteran experience will be 

compromised if the intersection of public policy and supplemental community-based 

capabilities is not executed in a context in which providers are prepared to operate. 

Therefore, the operations manual and associated processes must align with industry 

standards. The more unique the requirements to participate in and execute the 

‘‘new VCP’’ the more friction will result at the provider level, and the more difficult 

the experience will be for veterans. Medicare is the common standard upon which 

all other government programs are based and providers across the country are familiar with Medicare requirements. In addition, VA has stated a goal of moving toward the value-based reimbursement methodologies that Medicare is driving. 

THE WAY FORWARD

In closing, let me say that in a program like Choice, veteran and provider experience and satisfaction is everything. The success of any future version of the Veterans Choice Program will depend upon optimizing the capacity of VA (including the 

VAMC and local community-based outpatient clinics); making the provider experience as consistent with community standards as possible; and streamlining veterans’ experiences so that they are able to control the process and receive care when 

necessary. 

All this can be done while maintaining care in the community as a complementary capability within the broader context of VA health care. Health Net has effectively built an excellent customer and provider experience in other government 

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agency programs such as TRICARE, which was tied at number one with Kaiser 

Permanente for customer satisfaction, according to a national survey on health 

plans, the 2015 Tempkin Experience Ratings, conducted by the Temkin Group. We 

see no reason that VA and industry partnerships should not result in eligible veterans being just as highly satisfied. 

Health Net is proud to stand as a partner with VA and Congress in helping to 

deliver care to our nation’s veterans. Thank you for the opportunity to present our 

views and I look forward to answering any questions you may have. 

f 

Prepared Statement of Mr. David J. McIntyre, Jr. 

Introduction 

Good morning, Mr. Chairman and Members of the Veterans Affairs Subcommittee 

on Health. I am pleased to appear before you this morning to discuss the status of 

the development of the community care network in our geographic area of responsibility, which includes 28 states and three U.S. territories. The last time I appeared 

before you on this particular topic was last Summer, and a lot has occurred since 

then that has positively impacted access to care for the Veterans who call our area 

of responsibility home. 

Before I get started with my remarks, Mr. Chairman, I would like to thank the 

Chairman of the full Committee for his leadership and focus on ensuring that our 

nation’s Veterans have access to the health care they earned with their service. It 

has been and remains a privilege to be of service to his constituents. I know that 

they are going to miss him when he retires at the end of this Session; however, 

know that we will continue to stay focused at the side of the Department of Veterans Affairs (VA) in meeting the needs of those he has represented so capably. 

And, I am confident that his legacy will long endure. as VA continues to re-set for 

this generation’s warriors and the next. 

It is a privilege to appear alongside Dr. Baligh Yehia, from the Department of 

Veterans Affairs. From personal experience, I would like to observe that his handson and focused leadership, and that of a very capable team within VA, is enabling 

us all to move the needle and start to achieve success in the re-setting of VA’s 

leveraging of care in the community to augment that which is available directly 

within its direct delivery system. 

TriWest and VA continue to work in close partnership to improve access to care 

for Veterans across our service area. While we are beginning to see the fruit of our 

labors, I would be the first to admit that more remains to be done to fully fulfill 

the promise of the nation to those who have worn the uniform and sacrificed in 

service to this great nation. 

A Historical Perspective 

During TriWest’s 20 year history, the company I was fortunate to help form with 

a group of non-profit health plans and university hospital systems - and have been 

privileged to lead since then as President and CEO - has focused exclusively on 

leveraging the core competencies of our owner organizations and their strong market presence to ensure access to needed care when the federal systems on which 

those in uniform rely are unable to meet the needs directly. And, we and our more 

than 3,500 employees, most of whom are Veterans or family members of Veterans, 

count it an honor to be part of the team stretching ourselves in service to our nation’s heroes! 

Our first 18 years were spent supporting the Department of Defense (DoD) in 

standing up and operating the TRICARE program in a 21-state area. I’m proud of 

the work that we did to assist DoD in making TRICARE the most popular health 

plan in the country and meet the needs of millions across the TRICARE West Region who relied on us for that support. And, as those of us who were around in the 

early days of TRICARE can attest, we know it was neither an easy nor painless 

road. Now, working at the side of VA, while the challenges of implementing a new 

program have been similar to the early TRICARE days, due to the added layer of 

complication that led the Choice Program to be brought forth so quickly, I believe 

we can achieve the same results for Veterans who look to VA for their health care 

needs. 

In our experience under the TRICARE program, we had 15 months to prepare for 

the start-up of TRICARE and then nine months to stand up the program before the 

demand for services arrived. With the Veterans Choice Program, this 24-month period was shrunk to a little more than 30 days. Since then, you, VA and we, have 

been focused on making the changes necessary to achieve the success we all desired 

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with a program that demanded the aggressive design and implementation schedule 

given the crisis out of which it was born. 

While not yet where we all want to be in the re-setting of VA and the programs 

that exist to support it in the delivery of needed care and services for our nation’s 

Veterans, I would submit that a lot of progress has been made and I am proud of 

the fact that 100,000 Veterans are now being served each month in our geographic 

area of responsibility through the Choice Program. 

First, most of the policies that needed to be re-set have been acted on and are 

operational. to the benefit of Veterans and the providers that serve them. 

Second, the remaining operations gaps that exist are identified and the needed 

adjustments are being made. This is largely a result of the work that Dr. Yehia has 

done in bringing all of us together to form a common focus around five core initiatives: Simplify the Referral and Authorization Process; Decrease Returned Authorizations; Improve Customer Service; Get the Right Provider Every Time; and, Better 

Visibility into the Networks. 

Third, the networks in our vast area of operations, have now been fully tailored 

and are being leveraged to begin to deliver on the demand profile that exists. 

And, fourth, just last Friday, we finished the six month roll-out of an infrastructure and scale that is now beginning to deliver on the demand that exists. This took 

us from two sites of operations to 10 sites, with Friday’s opening in El Paso. 

I know that the road has not been painless or easy on anyone involved, especially 

for the Veterans we all seek to serve; however, there has been tremendous progress 

in our area, we are maturing the program and WILL achieve the expectations that 

you and your fellow members of Congress had when you mandated the creation of 

the Choice Program to more optimally meet the health care needs of our nation’s 

Veterans. As one who was there at the start of TRICARE, and through all of the 

painful periods and the refinements necessary to smooth out the operation... making 

it a model program for our nation’s defenders and their families, I would say that 

we are well on our way. And, enabling VA to consolidate all of the community care 

programs should be the last mile of modification needed to put us on a path to 

achieving the excellence we all expect of ourselves and wish for those we are privileged to serve. 

We all know the pathway we have been on, but I think it deserves repeating. 

Where We Started: PC3 

In September 2013, VA awarded the brand new Patient-Centered Community 

Care (PC3) contracts, and we were selected to serve 28 states and the Pacific. And, 

we were given 90 days to begin operations. 

TriWest rose to the occasion by leveraging the existing networks and strong relationships already in place due to our prior work under the TRICARE contract. Initial access to specialty care from our existing network providers began in January 

2014 with the ongoing expansion and addition of primary care providers coming online over the months that followed. That network building continues to this day as 

VA and we learn more about where demand exists that was otherwise not being met 

before this program began. 

PC3 was intended to be a nationwide program giving VA Medical Centers (VAMC) 

an efficient and consistent way to provide access to care for Veterans from a network of credentialed specialty care providers in the community when VA was unable 

to deliver the care directly. This would provide a consolidated network in each area, 

rather than continuing the inconsistent and expensive ad hoc approach of trying to 

contract by site for an array of providers. This was one of TriWest’s primary missions as a TRICARE contractor. So, we quickly embarked on the path of putting this 

together, only to learn that the VA sites really did not have a good handle on their 

demand profile. a challenge that would become even more extreme with the adoption of Choice. And, when you do not know the size and shape of your demand it 

makes it nearly impossible to effectively tailor networks. as we discovered painfully 

in the early days of PC3 and Choice. The goal, though, of having a tailored network 

of community providers to allow for the optimization of VA’s direct delivery system 

and meeting the specific needs of the Veteran population across each state unable 

to be met directly by VA remains very doable. as we are now proving in our area 

of operation. 

