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98–636 2016

ASSESSING THE PROMISE AND PROGRESS OF THE 

CHOICE PROGRAM 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, MAY 13, 2015 

Serial No. 114–19 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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


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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 

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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C O N T E N T S 

Wednesday, May 13, 2015 

Page 

Assessing the Promise and Progress of the Choice Program ............................... 1 

OPENING STATEMENTS 

Jeff Miller, Chairman .............................................................................................. 1 

Prepared Statement ......................................................................................... 50 

Corrine Brown, Ranking Member .......................................................................... 2 

Prepared Statement ......................................................................................... 51 

WITNESSES 

Donna Hoffmeier, Program Officer, VA Services, Health Net Federal Services 4 

Prepared Statement ......................................................................................... 52 

David J. McIntyre Jr., President and Chief Executive Officer, Tri West 

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

Prepared Statement ......................................................................................... 61 

Hon. Sloan Gibson, Deputy Secretary, U.S. Department of Veterans Affairs .... 7 

Prepared Statement ......................................................................................... 76 

Accompanied by: 

James Tuchschmidt MD, Interim Principal Deputy Secretary for Health, 

VHA, U.S. Department of Veterans Affairs 

Darin Selnick, Senior Veterans Affairs Advisor, Concerned Veterans for 

America ................................................................................................................. 38 

Prepared Statement ......................................................................................... 87 

Carlos Fuentes, Senior Legislative Associate, National Legislative Service, 

Veterans of Foreign Wars of the United States ................................................ 40 

Prepared Statement ......................................................................................... 91 

Roscoe G. Butler, Deputy Director for Health Care, Veterans Affairs and 

Rehabilitation Division, The American Legion .................................................. 41 

Prepared Statement ......................................................................................... 99 

Joseph A. Violante, National Legislative Director, DAV ...................................... 43 

Prepared Statement ......................................................................................... 104 

Christopher Neiweem, Legislative Associate, Iran and Afghanistan Veterans 

of America ............................................................................................................. 44 

Prepared Statement ......................................................................................... 114 

FOR THE RECORD 

Danny Breeding ....................................................................................................... 119 


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ASSESSING THE PROMISE AND PROGRESS OF 

THE CHOICE PROGRAM 

Wednesday, May 13, 2015 

HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, Washington, D.C. 

The committee met, pursuant to notice, at 10:02 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [chairman of 

the committee] presiding. 

Present: Representatives Miller, Lamborn, Bilirakis, Roe, 

Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham, 

Zeldin, Costello, Radewagen, Bost, Brown, Takano, Brownley, 

Titus, Kuster, O’Rourke, Rice, McNerney, and Walz. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The CHAIRMAN. Committee will come to order. 

Thank you for joining us this morning for today’s oversight hearing Assessing the Promise and Progress of the Choice Program. We 

have two full witness panels ahead of us. So I will keep my opening 

remarks short in the interest of time. 

We all know that the Choice Program was created last summer 

to address unparalleled access issues for veterans at the Department of Veterans Affairs, and 6 months after it was implemented, 

the program has successfully linked thousands of veterans with 

quality healthcare in their own home communities. And I think we 

can all be proud of that, and I applaud the VA and the two Choice 

Program third-party administrators, Health Net Federal Services 

and TriWest Healthcare Alliance for their initial efforts to quickly 

implement the program and their ongoing efforts to make it work 

well for the veterans who are in need. 

That said, the implementation, and administration of the Choice 

Program has been far from perfect. I think everybody can admit 

that, and many veterans are still waiting too long, traveling too far 

to receive the healthcare that they need. There are many reasons 

for this: A lack of outreach to veterans who may be eligible; a lack 

of training for frontline VA and TPA staff; a lack of urgency on the 

part of many VA medical facilities who continue to adhere to their 

old ways of doing business. And, of course, I think anyone of us 

could go on and on. 

But during the hearing today we are going to discuss how to 

eliminate impediments to greater veteran and provider participation in the Choice Program, and how to ensure that VA and TPA 

staff are properly trained and seamlessly coordinated to respond to 

veteran and non-VA provider questions, and to ensure the timely 


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delivery of care. And we will also begin discussing where VA goes 

from here. 

