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[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

 CHOICE CONSOLIDATION: EVALUATING ELIGIBILITY REQUIREMENTS FOR CARE IN 
                             THE COMMUNITY

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH
				
				 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       TUESDAY, FEBRUARY 2, 2016

                               __________

                           Serial No. 114-51

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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         Available via the World Wide Web: http://www.fdsys.gov
                     
                     
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             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.
                            C O N T E N T S

                              ----------                              

                       Tuesday, February 2, 2016

                                                                   Page

Choice Consolidation: Evaluating Eligibility Requirements For 
  Care In The Community..........................................     1

                           OPENING STATEMENTS

Honorable Dan Benishek, Chairman.................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Adrian M. Atizado, Deputy National Legislative Director, Disabled 
  American Veterans..............................................     3
    Prepared Statement...........................................    36
Carl Blake, Associate Executive Director for Government 
  Relations, Paralyzed Veterans of America.......................     5
    Prepared Statement...........................................    40
Duane Williams, Georgia Leadership Fellow, Iraq and Afghanistan 
  Veterans of America............................................     7
    Prepared Statement...........................................    44
Baligh Yehia, M.D., Assistant Deputy Under Secretary for Health 
  for Community Care, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    23
    Prepared Statement...........................................    45
        Accompanied by:

    Kristin Cunningham, Director, Business Policy, Chief Business 
        Office, Veterans Health Administration, U.S. Department 
        of Veterans Affairs

                       STATEMENTS FOR THE RECORD

Military Officers Association of America.........................    49
Veterans of Foreign Wars of The United States (VFW)..............    54

 
 CHOICE CONSOLIDATION: EVALUATING ELIGIBILITY REQUIREMENTS FOR CARE IN 
                             THE COMMUNITY

                              ----------                              

                       Tuesday, February 2, 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, Huelskamp, 
Coffman, Wenstrup, Abraham, Brownley, Takano, Ruiz, Kuster, and 
O'Rourke.

          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: Evaluating Eligibility 
Requirements for Care in the Community.
    Today's hearing is our first of the new year, our first 
during the second session of the 114th Congress, and most 
importantly our first in a series of hearings that we will be 
holding on different aspects of the Department of Veterans 
Affairs' plan to consolidate care in the community under the 
Choice Program.
    The VA currently uses seven mechanisms to provide care to 
veteran patients in the community. Each of these seven 
mechanisms works differently using seven different eligibility 
criteria, seven different reimbursement rates, seven different 
administrative processes, and seven different sets of business 
rules.
    Recognizing that using multiple means to achieve the same 
end was confusing and inefficient, Congress required the VA to 
develop a plan to consolidate all seven community care programs 
under a single umbrella, a new, improved Choice Program.
    The VA provided the bare bones of that plan last year and 
over the next several weeks, we will examine it in depth 
beginning with today's conversation on eligibility. Determining 
who will be eligible for what and when under the new Choice 
Program is perhaps the most important of all the discussions we 
will be holding over the next few months.
    Eligibility for care in the community now is determined 
largely by how long veteran patients have to wait for an 
appointment, how far they have to drive to get to the nearest 
VA medical facility, and when they get there, whether the VA 
can provide the service that they need.
    While these existing criterions are not perfect, VA's 
proposed plan does not change them significantly. The VA's plan 
does include several significant changes to eligibility 
criteria for emergent care, however, by authorizing veterans to 
seek care in urgent care centers and requiring cost sharing for 
emergency care services in non-VA centers in order to 
incentivize appropriate behavior.
    I am cautiously supportive of the eligibility criteria that 
the VA has laid out in the consolidation plan, though I remain 
concerned about many of the lack of details that the plan 
includes.
    Moving from seven disparate methods for referring veterans 
to community providers to one streamlined common-sense program 
is certainly necessarily, but changing the status quo is never 
easy. And as the saying goes, the devil is in the details, 
precious few of which the VA has provided so far.
    That is why I am glad to be joined this morning by Dr. 
Baligh Yehia, the new Assistant Deputy Under Secretary for 
Health for Community Care, who is leading the VA's 
consolidation efforts. I am hopeful that Dr. Yehia will be able 
to provide us some of the concrete details about how the VA 
will determine eligibility under the new Choice Program that 
the plan did not include. And I am looking forward to that 
discussion.
    I am also glad to be joined this morning by representatives 
from many of our veteran service organizations. As veteran 
advocates and veterans themselves, I look forward to hearing 
their unvarnished opinion about the proposed consolidation plan 
and whether they believe it will help us accomplish our most 
important goal which is increased access to high-quality care 
for veterans we are all here to serve.
    I thank you all for being here this morning and now yield 
to the Ranking Member, Ms. Brownley, for any opening statement 
she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman, and thank you for 
calling this hearing today.
    After more than a decade of war, veterans deserve to have 
ready access to the best health care available to them. Time 
and again, that is shown to be care provided by the VA. I am 
pleased the VA is here today to talk about their new Veterans 
Choice plan that will consolidate the seven disparate care 
authorities that exist currently in law. This plan submitted to 
Congress in 2015 would bring under one umbrella a program that 
is easy to understand and more importantly to implement. The 
program is intended to bring high-quality, safe health care to 
veterans wherever they choose to live.
    When Congress passed and the President signed the Veterans 
Access Care and Accountability Act in 2014, this was a promise 
to all veterans from all eras that they would get the care they 
earned on the battlefield in defense of our Nation.
    The Choice Program was rolled out in a rushed timetable 
under conditions dictated by Congress. I believe the department 
implemented the program to the best of their ability under 
trying circumstances.
    Today, Mr. Chairman, I am interested in hearing from the VA 
what the estimate of this new care in the community will cost 
and how long it will take to implement, also what this 
consolidation ultimately means for veterans and their access to 
quality health care. After all, making it easier for veterans 
to access care is the goal that we all have in this room of 
this plan.
    One aspect of health care often overlooked is helping those 
navigate the system with physical disabilities that force them 
to bring a caregiver with them. I have introduced legislation 
that would authorize payment of beneficiary travel expenses in 
connection with the care of a veteran with vision impairment, a 
spinal cord injury or disorder, or double or multiple 
amputations whose travel is in connection with care provided 
through the VA.
    It is important that all veterans have access to quality 
health care whether at the VA or in the community, but the care 
needs to be at the standards we have come to expect from the 
VA.
    I look forward to hearing from all of the witnesses today. 
I thank you for being here and moving forward in the coming 
days to bring the very best quality care to all of our 
veterans.
    And I yield back, Mr. Chairman.
    Mr. Benishek. Thank you.
    Joining us on our first panel this morning is Adrian 
Atizado, the Deputy National Legislative Director for the 
Disabled American Veterans; Carl Blake, the Associate Executive 
Director of Paralyzed Veterans of America; and Duane Williams, 
Georgia Leadership, Fellow for the Iraq and Afghanistan 
Veterans of America. Thank you all for being here today, 
gentlemen.
    Mr. Atizado, we will begin with you. Please proceed with 
your testimony.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, on 
behalf of the 1.3 million wartime ill and injured veterans of 
the DAV, I want to thank you for allowing us to testify today.
    You had asked to examine VA's plan to consolidate certain 
authorities that it uses to purchase care in the community into 
the proposed new Veterans Choice Program. You also asked us to 
assess whether the proposed eligibility criteria to access the 
new VCP are sufficient to increase access to care among veteran 
patients.
    The way we see it, Mr. Chairman, we believe VA's entire 
plan will increase access to care, no doubt. Whether it is 
sufficient, though, will remain to be seen.
    So, for example, the plan proposes to continue the existing 
geographic and temporal eligibility criteria of the current 
Veterans Choice Program as well as the availability of services 
criteria currently utilized in other authorities such as 
dialysis and PC3 contracts as well as the now defunct fee-basis 
care.
    All these criteria have their own limitations and 
vulnerabilities from veteran patients' perspective in allowing 
them to access care in the community. Now, on a system level, 
these criteria would continue to administratively separate the 
new VCP from the VA health care system which we believe does 
not foster full integration and limits the performance of these 
networks to the detriment of veteran patients.
    Under the separated construct, Mr. Chairman, we recommend 
serious consideration that eligibility to use the new VCP 
should mirror the current eligibility for VA health care giving 
the highest priority to service-connected veterans.
    However, DAV also believes clinical decisions about when 
and where and with who to receive care is one that should be 
between a veteran and his or her doctor without bureaucrats or 
regulations getting in that way.
    Under this construct, all of VA's authorities are 
consolidated and its medical benefits package reflects what is 
generally available and acceptable in the private sector. The 
seamless integration of community care into the VA health care 
system would be able to provide a full continuum of care.
    From a veteran patient's perspective, the future VA health 
care system with the integrated VCP should be responsive to the 
decisions between veterans and their providers. Veterans should 
be able to choose among the options within VA in the new 
Veterans Choice Program network and schedule appointments that 
are most convenient for them.
    For emergency and urgent care coverage, we applaud VA for 
including them in its plan. In fact, DAV had specifically urged 
the inclusion of urgent care into VA's medical benefits package 
and to better integrate emergency care with the overall health 
care delivery system.
    However, there is nothing more glaring that will deter 
appropriate access to emergency and urgent care in the 
community as the plan's imposition of co-payment to all 
veterans with little relief. VA clearly knows the value of ERs 
and urgent care clinics and their appropriateness as clinical 
settings because it owns and operates them in VA facilities 
across the country.
    If certain veterans do not pay co-payments today when 
receiving VA emergency and urgent care, we question why VA's 
imposition of co-payments to all veterans who receive similar 
care in the community. Simply put, if the future VA health care 
system with the integrated new Veterans Choice Program are 
unresponsive to the medical needs of veteran patients, why 
should veterans be penalized with a co-payment for a health 
care delivery system's shortcomings?
    At the very least, service-connected veterans should not 
face greater restriction in the future VA health care system 
when accessing care in the community.
    Finally, Mr. Chairman, we understand the scope of the 
consolidated plan is limited. However, we do caution Congress 
and the Administration on this fragmented approach to providing 
veterans timely access to care in the community.
    If Congress intends to increase veterans' access to high-
quality care across a continuum of care including care in the 
community, not addressing gaps and inconsistencies in VA's 
plan, in VA's medical benefits package as it sits against all 
available services in the community, we believe that VA will 
assuredly continue certain fragmentations of care that veterans 
experience today into the future.
    Veterans could be left unassisted across different 
providers and care settings fostering frustrating and unsafe 
patient experiences leading to medical errors, waste, and 
duplication that foster poor overall quality of care.
    You have our commitment, Mr. Chairman, that DAV stands 
ready to work both with you, the Congress, and VA to ensure 
veterans have ready access to high-quality care both in VA and 
in the community.
    Mr. Chairman, thank you for your time and attention and for 
the opportunity to present this testimony. I would be pleased 
to answer any questions you or Members on the Subcommittee may 
have. Thank you.

    [The prepared statement of Adrian M. Atizado appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Atizado.
    Mr. Blake, you can go ahead.

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Thank you, Mr. Chairman.
    Chairman Benishek, Ranking Member Brownley, Members of the 
Subcommittee, on behalf of Paralyzed Veterans of America, I 
would like to thank you for the opportunity to testify today.
    Let me say up front that we believe that the VA's community 
care consolidation plan lays out a positive path towards the 
delivery of timely quality care and improving access for 
veterans. However, we do believe that there are questions that 
remain as it relates to the veterans that we serve, veterans 
with catastrophic disabilities like spinal cord injury and 
disease.
    As eligibility dictates access to health care, so, too, 
does the capacity of the systems to provide that care. Over the 
years, the VA health care system has relied upon a number of 
methods and standards to measure access and timeliness of 
health care delivery.
    We have seen the VA standard evolve from the 14-day wait 
time to the 30-day wait time. We have seen Congress and the 
Administration seemingly accept an arbitrary 40-mile, 
geographic-based access standard. The fact is, there is no 
evidence to suggest that arbitrary wait time standards are an 
indicator of quality.
    Rather, they are bureaucratic tools to self-assess output 
performance. They are not a measure of quality care. To suggest 
otherwise is unfounded. Similarly, geographic-based access 
standards are not derived from industry best practices for the 
provision of health care.
    The independent assessment on access standards conducted by 
the Institute of Medicine determined that industry benchmarks 
for health care access vary widely throughout the private 
sector. IOM was unable to find national standards for access 
and wait times similar to the Veterans Choice Program 40-mile 
and 30-day standards.
    PVA, along with our partners in the Independent Budget, DAV 
and VFW, strongly agree with the IOM's recommendation that 
decisions involving designing and leading access assessment and 
reform should be informed by the participation of patients and 
their families and their providers. We believe that this 
concept will also best serve the needs of our members and all 
veterans.
    The irony of all this discussion about access standards is 
PVA members often travel farther than any other population in 
the specialized population of veterans or even all veterans in 
general seeking care from the VA. It is not unusual for PVA 
members to travel more than several hundred miles to reach one 
of the 25 SCI centers of care in the VA system. They do this 
because the VA SCI system of care is far and away the best 
option that they have to meet their specialized health care 
needs.
    The access problems these veterans face are usually not 
wait times or distance. They are the burden of cost. Ms. 
Brownley, I would like to thank you for bringing attention to 
that issue in your opening remarks.
    As a result, veterans may wait to be seen until their 
condition deteriorates requiring more costly and intensive 
care. This Subcommittee is reviewing the question of 
eligibility without even considering this important fact.
    Congress should expand travel benefits to include non-
service-connected, catastrophically-disabled veterans who are 
already granted a higher priority in the system to ensure that 
they are able to receive quality specialty care.
    PVA believes that the 30-day and 40-mile eligibility 
standards that determine access under the new VCP do not 
consider what is best for veterans with catastrophic 
disabilities to include SCI and D or any other veterans seeking 
care for that matter.
    PVA along with our IAV partners also support the plan to 
expand emergency care and urgent care in the community. 
However, we strongly oppose the proposal to charge $100 as a 
co-payment for emergency care and $50 for urgent care. This 
proposal seemingly makes no exception for veterans with 
service-connected disabilities or who are currently exempted 
from co-payments. These veterans should not be required to bear 
a cost share as it may disincentivize that veteran or their 
caregiver from accessing emergency treatment or urgent care 
defeating the whole purposes of expanding these two 
opportunities.
    As an alternative, VA should also consider establishing a 
national nurse advice line to help reduce over-reliance on 
emergency room care. The Defense Health Agency has reported 
that the TRICARE nurse advice line has helped triage the care 
for TRICARE beneficiaries.
    Those who are uncertain if they are experiencing a medical 
emergency and would otherwise visit an emergency room call the 
nurse advice line, and are given clinical recommendations for 
the type of care they should receive, when and where they 
should receive it.
    This advice line must also include, must include SCI 
trained providers who are able to identify potential 
complications specific to an SCI or D veteran.
    Mr. Chairman, I would like to thank you again for the 
opportunity to testify. Be happy to answer any questions that 
you may have.

    [The prepared statement of Carl Blake appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Blake.
    Mr. Williams, go ahead.

                  STATEMENT OF DUANE WILLIAMS

    Mr. Williams. Good morning, Mr. Chairman.
    Mr. Chairman, Ranking Member Brownley, distinguished 
Members of the Subcommittee, on behalf of Iraq and Afghanistan 
Veterans of America and our 425,000 members and supporters, 
thank you for an opportunity to share our views with you at 
today's hearing.
    By way of introduction, I am a retired Army person having 
served 26 years active duty, six years in the reserves. I serve 
as the Chairman of the Veterans Affairs Advisory Board of 
DeKalb County, Georgia, and I am responsible for Veterans' 
Recognition Advocacy and Research Program on behalf of 41,000 
veterans in that county.
    I also serve as the Iraq and Afghanistan Veterans 
Leadership Fellow focused on veteran leadership, development, 
policy advocacy, and team building. These experiences help me 
to understand the needs and challenges of veterans accessing 
quality care.
    IAVA is proud to have previously testified in front of this 
Subcommittee recommending the need for consolidation of care in 
the community of veterans enrolled in VA health care. We 
applaud Congress for requiring VA to put forth a plan for 
consolidation. We recognize the senior VA leaders for 
acknowledging the need for consolidation and for providing 
inclusive veteran-centric and transparent plans.
    The 2015 Choice Improvement Act helped begin the process of 
removing confusion for veterans. However, IAVA's most recent 
member survey indicated that five percent of the respondents 
that use the Choice Program and their reviews were mixed. For 
the 95 percent of IAVA members who have not used Choice, 43 
percent didn't use it because of confusion on how to use it and 
half were totally unfamiliar with the program.
    In Atlanta, Georgia, the enrollment for health care at the 
Atlanta VA Medical Center is growing faster than the capacity 
for primary care. According to the 2013 vet pop data, the 
number of veterans living in the 28-county metro Atlanta area 
was 294,000. By 2014, the data reflects 361,000 veterans living 
in the same area. And during the same period of time, the 
Atlanta VA hired 600 additional employees.
    Related to this, on January 20th, the Atlanta VA stated 
that the current completion for VA primary care appointments 
was 60 days. But by January 26th, the director advised me that 
the wait was reduced to 20.6 days. If these numbers hold true, 
the reduction in wait time by nearly 40 days within six days is 
remarkable. We hope other VA medical centers follow suit. We 
hope this Subcommittee will continue to monitor, analyze, and 
ensure the accuracy of wait time data.
    As Congress moves forward to simplify this process for 
veterans, IAVA recommends that the Congress works with the VA. 
Use the VA as a plan, as a framework for legislation to avoid 
the one-off proposals that might be misinformed or put politics 
ahead of veterans. After all, the Congress provided different 
plans that added to the confusion and inefficiencies leading to 
the need to consolidate care.
    We believe Congress should be mindful of these lessons 
learned from them and leverage the VA's plan as a framework for 
consolidation of care.
    Our second concern is VA's ability to effectively implement 
a plan to consolidate care across VA to avoid the mistakes made 
during the implementation of Choice. While the Choice 
Improvement Act of 2015 extended provider eligibility to any 
provider meeting VA criteria, the VA must use this opportunity 
to streamline and standardize the medical documentation 
requirements.
    Under the 2014 law, reimbursement rates for non-VA 
providers is limited to no more than Medicare. Reducing the 
administrative requirements can remove a barrier to more 
providers joining the network.
    VA intends for its health delivery model to be a patient-
centered medical home for veterans. Therefore, VA holds 
responsibility for the direct coordination of services for each 
veteran. Care coordination is a core function of primary care. 
Significant numbers of VA patient needs are complex.
    The factors that increase the complexity for our veterans 
are a number of them have multiple chronic health problems, 
social vulnerability, a large number of providers, and the 
patients lack the ability to coordinate their own care. 
Significant numbers of VA patients have anxiety disorders, 
dementia, depression, and kidney failure.
    IAVA recommends VA continue to collaborate with all 
stakeholders who share their vision to put the veterans first 
and focus on value-based leadership to change the VA culture. 
Given the shortcomings related to training front-line personnel 
in the implementation of Choice and customer service, VA should 
continue to put forth efforts to train all employees in the 
consolidated care model.
    Finally, IAVA encourages the Congress, VA and VSOs, the 
industry and other stakeholders to place increased importance 
on the quality of care that veterans receive, especially 
providers who haven't served veterans since their residency 
training.
    In closing, thanks to this Subcommittee for your leadership 
and your commitment to veterans. Mr. Chairman, I stand ready to 
answer any questions you may have.