I will say that the concept proved its worth early in the State of Arizona, where 

an extensive network was available in Maricopa County starting in January 2014. 

In fact, it was that network of nearly 7,000 community providers that would prove 

to be an invaluable tool in the Spring of that year. 

A Historical Perspective of Choice Program 

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In April 2014, the ‘‘furnace lit off’’ in Phoenix, and the country was shocked to 

learn of the shortcomings in the system. This served as the catalyst for fueling a 

focus on VA reform throughout the nation and the conversation about what a VA 

re-set should look like. At that time, nearly 15,000 Veterans were discovered to be 

on waiting lists for care in Phoenix alone. It is but one example of the re-setting 

that was needed and has since begun under the leadership of Secretary Bob McDonald, Deputy Secretary Sloan Gibson, and Under Secretary for Health Dr. David 

Shulkin. Since then there have been a number of Office of Inspector General reports 

published outlining similar findings. all pointing to the reality that Veterans were 

not getting the care they needed and deserved in a timely manner. 

The recognition that further reform was needed to meet Veteran health care 

needs led, as you know, to the Veterans Access, Choice and Accountability Act 

(VACAA) and ultimately, to the Veterans Choice Program. In August 2014, Congress appropriately passed VACAA, and required that this program be stood up 

quickly in the marketplace. VA faced with these new revelations and the urgent 

Congressional mandate asked its two PC3 contractors, TriWest and Health Net, to 

help implement the new Choice Card Act. In fact, we had just over 30 days to go 

from the policy specs being received from Congress and interpreted by VA to having 

a program designed and stood up by November 5, 2014 - just 16 months ago. 

Within record time, we created the infrastructure, hired and trained hundreds of 

staff, and got Choice Cards into the hands of four million Veterans in our area of 

responsibility. TriWest stood up a state-of-the-art contact center making sure that 

callers to the toll-free line were greeted by the voice of Secretary McDonald, thus 

underscoring the importance of this new initiative. All of this was accomplished 

within 30 days which you mandated in law. 

I recall vividly sitting in a meeting that VA held with industry in mid-September 

2014, as they were seeking to determine how to implement this necessary new program, and hearing many say that a program of this magnitude would take a minimum of 12–18 months to stand up and that DoD had been given about 36 months 

to design and then stand up a similar program with TRICARE. 

However, that was just not good enough in the face of the revelations of the 

delays that had come to light. Those who served our country without hesitation are 

not afforded such luxuries of time when our nation sends them across the globe in 

defense of our country. So, we swallowed hard and agreed to lean all the way forward to stand up the program knowing that it would be imperfect, just as TRICARE 

was in the early days, but that getting it in place and refining as we went forward 

would be critical to helping our fellow citizens who were standing in line because 

they were in need of care that was not available directly within VA. 

So, we stepped into the fire at the side of VA and did what others said could not 

be done and jointly stretched ourselves to stand up this critical new program in 

weeks (not months or years). Our contact centers went into operation, the Choice 

Cards went out, and care started to be rendered in the community when it could 

not be directly provided by VA. 

The partnership between VA and TriWest has progressed and matured substantially over the past year. This is a dynamic relationship in which we continue to 

refine and strengthen operational processes and communication, both on our end 

and VA’s end. Do we still have work to do? You bet we do! But, I am very proud 

of what we have all accomplished in such a short timeframe. And, I am confident 

that the trajectory on which we are all on to improve this much needed program 

will produce the same results as experienced with the refinements that came quickly within the TRICARE program. 

One of the core challenges when the PC3 program was first implemented was that 

we didn’t have a clear view of the demand for care. Thus, it made it difficult to ensure a precise supply of network and the subsequent infrastructure of systems and 

people needed to support that demand as a company. Additionally, we faced programmatic and statutory challenges with the Choice Program when it was first 

launched (which is discussed in detail later). But, we had to start moving and then 

refine later . which is exactly what we have done and continue to do with intensity, 

and will continue to lean forward to ensure that Veterans receive the care they have 

earned, and that Congress envisioned with the enactment of Choice! 

Volumes were low in the beginning as Veterans were just learning of the new access they were gaining through this program. Care requests were about 2,000 for 

that first month of 2014. While volume increased each month, care requests under 

PC3 only reached their peak at about 20,000 per month by the end of that year 

when the Choice Program came into the picture. 

The second iteration of the program, beginning in January 2015, focused on implementing Choice and finding solutions to some of those challenges - both internally 

at TriWest, as well as within VA itself. We saw steady increases in care requests 

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month by month. TriWest is now scheduling over 100,000 Choice appointments per 

month in 28 states, up from 2,000 per month in January 2015, a dramatic 50-fold 

increase. 

Network Growth 

Foreseeing the likely increase in utilization, we initiated a process with the team 

from VA to assess demand and determine the distribution and supply of network 

that would be needed in the community to support that demand. We call it the ‘‘Demand Capacity Assessment Process’’, which last Summer was conducted with nearly 

every VAMC within our service area. We met one on one with each medical center 

to assess how many providers of each specialty would be needed in addition to the 

supply of providers working at the VAMC to meet the needs of Veterans in each 

geographic area. This included not only a projection of the demand that was already 

known to exist but that which seemed ready to materialize with the added policy 

decisions regarding Choice coming out of Congress. We then took the output of this 

data-driven process and turned to our owner/network subcontractors and started to 

grow the network on a tailored basis to match the demand. 

We implemented the tools for this process Memorial Day weekend of 2014 for the 

work that we were tasked with to assist the Phoenix VA in working off the backlog 

of nearly 15,000 Veterans waiting in line for care. Those tools allowed us to assess 

the demand and the needed provider and staff supply to assist the Phoenix VA in 

successfully eliminating the initial backlog by the end of August 2014. 

Armed with the Demand Capacity Assessment Tools, we and the VAMCs in our 

geographic area of responsibility worked to assess demand and then we went about 

mapping the supply of providers that would be needed in each community to provide 

that which VA was unable to deliver directly. This targeted approach has resulted 

in the tailored construction of a network that now totals nearly 180,000 providers 

across our service area. 

The following is a map which plots the density and distribution of provider network: 

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While expanding the provider network was of primary focus, we also recognized 

that assuring the quality of our provider network also deserved special focus. To 

that end, in August 2015, TriWest was awarded full health care network accreditation pursuant to the Health Network, Version 7.1 from URAC, a Washington, D.C.- 

based health care accrediting organization that establishes quality standards for the 

health care industry. TriWest demonstrated that we meet key quality benchmarks 

for network management, provider credentialing, utilization management, quality 

management and improvement, and consumer protection. This accreditation is valid 

for three years, and demonstrates that those Veterans we are privileged to serve 

in support of VA have access to quality care. 

And, as we continued to focus on the expansion of our network, this past Summer 

2015, Congress refined the design of the Choice Program by enacting changes to 

help expand eligibility, thus providing greater access to care for Veterans. As a result, the number of care requests we received for private care has continued to grow 

dramatically. 

The Veteran Experience 

As part of our commitment to achieving the same performance outcome as we produced in TRICARE, we turned to a 20-year partner of ours to repeat an effort we 

undertook in that work. Once we had a few months of experience under our belt 

at the side of VA, we started a very focused and intentional effort to assess and understand current experience, identifying gaps and opportunities for improvement by 

conducting in person, ‘‘blueprinting’’ sessions alongside the industry leading Arizona 

State University’s world-renowned Center for Services Leadership (ASU CSL). In 

fact, it is they who train such industry leaders as Proctor and Gamble, Starbucks, 

Disney, and the like in the techniques of customer service mapping and process improvement. 