The Choice Program is just one of many ways that VA provides 

care outside of the walls of the Department. All too often VA’s numerous purchased care programs and authorities operate in conflict 

with one another using different eligibility requirements, different 

programmatic requirements, and different reimbursement rates to 

achieve the very same goal. That does not serve VA, the American 

taxpayer, or, most importantly, our veterans and their families 

well. 

As was stated many times last year, business as usual is not an 

option. Congress has consistently met the administration’s budget 

request for the Department of Veterans Affairs, and as a result, 

VA’s total budget has increased by 73 percent since 2009. In comparison, veteran patients have increased by only 32 percent since 

2009, yet VA has not, and cannot, fully meet the needs of the entirety of their patient population. This illustrates clearly that VA’s 

failures are not a matter of just money. They are a matter of management. There is no one way forward, but there can also be no 

mistaking that by challenging VA’s failing status quo approach to 

purchased care, we find ourselves at a crossroads of opportunity 

that never existed before. 

I am encouraged by and in agreement with the numerous testimonies today that emphasize the need to build a coordinated, managed care system that incorporates VA along with the needed community options and resources. 

While working to improve the Choice Program today, we must all 

prepare for the Choice Program of tomorrow, one that brings the 

universe of non-VA care together under one umbrella, so that the 

care our veterans receive is more efficient and effective, regardless 

of where it takes place. 

I look forward to working with veterans, with VA, with veteran 

service organizations, and all the interested stakeholders on this effort, beginning with the statements that you are going to be providing for us this morning. 

I appreciate, again, everybody being here, and with that I yield 

to the ranking member for her opening statement. 

Ms. Brown, you are recognized. 

[The prepared statement of Chairman Jeff Miller appears in the 

Appendix] 

OPENING STATEMENT OF RANKING MEMBER CORRINE 

BROWN 

Ms. BROWN. Thank you, Mr. Chairman, and thank you for calling 

this hearing today. 

As you know, it has been about 9 months since the President 

signed the Veteran Access, Choice and Accountability Act into law. 

This hearing is one in a series of hearings designated to follow the 

progress and abilities of VA to provide healthcare to veterans in 

the 21st century. I am sure we can all agree that VA provides the 

best healthcare for returning veterans in this country. However, we 

all know that there are challenges to this mission, and that the VA 

cannot do it all. 


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The Choice Program offers eligible veterans access to healthcare 

that they may not have had in the past. One of this committee’s 

highest priorities is to ensure that veterans receive the highest 

quality healthcare in a timely manner and in a safe environment. 

For those veterans who choose to use the Choice Program, I want 

to make sure that this is happening. 

Mr. Chairman, VA have served the special needs of returning 

veterans for 85 years and has the expertise in providing services 

that address their unique healthcare needs. My focus continues to 

be on ensuring that Veterans Affairs retains the ultimate responsibility for the healthcare of our veterans. Regardless of where they 

choose to live, the VA is the best system we have to serve the 

healthcare needs of veterans returning from war. We cannot allow 

circumstances that would render the system unable to serve the 

veteran it was built to serve. 

The DAV in its submitted testimony said, ‘‘Although the VA 

today provides comprehensive medical care to more than 6.5 million veterans each year, the VA system’s primary mission is to 

meet the unique specialized healthcare needs of the service-connected disability veteran—disabled veteran.’’ 

To accomplish this mission, VA healthcare is integrated with a 

clinical research program and academic environment for over 100 

or more outstanding schools of health professions to ensure veterans have access to the most advanced treatment in the world. I 

believe that says it all. 

I look forward to hearing from the Deputy Secretary today and 

all of the witnesses to learn how the VA can better treat those veterans who have given so much to defend the freedom we all hold 

so dearly. 

I yield back the balance of my time, Mr. Chairman. 

[The prepared statement of Ranking Member Corrine Brown appears in the Appendix] 

The CHAIRMAN. Thank you, Ms. Brown, for your opening comments. 

Joining us on our first panel this morning is Donna Hoffmeier, 

program officer for VA services for Health Net Federal Services, 

and David J. McIntyre, Jr., president, chief executive officer of 

TriWest Healthcare Alliance. And we are also joined by the honorable Sloan Gibson, Deputy Secretary for the Department of Veterans Affairs. Mr. Gibson is accompanied by Mr. James 

Tuchschmidt, interim principal Deputy Under Secretary for Health. 

Thank you all for being here this morning. 

Ms. Hoffmeier, please proceed with your opening statement. You 

are recognized for 5 minutes. 