    [The prepared statement of Duane Williams appears in the 
Appendix]

    Mr. Benishek. Thank you. And thank you all for your 
statements. I am going to yield myself five minutes for my 
questions.
    You know, as a doctor who took care of veterans in my 
private practice and with some VA coordination and also working 
at the VA doing care, many of the things that you brought up 
today, I have experienced in reality.
    And the frustration of veterans that I hear from now, and 
the work that my staff does to try to get veterans into care is 
so frustrating. And having a single system that really is based 
on clinical need makes much more sense and I completely 
understand that.
    And the whole difficulty with the criterion, I think is an 
effort to contain costs. One of my biggest gripes in my time 
here has been the inability to figure out what it actually 
costs the VA to take care of a patient. So, we don't know if 
care in the community is more expensive than care in the VA, 
frankly, although it seems to add more to the total cost.
    But let me just ask a couple of questions that have come up 
based on your testimony and some of the written statements. The 
Military Officers Association of America, for example, called 
on the elimination of these access standards and the 
establishment of clinically-based access standards instead.
    Can you elaborate a little bit more on your thoughts 
relating to that? I mean, the miles and the time versus what is 
clinically right, does anybody want to comment on that?
    Mr. Atizado, can you talk to me a little bit more about 
some of the things you brought up in your statement?
    Mr. Atizado. Sure, Mr. Chairman. I think first and 
foremost, what has to be said is where we come from which is 
from the patient's perspective. This plan really comes from a 
systems perspective, from the providers' perspective.
    And what we are trying to say is, in order to simplify 
eligibility and to ease access to care, whether it is in VA or 
in the community, there should really just be one eligibility 
criteria. Once you are enrolled in VA, you should have the 
option to use VA or the community, whichever is most convenient 
for the patient.
    As it relates to the doctors' recommendation, 
unfortunately, as you had mentioned, these criteria are really 
cost-containment measures. And we understand that. It is a 
feature of the health care system today, and most likely, will 
remain a feature in the future VA health care system.
    But by and large, the approach in the plan really is to 
disincentivize or make harder accessing care in the community. 
We think it should be the other way around. The plan should 
incentivize veterans to use VA, not disincentivize them from 
using the community. The plan should simplify accessing care as 
patients see it. It is very simple.
    Mr. Benishek. Well, I agree with you.
    Mr. Atizado. And our proposal really does that. Once you 
are in, you are in.
    Mr. Benishek. Mr. Blake.
    Mr. Blake. I think it is fair to say that part of the 
reason the Institute of Medicine couldn't find examples of 30 
days and 40 miles is because that is not how the larger health 
care system in America works. I think it is based on the idea 
that I meet with my provider and we determine as a partnership, 
as it were, what is best for me as a patient, when should I be 
seen, where would it be most appropriate for me to be seen, 
what procedure would be most appropriate.
    And while I think on some level that exists in VA in some 
places, the strictures that are in place right now, as Mr. 
Atizado mentioned, allow it to be maybe more rigidly managed is 
just not optimal. That is why we have joined with our partners 
in the IAV to say that the VA should move to a clinically-based 
access standard.
    I don't know if Dr. Yehia would admit it, but, you know, we 
were involved in a lot of the meetings, and I think they 
understand that. But they have to figure out how to develop a 
workable plan within the construct that they have available to 
them. I think 30 days and 40 miles allows you as the Congress 
to control based on how much it is going to cost. And if you 
open up the possibilities with a clinically-based access 
standard, it is a little more uncertain what the cost might 
actually be.
    Mr. Benishek. Well, my thoughts in talking to some of the 
VA administrators that I have talked to said that the different 
rules make their bureaucracy work so hard to try to get people 
to--one or the other, one of these criteria than we have now is 
just slowing the whole process down. And I think streamlining 
the eligibility would help in that regard because that is the 
biggest complaint I have had from the VA.
    Mr. Williams, do you have any further comments on that?
    Mr. Williams. Mr. Chairman, the only thing I would do if I 
put that in the context of the patient-centered medical home, 
the primary care physician has to be the person that decides 
what type of care the patient needs and what frequency they 
need. And I would think VA's primary care provider would know 
that. That is a frustration I dealt with myself.
    That provider ought to be able to say that this patient 
needs to be seen for specialty care at this point, and I need 
that information back to me within a reasonable amount of time 
and get that done. And they have to do that for the patient.
    Mr. Benishek. Thank you very much. I am out of time.
    Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    I think your statement regarding we really don't know what 
the cost of VA care is versus community care, we really don't 
know the answer to that. And that is a fundamental, I think, 
piece of data that we really need to understand.
    And I was just wondering for all three of the panelists 
here based on your organizations and the research that you do 
to support our veterans, if you have any sense of an answer to 
that sort of fundamental question in terms of health care 
delivery through the VA versus community care.
    Mr. Blake. I would only offer this much. I think there has 
been a number of studies that have probed at the question about 
cost differences and no definitive answer has ever been 
delivered.
    I think from the perspective of having done some of the 
budget work with the Independent Budget, I think the challenge 
is the VA health care system is not the private health care 
system. And we have to accept that up front first, so you can't 
just assume--you can't make it an apples to apples comparison 
even down to cost because the nature of the system and how it 
provides its services is not entirely reflective of the private 
health care system.
    So I don't know that we can ever get to a definitive answer 
and maybe that is the challenge. Maybe we need to set that 
aside as the question. Unfortunately, that is a key focus that 
Congress has to be focused on because you decide how much 
resources the VA is going to have to operate. And I don't envy 
that position that you set in.
    Ms. Brownley. Yeah. I just think, you know, intuitively 
there are some services that veterans receive. I am thinking 
about, you know, getting your eyes checked and getting a pair 
of glasses or audiology, services like that, which seems to me 
would be cheaper if that was all handled, you know, within the 
community than for veterans having to travel long distances and 
so forth and so on to get to their VA.
    So, I mean, I think it is a hard question to try to answer 
because I think it probably breaks down into a lot of different 
pieces as it relates to kind of specialty care beyond primary 
care. So it gets difficult.
    Mr. Williams, you had mentioned some of the surveying 
results that you have done with your organization, and I think 
you said that 43 percent of your veterans aren't utilizing the 
Choice Program because of confusion.
    Did you get any results in terms of veterans not using the 
program because the providers weren't there in the community 
and set up with the VA to be able to provide that care at all 
or--
    Mr. Williams. I don't think that was part of our surveys. I 
would have to get back with the IAVA leadership on the 
availability of providers in the community.
    Ms. Brownley. Because I think that, you know, I mean, we 
hear a lot about the Choice Program and, you know, I think in 
some sense about what we are talking about today and 
consolidating all of these programs. I think we all agree that 
consolidating these programs for community care is a good idea.
    You know, this criteria for access is, you know, is up for 
debate. But I think the consolidation pieces minimizing the 
confusion for the veteran, I think we all agree that is 
absolutely the right way to go.
    I mean, some of the criticisms that I hear, I was just 
talking to one of my colleagues from Florida earlier this 
morning and she was bending my ear about how the Choice Program 
in her district is just not working and she is hearing a lot of 
complaints from her veterans about the program and access to 
the program.
    So I don't know where I am really going with this, but I do 
hear a lot of feedback from people that are still--I know that 
there is a lot of work to increase the amount of providers in 
the Choice Program specifically, but I don't think that we 
are--again, probably in some areas, we have the right amount of 
providers and other areas, certainly in my district finding the 
providers has still been a challenge.
    So even if you wanted to utilize the program, even if you 
were willing to do all of the research to figure it all out and 
you met the criteria, in, you know, in some cases, the 
providers simply just aren't there yet. And perhaps part of 
that is because of the confusion.
    But, you know, I would be interested to hear from the two 
other gentlemen about just, and I have like two seconds left 
now, but maybe we can talk about it later, you know, what the 
feedback is from your members in terms of the success or 
challenges within the program.
    So I will yield back.
    Mr. Benishek. Dr. Huelskamp, you are recognized for five 
minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    I would like to follow-up on the questions from Ms. 
Brownley about the provider network and see how we can--I think 
Mr. Williams talked about reducing some of the administrative 
burdens.
    I will say in the 1st district of Kansas which I represent, 
it is probably the most rural and least served district by the 
VA. There are no VA hospitals, but I have 70 community 
hospitals. Just got the numbers last week. We have 1,309 
providers. That doesn't mean they are all happy to get into 
that network. They are willing, but the administrative burden 
is overwhelming.
    Every one of these facilities has been certified by 
Medicare for years. Now we have a separate certification 
process through the VA.
    Mr. Williams, you brought up in your testimony, are there 
things that you can recommend that we can get the VA--could you 
reduce the administrative burden so these providers are there? 
They are ready and willing. They will take the Medicare 
reimbursement which beats Medicaid. The Medicare, they will 
take that reimbursement, but the paperwork is much, much more 
intensive than anything else in the network.
    So some input from Mr. Williams. Mr. Blake or Mr. Atizado 
on that?
    Mr. Williams. Sir, I would just have to say, and this is 
pulling away from that, but I met with some of the leaders from 
the Georgia Medical Association and that was one of their 
concerns when it comes to the cost of physicians working in the 
network with the administrative costs that it costs their 
physicians because they were even concerned about reimbursement 
rates for Medicare and Medicaid versus administrative 
requirements.
    But they brought up that that was an issue with their 
participation in Choice, was the simple administrative 
overhead.
    Mr. Huelskamp. Yeah. Mr. Blake or Mr. Atizado?
    Mr. Atizado. Mr. Huelskamp, thank you for that question.
    I guess I think the first thing we need to recognize is 
that the Choice Program really is a pilot program. It is a 
temporary measure that was meant to address an access issue. 
The administrative rules as it relates to the law that was 
passed adds to that confusion.
    I do understand from Ranking Member Brownley's question 
that whether or not the networks are, in fact, meeting the need 
is a two-way street, you know. TRIWEST and Health Net have in 
my estimation tried to do a tremendous job in creating a 
national network in so many months and not having the 
appropriate description of demand from the VA health care 
system makes that job a little bit harder.
    I do believe that network is working much better now. They 
are increasing appointments at an incremental rate. But the 
administrative burden for providers to join any kind of network 
is inherent, right? If we want providers to be of a certain 
quality, they have to meet certain standards. Whether that be 
Medicare, so be it.
    Part of the provider agreement authority legislation that 
this Subcommittee has been wrestling with is that. Who are the 
providers we would want our veterans to seek care from? We can 
make that as hard or as simple as possible, but that really is 
a feature that is within our control.
    Mr. Huelskamp. I think you raise a great point and 
especially your first one about this being seen as an almost 
temporary program as to deal with a problem. I will say in 
rural areas, this is an ongoing problem and it didn't just 
start two years ago. We drive hundreds and hundreds and 
hundreds of miles and you are driving by ten hospitals to get 
to the VA hospital. Then you wait in line. And that is not good 
enough.
    And I think we have heard from the VA as well. They see 
this as temporary, a pilot program, an approach that maybe two 
years from now, it might go away. I will note to the Committee, 
don't forget the House bill didn't have some of these arbitrary 
standards. And we had some cost concerns and I understand that.
    But what is magic about 30 miles? What is magic about 30 
days or 40 miles? There is not, other than you have to drive 
that. And so I appreciate the input on that particularly.
    Are veterans still just presuming, and maybe Mr. Williams 
particularly with your survey, are they presuming this is just 
a pilot program that will go away and there will be another 
variation of this in the future, and does that limit their 
participation or any of the three?
    Mr. Blake. Well, I wouldn't say they presume it. I mean, 
everybody, I think, understands that this program will sunset 
either on a date certain or when the money runs out. You know, 
your district is one of those ones that has always sort of 
befuddled me.
    It was sort of tailor made for the old fee-basis standards 
which had written in regulations geographic inaccessibility. 
And for the life of me, I never understood what it would take 
to define it. That is what was attempted with the Choice 
Program with 40 miles in particular.
    Adrian mentioned an interesting point about the networks 
that TRIWEST and Health Net are trying to build. The challenge 
is building a demand-appropriate network. Within the construct 
of the framework that we propose with DAV and VFW is the idea 
that through the integrated network, which is the right way to 
deliver care by and large, it needs to be distilled down to the 
most local level.
    Mr. O'Rourke looked at this idea in El Paso. They went out 
and figured out exactly what the community was capable of, 
particularly in the area of mental health, to figure out what 
it would take in a partnership between VA and the community to 
meet demand.
    All that being said, most of our members from the PVA 
perspective just don't use Choice because the networks do not 
meet the demand that they have. And at the end of the day, the 
private sector struggles to meet the unique needs of SCI 
veterans, blinded veterans, veterans with polytrauma.
    So there is a complicated circumstance that exists here 
where the VA has to meet demand for principally primary care 
and mental health care which are sort of the big elephants, but 
you can't forget that there are many veterans who the VA is 
their only and best option and how that gets right-sized with 
whatever the new VCP ends up looking like.
    Mr. Huelskamp. All right. Thank you, Mr. Chairman.
    Mr. Benishek. Dr. Ruiz, you are recognized.
    Mr. Ruiz. Thank you, Chairman Benishek, Ranking Member 
Brownley, for holding this series of hearings centered on VA's 
proposal to consolidate community care.
    We have asked the panelists to tell us how they would 
modify the eligibility standards that are necessary to create a 
veteran-centered VA. But to answer these questions, you know, 
we need to look at the cracks that the Choice Act has left 
behind or the cracks within the Choice Act because these are 
the cracks that our veterans are falling through and these are 
the reason experiences of veterans in my district that do not 
reflect the successes that the department boasts.
    So my first question is, can you specifically identify what 
are those cracks? Which of our veterans are not getting the 
care through the Choice Program that it was intended to do?
    Mr. Atizado. I will give you a good example, Congressman 
Ruiz. Veterans need home and community-based services. The 
Choice Program does not allow VA facilities or doctors no 
matter how clinically appropriate it is to use Choice money to 
buy home and community-based services.
    In fact, only home and community-based services as we all 
know is a cheaper alternative to institutional care, less 
expensive, more veteran-centric. It is skilled nursing care. 
That is it. Out of all the home and community-based services 
that veterans can receive that VA can provide under existing 
law, that is it.
    Mr. Ruiz. How about you, Mr. Blake?
    Mr. Blake. Well, I would say that the Choice Program is 
simply not built to meet the specialized health care needs of 
veterans like SCI and D, substance abuse, polytrauma, and TBI, 
blinded veterans.
    I think that wide spectrum of unique populations of 
veterans that the VA serves, I don't think the Choice Program 
is designed to serve because they might be able to go outside 
the system, only in a perfect world might it work, where full 
integration with the community so that it is seamless, but that 
might be a dream.
    Mr. Ruiz. I think one of the problems with the eligibility 
criteria of a 40-mile distance is that you can have a VA clinic 
that does not offer the specialty care that our veterans need.
    For example, in my community, we have a clinic in Palm 
Desert in the center of the Coachella Valley, but it does not 
have a pain specialist working at that clinic, does not have, 
for example, a dentist or other specialty kind of care. So our 
veterans still have to travel an hour, hour and a half to the 
VA hospital to get that kind of specialty care.
    So when you talk about clinically appropriate eligibility, 
is that what you mean, like making sure that what they need in 
terms of the specialty care, they can acquire if it is not 
within the 40-mile distance?
    Mr. Atizado. Congressman Ruiz, what we mean by clinically-
based decisions is when veterans get to access the community 
care network. The way the plan is and even the Choice plan as 
it stands, it really requires veterans to, one, enroll in the 
VA health care system and then, two, be eligible for the Choice 
Program or even this new Choice Program. So it is really two 
separate eligibility criteria to begin with.
    Mr. Ruiz. Yeah. I think that we need to take pause and 
throw out a big caution out there. Many of our veterans are 
working poor, are retired, or work in rural areas. And we are 
working under the assumption that in those communities for some 
reason, those services exist.
    I come from an area that has both affluent and under-served 
communities. And I can tell you that in the under-served 
communities, you don't have specialists. You don't have 
community homes. You don't have any of the care that we are 
assuming that veterans can achieve outside of the VA.
    So I think that we have to really identify and not think 
that because we have the Choice Program because veterans can go 
to their neighborhood doctor that they are going to get the 
care that they need. We need to take into account the 
insufficiencies and the lack of resources and the vast majority 
of America that live in rural communities as well.
    Hotline, tell me about the hotline and what evidence is out 
there that it actually saves money and also incentivizes 
patients to use the VA?
    Mr. Blake. Well, I think there is a reference in my 
testimony what they have done through TRICARE shows that it is 
certainly a workable solution. That is not to say that TRICARE 
is the model of perfection in this case. But I think what we 
are trying to do is ensure that veterans are making the right 
decisions when it comes to emergency care and urgent care.
    I think we all believe that urgent care is a must. It is 
something the VA has not really ever done and, unfortunately, I 
think you have seen in the community in private sector now, a 
lot of health care is delivered through an urgent care setting. 
And so it is probably time for the VA to get involved in that 
because that alleviates the pressure on primary care. In the 
health care setting in VA, it relieves the pressure potentially 
on the mental health care which is--
    Mr. Ruiz. Right.
    Mr. Blake [continued]. --a big part of it.
    Mr. Ruiz. Urgent care was a result of a failed primary care 
system where people weren't able to access their primary care 
so they needed a quick in and out type of thing. But it can't 
replace primary care because when we are talking about a 
medical home, a place where a patient can get integrated care 
with case management that can really take care of the entirety 
of the patient, urgent care doesn't necessarily provide that as 
we think of them now.
    So there are some benefits to urgent care, but we also have 
to make sure that the veterans also get home-based 
comprehensive primary care that they deserve.
    Mr. Atizado. I agree with you, Congressman Ruiz. Yes, 
primary care is integral in coordination with care, but primary 
care is not all.
    Mr. Ruiz. Correct.
    Mr. Atizado. And it never will be all. And you are right. 
Urgent care has a place. There is an appropriate setting for 
seeking care in that. And we don't think veterans should be 
penalized because that is the appropriate setting for care.
    Mr. Blake. And I wasn't suggesting that urgent care is the 
solution. I mean, what we find now is a lot of veterans go to 
the emergency room. That would be true in the private sector 
except now you have urgent care everywhere, so the solution in 
the community has become everybody goes to urgent care. 
Veterans don't even have that option so they just overrun the 
emergency care setting in the VA while the primary care system 
just sort of lumbers along because it is overwhelmed as well.
    Mr. Ruiz. Well, my time is up, but I wanted to say that the 
veterans that I take care of in the emergency department and 
the veterans that I take care of in the office who are 
struggling with their benefits, who are struggling to make ends 
meet, who are struggling to get back on their feet, who are 
struggling to find a home that are homeless, $50 co-pay for 
urgent care, $100 in co-pay for the emergency department is 
completely a barrier that will continue the burden of illness 
and disease that they already have. So I agree with that.
    Mr. Benishek. Thank you.
    Dr. Abraham, you are recognized for five minutes.
    Mr. Abraham. Thank you, Mr. Chairman, Ms. Brownley, for 
having this hearing.
    Thanks to the witnesses. Appreciate your very direct 
testimony.
    And like Dr. Benishek and Dr. Ruiz, I come from a private 
setting, so looking at it from the outside in, so to speak, 
this should be such a simple solution, but evidently it is 
being muddled up and the water is being muddled by bureaucracy.
    I made some notes and I will go down them very quickly. 
Again, it should seem simple. I know that the VA and we as 
Congress have to watch the purse, but I am afraid we and the 
VA, especially on cost, is looking through the soda straw and 
not the overall picture simply because we in the medical field 
know that if that patient comes back and back and back for a 
problem that is not being addressed or not being fixed, costs 
just incrementally increase.
    And if the VA is unable to give us a cost per patient, then 
I wouldn't bet the house that they could give us how many times 
that veteran is having to come back because that issue was not 
resolved. And that just adds exponentially to the cost.
    So I am going to paraphrase, and please correct me if I 
misstate what I perceive that you told us in testimony, that 
the way to streamline and fix this issue is again simple. Once 
in, you are in. That should be fairly simple.
    I like the nurse assistant line. I know that does work in 
the private sector. I know it worked in my clinic, saving 
patients going to the emergency room. We had a nurse on call 
and countless of thousands of dollars I am sure were saved from 
either waiting until tomorrow, treating that patient over the 
phone, going to a not emergent facility as opposed to an ER.
    Mr. Blake, you said that no co-pay is a good thing and I 
would tend to agree with that. I will tell you that.
    Mr. Williams, you said there is still a lot of confusion in 
Choice. I think that goes back to both the fault of the VA and 
the Congress. We should have done a better job of putting it 
out there with bullet points and making it, you know, a one-
pager. It should not be that hard to explain this program. It 
should not be.
    Also, Mr. Williams, you said in your VISN that the VA added 
significant more employees and you saw wait times come down. Do 
we know or can we extrapolate that that actually improved care, 
or did it just eliminate wait times? I know it is a theoretical 
question, but just give me a gut feeling. What do you think?
    Mr. Williams. Congressman, it was absolutely important to 
hire those employees to cut the wait times.
    Mr. Abraham. And, again, I know, but do you think by 
cutting the wait, and, again, I am just asking an opinion, in a 
non-emergent setting, does cutting the wait time improve the 
quality of care that that veteran gets? I am assuming it does, 
but I am asking you. You have talked to your veterans. Do they 
perceive that as being an improvement of quality of care?
    Mr. Williams. In Georgia, the access to care is critical 
and access in a lot of our veterans' minds is interpreted as 
quality.
    Mr. Abraham. Okay. And I think one of you guys made a 
statement or maybe somebody on this panel about another issue 
is paying our providers, non-VA providers appropriately enough 
money to come into the system. And I can tell you it is still a 
very big problem.
    In my VISN 16, we have arrears of the VA system to our 
ambulance services, to our providers in the millions of 
dollars. So you are spot on there. It is a big problem. And 
that, again, I will put that on the VA explicitly for not 
paying their claims.
    So anything else? The no co-pays, the once in, all in, the 
increased--I am just looking for simple solutions to what 
should be a simple problem here.
    Mr. Blake. Mr. Abraham, I want to go back to something you 
said at the beginning about escalating costs and I am using 
this to piggyback on comments that Ms. Brownley made at the 
beginning.
    We have been advocating for travel reimbursement for, while 
it is a non-service-connected population, it is 
catastrophically-disabled veterans, and usually we get folks 
who balk at the idea that we recommend that for non-service-
connected disabled veterans.
    But they are already granted higher priority in the VA 
system because of the nature of their disabilities and the 
ability of the VA to meet their demands for health care when 
the private sector struggles with that challenge.
    And one of the reasons we have advocated for the 
beneficiary travel issue is because what we have seen in our 
membership is those folks who are non-service-connected will 
choose not to go to the VA and wait as long as possible because 
it is costly for somebody with a catastrophic disability to fly 
long distances, drive long distances, or whatever it may be to 
go seek that care.
    And the long-term cost to the VA when they finally show up, 
because they will show up and the VA is obligated by priority 
to care for them, will be substantially higher. So we would 
hope you would take a look at that as an issue, because it is a 
unique population that the VA serves because, yes, they are 
non-service-connected, but they have some of the most profound 
disabilities that VA serves.
    And that is the reason they go to the VA and yet the VA, 
many times, they are bearing a higher cost burden than they 
should have to because the veterans are disincentivized to get 
that care as soon as possible.
    Mr. Abraham. Thank you.
    I am out of time, Mr. Chairman. Thank you so much.
    Mr. Benishek. Thank you.
    Mr. Bilirakis, you are recognized.
    Mr. Bilirakis. Thank you so very much. I appreciate it.
    Thanks to the panel as well.
    Let me ask you a question on dental care. I know it is very 
limited as far as eligibility for veterans, but are veterans 
receiving dental care, let's say in the community if no one is 
available within the 40-mile range or the 30 days? I mean, what 
is going on with that?
    Mr. Atizado. I couldn't really tell you, Mr. Bilirakis. 
That is actually a very good question. I believe the 
eligibility for dental care as strict as it is already, getting 
it in the community is par for the course for VA when you are 
eligible for dental care.
    But, you know, that question really goes to a much larger 
issue which is, as good as VA's plan is as a first step towards 
creating an integrated community health care system that is 
integrated in the VA health care system, it is a good first 
step.
    The issue is it is not comprehensive enough. In other 
words, the authorities that the VA looked at to create its plan 
is not all its purchase care authorities. It is some of it.
    And those other parts that is not included in this plan 
which could very well not be included in the solution or the 
next iteration of Choice, as I mentioned in our testimony, if 
you carry that forward, you will still have fragmented care, 
whether that be dental care or home and community-based 
services or specialty care. There are other purchase care 
authorities that VA has and uses that is not part of this plan.
    Mr. Bilirakis. If you, in a perfect world with regard to 
the specialty care, if we wanted to open it up to the community 
for the veteran to have the ultimate choice, even if he lives 
within the 30-mile range, what have you, or she, what specialty 
would you recommend where the veteran would have direct access 
to community care? Can you give me a couple specialties?
    Mr. Blake. I don't think you can cherry pick and say, well, 
we are just going to let this group of veterans with this 
unique need have this option. That is probably--
    Mr. Bilirakis. Well, where is it they are having the most 
trouble accessing care in that specialty area?
    Mr. Atizado. Well, a good example would be if you were in 
the high plains, cardiologists. Here in D.C., a dermatologist. 
It really depends on what is available in the community.
    Mr. Bilirakis. Okay. So it depends on--
    Mr. Atizado. And it can vary widely. The Merritt Hawkins 
survey, that kind of shows that actually.
    Mr. Blake. I think that is why you can't just sort of apply 
a national fixed standard to it. When I mentioned earlier in my 
comments as they flesh out the details of an integrated 
network, you can't just sort of lay a national standard on it 
and say this is what the network should look like. I think that 
is probably the challenge that TRIWEST and Health Net are 
experiencing now.
    It has to be distilled down to the lowest level possible. 
That is the idea I think that Mr. O'Rourke was trying to get at 
with what he was looking at in El Paso because you have to 
understand every individual city, every individual town, the 
rural counties across America, everything is going to be 
different.
    So you can't just say, well, we are going to grant all 
these folks who maybe have a cardiology need, you know, access 
and nobody else when some veterans might be perfectly served by 
the VA and some not in that little cohort alone.
    Mr. Bilirakis. Okay. So, in other words, we would specify 
based on the area, the region in the country where there is a 
lack of maybe care, access to care in that particular region.
    All right. Let me go on to the next question. VA's 
consolidation plan addresses eligibility for community care, 
but not eligibility for enrollment in the VA health care system 
in the first place.
    So the question is, do you think that a review of VA's 
overall eligibility and enrollment is needed at this time, and 
would you support such an effort? And that is for the panel.
    Mr. Blake. Well, Mr. Bilirakis, I would point you to the 
concluding part of my written statement which suggests that 
perhaps it is time to consider whether veterans should just be 
eligible to enroll in the VA health care system.
    The vision of the Affordable Care Act which I hasten to 
mention because that brings up all kinds of political 
ramifications is to expand access to care for people in 
general. And we fought when the law was being written for the 
Affordable Care Act to ensure that VA was deemed credible 
coverage under that law.
    And the law says VA is deemed acceptable coverage under the 
strictures of the Affordable Care Act and yet there is a large 
group of people, particularly in the priority group 8 arena who 
are denied even accessing that. So why would you deny them an 
option for health care and say, well, you can only go over here 
under the rules of the Affordable Care Act, but under the rules 
as set for VA, you can't actually come into the system?
    So we think maybe it is worth considering whether there is 
this fear that if you just sort of open enrollment, sort of if 
you build it, they will come, that it will flood the VA system, 
but history has never proven that to be the case. When VA's 
system was open, veterans didn't flood the system. Even then, 
fully two thirds of all veterans chose not to enroll in the VA. 
So I think it is sort of a scaring assumption that, oh, all 
these veterans would enroll, which would increase utilization. 
It might, it might not. And I mean it is high risk, but there 
is a potential high reward from allowing veterans to access the 
benefits of VA health care.
    Mr. Bilirakis. Thank you very much, I appreciate it.
    I am out of time, Mr. Chairman. I yield back.
    Mr. Benishek. Mr. Coffman, you are recognized for five 
minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    Are there--and I will ask every panelist--are there any 
types of health care services that should be eligible for 
Choice without regards to any time or geographic requirements?
    And the reason why I mention this is because obviously 
mental health has become such a big issue for our veterans, and 
we have had testimony before to this Committee about VA's 
mental health being at times drug-centric in its treatment. And 
so to me, having had veterans commit suicide in my district and 
meet with those families and try and trace it back, when it 
becomes evident that they couldn't navigate the bureaucracy to 
be able to get an appointment in time to save their lives. And 
so wouldn't it make sense to allow veterans to see who they 
feel more comfortable with, see who they want, when they want, 
in terms of access to mental health care, as an example, and 
are there other examples?
    Whoever wants to start with that.
    Mr. Williams. Congressman, I will say this from the 
perspective of with my sisters and my late wife being Marines. 
My wife was adamant after one visit to the VA that she would 
never, ever go back in after having walked through a gauntlet 
of men. And it brought up something I did not know about what 
had happened when she had first joined the military. I don't 
think we should make women have to go through a gauntlet 
because I think it also discourages some of those who need the 
health care from getting it because they just don't want to 
walk through a gauntlet of men.
    Mr. Coffman. Okay. Mr. Blake?
    Mr. Blake. I would answer the question in this way. I would 
throw out the concept of choice all together for a second. If 
you had a fully integrated health care network, which is a 
division, I think that the VA has even though this is billed as 
just for community care, the way the health care network should 
work is a fully integrated health care network, and you have 
the patient-provider relationship within the construct of that 
network. The veteran goes to their provider, that veteran and 
that provider, which is the way in the private sector it also 
works, decide what is best for that veteran. Should I be seen 
at the VA? Should I be seen in the community? What is available 
now, what is available later? What services do I need?
    So the question of choice is sort of a false question.
    Mr. Coffman. Well, I don't know if it is a false question 
to the veteran. Let me phrase it this way. Who should make the 
decision? Should it be the veteran making the decision or 
should it be a bureaucrat making the decision in terms of 
access to mental health care?
    Yes?
    Mr. Atizado. Mr. Coffman, so this shared decision is really 
what we are talking about. When a veteran meets their primary 
care provider, hopefully it's a VA primary care provider, that 
discussion should go something like this. Well, it looks like, 
sir, that you have this condition, here are your options. I 
prefer as a provider you go down this route, but these are 
options of therapies that you can use to deal with this issue. 
Well, that is great, Doctor. I tell you what, I would rather go 
this route, I would rather take this option. Where can I get 
that care?
    That is the kind of decision-making we are talking about. 
The network should be responsive to that--
    Mr. Coffman. Well, let's take a step back here.
    Mr. Atizado. Sure.
    Mr. Coffman. Who are you going to empower to make the 
decision? This is my question. We are not bureaucrats here, we 
are veterans. I assume everybody here is a veteran. Who makes 
the decision? Does the veteran make the decision in terms of 
their own mental health care or are you saying that it is a 
shared decision between a VA employee and the veteran?
    Mr. Atizado. Okay, let me give you a straight answer. There 
is no one.
    Mr. Coffman. Well, that is the problem.
    Mr. Atizado. It really depends on--
    Mr. Coffman. These veterans that I have in my district that 
committed suicide, they couldn't navigate this system. So let 
me ask everybody one more time. As a veteran--now, what branch 
were you in?
    Mr. Atizado. I was in the Navy, sir.
    Mr. Coffman. Branch?
    Mr. Blake. Army.
    Mr. Coffman. Branch? Navy or Army?
    Yes or no, should veterans make the choice of their mental 
health care irrespective of the Choice Act? What is your 
position?
    Mr. Atizado. If they are capable in making that kind of a 
decision, yes.
    Mr. Coffman. Okay, great.
    Mr. Blake. It should be an informed choice.
    Mr. Williams. The veteran.
    Mr. Coffman. Thank you.
    Mr. Chairman, I yield back.
    Mr. Benishek. Dr. Wenstrup, you are recognized for five 
minutes.
    Mr. Wenstrup. Thank you, Dr. Benishek.
    I appreciate you all being here today. You know, my 
concern, I think everyone's concern here is that the veteran 
get care. And I think we get hung up on a little bit of optics. 
As someone coming from private practice, I guarantee you every 
member of my 26-doctor group would have been glad within our 
practice to have a sign up front that said we are VA providers 
and have the VA logo there. We just don't happen to practice 
within the walls of the VA and in part because it is a mess to 
deal with from the bureaucracy, and you can't be productive in 
the way that you can in private practice for a variety of 
reasons and we won't go into that.
    But even recently in hearing, you know, VA officials were 
saying, oh, we are seeing more patients than ever before. That 
is because they increased the number of doctors and expanded 
their hours, but they didn't get more productive. And when you 
are in private practice, you have got to maintain the quality 
if you want people to keep coming to you. That doesn't exist in 
the VA, although I think we have some great providers. So I am 
not knocking them, but the system makes it very difficult to be 
productive.
    So I am going to ask you, do you think there is an optical 
problem? And I don't like when we keep saying non-VA providers 
and I think we should just say that they are VA providers. They 
just happen to be outside the wall of the VA. And in that case 
you give people a choice on where they want to go.
    And when you talk about lack of specialities in different 
areas, well, that exists for everybody and people make a choice 
on where they live. Some people move close to a hospital 
because they have a heart problem. I mean, those are choices 
people have and we can't expect the VA, just because you are a 
veteran, have every speciality follow you around wherever you 
happen to live. So people have to make choices like that, 
whether they are veterans or not, that is just the reality of 
things.
    So my first question is, should we stop calling these 
providers non-VA providers like they have got some stigma? And 
do you think that veterans really really feel that they have to 
be within those walls to get proper care?
    Mr. Atizado. Congressman Wenstrup, the idea that calling 
private providers non-VA providers is a little bit of a 
misnomer. That really talks to not the quality of care that 
private providers are able to provide, it doesn't talk about 
their--what it really talks about is the kind of care VA 
provides.
    VA is a health care system unlike any other health care 
system in this country. Its dependencies stretch beyond the 
walls of a hospital or a CBOC. It has to work with VBA, NCA, 
IHS, rural community health centers. It is part of a social 
support ecosystem.
    Mr. Wenstrup. But there would still be that link.
    Mr. Atizado. I understand there should be that link. So 
whether you call it a VA provider or not, the recognition has 
to be that the VA provides a different kind of care, that it 
has different responsibilities. It has a teaching mission, it 
has a research mission, it has all sorts of--
    Mr. Wenstrup. You know what? that veteran who is sick 
doesn't care. They want to be seen and they want to be taken 
care of. They are not saying, oh, you do research here? They 
don't care about that. It is about getting the veteran taken 
care of.
    And so anyway, I am just going to move on from there 
because I want to make a point of something that we have 
discovered through this Committee when there was a study done. 
And you talk about costs and we have got to be concerned about 
costs, but a well visit to an average primary care doctor is 
about $85. Pay the copay if they want to go outside the VA. 
Guess what we discovered it costs? Because, see, no one in the 
VA talks about what it costs for your physical plant, your 
insurance, your supplies, your staff, your administration, they 
don't even know what that is until this study was done. It is 
about four to $600 per patient visit to go to the VA. We can't 
do that forever and it doesn't make any sense.
    When you send someone outside the VA and if they want to go 
there, if they want to go there it may be $85 and the VA is not 
picking up all the malpractice and everything else and I think 
we have got to consider that. And I want the veterans to have a 
choice, but as a provider, you know, I would say, hey, I am a 
provider for Blue Cross/Blue Shield, United Healthcare, the VA, 
whatever, I am a VA doc.
    And I think we have got to break that stigma and really 
look at what we are doing, so the patients do have a choice 
between going to the VA, going outside it if that is their 
preference, but really, start to look at the dollars and cents 
of what is taking place within the VA where it costs way too 
much to see a patient.
    And I yield back.
    Mr. Benishek. Thank you, Dr. Wenstrup.
    Does anyone else have a question for the panel?
    I really appreciate all of you coming here to testify and I 
really welcome your input as this process goes forward to feel 
free to come before any of us with further ideas as we explore 
how to make this better. So I really appreciate that and you 
are hereby excused from the panel.
    Thank you.
    Joining us on the second panel from the Department of 
Veterans Affairs is Dr. Baligh--and I am struggling with your 
name, sorry, Doc--Yehia, the Assistant Deputy Under Secretary 
for Health for Community Care, and he is accompanied by Kristin 
Cunningham, the Director of Business Policy for the VA's Chief 
Business Office. Thank you both for being here.
    Dr. Yehia, you may begin when you are ready.