One of the initial blueprinting sessions held last Summer included Veteran representatives, Phoenix VAMC leaders, Veterans Service Organization leaders and 

TriWest stakeholders. As a result of the blueprinting effort, TriWest and VA made 

changes to processes, program materials, and training to improve the experience for 

Veterans. The very early indications are that this time-tested approach, mirroring 

that of the most highly regarded customer service brands in America, is beginning 

to yield results that matter. TriWest has also introduced the ASU CSL process 

known as ‘‘service recovery’’ to address customer service breakdowns identified in 

our complaints and grievance process for inquiries received from Veterans, providers, Congressional offices and VSOs. This process ensures that root causes are 

analyzed by the leadership so that process improvements to customer service can 

be made. 

The Provider Experience 

Similarly, the provider experience is critical to both TriWest’s and our network 

subcontractors’ ability to build and maintain networks to serve Veterans. The 

Choice Program only works if it has strong participation from local providers who 

are reimbursed by the government in a timely manner for the service they provide 

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to Veterans. We recognize that many of the requirements placed on providers to 

participate in the PC3 and Choice programs create a significant administrative burden and often go beyond what is typically required of providers to treat patients. 

It is for this reason that we are making efforts to reduce this burden, where it can 

be controlled by TriWest, by streamlining our processes. As a result of the provider 

blueprinting effort, TriWest is now revising our provider letters and redesigning our 

Provider Portal (similar to what we did this past year with the VA portal) to improve the overall provider experience. We call this upgraded experience, ‘‘Provider 

2.0’’ - that will make it easier for providers to join the network and receive timely 

payments for the services they render under the Choice Program. We are taking the 

provider experience to another level for the almost 180,000 providers in our network 

who serve the health care needs of our nation’s Veterans. 

In an effort to lean forward further in the critical space of behavioral health, we 

have worked closely with the Phoenix VA, and initiated a pilot project to care for 

Veterans in urgent need of behavioral health services, who present themselves to 

the VA emergency department. TriWest has committed to helping place such individuals into the private sector for their emergency behavioral health needs in a 

timely manner, and to date has ensured that more than 200 Veterans have received 

the urgent behavioral health care they needed. That number represents saved lives. 

The behavioral health network is being utilized by some of the VAMCs in our 28- 

state region; in January 2016, 1,639 Veterans were served in the behavioral health 

community taking three days on average to get appointments scheduled, and 90% 

of them saw a provider in less than 30 days. We want to thank the team at VA 

for having the confidence to turn to us as a teammate, so that together we might 

address a challenge they were facing. 

Another example which illustrates the great partnership we have developed with 

VA - a partnership aimed at taking care of the Veterans that we are so privileged 

to serve - occurred in Phoenix (as well as nine other locations in the regions where 

we operate). 

In November 2015, TriWest energetically joined with VA on a special initiative 

- ‘‘Stand Down Day’’ to advance efforts to reduce the number of Veterans with highpriority or urgent care problems waiting longer than 30 days and to learn together 

what should constitute our focus in the months to come as we seek to further refine 

the operation of Choice. 

In a collaborative effort with VA, TriWest assembled a team to provide real-time, 

onsite support for the Stand Down efforts within 10 pre-determined VAMCs. 

Through this collaborative effort, TriWest worked 6,500 Choice Veterans and the associated referrals. On Saturday, November 14, 2015 TriWest supported the Stand 

Down with 868 employees working across all hub locations. TriWest staff responded 

to inbound phone calls from Veterans and VAMC representatives, responded in realtime to VA comments posted through the shared web portal, data entered all new 

referral requests received on the 14th, and placed outbound phone calls to Veterans 

to initiate the appointment process. In addition, TriWest staff (including myself and 

other senior leadership) joined the VA staff in 10 specific VAMCs to provide realtime, onsite support. 

As a result of VA initiating the Stand Down project, VA and TriWest were able 

to close the gap on outstanding health care service requests at VA and place a significant number of Veterans in the care of a community provider. The results for 

clinically urgent care were particularly strong as the large majority of care requests 

were appointed within five business days. 

For example, in Phoenix, the Phoenix VA submitted a file to TriWest containing 

Choice referrals for approximately 298 Veterans. TriWest identified 502 referrals for 

this population. Beginning on November 14, 2015 (and continued through December 

11, 2015) TriWest staff researched all unresolved referral requests and initiated contact with Veterans, providers, and VA staff. Overall, TriWest has been successful 

in reducing the number of those pending referrals to less than 30. The results for 

Phoenix demonstrate the growth of the network of community physicians as well as 

the tremendous collaboration between TriWest and VA to drive favorable outcomes 

in a timely manner. 

In the area of educating Veterans, providers and others about this program and 

its operation, TriWest has shown its presence at a number of local town hall and 

community meetings, as well as attendance and support at a number of Congressional Veteran Resource Clinics. We have briefed government, non-profit and civic 

leaders on the program and efforts to improve the processes. We are also very active 

with our support of the Veterans Economic Community Initiatives (VECI) program 

that was launched by Secretary McDonald in June 2015. This program is committed 

to providing employment opportunities for Veterans and their families through a 

network of support at the community level. In fact, many of our operations centers 

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we have opened throughout the country are located in VECI communities, and we 

opened our last Operations Center in El Paso, TX on March 18, 2016. 

Operational Growth, Innovations and Program Improvements 

Beginning in May 2015, TriWest responded to the growth in care requests by 

ramping up our workforce, expanding our footprint and our network, and working 

on operational efficiencies. To meet the increase in demand of care requests that is 

on pace to hit over 110,000 authorization requests by the end of this month, we 

have added eight new operations centers across our geographic areas of responsibility and implemented a VISN-centric strategy with each of our locations, to better 

serve those geographic areas ‘‘on the ground’’. Over the past few months, TriWest 

has opened operations centers in: San Diego (270 employees), Kansas City (over 500 

employees); Tempe, AZ (400 employees); Nashville (250 employees); Honolulu (60 

employees); Sacramento (270 employees); New Orleans (300 employees) and just a 

few days ago opened a final location in El Paso (235 employees) with the full collaboration of Congressman O’Rourke and his dedicated staff. My expectation is that 

once we are fully staffed at each of these sites (based upon the eligibility criteria 

that exists today), with all new staff online, that we will be able to fully handle the 

increasing demand coming through this program, which frankly has continued to be 

a bit of a struggle, as demand has continued to exceed all of our projections. 

At the same time, TriWest spent 2015 focused on innovations to help improve program operations across the enterprise. In addition to opening operations centers, 

hiring thousands of new employees and building networks, a large focus has been 

on upgrading systems. We stood alongside our partners at the Phoenix VA almost 

one year ago today to obtain their requirements for a new portal - a region-wide 

system that enables VA staff to seamlessly order and track health care services between themselves and TriWest. We had a team of people working in shifts, around 

the clock for three months, to develop the upgraded portal, which was implemented 

in several phases beginning in May 2015. The new portal was available to every 

VAMC within our region by July 2015. Today, VA has over 2,500 trained users on 

the system, and they rely on this system to manage most aspects of community 

health care delivered through the Choice Program. 

Another major initiative TriWest implemented to help manage the surge in program volume and growth in usage among Veterans, and aimed at customer service, 

was a new Customer Relationship Management System. This new tool will ultimately assist our staff in delivering effective and efficient customer service encounters, just as we did in TRICARE for those who have served. The system also brings 

improvements to the user interface and the ability to document outbound and inbound calls with Veterans - all aimed at improving customer service. 

And within our operations centers, we recently have also implemented a Behavioral Analytics Call Monitoring System which helps improve staff interactions with 

customers, VA staff, providers and Veterans alike. TriWest operations centers are 

now fielding nearly 300,000 incoming calls for care per month. Our operations centers are being built just as they were under our TRICARE contract - which was recognized for call center operation customer satisfaction excellence for five consecutive 

years under the J.D. Power and Associates Call Center Certification Program. That 

distinction acknowledges a strong commitment by TriWest operations centers to provide ‘‘An Outstanding Customer Service Experience.’’ It is how we have always operated, and we are committed to that high level of customer service operations again 

under this program. 

On the provider side, we have worked to streamline the claims payment process 

whereby providers submit their claims electronically which helps improve provider 

satisfaction with claims processing. Today, TriWest pays clean claims at a rate of 

97% in less than 30 days. 