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STATEMENTS OF DONNA HOFFMEIER, PROGRAM OFFICER, VA 

SERVICES, HEALTH NET FEDERAL SERVICES; DAVID J. 

MCINTYRE JR., PRESIDENT AND CHIEF EXECUTIVE OFFICER, TRIWEST HEALTHCARE ALLIANCE; HON. SLOAN GIBSON, DEPUTY SECRETARY, U.S. DEPARTMENT OF VETERANS 

AFFAIRS, ACCOMPANIED BY: JAMES TUCHSCHMIDT M.D., INTERIM PRINCIPAL DEPUTY UNDER SECRETARY FOR 

HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF DONNA HOFFMEIER 

Ms. HOFFMEIER. Thank you, Mr. Chairman. 

Chairman Miller, Ranking Member Brown, and members of the 

committee, I appreciate the opportunity to testify on Health Net’s 

administration of the Veterans Choice Program. Health Net is 

proud to be one of the longest serving healthcare administrators of 

government programs for the military and veterans communities. 

We are dedicated to ensuring our Nation’s veterans have prompt 

access to needed healthcare services, and believe there is great potential for the Choice Program to help VA deliver timely, coordinated, and convenient care to veterans. 

In September 2013, Health Net was awarded a contract for three 

of the six PC3 regions. We phased in implementation of PC3 between October 1 and April 1, 2014. Then in October, shortly after 

Congress passed and the President signed the Veteran’s Access 

Choice and Accountability Act of 2014, VA amended our PC3 contract to include several components in support of the Choice Act. 

To meet the required start date of November 5, we worked very 

closely with VA and TriWest to develop an aggressive implementation strategy and timelines. The ambitious schedule required us to 

develop process flows and to hire and train staff very quickly. Despite this aggressive implementation schedule, on November 5, veterans started to receive their Choice cards and were able to call 

into the toll free Choice telephone number to speak directly with 

a customer service representative to ask questions about the 

Choice Program or to request an appointment for services. 

Having said that, we know there have been challenges that have 

resulted in veteran frustration as well as frustration on the part 

of VA and our own staff. We had less than a week from the time 

we signed a contract modification to go live. With such an aggressive implementation schedule, there was little time to finalize process flows, educate veterans and community providers, and make 

needed system changes. 

While the collaboration with VA since the start has been good, 

there still is considerable work that needs to be done to reach a 

state of stability where the program is operating smoothly and the 

veteran experience is consistent and gratifying. 

We appreciate the opportunity to offer our thoughts on the future 

of the Choice Program. The Choice Program is a new program that 

was implemented, as I mentioned, in record time. As a result, there 

are a number of policy and process decisions and issues that are 

either unresolved or undocumented. If Choice is to succeed, these 

items must be addressed quickly. 


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As I stated earlier, we are working very closely with VA to address these issues. Many of these issues, however, could not have 

been anticipated prior to the start of the program. 

On the other hand, there are some that should have been addressed before the program began, but the implementation timeline 

did not afford adequate time to do so. 

The identification of policy and operational issues and concerns 

has been occurring very quickly. As a result, we have struggled to 

keep up with the developments and to adequately train our staff 

with the most up-to-date and accurate information. This situation 

is not ideal. 

Based on these dynamics, our top recommendation for moving 

Choice forward is to work with VA to develop a comprehensive, coordinated operational plan for Choice that clearly defines the program requirements, process flows, and rules of engagement. This 

strategy should provide a clear, well-defined road map that is communicated to all parties: VISN and VA medical center leadership 

and staff, both contractors, Congress, and, most importantly, veterans. 

While the strategy needs to clearly identify key initiatives and 

reasonable timelines for implementing those initiatives, it also 

needs to contain the flexibility to quickly address issues as they 

arise, and to make necessary course corrections. Key components 

must include resolution of outstanding policy and process issues, 

which currently are numerous; development of policy and operational guides that are mandated across the program; comprehensive training of contractor and VA staff using consistent process 

flows, operational guides, and scripting; and a clear and responsive 

process for resolution of legitimate issues and challenges. 

In closing, I would like to thank the committee for its leadership 

in ensuring our Nation’s veterans have prompt access to needed 

healthcare services. 