                STATEMENT OF BALIGH YEHIA, M.D.

    Dr. Yehia. Thank you. Good morning, Chairman Benishek, 
Ranking Member Brownley, and Members of the Subcommittee. Thank 
you for the opportunity to testify today regarding the 
Department's plan to consolidate community care programs, 
specifically streamlining eligibility criteria.
    I am accompanied today by Kristin Cunningham, who is the 
Director of Business Policy.
    I want to acknowledge our VSO partners, we have been 
working with them hand-in-hand since we started this process, 
and also your comments, Mr. Chairman, on the need to get to one 
system that works for veterans. And I am looking forward to 
discussing a little bit more about those clinical criteria that 
were mentioned.
    This plan aims to clarify eligibility criteria, build on 
existing infrastructure to develop a high-performing network, 
streamline clinical and administrative processes, and implement 
a continuum of care coordination services.
    These actions will improve access to care, expand and 
strengthen our relationship with community providers, allow us 
to operate more efficiently, and improve the veteran 
experience.
    As you know, VA is taking part in an enterprise-wide 
transformation called MyVA. MyVA will modernize VA's culture, 
processes and capabilities to put the needs of veterans and 
their family members first.
    Just a few weeks ago Secretary McDonald highlighted the 
department's 12 breakthrough priorities, all of which are 
designed to improve the delivery of timely care and benefits to 
veterans. One of those priorities is to improve community care.
    Community care has been and will always be a vital part of 
VA health care for veterans. In 2015, VA issued authorizations 
that resulted in about 12 million community care appointments 
and that is compared to 8.8 million in 2013, representing an 
increase of about 36 percent. Even though we have been 
providing more community care, we are eager to seize the 
opportunity to improve the experience for veterans, community 
providers and our employees. However, we need help from 
Congress to consolidate the complex and varied eligibility 
criteria for community care into a single set of standards. By 
doing this, veterans will have a clear understanding of their 
eligibility for community care and VA community providers will 
have a significantly lower administrative burden.
    The eligibility criteria outlined in the plan aim to 
increase access to timely care and patient choice while being 
mindful of taxpayer dollars. The plan gives veterans a choice 
to access some or all of their health care in the community if 
they meet one of the following criteria that is related to 
access, geographic distance and availability of service.
    A veteran would meet the access criteria if they are unable 
to schedule an appointment within VA's wait-time goals for 
providing that service or within the clinically necessary 
timeframe indicated by their provider.
    In terms of geographic distance, a veteran may receive 
community care if they are 40 miles or further driving distance 
from the primary care provider or they face an excessive burden 
in accessing a VA facility.
    Lastly, a veteran may access community care if the VA does 
not provide the service or if there is a compelling reason why 
the veteran needs to receive community care.
    By implementing a single set of eligibility criteria, 
veterans will have a clear understanding of their community 
care benefit. However, built into these criteria is a 
flexibility that I and my fellow clinicians at VA need to 
respond to unique circumstances. This is critically important 
to ensure that we meet the needs of individual veterans.
    The plan also addresses the challenges that many veterans 
face today when seeking emergency room care within the 
community. Due to complex laws and processes for veterans, VA 
is many times forced to deny a significant number of emergency 
treatment claims, leaving some veterans to shoulder that 
financial burden. By tackling these pain points, we anticipate 
that it will improve reimbursement of emergency room claims and 
reduce the need for manual review of every claim.
    In addition, the plan asks for congressional authority to 
offer urgent care services in the community. This action will 
increase access to care and reduce the number of emergency room 
visits.
    We are eager to move forward and we are open to any ideas 
that veterans, Congress, veterans' service organizations, and 
other stakeholders may have. We recognize this must be a 
collaborative effort and need Congress to provide necessary 
legislative changes and support moving forward to consolidate 
care, including the enactment of provider agreements and 
flexibility in funding for community care.
    I appreciate the opportunity to appear before you today and 
I am prepared to answer any questions that you and other 
Members of the Subcommittee have.