With all of these initiatives, tools and expansions in mind, I would be remiss if 

I did not mention that all these needed upgrades that have been implemented over 

the past 12 months or so, do not come without cost. Our company’s sole line of business is to care for Veterans - it’s who we are; it’s what we do. And from all we have 

done in dedicating ourselves to this mission, we have put the priority on getting this 

right for our nation’s Veterans because we and our non-profit owners believe that 

is the right thing to do. 

Investing around $70 million of our owner money thus far to further our and VA’s 

joint objectives to develop more optimal tools, tailor networks, and scale and re-footprint the company to more optimally deliver customer service at the side of VA, we 

are pleased with the refinement that is starting to materialize. The fact is that we 

continue to work hard alongside VA to do whatever it takes to make this program 

meet the vision from which it was created. 

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Still Hard At Work to Tackle Challenges 

Choice is working. We all know that challenges remain as the program continues 

to progress and mature, but the customer experience under the Choice Program is 

getting better with each passing day. Information provided by TriWest staff is more 

consistent and more accurate; providers are more familiar with the program; and 

we have implemented an initiative that allows any provider in our region to register 

online with us to be a Choice provider. Knowing who is willing to treat a Veteran 

under the Choice Program, even if they are not already a TriWest network provider, 

goes a long way towards speeding up the appointing process. 

Every day we focus on improving the program. I say this because each challenge 

presents an opportunity to make the system better and prove to Veterans that good 

can come from their utilization of this system which you created to facilitate the 

benefits they have earned. Whether it’s the 95-year old Veteran in northwestern Arizona who used to drive three hours to Phoenix for care (and now gets his physical 

therapy 10 minutes from home) or the Veteran who spoke with one of our staff after 

his knee replacement, noting he’s had 20 surgeries in his life and the process 

through Choice was ‘‘the easiest of them all’’ and ‘‘perfect’’, we know that Veterans 

are beginning to recognize the benefit of this program as utilization increases. 

TriWest Performance - Becoming ‘‘the Answer’’ for VA 

General George Patton said ‘‘a good plan violently executed now is better than a 

perfect plan executed next week’’. I think we now know personally the definition of 

‘‘violently executed’’, as that has been required of us. We adopted this mindset to 

begin working off the significant care backlogs in place when we were called upon 

to implement Choice in addition to our initial contract. And while more time to implement the program would’ve been ideal, not one of us involved in this wanted Veterans to wait a moment longer than absolutely necessary. It was critical to begin 

coordinating Veteran’s health care immediately. 

Beginning in 2014 when PC3 was implemented, the program started out slowly 

with a couple thousand care requests per month. Networks were being developed, 

and we phased our implementation by region beginning in January 2014. Then, in 

April 2014, the furnace lit off in Phoenix, which ignited a rapid increase in program 

utilization nationwide. Over time, program adoption grew, and by the end of 2014, 

TriWest received almost 22,000 care requests from VAMCs throughout our regions, 

as displayed below: 

At the tail end of 2014, and moving into 2015, the Choice program was birthed. 

At the start of the Choice program, we received requests for only 2,000 appointments for the entire month. This number has skyrocketed and expected to surpass 

110,000 this month - just one year into the program. For those of us who are math 

minded, that’s over a 4,900% increase in volume. The chart below shows the upward 

trajectory for the number of authorizations received per day in 2015, and the first 

two months of 2016: 

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Although this massive growth is a positive indication that more and more Veterans are receiving the care they deserve, it does call upon us to push the envelope 

in meeting the challenges. Despite having added numerous operations centers since 

last Summer, increasing staffing by thousands, adding several innovations to systems and process, we are still not finished with our task of catching up fully with 

the continually increasing demand. 

What is particularly staggering is the growth in the number of phone calls received. Just this last month, total calls were nearly 1 million. The growth in calls 

has been a bit like chasing a Tsunami, as the chart below illustrates. 

And, while we are still refining our operations in this area of staggering growth, 

I believe that the statistics are something about which we can be justifiably proud 

and demonstrate that we are gaining on it. They are as follows: less than 16 seconds 

average speed to answer, and an abandonment rate of 2%. 

In the midst of this surge in demand, a number of policy and operational improvements have been made. For example, most recently VA implemented a change order 

to our contract in early October 2015, which aimed at lessening the wait lists and 

speeding the Veteran’s access to care. That change involves using a more proactive 

approach to making health care appointments for Veterans, through the use of outbound calling. That is, through a streamlined process with VA, we now reach out 

to call the Veteran directly versus waiting for the Veteran to call us. The new outreach processes we have developed jointly with VA keeps the care requests moving 

rapidly through the system, so the Veteran receives care more expeditiously. 

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Finally, processes improvements continue to be worked as we fully implement additional operations centers, rounding out our presence in each of the VISNs within 

our regions. As any of us do in a new implementation or new job, we are striving 

to embrace a steep learning curve. Our employees will continue to become more efficient in their work, systems will continue to be tailored, and processes refined, ultimately resulting in the kind of favorable outcome that all Veterans deserve - thus 

fulfilling the overall goal of this program. 

Refinements in Policy 

At the outset of this crisis, Congress acted quickly to implement a program which 

provided enhanced access to Veterans health care. Since then, many legislative 

changes have occurred to address some nuances of this program that were unforeseen in the beginning. 

The first of such changes began in January 2015, under the Omnibus Appropriations Act, when Congress addressed the rate issues and this change helped align 

rates in the area with the marketplace - a key component to provider satisfaction 

and contracting in that state. 

Several months later, in July 2015, to further improve the program from a policy 

perspective, the ‘‘Surface Transportation and Veterans Health Care Improvement 

Act of 2015’’ modified several requirements of the Veterans Choice Act of 2014. 

First, the Act repealed the 60-day limit on follow up care. Instead, the authorization extends for the entire episode of care. In January 2016, we received the formal 

modification to implement this change, which has opened the doors for many Veterans who need urgent services lasting beyond 60 days, and helps with certain provider groups who desire to provide care to Veterans, but had been stifled by the 60 

day authorization rule. Now, Veterans who face serious conditions (such as the case 

studies I shared with you earlier) are able to receive the entire episode of care 

(chemotherapy treatment, maternity care, etc.) that is required to complete their 

treatment. 

Second, the Act repealed the August 1, 2012 enrollment limitation on eligibility 

of Veterans in the patient enrollment system. This critical change removed the requirement that you have to be enrolled in VA prior to August 2, 2014, to be eligible 

for Choice Program. The impact was great to Veterans, allowing near instantaneous 

determination of eligibility by the VAMC. 

Third, the Act extended provider eligibility to any health care provider meeting 

VA criteria - this change helped open the pool of providers who could provide health 

care to this deserving population. 

Finally, the Act based the 40-mile distance requirement as the distance traveled 

from a VA medical facility instead of ‘as the crow flies’, including one offering primary care for a Veteran seeking primary care. This gave more Veterans access to 

the program, especially in complicating geographic areas. 

Another program change last Summer that was directed at improving access was 

VA’s implementation of the Choice First program - which immediately expanded eligibility and opened the flood gates to care by giving a Veteran the ability to obtain 

services in the network when such specialty was not available at all within their 

local VA medical facility. 

Congress continued assessing necessary program modifications later into 2015. In 

September 2015, TriWest received a contract modification regarding outbound calls, 

and elimination of blind appointing, and we were authorized to begin working these 

changes on October 1. This more proactive approach to making health care appointments for Veterans prevents an authorization from sitting and aging, awaiting a 

phone call from the Veteran. As a result, more Veterans receive health care, and 

they receive it more timely. 

In late 2015, Congress expanded access to private doctors where its Community 

Based Outpatient Clinics lacked sufficient provider access, expanding the number 

of patients who are eligible to seek care in the community under the Choice Program. As a result, if VA has no primary care doctor on staff, a referral for private 

care is not required. This change alone estimated opening up the program to about 

160,000 more Veterans. 

