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25–017 2017

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 

( 

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

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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(III) 

C O N T E N T S 

Tuesday, 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 

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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 

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2 

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 highquality, 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 impleLeonard.horne on VACREP0180 with DISTILLER

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mented 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 

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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. 

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5 

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 

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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-serviceconnected, 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]

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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 

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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. 

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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. 

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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. 

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11 

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. 

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12 

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 proLeonard.horne on VACREP0180 with DISTILLER

13 

viders 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. 

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14 

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 clinicallybased 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 

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15 

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 

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16 

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 

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17 

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. 

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18 

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 

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19 

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? 

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20 

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. 

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21 

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. 

Leonard.horne on VACREP0180 with DISTILLER

22 

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. 

Leonard.horne on VACREP0180 with DISTILLER

23 

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 

Leonard.horne on VACREP0180 with DISTILLER

24 

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 

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25 

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 excesLeonard.horne on VACREP0180 with DISTILLER

26 

sive 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 ration- ale 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 

Leonard.horne on VACREP0180 with DISTILLER

27 

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 

Leonard.horne on VACREP0180 with DISTILLER

28 

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. 

Leonard.horne on VACREP0180 with DISTILLER

29 

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. 

Leonard.horne on VACREP0180 with DISTILLER

30 

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 nonVA 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? 

Leonard.horne on VACREP0180 with DISTILLER

31 

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. 

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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 

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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 

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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. 

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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.] 

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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: 

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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 conceptare 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 

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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. 

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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 serviceconnected 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 

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tion 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. 

f 

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 

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1 IOM (Institute of Medicine). 2015. Transforming Health Care Scheduling and Access: Getting 

to Now. Washington, DC: The National Academies Press 

days from a veteran’s preferred date. Less than a year later, VA changed its waittime 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. Geographicbased 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. 

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 SubLeonard.horne on VACREP0180 with DISTILLER

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committee 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 acLeonard.horne on VACREP0180 with DISTILLER

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ceptable 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. 

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Carl lives in Fredericksburg, Virginia with his wife Venus, son Jonathan and 

daughter Brooke. 

f 

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 

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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. 

f 

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 

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1 Independent Assessment Report Section B: Health Care Capabilities 

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: 

fi 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. 

fi 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. 

fi 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 priLeonard.horne on VACREP0180 with DISTILLER

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2Source: Veterans Health Administration, Office of Research and Development 

3Source: Veterans Health Administration, Office of Academic Affiliations 

ority 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. 

fi 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. 

fi 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. 

fi 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. 

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: 

fi 89,000 claims were denied because they did not meet the timely filing requirement. 

fi 140,000 claims were denied because a VA facility was determined to have been 

available. 

fi 320,000 claims were denied because the Veteran was determined to have OHI 

that should have paid for the care. 

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4Source: VHA Chief Business Office, Office of Informatics 

fi 98,000 claims were denied because the condition was determined not to be an 

emergency. 4

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 

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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. 

f 

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 veterancentric 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. 

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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 

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using the more reasonable driving distance criteria rather than the former straightline 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. 

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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 attentionthe 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 

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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 

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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. 

f 

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 proLeonard.horne on VACREP0180 with DISTILLER

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viders 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 

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lish 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. 

Æ 

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