    [The prepared statement of Baligh Yehia, M.D. appears in 
the Appendix]

    Mr. Benishek. Thank you, Doctor. I will yield myself five 
minutes for questions.
    So can you go into a little bit more detail about one of 
the big problems that we have of course is this emergency 
reimbursement issue. And, I mean, that happens all the time 
where a veteran goes to an urgent care clinic or the ER and the 
local hospital and then tries to get that approved and that is 
a pretty good example, I think.
    So how specifically are you going to fix that problem?
    Dr. Yehia. Thank you for that question.
    We knew when we started this work we have to tackle the 
emergency room benefit. We have talked with a lot of veterans, 
we received a lot of letters, as I am sure you have and others, 
about the challenges that many of them face when accessing 
community care as it relates to the ER benefit. And the biggest 
challenge is that they don't know if VA is going to end up 
paying for that care and I think that creates a perverse 
incentive many times to delay that care, and they feel they 
have to drive to a VA to be seen and part of that is the way 
that the laws and regulations have been written over time. We 
can't provide that clarity that we need.
    And so what we are hoping to do in the plan is to 
streamline that. We are using principles based on industry, so 
a lot of the things that we talk about in the plan of 
consistently applying what is called the prudent layperson 
definition of ER, the idea of copayments to make sure that we 
incentivize the right health behaviors. Those all came from 
TRICARE, from health plans, they are standard and common 
practice in many health systems.
    And then by doing that, we hope to minimize by a 
significant amount denied claims and kind of empower our 
patients and the veterans so they know that when they access 
the ER care in the community, that VA is going to be picking up 
the bill and they won't be shouldering that financial burden.
    Mr. Benishek. I understand your thoughts, but specifically 
how are you going to get the VA to be assured that they are 
going to be paid? Is there going to be a central number to 
call? I mean, your goal is, you want to make it right, but the 
reality of it is, it is not right now and you didn't tell me 
anything specifically that is going to make it right, from what 
I could understand.
    Dr. Yehia. Well, let me clarify it.
    So in our plan and to the Committee we have also provided 
some technical assistance that has specific legislative 
language to make it right. Right now when it comes to ER under 
our current authorities, we are the primary payer when it is 
service-connected care, we are the payer of last resort when it 
is non-service-connected care. And then there is a whole bunch 
of criteria that are outlined in rules and regulation where if 
someone passes a VA or--
    Mr. Benishek. The question is, so is there somewhere in 
your plan that will allow a veteran to make a single phone call 
and find out? I mean, it doesn't sound like you have said 
anything that allows that uncertainty to go away.
    Dr. Yehia. Well, yes. I think the first step is we have to 
actually consolidate and fix the problem, and once we fix it 
and it requires congressional action, then we communicate and 
make sure that folks understand.
    Mr. Benishek. I am not sure that requires congressional 
action, I think it may be more of a bureaucratic solution.
    I want to discuss this, one of the things you said in your 
statement, the distance and then how do you define unusual or 
excessive burden that may necessitate community care? Because 
that is a vague criterion. Can you tell me about that?
    Ms. Cunningham. Sir, I will help Dr. Yehia with that.
    In our current Choice law, the additional enhancements that 
were given to us in the May law, we were able to define the 
unusual or excessive burden. We implemented three of those 
provisions in June. The last provision required us to further 
define in regulation, we did that in the beginning of December 
and then rolled that out to our facilities.
    And we looked at that providing either the ability for 
clinicians to make a medical determination that the person's 
condition required them to get care closer to their home or we 
identified things that were just the nature of simplicity or 
the frequency of the services.
    So earlier during the VSO testimony, there was some 
discussion of getting, for instance, eye exams or audiology 
exams in the community because they are simple in nature. And 
those are actually some of the examples that we use when we 
talk about the simplistic nature of the type of service and 
being able to get that care under the unusual-or-excessive-
burden provision.
    Mr. Benishek. All right, thank you. I am out of time.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman, and I thank the 
panelists for being here.
    Just a very direct question, if you could just give me the 
rationale the VA has for imposing the copay of $100?
    Dr. Yehia. The copayment of $100 is meant to make sure that 
we provide care in the right venue. Many of our ERs are clogged 
up today and there is long wait times when folks go to the ER, 
and part of the problem is that a lot of non-emergent care is 
being driven to the ER.
    And increased access to urgent care, which is what we are 
proposing in our plan, a robust primary care health care 
system, those are all kind of tools in the toolbox to ensure 
that folks use the right setting. So the idea of the copayment 
here is to make sure that folks are able to seek the right care 
setting when they receive their care.
    Ms. Brownley. Did you evaluate other ways in which to 
accomplish the goal that you are describing?
    Dr. Yehia. Yes. And so I think I view this as more of like 
a suite of packages. When we look at kind of the data that is 
out there on how to make sure that we appropriately use ER 
care, some of the things that come up is, if you have readily 
access to primary care. So there are initiatives that are going 
on at VA today that are working more on providing increased 
access to same-day primary care.
    Urgent care, which is something that we propose in the plan 
as another option if you have, you know, the sniffles, you need 
a shot, you can go to urgent care as in the ER.
    I think the nurse hotline that was suggested by the VSO 
partners is another tool that many health plans including 
TRICARE use.
    All of those things are tools in the toolbox. I don't think 
they are meant to replace one or the other. They are actually 
supposed to be kind of supplemental, so at the end of the day 
we make sure that folks are using the right setting.
    In the future, as we kind of build this high-performing 
network, one of the other things that we really hope to do is 
focus on what is called super-utilizers and this came up a 
little bit earlier, those folks that are constantly going to 
the ER. There is a reason why they are doing that. Sometimes 
they don't have the right case management or they need other 
support, or need to be connected with certain services. And 
robust health plans and high-functioning organizations are able 
to identify who those folks are and provide services that they 
need.
    So I think at the end of the day copayments, as I said, is 
just one tool that we hope to use to make sure that folks 
access care in the right setting.
    Ms. Brownley. Well, it just sounds to me that we have--you 
have mentioned a couple of tools in the toolbox and so it seems 
to me that we should try to utilize those tools first before we 
use a more punitive tool of a $100 copay, but I am sure we will 
be talking more about that as time moves forward.
    So you had mentioned appointments and community care have 
grown over the last couple of years and you talked about 12 
million appointments within the community care. So what does 
that compare to, what is the amount of appointments that the VA 
has provided over the same period of time? Is this a ten-
percent number of overall appointments?
    Dr. Yehia. Yeah, I actually don't have that number off the 
top of my head, but I can take it for the record.
    Ms. Brownley. And in terms of the 30-day wait and the 40-
mile driving distance rule, is the VA trying to look at other 
approaches on that? Have you decided for cost purposes that 
this has to be a hard-and-fast rule?
    And I think we are trying to drill down on what the costs 
are. I mean, Dr. Wenstrup talked about, you know, and cited 
examples where it might be a lot cheaper in the community to 
receive services.
    So if you could address some of that, please.
    Dr. Yehia. Sure.
    So I think an important point to keep in mind is we are 
kind of considering this as an entire health care system, so 
the VA and community care and I view them as two sides of the 
same coin.
    The criteria that are set that relate to access, wait time 
and availability of service are really meant to serve as the 
floor. So we heard a lot of comments about clinical criteria. 
Embedded into each of those, as I tried to highlight in my 
opening statement, are decisions that the doctor and the 
patient together in the office can make. But the challenge with 
just keeping something very local is we won't be able to 
explain to our veterans, can I access community care? The 
answer would be, well, you have to talk to your doctor. And I 
don't think that is good enough.
    I think what we wanted to do is to provide at least some 
clarity and transparency and those are based on when you can't 
see a primary care doctor or they live far away from you, 40 
miles driving distance, then you have the choice to access 
care. There might be criteria above and beyond that, that we 
described a little bit in terms of unusual and excessive burden 
that in the office people can use to decide, but at least they 
know at minimum that they can access to community care if they 
hit that standard. The same thing goes with wait time and the 
same thing goes with availability of service.
    So I think the concept here is to make sure there is a 
level of transparency to what people's benefit is. If it is 
completely left up to be in the office, then I think we are 
left a little bit of where we are today, and before Choice, 
where people don't really know what are the criteria that they 
have to access community care.
    Ms. Brownley. I have exceeded my time. I yield back.
    Mr. Benishek. Dr. Wenstrup, you are recognized.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    Doctor, I appreciate your approach to this and I think you 
are trying to find the best practices and you are keeping the 
veteran and the patient in mind as much as anything else, and 
to have that continuity of care.
    And I will go back and I am speaking from my personal 
experience as a practitioner and from those that I know are 
still out there every day that want to take care of veterans in 
their private practice or some that give one day a week to go 
to the VA. Their frustration at the VA is, you know, I spent 
all day and I operated on two people, if they had been part of 
my system here, I could have operated on eight veterans today 
and with the same results.
    So I think you get that and understand where we are going. 
And I think you are headed in the direction where you see that 
the VA has to make those types of changes too, and try to get 
it to be more of a balanced type of system and not so 
drastically different from one another.
    Can you comment on any efforts in that direction?
    Dr. Yehia. Yeah, I really appreciate that.
    I think when we started kind of this work and part of the 
reason how we built this high-performing network is really 
putting at the center our partners, especially like DoD, our 
Federal partners and academics, because I practiced both at the 
VA and across the street in an academic facility and I have 
experienced similar things. And so the concept here is how do 
we make sure that we are good partners for our community 
providers. There was a number of comments earlier about that. I 
think the more consistent we can be and similar in areas to the 
private sector the better.
    I think there was a few comments about the different 
paperwork that our community providers have to fill out to 
partner with us, for that paperwork burden to be exactly the 
same as it takes for them to sign up with a United or a Humana 
or someone else.
    So I think our intention and our goal in the plan is to 
move as much as possible to what the industry does so that we 
don't put any excess burdens on community providers and for 
that matter our employees to operate differently.
    The thing that gives me a little bit of pause is, once we 
start getting off on these one-offs and things like that, we 
create complexity and we lose that. And so that is something 
that we are trying to push forward as being respectful of the 
differences, but at the same time really pushing towards that 
industry standard.
    Mr. Wenstrup. And to that point, one of the complaints that 
I hear is, well, I am seeing patients now but, you know, I am 
waiting forever for pay.
    Dr. Yehia. Yes.
    Mr. Wenstrup. Whether it is hospital systems or private 
practice and that is very frustrating. And there is people that 
do this all the time and maybe they should be doing it and not 
within the walls of the VA, taking care of those claims, it 
might be more efficient and better. I don't know if you have 
any comments on that.
    Dr. Yehia. I do have comments on that. And I am looking 
forward to the next hearing that discusses specifically prompt 
paying claims, because I am on the phone all the time with 
health systems that are frustrated with Choice. I think, you 
know, in the short amount of time that we have to stand up this 
program ourselves and our contracting partners, I think have 
done a good job, but we are not where we need to be.
    I think your comment about claims, it actually just so 
happens that today we released our first draft statement of 
work for what will be a new contract to support kind of this 
high-performing network and we are seeking input from industry 
on that. Part of that statement of work includes processing 
claims.
    And so I am happy to share that with you, I shared it with 
the Committee Members--or Committee staff earlier this morning, 
but I think you might be interested in looking at some of 
those.
    Mr. Wenstrup. No, I appreciate it. And I think that the 
more that you approach those difficulties, if you will, the 
more you will see excellent providers in the community taking 
care of veterans and they want to anyway, and I think that that 
will be a win-win for everybody. So thank you.
    I yield back.
    Mr. Benishek. Thanks.
    Mr. Takano, you are recognized.
    Mr. Takano. Yes. Thank you, Mr. Chairman.
    Dr. Yehia, as you streamline the eligibility requirements 
for the various care in the community pathways, what impact do 
you think it will have on the number of veterans who get their 
care in the community? Do you have any idea of how many more 
veterans will be seen through this new Veterans Choice Program?
    Dr. Yehia. So I will start and I will ask Kristin to jump 
in.
    We have been seeing more and more unique veterans using 
community care over the last couple years. The numbers that I 
just received recently were in the last fiscal year, we had 
about a million and a half veterans, unique veterans that at 
some point accessed community care. That is about a third of 
our veteran population is receiving some of their care outside 
of VA's walls. And that really gets to this whole concept of 
this integrated health care system that is both internal VA 
care and kind of community care.
    We think that as we improve the program, including 
streamlining eligibility, making sure that it is clear we have 
a good network that includes the best performers in the private 
sector that more people will use it. And when we articulate the 
costs of the program, we think that increased demand will come 
as the product is better, which will also increase the costs in 
some ways.
    So I think that the--I don't have like a crystal ball of 
the exact number, but I think--
    Mr. Takano. Of course not.
    Dr. Yehia [continued]. --the idea is, as we make it better 
and simpler and easier to use, more people will use it.
    Mr. Takano. Well, you kind of alluded to what I wanted to 
get to know is, do you have a ballpark projection of the 
overall estimated costs of the program to be, you know, as you 
kind of rough out this number, aside from the 1.5 billion for 
emergency treatment? It is going to be helpful for us to kind 
of know this.
    Dr. Yehia. Yes, and I can't agree more.
    So in our plan that we submitted, there is a section 
specifically on costs. We think that increased demand will be 
in the order of about $2 billion annually for the program. That 
includes a lot of the kind of eligibility criteria that 
Congress helped us out with over the course of the last year as 
we kind of continued to iterate and improve the program, kind 
of removing the enrollment date, some things about changing 
from a primary care provider to a primary care physician. So 
there has been a number of different things that have been 
passed over the last couple months that expand eligibility.
    But roughly speaking, I think with the eligibility criteria 
that we are proposing in the plan, it would be about $2 billion 
on top of the Care in the Community budget.
    Mr. Takano. On top of the, what was it we approved, like 
ten--
    Dr. Yehia. Yes, about--
    Mr. Takano [continued]. --$12 billion? And we thought we 
would have it used up by now, but we have seen a number of 
impediments to actually spending down that money and we thought 
we would have to be appropriating more.
    How many different appropriation accounts affects non-VA 
care would you say? I mean, my question is really, you know, 
how many different accounts do we have to sort of deal with for 
just this non-VA care space?
    Dr. Yehia. So I don't know the exact number. I know we have 
more than one and that has been a challenge that a lot of our 
field folks tell me.
    Part of what we are proposing and one of our legislative 
proposals is to get that one funding stream. We did have some 
flexibility at the end of the last fiscal year, so thank you 
for that. That allowed us to kind of access the Choice fund to 
pay for community care. I think it will be very important to 
have kind of one pot of money, one funding stream for community 
care, so that our clinicians and our medical centers know 
exactly how much they have to spend in this area.
    This has been a challenge because right now we go through 
Choice and if something doesn't work, we use another pot of 
money and it creates unnecessary redundancy. And so getting to 
that one funding stream I think will be important.
    Mr. Takano. You might have already covered this, I was just 
sort of jumping between Committee meetings here, but how much 
will extending emergency care to veterans cost? Did you already 
mention that in your testimony?
    Dr. Yehia. I did not, but it is in the report. It is on the 
order of about 1.5 to $2 billion, that's both ER care and 
urgent care.
    Mr. Takano. I am going to ask you this sort of offline, but 
I am real curious about drug treatment for veterans, whether it 
includes rehabilitation, just to what extent we have case 
management. I just want to understand that better in terms of 
our vets that are coming back with PTS and then some that are 
having some real substance abuse challenges. So I will follow-
up with the Department later.
    But, Mr. Chairman, my time is up. Thank you.
    Mr. Benishek. Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Dr. Yehia, thank you for your testimony and for all of your 
efforts to transform the VA and improve access, quality of care 
and outcomes for veterans.
    Earlier in the day, I was at a conference that Under 
Secretary Shulkin organized around preventing veteran suicide, 
which I would argue should be the priority here. And the word 
priority means something, right? If you prioritize something, 
it puts that at the top of the list.
    So I understand that there are 12 priorities, breakthrough 
priorities that the secretary outlined. I know there are a lot 
of moving parts and there are a lot of things to improve and to 
work on. But what strikes me is that if we really think that we 
have a crisis in veteran suicide and access to mental health 
today and it really requires urgency in resources, rethinking 
how we deliver that care and provide access to it, then we 
should really be organized around that. As you know and just 
for the benefit of the Committee and others who might not, in 
El Paso, which had the worst mental health access rates in the 
country and still struggles, I think we are third-from-worst 
today, which is an improvement, we essentially adopted a plan 
as a community with the VA and with your help to prioritize 
access to mental health care and to try to prevent veteran 
suicide. And the idea is that as important as it is to see a 
podiatrist to get your foot fixed or an endocrinologist if you 
have diabetes or a dentist to get your teeth fixed, preventing 
veteran suicide is more important than all of those. And 
ensuring that if you go to the VA, it is a--I know this is a 
term of art, but it is a center of excellence for PTSD, TBI, 
those unique conditions associated with combat and service.
    And you, the VA, has helped by piloting a navigator concept 
or care coordinator who helps if you have one of these service-
connected conditions you are seen in the VA by hopefully a 
world-class provider. If not, we are going to prioritize your 
care that is comparable to what a civilian would experience to 
the private sector. We have got great partnerships with Texas 
Tech, which is providing five psychiatrists so that we can 
expand capacity for care in the VA.
    And yet we just looked at the numbers, you have 116 or 
Congress has authorized 116 mental health provider positions 
within the El Paso VA and right now we are at 91 filled, which 
leaves us 25 short, and I would argue that 116 is probably too 
little to meet the demand that you have in El Paso.
    So what do we have to do? We have adopted the plan, we have 
got additional resources. If we are maximizing capacity in the 
community and implementing this transformation plan that you 
and the secretary have introduced and touted and which I am a 
big fan of, why aren't we seeing better results in terms of 
meeting what I think is the single greatest crisis facing 
veterans in this country, which is 22 veterans a day taking 
their own lives? If that is truly a priority, why are we not 
beating all the bushes, taking over the airwaves to recruit 
those mental health providers to communities like El Paso and 
others who are historically under-served, where I know for a 
fact because I talked to the surviving family members that 
veterans are killing themselves because they don't have access 
to mental health care?
    Why can't we hire those 25 positions? What is the holdup?
    Dr. Yehia. So I can't agree more with your sentiment and as 
you know many of the elements in the plan that you had for El 
Paso, there is a lot of that in the plan that we presented for 
the entire VA. I think the part of the challenge is, as to 
quote Secretary McDonald, you know, the VA is the canary in the 
coal mine. I think we have to get out there and do more 
recruiting.
    I have been on a number of trips with the secretary 
speaking at grand rounds in various hospitals across the 
country trying to recruit doctors, specifically mental health 
professionals and nurses to the VA. I have done it by myself as 
well, and I think we need to do that.
    I think we have an opportunity as we start to kind of 
change the message a little bit about where VA is going, but we 
will get--
    Mr. O'Rourke. Let me interrupt you just because--
    Dr. Yehia. Sure.
    Mr. O'Rourke [continued]. --of very little time. My fault 
for taking too much time at the outset, but with the Chairman's 
indulgence. Could the VA instruct the director in El Paso don't 
hire any more podiatrists or endocrinologists, you have got 
them in the community, you can refer them, that is a condition 
comparable to what the civilian population has, PTSD is very 
unique to veterans, only hire your traumatic brain experts, 
your PTSD experts, your psychologists and psychiatrists?
    I recognize your canary-in-a-coal-mine analogy that 
medicine in America is struggling with this and yet there is a 
way to resolve this with the current capacity, I know there is. 
I know there are psychiatrists and psychologists working in 
private practice who could be brought over to the VA with the 
right inducements, focus and leadership. Are we going to see 
that this year?
    Dr. Yehia. Well, I know that, as you know, Gail Graham who 
is working in El Paso at the Medical Center there, I think she 
is pulling out all the stops to try to recruit as many of those 
professionals as possible.
    I don't think the idea that like as you mentioned there is 
approved FTE slots for those, so I don't think that a 
podiatrist is standing in the way of a psychiatrist coming in 
the door in El Paso.
    Mr. O'Rourke. I am talking about a single-minded, almost 
exclusive focus on getting that up. It doesn't mean that other 
things are unimportant, all these conditions are important, I 
would just say this is the most important preventable way that 
veterans are dying that--
    Dr. Yehia. I think that is something that we have to kind 
of--we should chat a little bit more about that. I think there 
may be some different tools that we can use.
    Mr. O'Rourke. Okay. Thank you.
    Thank you, Mr. Chairman.
    Mr. Benishek. Ms. Kuster, you are recognized.
    Ms. Kuster. Thank you very much, Mr. Chairman. And good 
morning, great to be with you.
    I had a quick local question just off the bat and we have 
talked about this in the past, but New Hampshire, Alaska and 
Hawaii are the three states without a full-service VA hospital 
and we had a special agreement under the previous rule to drop 
the 40-mile requirement down to 20 miles. I am just wondering, 
the last time we talked that was under review and I wondered if 
that process has proceeded since November.
    Dr. Yehia. Thank you. We have continued to engage with 
various stakeholders as you mentioned, Alaska, Hawaii and New 
Hampshire. I have had calls with the field leadership in all of 
those different states to try to get a good understanding of 
what their specific needs are. This is a tough issue and I am 
looking for kind of suggestions and ideas here as well, because 
on one side we want to make sure that we streamline the 
program, create something that is easy to understand and 
administer and I think the more nuanced or one-offs that we do, 
the more complexity that is built in.
    So I want to be respectful of the local circumstances 
there, but at the same time, I am also keeping my mind on how 
can we make sure that there is some uniformity so that every 
state is not treated differently.
    So with all that said, I think some of the criteria that we 
have articulated in the plan really do provide good access to 
care for New Hampshire specifically. And one of the things that 
I think a lot of people sometimes gloss over, the availability 
of service is such a key component, because if that service is 
not offered at those centers it is automatically folks have the 
choice in the community. So even with the current criteria, I 
think that the folks specifically in New Hampshire will be well 
served.
    Ms. Kuster. And I think one way to do that is the expansion 
of the CBOCs, Community Based Outpatient Care. We just opened a 
beautiful new CBOC in Littleton, New Hampshire. But just for 
you to take back, I am still waiting for progress on two 
others, one in a town called Colebrook, New Hampshire, almost 
to the Canadian border, and another in a town that we call 
Berlin, New Hampshire. And they have to do with negotiations 
that are going on with community-based care and partnerships, 
which are a good thing, but I would love to get a little 
shoulder to the wheel here from headquarters in D.C. to move 
those along.
    I also wanted to just talk about how we are very frustrated 
by the third-party administrator and I know that is not the 
purpose of this hearing, but I want to put that complaint out 
there. Senator Shaheen, Senator Ayotte and I, have done a 
series of events around the state talking directly with 
veterans. This is our primary, the phone calls that we get in 
the office. It is just very very frustrating. And I know that 
the VA physicians and staff, medical professionals would prefer 
to be making the appointments anyway because they would prefer 
to have that relationship with the community provider, get the 
records back, be able to call the patient and say don't forget 
your appointment tomorrow.
    So are we making any progress on that? Because frankly, I 
would rather just take that back and this third-party 
administrator is not working out for my constituents.
    Dr. Yehia. Yeah, I appreciate that. I think I have a call 
with some of those Senators later this week. And I will say 
this, that our partners are our partners. We modified a 
contract at the very beginning to implement Choice in a short 
amount of time. That contract, that PC3 contract was not 
designed to run the Choice program, it just wasn't designed to 
do that.
    With that said, as I was mentioning a little bit earlier, 
today we released the statement of work. It is a draft 
statement of work, so it is the first step in a contracting 
process. I think you would be happy to note that in that 
contracting process or that statement of work the scheduling 
piece would reside at the VA and not with a contractor.
    So we are making progress. I think it is going to take some 
time for us to get there, but I have heard from the Medical 
Centers, I have heard from veterans, and I think that is the 
direction we want to move. So slowly we continue to provide 
oversight and work with our TPAs to improve their performance, 
but in the end when we are drafting the right kind of car to 
drive this program those things would be residing on the VA 
side, not on the contractor side.
    Ms. Kuster. That is good news and I apologize for missing 
that earlier, I was over in AG talking about veteran farmers. 
So thank you very much for your testimony.
    Mr. Benishek. Thanks, Ms. Kuster. And I reiterate or echo 
your feelings about this third-party administration thing and I 
realize that there was an urgency in getting the Choice 
started. I am going to ask a couple quick questions here too.
    Do you know when the Choice fund is going to be depleted 
this year?
    Dr. Yehia. To do a little bit of math, we started with the 
$10 billion. Last year we spent, in the last fiscal year about 
3.5 billion, this year we are anticipating about two billion, 
and then the remainder will be the year after.
    I want to caveat that just a little bit. Over the last 
three months we have seen kind of a dramatic increase in Choice 
use, almost double the three months prior. A lot of that has to 
do with more proactive outreach to veterans. So rather than 
kind of the onus on them picking up the phone and calling, we 
are doing the calling and saying, would you like to partake in 
Choice, is this something that you want? And we have seen a 
dramatic up-tick.
    So that is a little bit of the projections. I think we 
still haven't reached kind of steady state--
    Mr. Benishek. Okay.
    Dr. Yehia [continued]. --but we will get there.
    Mr. Benishek. Is the $2.1 billion estimate per year above 
current non-VA care costs expected to be the yearly program 
estimate going forward?
    Dr. Yehia. Is that outlined in the plan?
    Mr. Benishek. Well, I mean, you estimated me $2 billion 
more, is that the estimate for yearly--
    Dr. Yehia. Yeah, we estimated the costs for the first three 
years. As you know, it is a little hard to try to predict past 
that, but in those first couple years, it would be $2 billion 
on top of the normal community care budget.
    Mr. Benishek. So does the 2017-2018 budget request reflect 
the numbers that we have been talking about here? Isn't that 
coming out shortly?
    Dr. Yehia. I don't think that is--let me take that back.
    Mr. Benishek. All right. Any other questions?
    Thank you very much for your being here today, and you can 
look forward to some further questions from us as we go forward 
here. You are now excused.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    And without objection, that is ordered.
    The hearing is now adjourned. Thanks.