Finally, in November 2015, we received federal approval within our contract to 

allow TriWest to staff employees at VAMCs with the execution of an appropriate 

Memorandum of Understanding. As a result, TriWest has several cells of ‘‘embedded 

staff’’ within a multitude of medical centers, including New Orleans, Dallas, Harlingen, Anchorage and Phoenix, to more optimally coordinate work at the local level. 

Oftentimes, Veterans are able to walk right down the hall after a medical appointment that identified need for care in the community. In that office, they can get educated about the program, we learn of their preferences, and we start the process 

of securing them an appointment in the community. We know from our work during 

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the TRICARE program that having staff embedded in a medical facility can go a 

long way toward making the use of the program a more seamless experience. Those 

TriWest staff got to know the government staff, the beneficiaries, and also the providers in the community. All of that helped speed the process of getting care provided in a timely manner in the community. 

Overall, I commend Congress for all the steps it has taken this past year which 

have driven great program improvements. In addition to the changes that have already been modified into our contract, we also anticipate a change in Medicare payment, whereby providers no longer have to be Medicare participating in order to see 

one of our nation’s Veterans. This change has recently occurred with behavioral 

health providers, whereby behavioral health care can now be provided by master’s 

level counselors; therefore, master’s level counselors will now be able to participate 

in PC3 or Choice and will be eligible to receive authorizations to provide behavioral 

health care to Veterans. This change will help enhance Veterans’ access to such 

services, and will be another piece to the puzzle of opening up more access to care 

for those providers who wish to provide care for Veterans nationwide. 

The pace is swift and, as you can see, changes are plentiful, but we are implementing quickly, changing programs and refining processes along the way, and 

MUCH has been done to set the groundwork to improve the overall program and 

enhance access to care for our nation’s Veterans. 

Looking Forward -Pushing the Art of the Possible 

Now that we have had a glimpse into the past, let me take you to a very important part - the future and the ‘next generation’ of the program, so that Veterans 

get the best care they need and deserve. Here’s what I see over the next six months 

that is part of the formula for success moving forward. 

At this point, I can confidently say that the Choice Program is working—more 

Veterans are receiving the care they have earned and deserve. It must work even 

better and faster to meet Veterans’ needs, and TriWest is committed to the continued partnership with VA to continue to close the gaps. 

One thing we know for certain is that through all of this, the Choice Program 

brought significant availability to health care for Veterans by making many community providers available to enhance access when access to care in VA is not sufficient to meet the need. Deputy Secretary, Sloan Gibson, stated during the House 

VA Committee hearing on November 18, 2015 that there have been seven million 

more appointments scheduled this year compared to last year. While not all of this 

has flowed through Choice, the volume is continuing to increase as we refine our 

capability and enhance our supply of network and staff to match demand. Despite 

all the maturation that still needs to occur to perfect the program, this is great 

progress, because millions more Veterans are receiving health care under this program than last year. Now, Veterans are demonstrating that they are gaining trust 

in the program and TriWest, and they are seeking the care they need. Veterans are 

voting with their feet-despite the start-up challenges, in the TriWest area of responsibility, last month over 100,000 Veterans chose to use Congress’ VA Choice Act, including the 95 year old Veteran in Phoenix who no longer has to drive three hours 

for his physical therapy. 

Demand for health care will grow as Veterans who may have become discouraged 

and given up seeking care will return as the backlogs are reducing across the system and as we continue to work together to effectively address access issues. We 

expect that as Veterans continue to gain trust in the Choice Program, they will continue to seek out this care when VA is unable to meet the need directly. It is for 

this reason that we will continue to expand our operations over the next six to nine 

months and beyond to ensure we do our part to see that Veterans get the care they 

have earned. 

The network will continue to expand and be high performing, so that the Veterans 

we serve - and the VAMCs we serve alongside - will continue to have the ability 

to access needed care in a timely fashion. 

Legislative advances to help move this program forward will have taken a strong 

foothold. And, we and VA just executed a change in the contract that allows us to 

decouple the receipt of medical documentation from payment for a provider. While 

we will still pursue the needed medical documentation from the provider, so that 

it can get to the VA doctor quarterbacking the care for the Veteran and end up in 

the Veteran’s consolidated medical record in VA, this will speed up our ability to 

pay the provider so that nearly all payments will match our performance on clean 

claims of more than 97% being paid within 30 days. 

We are in the midst of a major VA health care reform, and we have the opportunity to make the health care delivery model the most efficient it can be. In my 

opinion, the best system for Veterans is a VA public-private partnership that builds 

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on what VA does best, while leveraging private sector provider networks and best 

business practices created by TriWest. This partnership provides accountability and 

transparency while also fostering innovation. But, VA must ultimately be the backbone, focusing on their core mission of taking care of its soldiers inside the four 

walls of VA. And, VA must allow their private sector partner, TriWest, to do what 

we do best which is to build and enhance networks, process claims, schedule appointments, and help coordinate care for the best outcomes for the Veteran, with 

flexibility, effectiveness and efficiency. We must continue to work together for the 

betterment of VA health care, alongside VA and Congress, and we all must continue 

to build upon the core that we have already developed. 

Conclusion 

Mr. Chairman, I hope my testimony has provided some useful information as to 

how TriWest became a part of this effort, where we are today, and where we are 

headed in the future. I also hope it has convinced you that the company I am proud 

to lead considers it an honor and privilege to work every day to provide access to 

care for those who have served this nation in uniform. We have always stood ready 

to implement VA health care needs within record speed and record time, and will 

continue to dedicate ourselves to this critical task, all in support of our nation’s Veterans. It is an awesome responsibility and our non-profit owners look forward to 

continuing to be a large part of the formula for future success in assisting VA in 

delivering on its responsibilities to our heroes on behalf of a grateful nation! 

Thank you again Mr. Chairman for this opportunity to appear before you and 

your colleagues this morning. I look forward to answering any questions you might 

have. 

f 

Prepared Statement of Dr. Baligh Yehia 

Good morning, Chairman Benishek, Ranking Member Brownley, and Members of 

the Subcommittee. Thank you for the opportunity to further discuss the plan to provide Veterans access to a community care network as described in the Department 

of Veterans Affairs (VA) October 30, 2015, report on the consolidation of community 

care programs. The community care network will provide Veterans with access to 

high-quality providers and the ability to make an informed choice regarding their 

health care. I am accompanied today by Dr. Gene Migliaccio, Deputy Chief Business 

Officer for Purchased Care. 

VA is committed to providing Veterans access to timely, high-quality health care. 

In today’s complex and changing health care environment, where VA is experiencing 

a steep increase in the demand for care, it is essential for VA to partner with providers in communities across the country to meet Veterans’ needs. To be effective, 

these partnerships must be principle-based, streamlined, and easy to navigate for 

Veterans, community providers, and VA employees. Historically, VA has used numerous programs, each with their own unique set of requirements, to create these 

critical partnerships with community providers. This resulted in a complex and confusing landscape for Veterans, community providers, and VA employees. 

Acknowledging these issues, VA is taking action as part of an enterprise-wide 

transformation called MyVA. MyVA will modernize VA’s culture, processes, and capabilities to put the needs, expectations, and interests of Veterans and their families 

first. Included in this transformation is a plan for the consolidation of community 

care programs and business processes, consistent with Title IV of the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015, the VA Budget and Choice Improvement Act, and recommendations set forth in the Independent 

Assessment of the Health Care Delivery Systems and Management Processes of the 

Department of Veterans Affairs (Independent Assessment Report) that was required 

by Section 201 of the Veterans Access, Choice, and Accountability Act of 2014 

(Choice Act). 

On October 30, 2015, VA provided Congress with a plan to consolidate all VA’s 

purchased care programs. The plan included some aspects of the current Veterans 

Choice Program established by Section 101 of the Choice Act and incorporated additional elements designed to improve the delivery of community care. 