I also would like to thank you Congresswoman Brown for your 

leadership in helping to educate veterans and community providers 

on the Choice Program. The meetings you convened with veterans 

and community providers in Jacksonville were invaluable. We appreciate the opportunity to participate in those meetings. We are 

committed to continuing our collaboration with VA to ensure that 

the Choice Program succeeds. Working together and with the support and leadership of this committee, we are confident that Choice 

will deliver on our obligations to this country’s veterans. 

Thank you, Mr. Chairman. 

[The prepared statement of Ms. Hoffmeier appears in the Appendix] 

The CHAIRMAN. Thank you very much. 

Mr. McIntyre, you are recognized for 5 minutes. 

STATEMENT OF DAVID J. MCINTYRE, JR. 

Mr. MCINTYRE. Chairman Miller, Ranking Member Brown, and 

members of the distinguished committee, it is a privilege to be back 

before you on behalf of our company’s nonprofit owners and its employees as you assess the promise and progress of the Veterans 

Choice Program. 


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Mr. Chairman, I stood this morning reflecting on the quietness 

of the Disabled Veterans Memorial at the base of the Capitol, 

which was built to honor the sacrifices of those whom we all count 

as our heroes. I thought of the conversation you and I had there 

that morning of its dedication. Your question to me was whether 

Choice would be operational on November 5. You stressed the importance of being ready on time, although you admitted that it was 

a tall order. And you may remember I assured you that I was confident that the VA, our colleagues at Health Net, and we would not 

fail in the task. 

Following the ceremony, grounded in what my responsibilities 

were, I flew back to Arizona to start the design and construction 

process with my team, along with the teams from VA and Health 

Net with an intensity and purpose that endures to this day. 

We continue our collaborative work to ensure that the paradigm 

shift you and nearly every Member of Congress sought in the passage of the Choice Act. Indeed, just as you defined on November 

5, the reality did start to take hold, as together we stood up the 

Choice Program on time. We got cards out with an individual letter 

from the Secretary to each veteran, and we started taking phone 

calls. 

But, of course, that was just the beginning. Now we have work 

to do to make sure that we refine the program that you wanted to 

see brought into place. 

Just like the start of the TRICARE program nearly 20 years ago, 

which I was privileged to be a part of, along with my colleagues 

at TriWest, there was a lot of work to do to achieve the promise 

of that program and mold it into what’s become one of the best 

health plans in America. Back then, it took a highly collaborative 

effort between Congress, the Defense Department, private sector 

contractors, beneficiary associations, and the VSOs. The same will 

be true, I believe, of this program, and I believe the same promise 

exists with this that exists with TRICARE. 

As we discussed at the last hearing at which I appeared before 

the Veterans Choice Program, there was PC3. Actually, PC3 was 

responsible for assisting the Phoenix VA in addressing the backlogs 

that were uncovered on April 9. Sixty-three hundred providers in 

Maricopa County leaned forward at the side of the VA in Phoenix 

to take care of the more than 14,000 veterans that were backlogged, and we did it by August 17 together. 

Now, at the end of the day, that network alone was not going to 

give us the types of choices that you felt were necessary in order 

to make this all work. So we continued to grow a network. We now 

have 100,000 providers contacted in 28 States and the Pacific, and 

over 4,500 facilities, which include academic medical centers to the 

tune of about 40 of the academic—40 percent of the academic affiliates that are in our area of responsibility. 

Just yesterday the University of California at San Diego signed 

a contract to be part of the partnership that has been birthed collaboratively in San Diego. 

So, yes, we stood it up on time. But as we know, there is a fair 

amount of work still to be done. We have now refined, at least for 

the first increment, the 40-mile drive distance. We have gone from 

ruler to drive time. We are conducting training and more outreach. 


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We are accelerating the transfer of the daily eligibility file requirement that needs to occur. And we are concluding a pilot in how we 

will share clinical information on a more timely basis so that the 

needs of veterans and the information that providers might need 

would be at the core of what we are doing. There is a clinical policy 

work group that is meetings on a regular basis to define the gaps 

that need to be closed in that space. 

At the end of the day on our end, we are refining our customer 

service. We are establishing a new IT platform that we will be rolling out just after Memorial Day after a 24/7 build, and we are 

seeking from the opportunity to work collaboratively in the marketplace to make sure that the networks are tailored to match the precise demand that a VA facility has. That work is underway. 