    [Whereupon, at 11:52 a.m., the Subcommittee was adjourned.]

                          A P P E N D I X

                              ----------                              

                Prepared Statement of Adrian M. Atizado
    Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to submit 
this statement for the record of today's hearing. As you know, DAV is a 
Congressionally chartered national veterans organization of 1.3 million 
wartime veterans, all of whom were injured or made ill due to military 
service.
    Your invitation letter indicated the focus of today's hearing is to 
examine plans of the Department of Veterans Affairs (VA) with regard to 
eligibility for non-VA care under the proposed New Veterans Choice 
Program (VCP), as mandated in Public Law 114-41, and to assess whether 
they are sufficient to increase access to care among veteran patients. 
We appreciate the opportunity to share our views and recommendations in 
this regard.
    When it comes to our nation keeping its promises, perhaps none are 
as important as the promise to care for injuries and illnesses suffered 
by the men and women who served. VA's capacity to meet its needs is 
limited by its annual appropriations allocated to VA by Congress. Thus, 
VA's health care mission involves, among other things, keeping 
expenditures under a resource ceiling. The inherent limitation 
impacting veterans' access to care is what type of service they may 
need, where it is available and the availability of resources to 
purchase the care in the community.
    Indeed, the findings of a presidential task force reported in 2003 
and the Independent Assessment report issued by MITRE Corp., Rand Corp. 
and others last September confirm what DAV and our Independent Budget 
(IB) partners (Paralyzed Veterans of America and Veterans of Foreign 
Wars) have said for more than a decade: the resources provided to VA 
health care have been inadequate to meet the mission to care for 
veterans. In fact, we have repeatedly testified to Congress about this 
``mismatch'' and ``misalignment'' of resources and demand.
    To be clear, DAV does not believe that simply increasing funding by 
itself-without making some significant reforms to the underlying VA 
health care system-will lead to better health outcomes for veterans 
over the next 20 years. However, no VA reform plan has any chance of 
success unless sufficient resources are consistently provided to meet 
the true need and demand for services by veterans, when and where they 
need them.
    Our members have unfortunately experienced the adverse consequences 
of this mismatch first-hand when VA policy for purchasing certain care 
is inconsistent, unclear, and/or comes without commensurate resources. 
Funding uncertainty compels some facilities to develop local policies, 
procedures, or dicta which generally limit veterans' access to 
community care paid for by VA.
    Unless tensions between resources, demand and authorities are 
addressed with a clear understanding of the circumstances in which care 
is purchased in the community, and how this policy fits into VA's 
broader health care mission, the probability is quite high that even 
the best intended policies and procedures will continue to undermine 
the veterans' perception and experience of the coordination, quality 
and value of health services provided or paid for by VA.
    In reviewing the eligibility for non-VA care under Choice 
consolidation, as mandated in Public Law 114-41, and whether they are 
sufficient to increase access to care among veteran patients, we 
believe it offers the potential for expanding and improving access to 
care. According to VA, its entire plan will increase access to non-VA 
care and ``require additional annual resources between $1.5 and $2.5 
billion in the first year and are likely to increase thereafter.''
    The eligibility for non-VA care under Choice consolidation is laid 
out in four parts: hospital care and medical services; emergency and 
urgent care; and outpatient medication and durable medical equipment. 
DAV's statement will review each of these parts including grievances, 
disputes, and appeals, and provide our views and recommendations where 
warranted.

Hospital Care and Medical Services:

    VA's plan: ``The eligibility criteria for Hospital Care and Medical 
Services, including Dentistry services, in the community will continue 
to be focused broadly on wait-times for care, geographic access/
distance, and availability of services. The criteria will be 
streamlined into a single set of rules applied across the VA health 
care system.''

Geographic and temporal eligibility criteria

    The plan proposes to continue the existing geographic and temporal 
eligibility criteria of the Veterans Choice program as authorized by 
the Veterans Access, Choice, and Accountability Act of 2014. We note 
the choice program criteria remains underdevelopment having been 
amended from its original form, and veterans today remain frustrated by 
the current criteria not being sensitive to their medical care needs 
and preferences.
    We believe VA's proposed geographic and temporal criteria for 
community care eligibility in the New Veterans Choice Program (NVCP), 
while simple in concept-are arbitrary. It continues to administratively 
separate NVCP from the VA health care system, does not foster full 
integration, and limits performance to the detriment of veteran 
patients.
    Under this separated construct, because DAV was founded on the 
principle that this nation's first duty to veterans is the 
rehabilitation and welfare of its wartime disabled, because VA's 
capacity to provide for ``the rehabilitation and welfare of its wartime 
disabled'' is limited by its annual appropriations allocated to VA by 
Congress, and because of the natural tension between demand, resources, 
and authorities, we recommend consideration that the eligibility to use 
the NVCP should mirror the eligibility for VA health care, giving the 
highest priority to service-connected veterans.
    Notably, the independent assessment on access standards conducted 
by the Institute of Medicine (IOM) determined that industry best 
practices focus on clinical need and the interaction between clinicians 
and their patients. We could not agree more.
    For veteran patients, waiting for a health service begins when the 
veteran and the appropriate clinician agree to a service, and when the 
veteran is ready and available to receive it. Thus, DAV, along with the 
co-authors of the IB, believes it is time to move towards a health care 
delivery system that keeps clinical decisions about when and where to 
receive care between a veteran and his or her doctor - without 
bureaucrats, regulations or legislation getting in the way.
    From the veteran patient's perspective, the decision-making process 
can be more than a clinical decision-and it can often be a complicated 
one. Many veterans who use the VA health care system present complex 
health and social challenges requiring more than simple coordination of 
care, often including coordination of supports and other services. A 
decision on where, when and with whom to obtain care may need to 
involve the veteran's social support network such as caregivers, family 
members and friends to address factors and limitations such as the time 
required to complete a visit, procedure, or treatment plan, 
availability of appropriate transportation when needed, and various 
financial considerations.
    This is why DAV, as part of the IB, proposed creating local 
Veteran-Centered Integrated Health Care Networks to seamlessly 
integrate community care into the VA system and to provide a full 
continuum of care through such networks. The future VA health care 
system with an integrated NVCP should be responsive to the decision 
made between veterans and their providers. Veterans should be able to 
choose among the options within VA and the NVCP network and schedule 
appointments that are most convenient for them.

Availability of service eligibility criteria

    In addition to geographic and temporal criteria, VA's plan also 
proposes an eligibility criterion for hospital care and medical 
services, including dentistry services, in the community that focused 
on ``availability of service.'' Specifically, when a VA facility cannot 
directly provide a particular service or when a VA facility determines 
there is a compelling reason a veteran needs to receive care from a 
community provider, then outside care would be authorized.
    We believe the ``compelling reason'' criterion may inappropriately 
limit access to community care through NVCP. We have received reports 
about treatments, procedures or tests available in the private sector, 
which the veteran's VA health care team has determined ``is not 
necessary.'' These complaints are more pronounced when a veteran's non-
VA provider recommends a service that is neither cosmetic nor 
experimental, but which VA has determined ``is not necessary.''
    Veterans-centric care means including veterans participation in 
their care. This means providing veterans options, whether that be a 
second option or describing all the different treatments that are 
endorsed by clinical literature and even though the veteran's doctor 
may favor one over another, the final decision ultimately stops-or 
should stop-with the patient. When these options are not presented 
particularly for preference-sensitive conditions and treatment options, 
disagreements between the veteran and their provider can and does 
occur.

Grievances, Disputes, and Appeals

    We agree with VA's plan that ``[T]o ensure VA meets the unique 
needs of Veterans.the process also will include clear appeal and 
grievance mechanisms for Veterans to dispute eligibility 
determinations.'' We also support VA's plan for ``[a] formal, timely 
appeals process will provide Veterans a clear point of contact for 
concerns about the status of their authorization.'' When authorization 
questions arise, there is a clear path for appeals through the call 
center.
    Congress and VA should consider an appeal mechanism that covers all 
decision and determination points, not just eligibility determinations 
for the NVCP. To this end, DAV stands committed to working with VA in 
developing mechanism(s) designed to address grievances, disputes, and 
appeals.
    As part of the IB, we envision the Veterans Experience Office 
playing a role in this regard. VA Secretary McDonald has made improving 
veterans experience a main pillar of the MyVA transformation. To ensure 
VA leaders are aware of the issues veterans face when they obtain their 
earned benefits and health care, the MyVA taskforce has established the 
Veterans Experience Office, with a Chief Veterans Experience Officer 
who reports directly to the Office of the Secretary. VA plans to have 
veterans experience officers throughout the country who collect and 
disseminate best practices for improving customer service, coordinate 
community outreach efforts, and serve as subject matter experts on the 
benefits and services VA provides to veterans.
    The Veterans Experience Office should be strengthened by combining 
its capabilities with the patient advocate program. Veterans experience 
officers would advocate for the needs of individual veterans who 
encounter problems obtaining VA benefits and services. They would also 
be responsible for ensuring the health care protections afforded under 
title 38, United States Code, a veteran's right to seek redress through 
clinical and administrative appeals, claims under section 1151 of title 
38, United States Code, the Federal Tort Claims Act, and the right to 
free representation by accredited veterans service organizations are 
fully applied and complied with by all providers who participate in 
Veteran-Centered Integrated Health Care Networks, both in the public 
and private sector.

The Plan for Emergency and Urgent Care:

    VA's plan: ``Eligibility criteria will increase access to these 
services and simplify access rules to prevent the denial of claims for 
the appropriate use of these services.''
    During our engagements with VA in the development of its plan, DAV 
specifically urged the inclusion of urgent care into VA's medical 
benefits package and to better integrate emergency care with the 
overall health care delivery system.
    VA's plan also indicates it will focus on a more consistent 
application of the ``prudent layperson'' definition of emergency 
treatment across claims to reduce the administrative burden on VA to 
conduct a nuanced review of each emergency treatment claim.
    Presumably, the more consistent application of the prudent 
layperson standard will rely in part on ``Develop[ing] business rules 
to trigger audit of emergency treatment and urgent care claims to 
identify potential overuse or fraud, waste, and abuse of these 
services.''
    VA believes its plan will ``encourage Veterans to use these 
services appropriately and not as a substitute for primary care.by 
requiring cost-sharing for emergency treatment'' unless the veteran is 
admitted to an inpatient status, or if it [causes] an undue financial 
burden to the veteran. In addition, it will ``limit cases where 
Veterans are held responsible for a bill for emergency treatment or 
urgent care because they did not fully understand the criteria for VA 
coverage.''
    We applaud VA for including in its plan expanded access to, and 
simplification of the eligibility requirements for, emergency and 
urgent care coverage.

Prudent Layperson

    DAV has received a resolution from our membership regarding urgent 
and emergency care as they pertain to the VA health care system. 
Specifically, our members believe urgent and emergency care should be 
integral to VA's medical benefits package.
    Our resolution regarding emergency care also urges the VA to 
provide for a more liberal interpretation of its policy governing 
reimbursement to veterans who have received emergency care at non-VA 
facilities. VA readily admits that ``[M]any of these denials are the 
result of inconsistent application of the ``prudent layperson'' 
standard from claim to claim and confusion among Veterans about when 
they are eligible to receive emergency treatment through community 
care.''
    We recommend VA's plan use a national prudent layperson emergency 
care standard that provides coverage based on a patient's presenting 
symptoms and relative urgency of need, rather than the final diagnosis, 
VA's current standard.

24-Month Requirement

    The VA plan proposes the eligibility for reimbursement of costs 
associated with emergency treatment be limited to those enrolled in VA 
health care and who are active VA health care patients (i.e., sought 
care from VA within the past 24 months).
    As opposed to VA, DAV believes the 24-month requirement does not 
``incentiviz[e] appropriate health behaviors,'' as claimed in VA's 
plan. DAV has testified on a number of occasions in support of 
legislation to eliminate the current law provision that requires 
enrolled veterans to have received care from VA within the 24-month 
period prior to date of the emergency care, as a precursor to 
reimbursement.
    Absent a change in law, veterans who are fortunate enough to not 
need VA or VA-authorized care at least once every 24 months would need 
to make an unnecessary VA medical appointment in order to remain 
eligible for emergency and urgent care reimbursement under the NVCP. 
DAV continues to recommend to Congress that this artificial limitation 
on use of emergency care be lifted.

Copayment

    DAV has received a resolution from our membership calling for the 
elimination or reduction of VA health care out-of-pocket costs for 
service-connected disabled veterans.
    Premiums, health care cost sharing, and deductibles are a feature 
of health care systems in which some costs are shared by the insured 
and the insurer in a contractual relationship between the patient, 
payer and provider. In DAV's view service-connected disabled veterans 
have already paid the price of any health care copayment or cost-
sharing scheme imposed the federal government.
    Notwithstanding the imposition of copayments to all veterans 
seeking emergency and urgent care, the plan fails to consider those 
instances where an emergency department or urgent care clinic would the 
most appropriate setting for the care veterans need.
    DAV recommends, in addition to those situations where copayments 
would be waived under the plan, including similar relief when an 
emergency department of urgent care clinic is the most appropriate 
setting.
    From the veteran patient's perspective, not all VA primary care 
clinics or teams are capable of providing fast, life-or-limb-saving 
care. Moreover, veterans need urgent care when VA primary care 
appointments are unavailable or treatment is needed outside of office 
hours. If the VA health care system and the integrated NVCP are 
unresponsive to these needs, the proposed co-payments should not apply.
    We appreciate VA's desire to incentivize appropriate health 
behavior; however, we insist VA provide positive rather than punitive 
incentives. As part of the IB, VA should consider establishing a 
national nurse advice line to help reduce overreliance on emergency 
room care. The Defense Health Agency (DHA) has reported that the 
TRICARE Nurse Advice Line has helped triage the care TRICARE 
beneficiaries receive. Beneficiaries who are uncertain if they are 
experiencing a medical emergency and would otherwise visit an emergency 
room, call the nurse advice line and are given clinical recommendations 
for the type of care they should receive. As a result, the number of 
beneficiaries who turn to an emergency room for their care is much 
lower than those who intended to use emergency room care before they 
called the nurse advice line. By consolidating the nurse advice lines 
and medical advice lines many VA medical facilities already operate, VA 
would be able to emulate DHA's success in reducing overreliance of 
emergency room care without having to increase cost-shares for 
veterans.