VA currently has a variety of agreements with providers in the community, but 

limited national visibility into supply and demand needs. There are no standardized 

approaches for provider credentialing, quality monitoring, or identification of 

best-in-class providers. High-performing networks in health care apply standardized credentialing and quality criteria. They can identify and recruit high-quality 

providers for the network. As described in the plan, the VA Core Network includes 

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high-quality health care assets in the Department of Defense (DoD), Indian Health 

Service (IHS), Tribal Health Programs (THP), Federally Qualified Health Centers 

(FQHC), and academic teaching affiliates. The community care network includes 

commercial providers in Preferred and Standard tiers based on quality and value 

performance. Standardized credentialing will decrease administrative barriers for 

providers, while more rigorous and consistent quality monitoring will promote highquality care for Veterans. 

BACKGROUND

To identify provider eligibility requirements and design a high-performing network for VA, we have examined best practices for provider networks, credentialing, 

and quality standards. Provider network design and implementation are constantly 

shifting to accommodate changes to the U.S. health care landscape, including coverage requirements and provider incentive models. A provider network consists of 

licensed health care professionals (e.g., doctors, nurse practitioners, physician assistants, and nurses) and medical facilities (e.g., hospitals, outpatient surgery centers, 

and diagnostic imaging centers) that agree to provide services at pre-negotiated 

rates. A robust provider network has an adequate number of health care professionals in terms of quality, mix/type of specialty, and geographic distribution, as 

well as facilities, to meet demand needs. 

High-performing tiered networks promote high-quality care, improve health outcomes, and reduce system costs. They include providers who meet the minimum 

standards and preferred providers who meet additional quality and value standards. 

These networks help patients identify providers who can deliver culturally competent care and publish provider information for patients (e.g., quality designations 

and patient feedback). 

To effectively develop and maintain high-performing tiered networks, 

industry-leading organizations use network development, contracting and reimbursement, provider relations, credentialing, and clinical quality monitoring functions. The network development function implements provider payment strategies 

and determines the optimal size, composition, and geographic distribution of the 

network. Contracting and reimbursement capabilities include negotiating provider 

agreements, obtaining exception approvals to standard provisions as needed, and 

maintaining reimbursement data. The provider relations function manages ongoing 

communication and education initiatives with the provider community, while also 

addressing inquiries and grievances. To improve the stakeholder experience and 

simplify processes, leading organizations invest in customer service personnel and 

web-based tools for patients and providers (e.g., navigation tools to help patients become familiar with care processes). 

Credentialing is the process of reviewing the general qualifications and practice 

history of providers using guidance from organizations such as the National Committee for Quality Assurance (NCQA) or The Joint Commission. Commercial provider networks review education, training, employment, and disciplinary history. 

Leading organizations use credentialing systems that automate tasks and incorporate analytics-driven decision-making. The processing time for credentialing a 

new provider in a commercial network is typically 30 business days. Commercial 

networks re-credential providers to monitor ongoing adherence to standards based 

on regular intervals (usually 24 - 36 months). Providers that do not meet specific 

standards (e.g., because of recurring malpractice claims or sanctions against a professional license) can be removed from the network. 

In the U.S., health care is not delivered consistently. There are notable differences 

in health care spending, resource utilization, and quality of care depending on factors such as the licensed health care professional, medical facility, geographic region, and patient population. Increased utilization and spending do not always lead 

to better outcomes. To promote consistent high-quality care that is safe, timely, effective, efficient, and patient centered, industry-leading organizations are working 

to measure provider performance and recognize high performers. Metrics employ 

evidence-based performance criteria based on rigorous and transparent methodologies. Sources for quality measures can include NCQA, the National Quality Forum, 

Agency for Healthcare Research and Quality, and The Joint Commission. Effective 

coordination of care and health information management also directly affects quality 

of care. 

CURRENT STATE

Current VA community provider relationships are formed through multiple overlapping programs with federally funded health care entities and commercial providers. VA contracts or has agreements with approximately 40 DoD facilities (with 

access to TRICARE Managed Care Contractors on a case-by-case basis), 100 IHS faLeonard.horne on VACREP0180 with DISTILLER

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cilities, 80 THPs, 700 academic teaching affiliates, 700 FQHCs, 76,000 locally contracted providers, and 200,000 additional providers through current national contracts, such as PC3 and Choice. Despite the large numbers of providers, VA does 

not have ongoing visibility into many provider locations, nor an understanding of 

supply and demand imbalances. Therefore, VA does not have coverage in certain 

areas to provide accessible care to Veterans, nor a single mechanism to actively 

manage provider relationships. 

VA has multiple processes for credentialing community providers and different 

credentialing criteria, depending on the authority that is the basis for furnishing 

community care. VA does not have a standardized approach to measure delivery of 

quality care furnished through contracts and agreements with community providers. 

Some sharing agreements are administered locally, and quality reporting requirements vary depending on the agreement. As a result, VA currently has limited visibility into best-in-class providers. Once providers have agreed to provide care to Veterans, VA does not have a national mechanism to track quality of care issues. With 

variable quality monitoring processes, providers are held to different standards and 

VA faces a larger burden in monitoring quality compliance. 

FUTURE STATE

To align with VA’s mission to better serve Veterans, VA plans to provide access 

to a high-performing network drawing from best practices across industry and federally funded organizations. Key elements of the high-performing network include: 

• Appling industry-leading health plan practices for tiered network design; • Enhancing unique relationships with federally funded and academic teaching 

affiliates; • Promoting Veteran choice, access to care, and high-quality care delivery; • Using streamlined and consistent credentialing and quality monitoring processes; • Incorporating network management functions, including network development, 

contracting and reimbursement, credentialing, clinical quality monitoring, and 

provider relations; • Consistently monitoring supply and demand changes to make appropriate network adjustments, achieving access standards, and coverage for primary and 

specialty care; • Effectively coordinating care in a Veteran-centered way; and • Using clinical and administrative metrics to continually measure and improve 

performance. 

As proposed in the October 30, 2015, report on the consolidation of community 

care programs, the VA Core Network will include providers in the DoD, IHS, THPs, 

FQHCs, and academic teaching affiliates. VA’s relationships with these providers 

are unique and have evolved over time. Sustaining and expanding Core Network relationships aligns with VA’s mission, vision, and strategies. VA will work to develop 

simple and consistent agreements with Core providers that are principle-based and 

focus quality and outcomes. 

External providers - those outside the Core Network - can belong to Standard or 

Preferred tiers, which will expand over time. VA plans to make the process for joining the external network simple. Providers in the Preferred and Standard tiers must 

meet uniform credentialing requirements to participate in the high-performing network. Based on industry feedback received from the Department’s February 9, 2016 

‘‘VA Community Care Network’’ draft performance work statement, VA is working 

to develop requirements that match industry standard. Providers in the preferred 

tier must meet minimum credentialing requirements while also demonstrating highvalue care. 

The high-performing network will require network development, contracting and 

reimbursement, credentialing, clinical quality monitoring, and provider relations 

functions. VA will employ an audit function to oversee credentialing and adherence 

to quality standards. Veterans will have the ability to choose community providers 

and make informed decisions based on publicly available information. Veterans currently accessing community care can remain with their community providers, if the 

provider meets minimum requirements, or choose other providers in the network. 

Veterans also can recommend their providers for inclusion in the network. VA will 

consider publishing provider designations, credentials, and Veteran feedback. To 

promote awareness about military culture and unique issues Veterans face, VA will 

encourage providers to complete relevant trainings and make available educational 

resources. 

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clude the highest quality providers, but also recognizes the need to establish a broad 

and flexible network providing convenient care near to where Veterans live. In the 

high-performing network, credentialing processes will be simple, consistent, and in 

alignment with best practices. The re-credentialing process will evaluate ongoing 

provider qualifications to confirm health outcomes and adherence to standards. 

These can include value, complaint history, Veteran experience, and a baseline assessment of care appropriateness every 24 - 36 months. VA will audit and enforce 

credentialing practices in the high-performing network. High-level provider 

credentialing standards include: 

• Educational credentials, certifications, licensure, training, and experience; • Employment and pre-employment history; • Supplemental attestation questions, disciplinary screening, and sanctions; and • Agreements with providers to meet access and quality of care standards. 

VA will work directly with providers currently caring for Veterans to include them 

in the network for continuity of care. Providers who meet credentialing criteria will 

complete a simple enrollment process and can join the VA network. Over time, poor 

performing providers will be removed from the network. 