We need a couple of things from you. One is, I think we should 

be revisiting the question of whether a 60-day authorization limitation makes sense. Secondly, there is a need, from my perspective, 

to harmonize the differences between the PC3 program and the 

Choice Program so that we can make sure that we are leveraging 

those networks about which I spoke. 

Volume is coming. Visits have been made to El Paso, Las Vegas, 

and other markets. On Friday I will be in Memphis working with 

the team there. 

Mr. Chairman and members of the committee, supporting the 

care needs of American’s veterans is a tremendous honor and privilege. We thank you for that opportunity. We thank the VA for the 

partnership, and we look forward to working at your side in achieving the promise that Choice presents to America’s veterans and 

their families. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. McIntyre appears in the Appendix] 

The CHAIRMAN. Thank you, Mr. McIntyre. 

Mr. Gibson, you are now recognized for your opening statement. 

STATEMENT OF HON. SLOAN GIBSON 

Mr. GIBSON. Chairman Miller, Ranking Member Brown, members of the committee, we are committed to making the Choice Program work and to providing veterans timely and geographically accessible quality care, including using care in the community whenever necessary. 

I will talk shortly about what we are doing and the help we need 

from Congress to make that happen. 

First, I want to talk briefly about improvements in access to care. 

Most mornings at 9 a.m. for the last year, senior leaders from 

across the Department have gathered to focus on improving veterans’ access to care. We have concentrated on key drivers of access, including increasing medical center staffing by 11,000, adding 

space, boosting care during extended hours and weekends by about 

10 percent, and increasing staff productivity. The result? 2.5 million more completed appointments inside VA this past year. Relative value units, RVUs, our common measure of care delivered 

across the healthcare industry, are up 9 percent. Another focus 

area for improving access has been increasing the use of care in the 

community. 


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In 2014, VA issued 2.1 million authorizations for care in the community, which resulted in more than 16 million completed appointments. Year-to-date 2015 authorizations are up 44 percent, which 

will result in millions of additional appointments for community 

care. Veterans are responding to this improved access. More are 

enrolling for VA care. Among those enrolled, more are actually 

using VA for their care, and among those using VA, they are increasing their reliance on VA care. This is especially the case 

where we have been investing most heavily due to long wait times. 

In Phoenix, where we have added hundreds of additional staff, 

we have increased completed appointments 20 percent. RVUs are 

up 21 percent, and authorizations for care in the community are up 

123 percent. Much of that in thanks to TriWest Healthcare and 

their support of care in the community there in the Phoenix market. 

But wait times aren’t down, because veterans continue to come 

to VA in increasing numbers to receive their care. In Las Vegas, 

we have got a 17 percent increase in veterans receiving care since 

we opened the new medical center there. In Denver, we have 

opened outpatient clinics and added more than 500 additional staff. 

Veterans using VA are up 9 percent. In Fayetteville, North Carolina, where wait times continue to be a problem, we have increased 

appointments 13 percent. Veterans using VA for care are up 10 

percent. And in all of these locations, we have had dramatic increases in care in the community. 

As Secretary McDonald has testified during budget hearings, the 

primary reasons for increasing demand are, one, an aging veteran 

population; increases in the number of medical conditions that veterans are claiming; and a rise in the degree of their disability; and 

as we can see here, improving access to care. 

As I mentioned at the outset, community care is critical for improving access. We use it, and we have for years, in programs other 

than Choice. 

In fiscal year 2013, VA has spent approximately $7.9 billion on 

community care other than Choice. In 2014, that rose to $8.5 billion, and we estimate that at the current rate of growth, VA will 

spend approximately $9.9 billion, including Choice, roughly a 25 

percent increase in just 2 years. 

At the same time, we have had a large increase in care in the 

community, Choice has not worked as intended. Here are some of 

the things that we are doing to fix it. On April 24, we changed the 

measurement from straight line driving distance using the fastest 

route. This roughly doubles the number of veterans eligible for 40 

miles under Choice. But there is much more to do. A follow-on 

mailing to all eligible veterans is about to go out. We have just 

launched a major change in internal processes to make Choice the 

default option for care in the community; additional staff training 

and communication; extensive provider communications; improvements to the Web site and ramped-up social networking; new 

mechanisms to gather timely feedback directly from veterans as 

well as directly from frontline staff. These are all already underway, or in the process of being launched. 