Define Emergency Condition

    Moreover, in the interest of parity in VA's legislative proposal to 
address its existing authorities to reimburse the cost of emergency 
treatment, we recommend ``emergency condition'' be defined. We urge 
serious consideration be given to reliance on the Emergency Medical 
Treatment and Labor Act (EMTALA), with a minor amendment to include 
behavioral conditions, so that the definition of an emergency condition 
for VA purposes would be ``a medical [or behavioral] condition 
manifesting itself by acute symptoms of sufficient severity (including 
severe pain) such that the absence of immediate medical attention could 
reasonably be expected to result in placing the individual's health [or 
the health of an unborn child] in serious jeopardy, serious impairment 
to bodily functions, or serious dysfunction of bodily organs. With 
respect to a pregnant woman who is having contractions that there is 
inadequate time to effect a safe transfer to another hospital before 
delivery, or that transfer may pose a threat to the health or safety of 
the woman or the unborn child.''

Outpatient Medication and Durable Medical Equipment; Extended Care 
    Services:

    VA's plan: ``Eligibility criteria will not be altered in this 
report, as any adjustment would constitute a fundamental change to the 
VA health benefit.''
    VA's plan is to leverage its rates for outpatient medical and 
durable medical equipment (DME) by requiring veterans to receive these 
services through VA facilities with limited exceptions, including 
urgent prescription medications, allowing veterans to pay out of pocket 
and seek reimbursement from VA.

Limitations of Plan and Approach

    We understand the scope of VA's plan being limited to those ``non-
Department provider programs'' prescribed by Congress in P.L. 114-41; 
however, we caution Congress and the Administration on this fragmented 
approach to provide timely access to care in the community, which may 
produce adverse consequences.
    VA's health care mission covers the continuum of care providing 
inpatient and outpatient services, including pharmacy, prosthetics, and 
mental health; gender-specific care, long-term care in both 
institutional and non-institutional settings. The limits of the plan is 
identified by some health care benefits such as dental care that carry 
additional statutory eligibility requirements, and extended care, which 
VA indicates is ``out of the scope of this effort to adjust the 
eligibility criteria.'' The VA plan for the NVCP also does not propose 
changes to the VA health benefit or to other eligibility requirements 
for care purchased through other authorities not contemplated in 
Section 4002 of PL 114-41.
    If Congress intends to increase veterans' access to care, including 
care in the community, it should recognize that by not addressing gaps 
and inconsistencies in VA's plan (all of VA's purchased care 
authorities-including cost controls through differing eligibility 
requirements and other stipulations), VA's medical benefits package, 
and the full range of health services available in the community, VA 
will assuredly continue certain fragmentation of care veterans 
experience today into the future. Veterans could be left unassisted 
across different providers and care settings, fostering frustrating and 
unsafe patient experiences, leading to medical errors, waste, and 
duplication that foster poor overall quality of care.
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to present this testimony. DAV will be pleased to respond 
to any questions on the topics discussed in this statement that need 
additional information or clarification.

                                 
                    Prepared Statement of Carl Blake
    Chairman Benishek, Ranking Member Brownley, and members of the 
Subcommittee, on behalf of Paralyzed Veterans of America (PVA), I would 
like to thank you for the opportunity to testify today. We appreciate 
the fact that the Subcommittee is addressing the very serious question 
of eligibility for health care services for veterans through the 
Department of Veterans Affairs (VA) community care plan. Let me say up 
front, that PVA generally thinks that the VA plan is a very good one. 
It clearly represents a model of how health care should be delivered. 
In fact, it mirrors in many ways the veterans' health care reform 
framework that PVA, along with our partners in The Independent Budget-
Disabled American Veterans and Veterans of Foreign Wars-have presented 
to the full Committee, as well as to Senate VA Committee, the 
Commission on Care and the VA itself.
    As eligibility dictates access to veterans health care, so too does 
the capacity of the systems providing that care. Over the years, the VA 
health care system has relied on a number of methods and standards to 
measure access and timeliness of health care delivery. Prior to the 
scandal that enveloped the VA health care system in the spring of 2014, 
the Department's wait-time goal was 14 days from a veterans preferred 
date for existing patients or 14 days from the date an appointment 
request was created for new patients. After the health care access 
crisis exposed that the 14-day goal was unattainable, VA reevaluated 
its standard and moved to 30 days from a veteran's preferred date. Less 
than a year later, VA changed its wait-time standard again to 
facilitate the implementation of the Veterans Choice Program. In an 
attempt to align its standards with industry best practices, VA elected 
to base its wait-time goal on clinical need first and rely on a 
veteran's preference when a clinically indicated date was not 
identified. There is no evidence to suggest that arbitrary wait-time 
standards are indicative of quality, rather they are bureaucratic tools 
to self-assess output performance. They are not a measure of quality 
care and to suggest otherwise is unfounded.
    Over the years, VA has also relied upon a number of geographic-
based access standards to determine eligibility. Through the Strategic 
Capital Investment Planning (SCIP) process, dating back to its fiscal 
year 2008 budget request, VA has used a 60-minute drive-time distance 
for veterans who live in urban areas and 90 minutes for veterans who 
live in rural areas as a standard for specialty care. In 2013, VA's 
long range SCIP process began to include a corporate target of 70 
percent of veterans having access to VA primary care within a 30-minute 
drive time in urban areas and 60 minutes in rural areas. Additional 
geographic-based standards have accompanied statutory programs, to 
include 40 miles from a primary care provider (as well as 30 days) for 
the Veterans Choice Program, or 60-minute drive time from primary care, 
120 minutes from acute care, and 240 minutes from tertiary care under 
Project ARCH. VA has also established geographic-based network 
standards for contracted programs. Under Project HERO, VA required 
Humana to provide access to required services within 50 miles of a 
veteran's home. Under PC3, HealthNet and TriWest are required to 
provide health care options within a 60 minute drive for veterans who 
live in urban areas, 120 minutes for veterans who live in rural areas, 
and 240 minutes for veterans who live in highly rural areas, when 
seeking general care. For veterans who need a higher level of care, the 
PC3 network must provide them with options within 120 minutes for urban 
areas, 240 minutes for rural areas, and an acceptable community 
standard for highly rural veterans. Geographic-based access standards 
are another means of narrowing the scope of how VA measures its 
performance and simplifies the budgeting projections. Geographic-based 
access standards are not derived from industry best practices for the 
provision of health care.
    The independent assessment on access standards conducted by the 
Institute of Medicine (IOM) determined that industry benchmarks for 
health care access vary widely throughout the private sector. IOM was 
unable to find national standards for access and wait-times similar to 
the Veterans Choice Program's 40-mile and 30-day standards. Instead of 
focusing on set mileage or days-based calculations, IOM found that 
industry best practices focus on clinical need and the interaction 
between clinicians and their patients. PVA, along with our partners in 
The Independent Budget, strongly agrees with the IOM's recommendation 
that ``decisions involving designing and leading access assessment and 
reform should be informed by the participation of patients and their 
families. \1\'' We believe that this concept will also best serve the 
needs of our members and all veterans.
---------------------------------------------------------------------------
    \1\ IOM (Institute of Medicine). 2015. Transforming Health Care 
Scheduling and Access: Getting to Now. Washington, DC: The National 
Academies Press
---------------------------------------------------------------------------
    The Independent Budget has reported for years that VA's access 
standards are not aligned with veterans' perceptions. Moreover, the IB 
firmly believes that federally regulated, arbitrary access standards, 
such as living 40 miles from a VA clinic or waiting up to 30 days for 
an appointment, should not inhibit a veteran's access to care. That is 
why we propose to move away from federally regulated access standards. 
Under the IB's framework, access to care would be a clinically based 
decision made between a veteran and his or her doctor or health care 
professional. Once the clinical parameters are determined, veterans 
would be able to choose among the options developed within the network 
and schedule appointments that are most convenient to them. Veterans 
not satisfied with clinical determinations or scheduling options would 
be able to seek a second clinical review of their health care needs.
    The irony of all these access standards is PVA members often travel 
farther than any of the other special populations of veterans served by 
VA, or even veterans in general seeking care from VA. It is not unusual 
for PVA members, and other veterans with spinal cord injury or disease 
(SCI/D), to travel hundreds of miles to reach one of the 25 spinal cord 
injury centers located around the country. They do this because the VA 
SCI system of care is far and away the best option they have to meet 
their specialized health care needs. The access problems these veterans 
face are usually not wait times or distance, but the cost of travel. As 
a result, veterans may wait to be seen until their condition 
deteriorates, requiring more costly and intensive care. Congress should 
expand travel benefits to non-service connected, disabled veterans, to 
ensure they are able to receive quality specialty care. This 
Subcommittee is reviewing the question of eligibility without even 
considering this important fact. PVA believes that the 30-day and 40-
mile eligibility standards that determine access under the new Veterans 
Choice Program (VCP) do not consider what is best for veterans with 
catastrophic disabilities, to include SCI/D. Moreover, arbitrary access 
standards will not increase eligibility or guarantee timely, quality 
care.
    PVA strongly believes that veterans have earned and deserve to 
receive high quality, comprehensive, accessible and veteran-centric 
care. In most instances, VA care is the best and preferred option, 
particularly for veterans with SCI/D and other specialized health care 
needs. However, we acknowledge that VA cannot provide all services to 
all veterans in all locations at all times. This became clear from the 
access crisis that came to the forefront in April 2014 and has 
continued to burden the VA as more and more veterans seek care from, 
and through, VA. Adequate resources should be devoted to building a 
comprehensive health care system within VA supported by a dynamic, 
integrated health care network that leverages private sector providers 
and other public health care systems to expand viable options. This is 
essentially the concept the VA has proposed in its community care 
consolidation plan and is mirrored by the framework the IB has 
presented as well.
    PVA supports the idea to move beyond arbitrary federal standards 
regulating veterans' access to care in the community. However, we are 
not convinced that the VA's plan goes quite far enough. We believe it 
is time to move towards a health care delivery system that keeps 
clinical decisions about when and where to receive care between a 
veteran and his or her doctor-without bureaucrats, regulations or 
legislation getting in the way.
    PVA, and our IB partners, also supports the plan to expand 
emergency treatment and urgent care in the community. However, we 
strongly oppose the proposal for an across the board $100 co-payment 
for emergency care and $50 for urgent care. This proposal seemingly 
makes no exception for veterans with service-connected disabilities or 
who are currently exempted from co-payments. These veterans should not 
be required to bear a cost-share as it may disincentive the veteran or 
their caregiver from accessing emergency treatment or urgent care. For 
many disabled veterans who are unable to work and living off their 
earned benefits, a trip to an urgent care clinic for $50 might be just 
enough of a burden that they delay being seen. We know this delay means 
an increased chance that something as seemingly benign as a small wound 
becomes a costly infection.
    As an alternative, VA should consider establishing a national nurse 
advice line to help reduce overreliance on emergency room care. The 
Defense Health Agency (DHA) has reported that the TRICARE Nurse Advice 
Line has helped triage the care TRICARE beneficiaries receive. Those 
who are uncertain if they are experiencing a medical emergency, and 
would otherwise visit an emergency room, call the nurse advice line and 
are given clinical recommendations for the type of care they should 
receive. Such an advice line must have available SCI trained providers, 
who are able to identify potential complications specific to an SCI 
veteran. As a result, the number of beneficiaries who turn to an 
emergency room for their care is much lower than those who intended to 
use emergency room care before they called the nurse advice line. By 
consolidating the nurse advice lines and medical advice lines many VA 
medical facilities already operate, VA would be able to emulate DHA's 
success in reducing overreliance of emergency room care without having 
to increase cost-shares for veterans.
    Additionally, PVA, as well as the IB, has raised serious concerns 
with the requirement that eligible veterans must be ``active health 
care participants in VA'' in order to access these benefits. The strict 
24-month requirement is extremely problematic for newly enrolled 
veterans, many of whom have not been afforded the opportunity to 
receive a VA appointment due to limited capacity, despite their timely, 
good faith efforts to make appointments following their separation from 
military service. This barrier has caused undue hardship on veterans 
who are undergoing the difficult transition from military service back 
to civilian life, and has resulted in veterans receiving unnecessarily 
large medical bills through no fault of their own. VA is aware of this 
problem and has requested the authority to make this exemption; 
however, the consolidation plan does not specifically address this 
needed change. Furthermore, this restriction could negatively impact 
healthier veterans who do not need as much health care as others and 
may go more than two years without accessing VA care. This requirement 
could encourage veterans to seek unnecessary services from VA in order 
to remain eligible for VA's emergency and urgent care services.
    Ultimately, a comprehensive health care network should not be 
designed to limit eligibility and exclude veterans seeking care. PVA 
has long argued that limiting eligibility to VA health care services 
undermines the intention of the Affordable Care Act (ACA). PVA played a 
key role in ensuring that VA health care was deemed acceptable coverage 
under the ACA. And yet, millions of veterans are still denied 
enrollment into the VA due to the prohibition on new Priority Group 8 
enrollments.VA should immediately lift the ban on Priority Group 8 
enrollments to make veterans who need health care eligible for these 
critical services. If VA will not make that decision, then Congress 
should pass legislation to do so.
    Mr. Chairman, I would like to thank you once again for the 
opportunity to testify. We encourage this Subcommittee, and all of 
Congress, to closely examine the VA's community care consolidation plan 
and provide the necessary resources and support to see this plan 
through to implementation. While there are issues that must still be 
worked out with this plan, this is a real step towards ensuring greater 
access to critical health care services for veterans. We would be happy 
to answer any questions that you might have.
Information Required by Rule XI 2(g)(4) of the House of Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
                            Fiscal Year 2016
    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events - Grant to support rehabilitation sports 
activities - $200,000.
                            Fiscal Year 2015
    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events - Grant to support rehabilitation sports 
activities - $425,000.
                            Fiscal Year 2014
    No federal grants or contracts received.
                     Disclosure of Foreign Payments
    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.

William Carl Blake
Associate Executive Director for Government Relations
Paralyzed Veterans of America
801 18th Street NW
Washington, D.C. 20006
(202) 416-7708

    Carl Blake is the Associate Executive Director for Government 
Relations for Paralyzed Veterans of America (PVA) at PVA's National 
Office in Washington, D.C. He is responsible for the planning, 
coordination, and implementation of PVA's National Legislative and 
Advocacy Program agendas with the United States Congress and federal 
departments and agencies. He develops and executes PVA's Washington 
agenda in areas of budget, appropriations, health care, and veterans' 
benefits issues, as well as disability civil rights. He also represents 
PVA to federal agencies including the Department of Defense, Department 
of Labor, Small Business Administration, the Department of 
Transportation, Department of Justice, and the Office of Personnel 
Management. He coordinates all activities with PVA's Association of 
Chapter Government Relations Directors as well with PVA's Executive 
Committee, Board of Directors, and senior leadership.
    Carl was raised in Woodford, Virginia. He attended the United 
States Military Academy at West Point, New York. He received a Bachelor 
of Science Degree from the Military Academy in May 1998.
    Upon graduation from the Military Academy, he was commissioned as a 
Second Lieutenant in the Infantry in the United States Army. He was 
assigned to the 2nd Battalion, 504th Parachute Infantry Regiment (1st 
Brigade) of the 82nd Airborne Division at Fort Bragg, North Carolina. 
He graduated from Infantry Officer Basic Course, U.S. Army Ranger 
School, U.S. Army Airborne School, and Air Assault School. His awards 
include the Army Commendation Medal, Expert Infantryman's Badge, and 
German Parachutist Badge. Carl retired from the military in October 
2000 due to injuries suffered during a parachute training exercise.
    Carl is a member of the Virginia-Mid-Atlantic chapter of the 
Paralyzed Veterans of America.
    Carl lives in Fredericksburg, Virginia with his wife Venus, son 
Jonathan and daughter Brooke.

                                 
                  Prepared Statement of Duane Williams
    Chairman Benishek, Ranking Member Brownley and distinguished 
Members of the Subcommittee:
    On behalf of the Iraq and Afghanistan Veterans of America (IAVA) 
and our 425,000 members and supporters, thank you for the opportunity 
to share our views with you at today's hearing: ``Choice Consolidation: 
Evaluating Eligibility Requirements for Care in the Community.''
    By way of introduction, I am retired from the U.S. Army having 
served 26 years on active duty and 6 additional years in the reserve 
component. Currently I serve as the Chairman of the Veterans Affairs 
Advisory Board of DeKalb County, Georgia, which is responsible for the 
county's veteran recognition, advocacy and research programs on behalf 
of its 41,000 veterans. I also serve IAVA as a Georgia Leadership 
Fellow, focusing on veteran leadership development, policy advocacy and 
team building. These experiences help me better understand the needs of 
veterans but also the challenges they face accessing quality care in a 
timely and efficient manner.
    IAVA is proud to have previously testified in front of this 
Subcommittee recommending the need for consolidation of care in the 
community for veterans enrolled in VA health care, and we applaud 
Congress for requiring VA to put forward a plan for consolidation. We 
also want to recognize senior leaders at VA for acknowledging the need 
for consolidation and providing an inclusive, veteran-centric and 
transparent plan.
    Last year, when the Surface Transportation and Veterans Health Care 
Choice Improvement Act of 2015 became law, it helped begin the process 
of removing a lot of confusion for veterans. However, according to 
IAVA's most recent Member Survey, only five percent of respondents had 
taken advantage of the Choice Program, and their reviews on 
satisfaction were mixed. For the 95 percent of IAVA members who had not 
used it, 43 percent reported not using it because of confusion as to 
how to use it. It's clear that simplification is needed.
    Confusion over the Choice Card is not the only barrier to accessing 
timely and quality care. In IAVA's member survey, nearly half of the 
respondents were not even familiar with the Choice Program.
    In my home of Atlanta, Georgia, the enrollment for health care at 
the Atlanta VA Medical Center (VAMC) is growing faster than the 
capability for primary care. According to VA population data, the 
number of veterans residing in the 28-county metropolitan Atlanta area 
in 2013 was 294,000. The 2014 VA population data reflects more than 
361,000 veterans living in that same area. To meet this increased use, 
in the past 18 months, the Atlanta VAMC has hired an additional 600 
employees.
    Related to this move, on January 20, 2016, Atlanta VAMC stated the 
current wait for VA initial primary care appointments was at 60 days, 
but after speaking to the VISN 7 VHA Director on January 26, she 
advised me she was able to help the Atlanta VAMC Director reduce the 
60-day wait time down to 20.6 days. If this number holds true, the 
reduction in wait time by nearly 40 days in the matter of 6 days, is 
remarkable. We hope other VA medical centers will follow suit, and we 
hope this Subcommittee will continue to monitor, analyze and ensure 
accuracy of wait time data, including at the Atlanta VAMC.
    As Congress hopefully moves forward to simplify a confusing process 
for veterans, IAVA highly recommends Congress work with VA and use its 
plan as the framework for legislation in order to avoid one-off 
proposals that are misinformed or put politics ahead of veterans. After 
all, it was Congress who provided the numerous different plans that 
added to the confusion and inefficiencies which resulted in the need to 
consolidate care. We believe Congress should be mindful of these 
lessons, learn from them and leverage the VA's plan as the framework 
for consolidation of care moving forward.
    Our second concern centers around VA's ability to effectively 
implement a plan to consolidate care across their enterprise in a way 
that avoids many of the mistakes made during the implementation of 
Choice and truly puts veterans at the center of every decision. While 
the VA Budget and Choice Improvement Act of 2015 extended provider 
eligibility to any health care provider meeting VA criteria, the VA 
must use this opportunity to streamline and standardize the 
requirements for medical documentation. Under the Choice Act of 2014, 
reimbursement rates for non-VA providers is limited to no more than the 
MEDICARE reimbursement rate, thus standardizing and reducing 
administrative requirements can remove a barrier to more providers 
joining the network.
    The VA intends for its health delivery model to be the patient-
centered medical home for the veterans under its care; therefore, the 
VA holds responsibility for direct coordination of services for each 
veteran. Care coordination is one of the core functions of primary 
care. A significant number of the VA's patient needs are complex, and 
as the complexity increases, the challenges in facilitating the 
delivery of the appropriate care increases. Factors that increase the 
complexity of care include: multiple chronic health problems, the 
social vulnerability of the patient, the number of providers and the 
patient's ability to coordinate their care. Due to the significant 
number of VA patients with anxiety disorders, dementia, depression and 
kidney failure, it is necessary for the VA to maintain significant 
control and accountability for the provision of veterans' care.
    To address these inconsistencies and shortcomings, IAVA recommends 
the VA continue to collaborate with all stakeholders who share their 
vision of putting the veteran first and focus on values-based 
leadership in an attempt to change the culture of VA across the 
country. Given the shortcomings related to training frontline personnel 
on the implementation of Choice and customer service generally, the VA 
should also continue its efforts with myVA and make sure all VA 
employees are trained properly and consistently on the VA plan to 
consolidate care.
    Finally, IAVA encourages everyone, Congress, VA, VSOs, industry and 
other stakeholders, to place an increased importance on the quality of 
care veterans are receiving, especially new providers who have not 
served veterans since their residency training. It is important under 
the medical home model of primary care that the VA continues to 
coordinate and be accountable for the care provided to veterans given 
the complexity of care required.
    In closing, IAVA would like to thank this Subcommittee for your 
leadership and continued commitment to our veterans. It is a privilege 
to testify in front of the Subcommittee today, and we reaffirm our 
commitment to working with Congress, VA and our VSO partners to ensure 
veterans have access to the highest quality care available, and our 
country fulfills its sacred obligation to care for those who have borne 
the battle. We do believe there is an opportunity to transform the VA 
for today's veterans if we all work together.
    Thank you, and I'd be happy to answer any questions you may have.