In the VA Core Network, VA will delegate credentialing or perform credentialing 

functions when applicable. Federally funded credentialing institutions include DoD, 

IHS, FQHCs, and THPs. In the external network, either VA or a ‘‘network manager’’ 

will assume ownership of credentialing and will apply industry-leading practices. 

VA will work toward establishing simple, consistent, and high-quality agreements 

with Core and external providers in the high-performing network. In order to promote quality of care, VA will monitor and enforce rigorous quality reporting and 

performance standards in line with industry, conduct data analytics on disease management, and share VA critical pathway information. VA plans to shift toward 

adopting value-based care models in the high-performing network. 

Creating a community care network will maximize the use of high-quality federally funded health care assets, while sustaining unique and important VA relationships. In addition, VA promotes high-quality care by creating preferred and standard tiers. For the preferred designation, providers must meet quality and value 

metrics that are based on evidence-based care guidelines. VA plans to uniformly 

apply best practices to determine criteria for both tiers. VA will work to determine 

specific metric reporting and performance benchmarks using recognized institutions. 

CONCLUSION

VA appreciates the opportunity to discuss the community care network element 

of our plan. The Network system described in our plan would empower Veterans to 

make informed decisions about which providers they want to use, by highlighting 

providers with higher quality, care coordination, and satisfaction scores. Additionally, it will help reduce confusion for Veterans as they interact with and transition 

between VA facilities and community facilities. This provision also supports our efforts to make our system more in line with industry standards, as tiered networks 

are common in the delivery of value-based care, as seen with TRICARE and many 

private sector health plans. 

As we have described at other hearings, VA will implement improvements to the 

delivery of community care through an incremental approach as outlined in the 

plan. VA looks forward to continued discussions on how to refine the approach described in our plan, with the goal of improving Veteran’s health outcomes and experience, as well as maximizing the quality, efficiency, and sustainability of VA’s 

health programs. These improvements, like many of the enhancements VA has already made, are only possible with Congressional support, including legislation and 

necessary funding. 

Mr. Chairman, I appreciate the opportunity to appear before you today. We are 

prepared to answer any questions you or other Members of the Committee may 

have. 

f 

Statements For The Record 

THE AMERICAN LEGION 

The American Legion believes in a strong, robust veterans’ healthcare system that 

is designed to treat the unique needs of those men and women who have served 

their country. However, even in the best of circumstances there are situations where 

the system cannot keep up with the health care needs of the growing veteran popuLeonard.horne on VACREP0180 with DISTILLER

50 

lation requiring VA services, and the veteran must seek care in the community. 

Rather than treating this situation as an afterthought, an add-on to the existing 

system, The American Legion has called for the Department of Veterans Affairs 

(VA) to ‘‘develop a well-defined and consistent non-VA care coordination program, 

policy and procedure that includes a patient centered care strategy which takes veterans’ unique medical injuries and illnesses as well as their travel and distance into 

account.’’ 

Chairmen Benishek, Ranking Members Brownley and distinguished members of 

the Subcommittees on Health on behalf of National Commander Dale Barnett and 

The American Legion; the country’s largest patriotic wartime service organization 

for veterans, comprising over 2 million members and serving every man and woman 

who has worn the uniform for this country; we welcome this opportunity to comment 

on ‘‘Choice Consolidation: Leveraging Provider Networks to Increase Veteran Access.’’ 

BACKGROUND

Historically, one of the main missions of VA is to be a provider of direct 

healthcare to veterans through the Veterans Health Administration (VHA). However, for many decades the VA has also acted as a payer by relying on non-VA care 

providers, i.e., care in the community, when it has not been able to provide that care 

in a timely or cost effective manner. 

The 2014 veterans’ access to care crisis revealed, though, that VA was not appropriately utilizing these provider/payer programs to meet the needs of the growing 

veteran population requiring VA services. 

As a result, Congress created the Veteran Choice Program (VCP) after learning 

that VA facilities were falsifying appointment logs to disguise delays in patient care. 

However, it quickly became apparent that layering yet another program on top of 

the numerous existing non-VA care programs, each with their own unique set of requirements, resulted in a complex and confusing landscape for veterans and community providers, as well as the VA employees that serve and support them. 

Therefore, Congress passed the Surface Transportation and Veterans Health Care 

Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act) in July 

2015 after VA sought the opportunity to consolidate its multiple care in the community authorities and programs. This legislation required VA to develop a plan to consolidate existing community care programs. 

On October 30, 2015, VA delivered to Congress the department’s Plan to Consolidate Community Care Programs, its vision for the future outlining improvements 

for how VA will deliver health care to veterans. The plan seeks to consolidate and 

streamline existing community care programs into an integrated care delivery system and enhance the way VA partners with other federal health care providers, academic affiliates and community providers. It promises to simplify community care 

and gives more veterans access to the best care anywhere through a high performing network that keeps veterans at the center of care. 

Generally, The American Legion supports the plan to consolidate VA’s multiple 

and disparate purchased care programs into one New Veterans Choice Program 

(New VCP). We believe it has the potential to improve and expand veterans’ access 

to health care and address many of the existing problems currently experienced by 

veterans who elect to receive some of their care in the community when they can’t 

do so within the VHA. 

LEVERAGING PROVIDER NETWORKS TO INCREASE VETERAN ACCESS

Under the New VCP program, VA would establish a single set of eligibility criteria for private care; expand access to emergency treatment and urgent care; simplify the referral and authorization system; and improve the claims, billing and reimbursement processes. 

The health care network under New VCP would be larger as well. VA Undersecretary Shulkin aptly describes it in a recent New England Journal of Medicine article. 

The network would consist of three groupings of providers. The core network 

would include all VA-run hospitals, clinics, and centers, as well as appropriate facilities run by other federal agencies, tribal health partners, and academic teaching institutions that have already established relationships with the VA. Many of these 

facilities have expertise in military service-related conditions, and all have the core 

competencies required for providing comprehensive, coordinated care. These facilities would increase access to highly specialized care and address the needs of some 

veterans living in remote areas. 

The second network would include organized private-sector delivery systems that 

meet performance criteria for clinical outcomes, appropriateness criteria, access 

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standards, and service levels. The process for acceptance into this second network 

would be highly competitive and based on documented results. Integrated systems 

of care would be ideally suited for inclusion, since their providers have been investing in coordinated care for some time. 

A third network would allow veterans to obtain care from additional participating 

private-sector providers, ensuring access for veterans who don’t live within a reasonable distance of providers in the other networks. Providers in this network would 

need to agree to submit clinical data and documentation to VA health information 

exchanges. 

At a March 15, 2016, Senate Veterans Affairs Committee hearing, The American 

Legion commented on VA’s concept of a Tiered High Performance Network indicating that we support Senator Tester’s language in S. 2633: Improving Veterans 

Access to Care in the Community Act which allows VA to set up tiered networks. 

As we understand it, this structure is meant to empower veterans to make informed choices, provide access to the highest possible quality care by identifying the 

best performing providers in the community, and enabling better coordination of 

care for better outcomes. However, it does not dictate how veterans will use the network. 

The American Legion wants to make clear, though, that we do not support a 

wholesale option to circumvent the VA infrastructure or healthcare system entirely. 

Veterans can and should receive their care within the VHA system, as the benefits 

available to them within this system are myriad. Not only do veterans vastly prefer 

to receive care within VA and comment highly favorably on the care they get when 

they have timely access, the VHA system is specifically designed with the needs of 

the veterans in mind. No other healthcare system or network provides the kind of 

comprehensive care that considers the factors of the circumstances of a veteran’s 

military service. No other system is primed to ensure that veterans who have served 

in areas with known associations to toxic exposures such as Vietnam or the Persian 

Gulf region are screened for conditions known to be associated with those exposures. 

No other system is as proactive in screening for and providing treatment for 

posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) the ‘‘signature wounds’’ of the Global War on Terror. 