In the longer term, we must rationalize community care into a 

single channel. The different programs with different rules, difVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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ferent reimbursement rates, different methods of payment and 

funding routes are too complicated. They are too complicated for 

veterans; they are too complicated for providers; and they are too 

complicated for our employees who are trying to manage care. I expect that we will need your help on that change. 

Next, let me touch on the other 40-mile issue. We have completed in-depth analysis using patient level data to estimate the 

cost of a legislative change to provide Choice to all veterans more 

than 40 miles from where they can get the care they need. We have 

shared that analysis with some members of this committee, with 

staff, and with the CBO. It confirms the extraordinary cost that 

has been estimated previously. We have also briefed the staff on 

a broad range of other options and believe there are one or more 

options worthy of discussion and very careful consideration. 

While we are working together on an intermediate term solution, 

we are requesting Congress grant VA a greater flexibility to expand the hardship criteria in Choice beyond geographic barriers. 

This authority would allow us to mitigate the impact of distance 

and other hardships for many veterans. We need greater flexibility 

around some requirements that preclude us from using Choice for 

services such as obstetrics, dentistry and long-term care. We also 

ask for modification of the 60-day authorization period set forth in 

the law to bring this more in line with industry standards. 

As described above, we accelerated access to care in the community this year anticipating a substantial portion would be funded 

through Choice. For various reasons, most touched on previously, 

we will be unable to sustain that pace without greater program 

flexibility and flexibility to utilize at least some portion of Choice 

Program funds to cover the cost of other care in the community. We 

are requesting some measure of funding flexibility to support this 

care for veterans. 

On May 1 VA sent to Congress a legislative proposal providing 

major improvements to VA’s authority to use provider agreements 

for the purchase of community care. We request your support. 

Lastly, we are requesting flexibility in one other area of veteran 

care: Hepatitis C treatments. You are all familiar with the miraculous impact of the new generation of drugs. Veterans that have 

been Hep C positive for years now have a cure within reach with 

minimal side effects. Because of the newness of these drugs, there 

was no funding provided in our 2015 budget request. 

We moved $688 million from care in the community anticipating 

a shift in cost for that care to Choice to fund treatment for veterans 

with these new drugs. It was the right thing to do, but it was not 

enough. We are requesting flexibility to use a limited amount of 

Choice Program dollars to make this cure available to veterans between now and the end of fiscal year. 

So, we are improving access to care. We are committed to making 

Choice work and have very specific actions underway to do just 

that. And we need some help, especially additional flexibility to 

make it possible for us to meet the healthcare of our veterans. 

We look forward to your questions. 

[The prepared statement of Mr. Gibson appears in the Appendix] 


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The CHAIRMAN. Thank you very much. I think we can all agree 

that using the new generation of drugs is critical for not only the 

veteran but the long-term cost associated with that. 

My question is, what did you request in the 2015 budget? Was there $100 million or nothing? What—— 

Mr. GIBSON. For the new generation of drugs, my understanding 

is that in our request, there was not any funding for the new generation of drugs. When you go back and look at the timeline of 

these drugs being approved and the expected utilization, we didn’t 

have any kind of clarity at the time of the 2015 budget request. 

The CHAIRMAN. Is that because you didn’t know what the cost of 

the drug was going to be? You knew what your parameters were 

as far as the veterans that were already testing positive for Hep 

C. Correct? 

Mr. GIBSON. We have maintained a working list of veterans that 

have tested positive for Hepatitis C. I think the questions had to 

do with what drugs had been approved at the time we were formulating our 2015 budget request and what the costs for those drugs 

would be and then the anticipated utilization. 

The CHAIRMAN. Thank you. 

Mr. McIntyre, in your written statement you reference some VA 

facilities that have, and your quote was, ‘‘simply continued to use 

almost exclusively their historical non-VA care program to buy care 

from the community providers,’’ end quote rather than using the 

Choice or the PC3 programs. So can you tell us where the facilities 

are? We need to know why they are choosing to do that, and is it 

in, obviously, a particular geographic region of the country? 

Mr. MCINTYRE. Congressman Miller, the VA central office is completely engaged in that topic now as a result of a conversation 

about 6 or 7 weeks ago where we stress tested on both sides the 

question of whether direct contracts made sense when it was the 

case that we had actual networks established, and in some cases, 

established with exactly the same providers in the community. And 

the Department stress tested that question with us directly, and 

we have arrived at the conclusion, I believe, based on the behavior 

of where we are headed, that to the degree that we have networks 

that are developed, that those are the networks that would be used 

for the purpose of delivering care unless they needed to themselves 

be augmented. 