                               Biography

    As Leadership Fellow, Mr. Williams is a catalyst for veteran 
leadership development, policy advocacy and team building. He spent 26 
years in the Army, two years in the National Guard and four years in 
the Army Reserves. In his last combat assignment, he was responsible to 
the MNFI Surgeon and MNFI Commanding General for independent 
coordination with various government and non-governmental agencies to 
support health sector partnership programs with the Iraqi government. 
He is currently the Chairman of the Veterans Affairs Advisory Board of 
DeKalb County, Georgia, responsible for the county's veteran 
recognition, advocacy and research programs on behalf of the 41,000 
veterans in one of Georgia's largest counties. Mr. Williams holds 
advanced degrees in Religion and Public Policy.
            Statement on Receipt of Grants or Contract Funds
    Neither Mr. Williams, nor the organization he represents, Iraq and 
Afghanistan Veterans of America, has received federal grant or contract 
funds relevant to the subject matter of this testimony during the 
current or past two fiscal years.

                                 
                Prepared Statement of Baligh Yehia, M.D.
    Good morning, Chairman Benishek, Ranking Member Brownley, and 
Members of the Committee. Thank you for the opportunity to discuss the 
Department of Veterans Affairs' (VA) proposal to consolidate VA's 
community care programs to increase access to health care, specifically 
the portion of the proposal that would streamline eligibility criteria 
to reduce confusion and frustration among Veterans, community 
providers, and VA staff. I am accompanied today by Kristin Cunningham, 
Director, Business Policy in VHA's Chief Business Office.
    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 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 and community providers, as well as 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 its plan for the 
consolidation of all purchased care programs into one New Veterans 
Choice Program (New VCP). The New VCP will include some aspects of the 
current Veterans Choice Program established by section 101 of the 
Choice Act and incorporate additional elements designed to improve the 
delivery of community care.
    One aspect to the New VCP would be establishing clear eligibility 
requirements for community care. Currently, overlapping eligibility 
criteria for different methods of accessing community care creates 
confusion among Veterans, community providers, and VA staff. 
Eligibility to enroll in and access VA's health care system would not 
change with the New VCP. However, the New VCP would define a single set 
of eligibility requirements for the circumstances under which Veterans 
may choose to receive health benefits from community providers as well 
as expand and simplify access to emergency treatment and urgent care. 
This will enable timely and convenient access to care in alignment with 
best practices.

Background

    Current eligibility creates confusion due to multiple, overlapping 
criteria for each different method of purchasing care. The New VCP 
would reduce confusion by standardizing requirements across facilities 
regarding when a Veteran may choose to receive community care, while 
still providing local flexibility to respond to unique needs of 
Veterans (e.g., local services, geography, and unusual or excessive 
burden). The need for simplifying eligibility criteria directly 
addresses the recommendation to ``streamline programs for providing 
access to purchased care and use them strategically to maximize 
access'' outlined in the Independent Assessment Report \1\. The 
eligibility criteria will be grouped into the following categories:
---------------------------------------------------------------------------
    \1\ Independent Assessment Report Section B: Health Care 
Capabilities

    u  Hospital Care and Medical Services: Patient eligibility criteria 
for the New VCP will provide Veterans with timely and convenient access 
to care based on wait times, distance to a VA Primary Care Provider 
(PCP), or availability of services.
    u  Emergency Treatment and Urgent Care: Eligibility criteria will 
increase access to these services and simplify access rules to prevent 
the denial of claims for the appropriate use of these services.
    u  Outpatient medication and Durable Medical Equipment (DME): 
extended care services: Eligibility criteria will not be altered as any 
adjustment would constitute a fundamental change to the VA health 
benefit.

    VA compared the current eligibility criteria for purchasing 
community care to commercial health plans and Federal program 
approaches to develop the New VCP criteria. A number of findings from 
this review informed design of the patient eligibility criteria for the 
New VCP.

Eligibility for VA Health Benefit and Eligibility for Community Care

    Eligibility for community care is independent of eligibility to 
enroll in VA health benefits. A Veteran must be eligible for and 
enrolled in the VA health benefit before VA will evaluate the Veteran 
for eligibility for community care. Eligibility for enrollment in the 
VA health benefit is based on level of Service-Connected (SC) 
disability, other special authorities (e.g., awardees of the Medal of 
Honor and former Prisoners of War), and income. These characteristics 
determine a Veteran's enrollment priority group. Enrollment priority 
groups range from 1 to 8, with 1 being the highest priority. All 
enrolled Veterans enjoy access to VA's comprehensive medical benefits 
package; however, some benefits (e.g., dental care) have additional 
statutory eligibility requirements. After a Veteran is enrolled in VA 
health care, the eligibility criteria for VA's various methods for 
purchasing care in the community then can be applied to determine when 
a Veteran may receive his or her health benefits outside of a VA 
facility.

Unique Considerations for VA

    There are a number of factors that make VA unique compared to 
commercial health plans.

    u  Coverage - VA is required to provide coverage to Veterans in 
areas where VA does not have physical facilities or an established 
provider network. Commercial health plans generally do not offer 
products where they cannot meet coverage requirements.
    u  Other Health Insurance (OHI) - Approximately 78 percent of 
Veterans have OHI and only rely on VA for certain services (e.g., 
hearing aids and eyeglasses). Changing the services Veterans are 
eligible to receive in the community or what they pay for those 
services could affect Veteran's reliance on VA versus OHI, including 
TRICARE, Medicare, and Medicaid.
    u  Teaching and Research Missions - In addition to providing high-
quality care to men and women Veterans, VA has research and education 
missions critical to the VA system and the nation as a whole. In 2014, 
VA supported 2,224 medical and prosthetic research projects totaling 
$586 million in research investment \2\ and provided clinical training 
to 41,223 medical residents, 22,931 medical students, 311 Advanced 
Fellows, and 1,398 dental residents and dental students \3\. In 
addition, many Veterans value participation in VA training and research 
and consider them to be an important part of the VA care experience. 
Over time, decreasing utilization of VA facilities may jeopardize VA's 
ability to deliver on these missions.
---------------------------------------------------------------------------
    \2\ Source: Veterans Health Administration, Office of Research and 
Development
    \3\ Source: Veterans Health Administration, Office of Academic 
Affiliations

---------------------------------------------------------------------------
Current State

    VA has multiple sets of eligibility criteria for the various 
authorities and methods of purchasing community care. Several of these 
criteria overlap, creating confusion among Veterans, community 
providers, and VA staff and providers. Broadly, these criteria have 
focused on providing surge capacity and have been grouped into three 
categories:

    1.  Wait-Times for Care: VA was not able to provide the service 
within an acceptable time frame, based on medical need.
    2.  Geographic Access/Distance: A VA facility was not available 
within an acceptable travel distance of the Veteran's home.
    3.  Availability of Service: A facility in the local VA network 
either did not provide the required service or there was a compelling 
reason why the Veteran needed to receive care from a community 
provider.

    Additionally, eligibility varies by the category of care (hospital 
care and medical services; and emergency treatment):

Emergency Treatment

    Currently, a Veteran is eligible to receive emergency treatment 
through community care by authority of 38 United States Code (U.S.C.) 
Section 1703, 38 U.S.C. Section 1725, and 38 U.S.C. Section 1728. 
Eligibility for emergency treatment varies by authority.
    Since determination of these claims is nuanced, and unclear for 
Veterans, there are a large number of denied claims. When denied, the 
financial responsibility for these claims, which can be substantial, 
often falls on Veterans or their OHI, resulting in unanticipated 
financial challenges for Veterans. As an example, between the beginning 
of FY 2014 and August 2015, approximately:

    u  89,000 claims were denied because they did not meet the timely 
filing requirement.
    u  140,000 claims were denied because a VA facility was determined 
to have been available.
    u  320,000 claims were denied because the Veteran was determined to 
have OHI that should have paid for the care.
    u  98,000 claims were denied because the condition was determined 
not to be an emergency. \4\
---------------------------------------------------------------------------
    \4\ Source: VHA Chief Business Office, Office of Informatics

    In FY 2014, approximately 30 percent of the 2.9 million emergency 
treatment claims filed with VA were denied, amounting to $2.6 billion 
in billed charges that reverted to Veterans and their OHI. Many of 
these denials are the result of inconsistent application of the 
``prudent layperson'' standard from claim to claim and confusion among 
Veterans about when they are eligible to receive emergency treatment 
through community care. Additionally, VA is not authorized to reimburse 
Veterans for urgent care, which is typically lower cost than emergency 
---------------------------------------------------------------------------
treatment, and encourages health care in the appropriate setting.

Future State

    The objective of the New VCP is to create a set of criteria that 
are simple and intuitive for Veterans, community providers, and VA 
staff. This will be accomplished by eliminating the multiple 
overlapping criteria for accessing Hospital Care and Medical Services, 
including Dentistry, in the community. The single, nationally defined 
set of eligibility criteria for the New VCP can be consistently 
implemented while providing VA facilities the flexibility to respond to 
unique circumstances, such as excessive burden in traveling to a VA 
facility or the medically-indicated need to see a provider in a 
timeline shorter than the VA wait-time standard for a service. In 
addition, the New VCP includes simple criteria for accessing Emergency 
Treatment and Urgent Care. This should increase access and reduce 
denied claims while incentivizing appropriate use of these services.
    Eligibility criteria for each category of care are as follows.

Hospital Care and Medical Services

    The eligibility criteria for Hospital Care and Medical Services, 
including Dentistry services, in the community will continue to be 
focused broadly on wait-times for care, geographic access/distance, and 
availability of services. The criteria will be streamlined into a 
single set of rules applied across the VA health care system. To ensure 
VA meets the unique needs of Veterans, VA will have flexibility at the 
local level through clarified guidance on exceptions. The process also 
will include clear appeal and grievance mechanisms for Veterans to 
dispute eligibility determinations.
    When Veterans are determined to be eligible for community care, VA 
will provide them with information on providers and appointment 
availability at VA and in the community. This will allow Veterans to 
choose a convenient appointment from the provider of their choice. The 
primary change in this proposed vision is to focus eligibility for 
geographic access/distance on access to a PCP. PCPs play a critical 
role in coordinating care and providing preventative care, so 
convenient access is necessary. Veterans eligible for the New VCP under 
either of the geographic access/distance criteria will have the option 
to choose a community PCP. The community PCP could then refer the 
Veteran to specialty care in the community or at VA as appropriate and 
authorized by VA. This approach is consistent with best practices, 
which emphasize providing access to a PCP.

Emergency Treatment and Urgent Care

    As part of the New VCP, VA had proposed an update to emergency 
treatment and urgent care in the community authorities, as one option 
to attempt to simplify Veterans' experiences in seeking care. VA 
estimated that the expanded emergency treatment and urgent care 
proposal could cost over $1.5 billion, independent of other aspects of 
the New VCP.

Conclusion

    As VA continues to refine its health care delivery model, we look 
forward to providing more detail on how to convert the principles 
outlined in VA's plan into an executable, fiscally-sustainable future 
state. In addition, VA plans to review feedback and potentially 
incorporate recommendations from the Commission on Care and other 
stakeholders including Veterans, community providers, VA staff, and 
industry leaders. VA will work with Congress and the Administration to 
refine the approach described in the 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.
    Delivering the New VCP will not be successful without approval of 
recommended legislative changes and recommended budget. Expanded Access 
to Emergency Treatment and Urgent Care is important in providing 
Veterans with appropriate access to these services, but is severable 
from other aspects of the program and could be implemented separately. 
VA is willing to work with Congress to address the cumbersome emergency 
treatments authorities which have a negative impact on Veterans both 
reducing access to critical services and increased financial liability.
    Transformation of VA's community care program will address gaps in 
Veterans' access to health care in a simple, streamlined, and effective 
manner. This transformation will require a systems approach, taking 
into account the interdependent nature of external and internal factors 
involved in VA's health care system. MyVA will guide overall 
improvements to VA's culture, processes, and capabilities and the New 
VCP will serve as a central component of this transformation. VA looks 
forward to a successful implementation of the New VCP and partnering 
with Congress to support requested legislative authorities and 
additional resources. This transformation will position VA to improve 
access to care, expand and strengthen relationships with community 
providers, operate more efficiently, and improve the overall Veteran's 
experience.
    Thank you. We look forward to your questions.

                                 
                       Statements For The Record

                MILITARY OFFICERS ASSOCIATION OF AMERICA
    CHAIRMAN Benishek, RANKING MEMBER Brownley, and Members of the 
Subcommittee, on behalf of the more than 390,000 members of the 
Military Officers Association of America (MOAA), I am grateful for the 
opportunity to present MOAA's views on the Department of Veterans 
Affairs (VA) eligibility requirements as outlined in its proposed Plan 
for Consolidating Community Care.
    MOAA does not receive any grants or contracts from the federal 
government.
    MOAA is grateful for the Subcommittee's steadfast commitment and 
exceptional support to our nation's veterans and their families. 
Notably, the passage of the two key bills, the Veterans Access, Choice 
and Accountability Act of 2014 (VACAA P.L. 113-146, or the Choice Act) 
and the Title IV of the Surface Transportation and Veterans Health Care 
Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act), 
as well as additional funding to address shortfalls in several Veterans 
Affairs Health Administration (VHA) accounts. These bills and funding 
are foundational steps to reforming VA to better serve our veterans and 
their families.
    The Secretary of VA, Bob McDonald, and his leadership team have 
also committed significant resources and attention to not only fixing 
current access problems, but are also moving swiftly to implement 
reform through a major effort called MyVA. We applaud the Secretary's 
vision and determination to get MyVA implemented and institutionalized 
as much as possible before leaving office.
                           EXECUTIVE SUMMARY
    The guiding question before the Subcommittee today is, ``Will the 
eligibility requirements outlined in the Department of Veterans 
Affairs' (VA) plan to Consolidate Community Care Programs be sufficient 
to increase access to care among veteran patients?''
    The Military Officers Association of America (MOAA) appreciates the 
opportunity to explore the question with the Subcommittee and to share 
our thoughts on the Secretary's proposed New Veterans Choice Program 
(VCP) Plan, congressionally mandated in Title IV, Surface 
Transportation and Veterans Health Care Choice Improvement Act of 2015.
    Generally, MOAA supports the plan to consolidate VA's multiple and 
disparate purchased care programs into one New VCP. We believe it has 
the potential to improve and expand veterans' access to health care. 
Much depends, however, on the Department's success in working with its 
employees, Congress, the VA Commission on Care, veterans and military 
service organizations (VSOs/MSOs), and other stakeholders as the agency 
moves forward in developing and implementing the plan.
    MOAA commends VA Secretary Bob McDonald for his MyVA vision and 
tenacious leadership as he leads the largest and most complex 
integrated health system in America in a new direction, seeking to 
transform the Department into a veteran-centric organization by 
``modernizing VA's culture, processes, and capabilities in order to 
meet the needs, expectations, and interests of Veterans and their 
families first.'' We are also pleased to see the New VCP aligns with 
the Secretary's MyVA transformation efforts.
    VA established a strong communications channel and process to 
engage stakeholders. This unprecedented collaborative process included 
frequent and ongoing dialog and feedback which continues today as VA 
moves forward in further developing and implementing the plan. Such 
effort indicates VA's sincere commitment to putting veterans and 
families first and is at the center of its plans for consolidating 
community care.
    While MOAA is very encouraged by the Secretary's transformation 
efforts, we respectfully urge Congress, the Commission on Care and the 
VA to:

      Adopt The Independent Budget's (IB) recent concept paper, 
a Framework for Veterans Health Care, incorporating the Disabled 
American Veterans (DAV), Paralyzed Veterans of America (PVA) and the 
Veterans of Foreign Wars (VFW) recommendations for transforming the VHA 
into a more robust system of health care for veterans.
      Eliminate the current arbitrary federal access standards 
(based on wait times, distance to a VA facility, or availability of 
services) and consider establishing a new clinically-based standard for 
both in-house and community care, where decision-making involves the 
veteran (including family/caregivers) and physician or medical 
professional in the process (per the IB VSOs) to provide a less 
complicated standard for accessing care.
      Support VA's plan for expanding access to emergency 
treatment and urgent care services, but oppose the copay requirement 
for veterans accessing such care, particularly those with service-
connected conditions.
      Direct resources and funding at modernizing the VA human 
resources system and requiring VA to implement a workforce management 
and succession planning strategy for attracting, training, retaining, 
and sustaining high quality personnel.