In addition, for over half a century, the VHA has had a long-standing and outstanding relationship with their medical school affiliates. VHA uses medical school 

affiliations to recruit, and retain high quality medical professionals to provide veterans with access to cutting edge technologies that may have not be offered in the 

private sector. VHA has the largest coordinated education and training program for 

health care professionals in the country and medical school affiliations allows their 

new medical professionals to be trained in the VA healthcare system. Clearly 

leveraging public-private relationships, particularly with educational institutions, 

will be a key component in building successful networks of providers to handle the 

overflow from VA in community care. 

A secondary advantage of the partnerships with medical schools is it opens a clear 

and natural avenue for research partnerships. Often overlooked while solely focusing on the provision of care aspect of VA’s mission is the research component of VA’s 

core mission. VA can and should return to its top position as a cutting edge innovator in America medicine and affiliations with medical schools and research are a 

critical component of that ascendency. The American Legion is strongly committed 

to support for mutually beneficial affiliations between VHA and medical schools. 

The root of the problem comes down to the question of whether or not VA is capable of building the required networks of care, or whether this task should be 

outsourced to third party agencies (TPAs) as was done for the Choice program. 

While VA has struggled in the past with large scale project organization, such as 

with the four recent hospital development plans in Florida, Nevada, Colorado and 

Louisiana, the decision to use TPAs may not be much better. The two TPAs chosen 

for the Choice program, TriWest and HealthNet, were chosen during the very short 

90 day period VA had to begin implementing the program. There were certainly 

problems working with those providers getting Choice up and running including infrastructure problems as well as billing. When the options for building the network 

of providers are VA doing it themselves and using TPAs, both sides perhaps raise 

more questions than they answer. 

This is a complicated problem and The American Legion can’t attest to VA’s capabilities one way or the other that would support or deny success, but we can say 

that if VA is capable of building such a network as they propose, that it will be more 

cost effective and support VA’s mission to be in a better position to provide better 

and a more seamless healthcare experience for veterans. Based on our experience 

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with Access Reach Closer to Home (ARCH), Patient Centered Community Care 

(PC3), and Community contracted care, in many ways, VA is already doing it. 

A plan for a New Veterans Choice Program needs approval from Congress. VA 

needs to overhaul its outside care reimbursement programs, consolidating them into 

a more efficient bureaucracy able to dynamically interact with the network of federal, public, and private providers that are to supplement VA direct provided care. 

The American Legion believes that VA’s plan is a reasonable one given the desired 

results. 

As you know, Senators Tester and Burr in conjunction with the Senate Veterans 

Affairs Committee are crafting legislation to fix the Choice program and codify the 

New VCP. The American Legion encourages this committee to work closely with 

your senate colleagues on a final compromise bill which incorporates the best of the 

proposals that are being considered. 

In conclusion, The American Legion believes that together we can accomplish legislative changes to streamline Care in the Community programs before the end of 

this session of Congress. We can’t let another year slip away. Our veterans deserve 

the same sense of urgency now that Congress has shown numerous times since the 

VA scandal first erupted in 2014. 

As always, The American Legion thanks the Subcommittees on Health for the opportunity to explain the position of the over 2 million veteran members of this organization. For additional information regarding this testimony, please contact Mr. 

Warren J. Goldstein at The American Legion’s Legislative Division at (202) 861– 

2700 or wgoldstein@legion.org 

f 

VETERANS CHOICE IN HEALTH CARE FACTSHEET 

• The structure of the network facilitates provider participation; it does not dictate how Veterans will use the network. 

• A Veteran seeking community care will have the ability to choose his or her 

providers. 

• Tiered Networks empower Veterans to make informed decisions about which 

providers they want to use, by highlighting providers with higher quality, care 

coordination, and satisfaction scores. 

• Use of tiered networks is common in industry and government (e.g., Medicare 

TRICARE Prime), and is useful in delivering value-based care. 

VETERANS WILL HAVE CHOICE IN PROVIDERS: 

• A Veteran will have the ability to choose which provider he or she would like 

to see for care. The tiered network structure will allow VA to provide the Veteran with information to make an informed choice about the right provider to 

see. 

• The tiered network will improve the way Veterans interact with community 

care by reducing confusion in where to seek care, providing the highest-quality 

care available, and streamlining the transition from a VA facility to a community facility. 

• A Veteran seeking community care will be asked which provider he or she 

would like to see and will primarily fall into one of the following scenarios: 

,I Veteran with specific provider request: The Veteran has requested a specific 

provider (e.g., cardiologist) in mind. If the provider is in the network, the Veteran 

will be able to schedule an appointment with that provider. If the provider is not 

in the network, they will be asked to join the network. Once the provider is in the 

network, the Veteran will be able to schedule an appointment with that provider. 

,I Veteran without specific provider request: The Veteran does not have a specific 

provider (e.g., cardiologist) in mind. VA will provide a recommendation of providers 

in their geographic area for Veterans to choose from. Providers will be organized 

based on quality and alignment with academic affiliates and Federal partners. 

• Bottom line is that a tiered network structure creates value for Veterans by 

providing informed choice on which provider to see for care. 

TIERED NETWORKS ARE USEFUL TO ORGANIZE PROVIDERS: 

• VA is proposing 3 tiers: 

,I Tier 1: DoD, Indian Health Service, Tribal Health Programs, Federally Qualified Health Centers, and academic affiliates providers 

,I Tier 2: Top rated community providers (e.g., quality) 

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,I Tier 3: Community providers who meet standard criteria (e.g., Medicare-eligible and have an active health care licensure) 

• The tiered network will be a back-end structure used by VA to 

,I Monitor quality of care Veterans receive 

,I Improve the Veterans experience with care 

,I Provide oversight 

ADVANTAGES OF USING A TIERED NETWORK STRUCTURE

• A tiered network structure will enhance Veterans choice. It will: 

,I Empower eligible Veterans to make an informed decision on which community 

provider he or she wishes to see. 

,I Provide Veterans access to the highest quality care by identifying the best performing providers in the community. 

,I Incentivizes providers to continuously evaluate and improve their performance. 

,I Provides comprehensive care coordination between VA and community providers. 

TIERED NETWORK STRUCTURE IS CRITICAL FOR ACADEMIC AFFILIATE PARTNERSHIPS

• VA accomplishes critical education and training efforts through coordinated programs and activities in partnership with affiliated U.S. academic institutions. 

VA is affiliated with more than 1,800 educational institutions (95% of allopathic 

medical schools and over 87% of osteopathic medical schools). 

• A tiered network structure maintains VA’s commitment to teaching and training health care professionals through the inclusion of Academic Affiliates in 

Tier 1. 

• Some Academic Affiliates did not choose to participate in the Choice Program 

and therefore were no longer able receive Veteran patients since VA was using 

Choice as the first option in buying care. This dramatically impacted the teaching programs of some Academic Affiliates. Inclusion of Academic Affiliates in 

the Tiered Network will enable VA to sustain and strengthen relationships with 

affiliated and allow Veterans access to the high quality, timely care they deliver. 

• VA’s ability to provide clinical care depends on our relationships with Academic 

Affiliates as many internal VA providers are Affiliated with Academic Institutions. As a result, deterioration in these relationships could result in less providers available to care for Veterans. 

TIERED NETWORK STRUCTURE IS CRITICAL FOR DEPARTMENT OF DEFENSE (DOD)

• A tiered network structure maintains VA’s commitment to teaching and training health care professionals through the inclusion of Department of Defense 

facilities in Tier 1. 

• Partnership with VA enables DoD appropriate personnel readiness as: 

,I Treating Veteran patients allows DoD health care professionals to see the additional volume of patients with the diversity of needs necessary for maintenance of 

certain licenses. 

,I VA provides resident training programs for Military health care providers 

,I DoD providers gain additional hands-on health care experience, contributing to 

the improvement of overall quality of care. 

• Partnership Highlight: VA and DoD recognize the importance of providing coordinated and comprehensive rehabilitation services to support recovery form 

polytrauma. Both agencies have a long history in partnership in providing 

polytrauma care that is a patient-centered, interdisciplinary approach that 

works with the injured individual and his or her family to address all aspects 

of the injury as it impacts the person’s life. 

Æ 

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