So I will go to Dallas, Texas for a second where we had a meeting a few weeks ago. We looked at the entirety of demand between 

myself, the VAMC director, and the VISN director at the same 

table with the entire staff to determine what demand they had for 

everything in the marketplace, and what the network looked like 

juxtaposed to that demand. And then made the decision at that 

table that they would be buying their care through that network. 

We have one more piece to fill in. That is the same conclusion that 

was reached in Phoenix right after April 10. That is the same conclusion that was reached in Hawaii. We now have an entire network built out in that market, and it got done collaboratively. 

So to the degree that we want to leverage the capabilities of the 

two organizations that have been hired to support the VA, we need 

the right tools, we need the right collaboration, and then we need 

to make sure that there is discipline on the other side so that unVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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like in Albuquerque, New Mexico, where we happen to have the 

University of New Mexico in our network, but they also have a direct contract, and 85 percent of the care moves through that noncontracted environment on our side at a higher cost to the taxpayer, we need to start to transition these things with the discipline that is needed. And I believe that the senior leadership responded smartly and appropriately 7 weeks ago, and we have been 

on a series of visits ever since. The next one of which will be in 

Memphis, Tennessee on Friday. 

Dr. TUCHSCHMIDT. If I could, Mr. Chairman, just to add that we 

have issued guidance to our facilities to use the Choice Program as 

the preferred way of gaining care in the community for veterans 

when we cannot treat them in a timely way. So the first option is 

to find a VA facility that, in fact, can provide that care, and if we 

can’t provide that care within the time standard that we have, that 

we use Choice as the preferential channel for which we get that 

care. 

And we are working right now with both TriWest and Health 

Net to contact the roughly 87,000 physicians and providers that 

have been delivering care to veterans who are normal otherwise 

non-Choice purchase care mechanisms to reach out to those folks 

and to try and get them to join the network so that they can continue to provide care to our patients. 

The CHAIRMAN. Thank you. 

Ms. Brown. 

Ms. BROWN. Oh, I am sorry. 

The CHAIRMAN. Mr. Takano. 

Ms. BROWN. Then I will have the last statement. 

Mr. TAKANO. Thank you, Madam Ranking Member. Thank you, 

Mr. Chairman. 

Mr. Gibson, you know, a very real concern of mine is that for the 

Choice Program to be successful we need to guarantee a robust 

supply of non-VA providers to care for our veterans in a timely 

manner. In my district, and I know many of my colleagues on this 

committee face the very same issue, we have several primary care 

and mental health shortage areas. Our providers are already 

stretched thin trying to care for the non-veteran population. We 

have to do more to train providers and attract them to underserved 

areas. And that is why I worked with Representatives Titus and 

O’Rourke to include the 1,500 GME residencies in the Choice Act. 

You mentioned that the initial 200 residencies, in your statement, that the VA has awarded those initial 200 residencies. Can 

you give me more detail about the VA strategy for awarding these 

residency slots? 

Dr. TUCHSCHMIDT. Sure. Yes. We had about 330-plus requests for 

new residency slots this year. The intention is to use those 15 and 

stand up those 15 slots over a roughly 5-year period. I, quite frankly, was surprised that we were going to have as many requests for 

July as we did. And as you have said, we have awarded 204 positions. 

There are criteria in the law that they are for scarce specialties, 

scarce medical disciplines, and in scarce areas. Right? So those are 

the criteria that we have awarded. 


VACREP0180 with DISTILLER
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This year, roughly 74 of those slots are primary care slots, 58 of 

them are mental health slots, and 38 of the slots went to new or 

expanding programs in—residency programs in the country. We 

had a lot of requests from new programs that were starting, particularly in rural areas. We don’t own these residency slots, the 

universities do, and then we are basically financially supporting 

those slots and supporting the training opportunity for those residents. 

New places, particularly smaller places, have to meet certain 

standards to be—for those programs to be accredited, and they 

were just not ready yet to accept those positions, I think. 

So we have—we are following the criteria that are in the law, 

targeting hard-to-recruit specialties and rural areas, and I think 

that next year as we get into the second round of this we are going 

to find that there are a lot more of the smaller programs, new programs, that are actually going to be up and ready to run those programs. 