    The ultimate test of any successful reform is whether VA is able to 
deliver the things veterans and their families value most-high quality, 
accessible, comprehensive, and culturally competent medical care and 
services that will meet their unique needs and circumstances.
                               BACKGROUND
    The MyVA initiative was launched soon after Secretary McDonald's 
confirmation and the passage of the Choice Act. MyVA is an enterprise-
wide transformation initiative. According to the Secretary, the 
initiative will modernize VA's culture, processes, and capabilities to 
put the needs, expectations, and interests of Veterans and their 
families first.
    Issues related to access to medical care have long plagued the 
system. After news broke of secret waiting lists at the Phoenix, 
Arizona VA medical hospital in the early 2014, MOAA wrote a letter to 
the President and leaders of the House and Senate Veterans Affairs 
Committees to say bureaucratic red tape and gross inefficiencies were 
preventing veterans from accessing care and required immediate 
attention.
    MOAA urged the President to establish an independent, high-level 
commission to examine the VHA to better understand the challenges that 
lie ahead so the VA is prepared to meet the long-term needs of millions 
of veterans who have served our nation. Lawmakers heard our message and 
passed the Veterans Choice Act on August 7, 2014, which included 
establishing a VA Commission on Care.
    The Commission was established on August 7, 2015 to examine the 
access of veterans to health care from VA and how best to organize VHA, 
locate health care resources, and deliver health care to veterans over 
the next 20 years. It is expected to submit its findings and 
recommendations to the VA and Congress early this year.
    The Choice Act also directed an independent study to look at the 
delivery systems and management processes of VHA in order to provide a 
holistic view of the system and its relationship within the VA. The 
Independent Assessment was completed on September 1, 2015.
    Within three months of the passage of the Choice Act, VA 
implemented the Choice Program on November 5, 2014. The program allows 
eligible veterans to receive health care in their local communities 
from private or non-VA providers. But VA struggled from the beginning 
to transition to the Choice Program. Accessing the program was 
problematic and eligibility requirements were confusing and frustrating 
not only to veterans, but also to VA employees and providers trying to 
implement the program. As a result, veterans continued to experience 
long wait times for care.
    At the urging of MOAA and several partners in The Military 
Coalition, VA expanded the Choice Program rules on December 1, 2015. VA 
changed the eligibility rules to measure distance from a veteran's home 
of record to the closest VA facility using the more reasonable driving 
distance criteria rather than the former straight-line method. The 
change increased patient eligibility so more veterans could get care at 
private hospitals and clinics closer to home, more than doubling the 
number of veterans eligible for the program.
    Even with the change and more individuals eligible for the program, 
veterans continued complaining about having trouble accessing medical 
care through the Choice Program.
    On July 31, 2015, Congress took bold action by passing the VA 
Budget and Choice Improvement Act to address lingering Choice Program 
problems and to fix a major budget crisis that had been brewing in VA 
because of increased demand from veterans for health care services.
    The law provided for important modifications and enhancements to 
the Choice Program, such as:

      Eliminating the prior enrollment date requirement of 
August 1, 2014 for veterans to have been enrolled in the VA health care 
system, allowing all veterans enrolled in VA health care to be 
eligible;
      Allowing the agency to waive the 30-day wait time for 
veterans needing care;
      Increasing the number of providers in the program; and,
      Changing the distance requirement, allowing veterans 
seeking primary care who live within 40 miles of a VA medical facility, 
including a community-based outpatient clinic that does not have a 
full-time physician to use Choice for that care.

    Additionally, the bill also provided some significant reforms to 
improve health service delivery and access in the future, including 
directing the Secretary to submit a plan to Congress by November 1, 
2015, on how it will consolidate all non-VA care programs under one, 
the Choice Program.
    VA submitted its Plan to Consolidate Community Care Programs 
October 30, 2015. The plan proposes consolidation of all seven 
purchased care programs into one New Veterans Choice Program called the 
New VCP.
                  CURRENT STATUS OF THE CHOICE PROGRAM
    Despite frustrations with the Choice Program implementation, most 
agree there has been significant progress in improving access in a 
relatively short period of time. Though access to care is improving, VA 
continues to experience multiple systemic issues across the agency, 
impacting current mission as well as its ability to modernize to meet 
the growing demand and changing veteran population.
    In fact, the 2015 Independent Assessment Report required by the 
VACAA cited four systemic findings that impact VHA's ability to execute 
its mission (Page xii):

      A disconnect in alignment of demand, resources and 
authority.
      Uneven bureaucratic operations and processes.
      Non-integrated variations in clinical and business data 
tools.
      Leaders are not fully empowered due to a lack of clear 
authority, priorities and goals.

    Although the veteran population is expected to decline over the 
next decade, a unique mixture of demographic factors is leading to 
increased demand for VA services and is expected to continue for the 
foreseeable future.
    Aging Vietnam veterans are using more services at increased costs. 
Successful marketing of the Choice Program to increase awareness has 
led veterans to seek care who may previously have decided not to use 
the VA. The conclusion of conflicts in Iraq and Afghanistan is bringing 
in a new generation of Post-9/11 veterans to the system. A growing 
number of women veterans, now 10 percent of the military, are seeking 
VA treatment at higher rates than their male counterparts.
    Aging infrastructure; antiquated financial, human resource, and 
technology systems; and budget shortfalls further limit VA's ability to 
make much-needed change and improvements on its own.
    Today's VA health system is more complex and access requirements 
more complicated than ever, even after decades of reform efforts and 
enhancements like the Choice Program. Veterans must contend with a 
multiplicity of access points, eligibility criteria and gatekeepers in 
trying to access health care and services. The experiences of veterans 
using VA health care vary widely across the country. The 
inconsistencies and complexities across the health system erode the 
trust and confidence veterans have in their system, particularly when 
they are told that new programs like Choice will help them get the care 
they need sooner, rather than later.
    MOAA members reflect some of the mixed experiences and feelings 
veterans have with VA health care, including accessing the Choice 
Program. Some of their comments include:

      90 Year Old Male WWII Veteran-``I've always had a great 
experience with my audiology care and responsive service at the VAMC in 
Phoenix, Arizona.''
      70+ Year Old Female Vietnam Veteran-``I did not intend to 
use the Choice Program. I have always been satisfied with the 
responsive on- and off-site services offered at the Sheridan, Wyoming 
VAMC. However, I was advised that I ``have no choice'' with the 
inaccurately named VETERANS CHOICE PROGRAM. I must acquiesce in the new 
procedures for off-site services or pay for those services myself.The 
vets on the bottom of this avalanche of bureaucratic insanity are worse 
off than ever in their access to timely healthcare.''
      40+ Year Old Male OIF/OEF Veteran-``Thank goodness the 
VAMC in Los Angeles, California stepped in and helped me get my 
benefits and medical care I desperately needed.'' This wounded warrior 
was forced out of the military with no assistance in helping him with 
his transition. He ended up being rated 100% unemployable, and the VAMC 
helped him get immediate medical care and services, giving him and his 
family the longer term security they needed.
      32 Year Old Male OEF Veteran-``I'll never go back to the 
Washington, DC VAMC again.'' This veteran was in a very unstable 
condition when coming to MOAA for help. He was suffering with chronic 
pain and post-traumatic stress from combat and had been sexually 
assaulted post-deployment before leaving active duty. The system was 
unresponsive in helping him move up his appointment to see his primary 
care provider, directing him instead to seek care in the emergency room 
if he thought he needed immediate mental health attention-the ER would 
then send him to the clinic to see a behavioral health provider.

    Implementing the Choice Program has brought to light many of the 
systemic issues mentioned earlier and with it the perfect opportunity 
to consider a new vision for VA health care that might otherwise have 
been missed.
    VA has certainly embraced the opportunity for a new vision for 
reform in its New VCP concept. The plan is a step in the right 
direction to simplify community care and integrate the entire system to 
enhance the veterans' experience and health outcomes.
               THE NEW VETERANS CHOICE PROGRAM (NEW VCP)
    The Secretary and his staff deserve great credit for the work 
undertaken to coordinate and produce the New VCP, particularly given 
the tight time constraints for producing the end product. The proposed 
plan to consolidate community care provides a good foundation for 
Congress, the Commission on Care, the VA, and other stakeholders to 
consider in the process of deliberating the future of VHA.
    MOAA, like many of our VSO and MSO colleagues working with VA to 
develop the New VCP concept, believes the plan offers the potential for 
expanding and improving access to care, particularly for veterans in 
need of emergency services and urgent care. Regardless of what the 
system of care in the future will look like, the nation has a 
responsibility to ensure veterans have access to the care, benefits and 
services they have earned, deserve and value.
    The key elements of a health system veterans and their families/
caregivers value most include high quality, accessible, comprehensive, 
and veteran-centric care-a system that is simple, easy to understand 
and navigate, and is seamless whether the care is delivered in-house or 
in the community.
    VA's intent in its plan for consolidating community care program is 
to have ``clear eligibility criteria, streamline referral and 
authorization processes, make customer support available when needed, 
and eliminate ambiguity around eligibility and personal financial 
obligations for care.''
    VA states the New VCP criteria will also be flexible enough to 
respond to the unique needs of veterans and eligibility requirements. 
This will be evaluated over time depending on health care innovations 
and changes to the veteran population.
    However, VA's plan for hospital and medical services continues to 
base eligibility on wait times, geographic access to care and 
availability of services. That is, the same confusing and 
inconsistently applied eligibility criteria used in the current Choice 
Program.
    VA does propose expanding eligibility for emergency treatment and 
urgent care services. MOAA is very supportive of the expansion but 
opposed to requiring veterans to pay a cost share to access these 
services. VA's plan would require copays of $100 for emergency 
treatment and $50 for urgent care services for veterans with or without 
a service-connected condition. We believe this is a major departure 
from current eligibility requirements and will negatively impact 
veterans and their families. Such a requirement presents yet another 
set of criteria for VA to manage and another impediment to veterans 
accessing care.
    The new VCP is an ambitious plan. Any significant reform of VHA 
will require strong, sustained leadership at all levels of the 
Department. Ten of the top 16 VHA executives are new since the 
Secretary took office, and VA is facing some of the most troubling 
human resource challenges of its time in recruiting, training, 
retaining, and developing a viable workforce for the future.
    Clearly, VA must reform. What remains to be seen is whether VA will 
have the strong, consistent leadership, vision and commitment at all 
levels of the organization necessary to drive the real, cultural and 
transformative changes needed across the entire VA Health 
Administration (VHA)-one that remains focused on veterans and is agile 
enough in adapting to the changing veteran population and advances in 
American medicine.
    At its January 2016 VA Commission on Care meeting, Dr. Kenneth 
Kizer, the former Under Secretary of Health Administration from 1994-
1999, told commissioners the issues facing VA today aren't much 
different from earlier times when he led the last major reformation.
    When commissioners asked him what needs to be done to fix VA, Kizer 
said, ``These are all fixable issues with the right leadership and 
commitment.'' He went on to say, ``VA's biggest challenge is 
leadership-the culture is driven by the right leadership in the right 
places at all levels, including Congress.''
    Multiple ideas and solutions to reform VHA have come forward in 
recent months, providing a unique opportunity to take a fresh look at 
health care.
    One such idea MOAA believes should be seriously considered is the 
Independent Budget's (IB) VSO concept. The IB's Framework for Veterans 
Health Care approach builds upon VA's progress in transforming VHA, but 
goes beyond the legislative, regulatory and bureaucratic constraints 
confining the system today.
    For example, the IB recommends moving away from arbitrary federal 
access standards to a clinically-based decision made between a veteran 
(to include family/caregivers) and their physician or health care 
professional, offering great potential for simplifying eligibility 
requirements and expanding access across the system, beyond just 
community care.
    The IB framework starts with the idea of what a veterans' health 
care system should look like, rather than what VHA should look like. 
MOAA believes this is an important distinction for the Commission on 
Care to consider when making its recommendations to Congress.
                          MOAA RECOMMENDATIONS
    While MOAA is very encouraged by the Secretary's transformation 
efforts, we urge Congress, the Commission on Care and the VA to:

      Adopt the Independent Budget's (IB) Framework for 
Veterans Health Care approach by incorporating the concept 
recommendations in any plans for transforming the VHA.
      Eliminate the current arbitrary federal access standards 
and establish a new clinically-based standard for both in-house and 
community care, to include veterans (and family/caregivers) and their 
physician or medical professional in the decision-making process to 
yield a less complicated standard for accessing care.
      Support VA's plan for expanding access to emergency 
treatment and urgent care services, but oppose the copay requirement 
for veterans accessing such care, particularly those with service-
connected conditions.
      Direct resources and funding at modernizing the VA human 
resources system, requiring VA to implement a workforce management and 
succession planning strategy for attracting, training, retaining, and 
sustaining high quality personnel.
                               CONCLUSION
    MOAA is grateful to the Members of the Subcommittee for your 
leadership in supporting our veterans, their families and caregivers.
    We look forward to working with Congress, the Commission on Care 
and the VA as we seek to reform VHA into a world-class system that puts 
veterans and their families/caregivers at the center of their health 
care.

Biography of Rene Campos, CDR, USN (Ret.)
Deputy Director, Government Relations

    Commander Rene Campos rejoined the MOAA staff in February 2015 as 
the Deputy Director, Government Relations, managing matters related to 
military and veterans' health care, wounded, ill and injured, and 
caregivers. She previously helped establish a military family program 
at MOAA, working on defense and military quality of life programs and 
policy issues. In September 2007, she joined the MOAA health care team, 
specializing in Departments of Defense and Veterans Affairs health care 
systems, as well as advocating for seamless transition programs and 
women in the military issues.
    She began her 30-year career as a photographer's mate, enlisting in 
1973 and was later commissioned a naval officer in 1982. Her last 
assignment was at the Pentagon as the Associate Director, Office of 
Family Policy in the Office of the Deputy Under Secretary of Defense 
for Military Personnel and Family Policy.
    Commander Campos serves as a member of The Military Coalition (TMC) 
- a consortium of nationally prominent uniformed services and veterans' 
organizations, representing approximately 5.5 million current and 
former members of the seven uniformed services, including their 
families and survivors, serving on the Health Care; Morale, Welfare & 
Recreation and Military Construction, and Base Realignment & Closure; 
Veterans; and Personnel, Compensation and Commissary Committees.

                                 
             VETERANS OF FOREIGN WARS OF THE UNITED STATES
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and our Auxiliary, thank you for the 
opportunity to offer our thoughts on the Department of Veterans 
Affairs' (VA) plan to consolidate its community care programs.
    The VFW strongly believes that veterans have earned and deserve 
timely access to high quality, comprehensive, and veteran-centered 
health care. For the past year, Congress and VA have devoted time and 
resources to determining when such care should be delivered at VA 
medical facilities and when veterans should be afforded the opportunity 
to receive care through private sector health care providers. To the 
VFW the answer is simple: when a veteran and his or her doctor 
determine it is clinically necessary, the highest quality and the most 
accessible option.
    Since the access crisis erupted in the spring of 2014, the VFW has 
taken a proactive approach to evaluating the state of the VA health 
care system. Through our work we have collected direct feedback from 
tens of thousands of veterans regarding their experiences receiving 
health care. What we have learned is that veterans turn to VA despite 
80 percent of them having other health care options because they like 
the quality of care they receive, they believe VA health care is an 
earned benefit, and VA is best suited to care for their service-
connected injuries and illnesses. While VA is the preferred option for 
eligible veterans, it is not always the most convenient one. That is 
why the VFW strongly believes that community health care providers must 
be integrated into the VA health care system to expand access to 
timely, high quality, comprehensive and veteran-centric health care to 
the veterans who rely on VA for their health care needs.
    The VFW supports many aspects of VA's plan to consolidate its 
community care programs. Specifically, the VFW strongly supports VA's 
plan that would move away from federally mandated wait-time standards 
and enable veterans and their doctors to determine how long they are 
clinically able to wait for their health care. We agree with VA that 
the amount of time veterans wait for care should not be confined by 
statute. The number of days a veteran is able to wait for care must be 
a determination based on his or her medical conditions and symptoms. 
For example, a veteran who is likely to have heart complications and is 
experiencing chest pain cannot wait 30 days to be seen by a 
cardiologist, which is the current practice, regardless if it is at a 
VA medical facility or private sector hospital. However, a veteran who 
requires a routine medical examination may be able to wait longer than 
30 days.
    Furthermore, allowing access to be defined by a patient and his or 
her doctor would align VA access standards with industry best 
practices. In a recent Institute of Medicine (IOM) study on access 
standards, IOM recommended that ``decisions involving designing and 
leading access assessment and reform should be informed by the 
participation of patients and their families.''
    IOM's study also recommends that VA ``continuously assess and 
adjust the match between the demand for services and the organizational 
tools, personnel, and overall capacity available to meet the demand.'' 
That is why the VFW supports VA's intent to create high performing 
networks based on the availability and capabilities of each health care 
market. Doing so would ensure VA is able to identify private sector 
providers who are ready and able to deliver timely, high-quality, 
comprehensive and veteran-centric health care and empower those 
providers to care for America's veterans.
    However, the VFW does not agree with VA's plan to continue to use 
the arbitrary 40-mile standard to determine when veterans are afforded 
the opportunity to access the private sector providers within its high 
performing networks. Instead of using distance to determine when 
veterans are able to leave VA, distance should be used to determine 
when VA must expand health care options to ensure all veterans are 
afforded the opportunity to receive veteran-centric and coordinated 
care when they need it and where it is most appropriate.
    That is why the VFW strongly believes that private sector health 
care providers who participate in VA's high performing networks must be 
integrated into the VA health care system and considered an extension 
of VA health care. Meaning, a veteran must receive equal or greater 
quality of care through a high performing network private sector 
provider than a veteran would receive from a VA medical facility. To 
the VFW, this includes the ability to seamlessly schedule and navigate 
from a VA medical facility to a private sector provider and vice versa.
    For example, a veteran who has a private sector primary care 
provider must be able to schedule a specialty care appointment at a VA 
medical facility and have all related medical records from that visit 
transmitted to the veteran's provider to ensure the veteran's care is 
integrated as it would be if he or she were receiving all his or her 
care at a VA medical facility. Conversely, a veteran who receives his 
or her primary care at a VA medical facility must have a seamless 
experience when receiving specialty care through a network provider.
    That is why the VFW believes that once a veteran and his or her 
doctor determines clinically based limits on a veteran's ability to 
travel, that veteran must be allowed to pick from options available 
within the local high performing network, including all public and 
private sector options.
    To properly size high performing networks to each community, the 
VFW recommends establishing metrics to identify clinical access gaps 
based on veteran population density and distance to care and services 
available within high performing networks, including VA and community 
providers. Such access gap metrics would serve to identify areas where 
the veterans' health care system must expand capacity through 
agreements with community health care providers, sharing facilities 
with private or public health care entities, or building capacity.
    We do not have to look far for an example of how distance is used 
to expand capacity instead of determining when veterans are able to 
consider non-VA options. Instead of requiring every veteran who lives 
within 75 miles of a national cemetery to be interred in that cemetery, 
the National Cemetery Administration's (NCA) goal is for 96 percent of 
all veterans to have interment options within 75 miles of their home. 
This includes viable burial options at cemeteries that have been built, 
expanded, or improved through NCA cemetery grants.
    When the demand exists, NCA proposes the construction of a new 
national cemetery. However, NCA also uses agreements and grants with 
states, United States territories and federally recognized tribal 
organizations to establish, expand, or improve veterans' cemeteries in 
areas where NCA has no plans to build or maintain a national cemetery. 
Cemeteries assisted by an NCA grant are required to be exclusively 
reserved for veterans and eligible family members and maintained by the 
same standards as an NCA managed national cemetery - meaning that 
veterans interred in NCA assisted state, territorial, or tribal 
cemeteries are afforded the same honors as those interred in a national 
cemetery.
    The VFW also supports VA's plan to expand access to urgent care at 
VA medical facilities and through private and public urgent care 
clinics across the country to fill the gap between emergency room care 
and outpatient care. We also support VA's plan to loosen its definition 
of an emergency to expand access to private sector emergency room care. 
However, the VFW strongly opposes any recommendation to bill veterans 
for service-connected care. Any cost share associated with emergent or 
urgent care eligibility must be aligned with VA's current copayment 
structure, which exempts veterans who do not have the financial means 
to pay cost shares and veterans who receive cost-free care due to 
service-connected disabilities.
    To curb overreliance of emergency room and urgent care, the VFW 
recommends that VA establish a national nurse advice line that would 
help veterans determine the appropriate level of care needed to address 
their medical concerns. The Defense Health Agency (DHA) has reported 
that the TRICARE Nurse Advice Line has helped triage the care TRICARE 
beneficiaries receive. As a result, the number of beneficiaries who 
have turned to an emergency room for their care is much lower than 
those who intended to use emergency room care before calling the nurse 
advice line. VA could leverage its existing pool of nurse and medical 
advice lines to establish a national advice line to emulate DHA's 
success or partner with DHA to expand the TRICARE Nurse Advice Line to 
veterans.
    As this Subcommittee continues to evaluate VA's plan to consolidate 
its community care programs, the VFW will continue to ensure the voice, 
preference, and health care needs of veterans are prioritized and 
ensure VA health care reforms serve the best interest of our Nation's 
veterans.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any federal grants in Fiscal Year 2016, nor has it 
received any federal grants in the two previous Fiscal Years.
    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

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