Just to make this—kind of bring the point home, when we establish a new residency in one of our VA facilities, there have to be 

call rooms for those residents to sleep in. There have to be work 

spaces for them to work in. All that kind of stuff. There has to be 

qualified faculty at that VA medical center to be able to do that 

work. So you have to recruit that faculty. You have to do the interim projects to have the sleeping quarters and all that kind of 

stuff, and that is kind of where we are in the process. 

Mr. TAKANO. Well, Mr. Tuchschmidt, I appreciate all that, what 

you told me. I am surprised that you were surprised that you had 

so many applications because, as you know, there is a tremendous 

shortage of GMEs across this country, especially in rural areas. 

And I am wondering if there are ways that we can look at more 

flexibility as to how we deploy these residencies, because they are 

key to the maldistribution of providers in our country. They tend 

to gravitate toward areas which already have a robust medical infrastructure, and there are certain parts of our country, especially 

in the southwest and the rural areas that need these—as you 

know, where the residencies are located are key to where these 

physicians actually will choose to practice for the rest of their lives. 

60 percent—we have a 60 percent chance of capturing a resident, 

and in areas like mine where we have a shortage of physicians in 

the non-VA population, I see—and I understand that we have a 

shortage within the VA, you know, physicians, and your ability to 

compete for those physicians to actually work at the VA is—if you 

are in competition with an environment of a shortage of physicians, 

we have a real problem. And I would submit to you that we need 

to work together to increase the level of GMEs, generally, for the 

VA and non-VA population to really handle this wait list problem. 

Mr. TUCHSCHMIDT. Absolutely. And I am happy to go back and 

talk with our academic folks to see if there is some additional flexibility that we might need to be able to do this. 

And I was only surprised because we were starting out of cycle 

for the first—— 

Mr. TAKANO. This is truly something where red States and blue 

States should become purple. Don’t you think? 

Great. Thank you. 


VACREP0180 with DISTILLER
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I yield back, Mr. Chairman. 

The CHAIRMAN. Thank you. 

Dr. Roe. 

Dr. ROE. Thank you, Mr. Chairman, and thank you all for being 

here today. 

I am going to read you a letter just very quickly from a veteran 

service officer. 

‘‘Dear Bill,’’ and that is one of my district people, ‘‘Nice to see you 

again this week in Morristown. Per our conversation regarding the 

veterans Choice card, all I’ve heard from local veterans in Hawkins 

County is it’s a joke. Personally, I called the toll-free number and 

was told by a lady that the area I lived in was not programmed 

in. I was told to call back in 7 to 10 days to check if the information was available. This was in December after the October rollout. 

I also heard from a few veterans who were told because of residing 

in the immediate Rogersville area, we had a VA facility and they 

could attend there after obtaining their own appointment. They 

were referring to our CBOC, which has only one primary care doctor, and, by the way, that’s the only doctor there who’s overworked 

due to patient load. No specialty physicians are located in our 

CBOC. Hearing other disgruntled stories throughout the Tennessee 

Department of Veterans Affairs poorly training, I must agree with 

my fellow veterans I serve, the program is a joke indeed. 

Some common sense needed to be implemented before the program was rolled out, mainly the miles issue, and of course realizing 

the difference between a CBOC and a VA medical center.’’ And 

then he goes on to say, ‘‘I use the VA healthcare pretty much exclusively. I have only good things to say about my treatment. I am 

just thankful I hadn’t had to depend on the Choice card for my 

care. With my service-connected PTSD, I would probably make a 

fool of myself. With best regards, Congressman Roe.’’ 

So that is what one VSO said. A little bumpy on the rollout. 

A couple of other things that I want to bring up that has bothered me with any government program, whether it is the VA or 

anything else, and this number may be wrong, but we just knew 

there were veterans out there that could not get care, so rolled this 

program out, and according to our staff memo here, it says, ‘‘As of 

last week, 53,828 Choice authorizations have been made, and 

43,044 appointments have been scheduled.’’ 

We have spent $500 million doing that, which is $11,616 per appointment. That seems a little high. And I wonder why that is, why 

the administrative costs gobble up more money than the care going 

to the veteran. That just—it boggles my brain, although I will tell 

you it is actually better than healthcare.gov in Hawaii which was 

$24,000 per customer. So you actually are doing half of what they 

charge in cost. And there are programs out there, whether it is 

TriWest or Medicare, whatever, systems that already work. Now, 

I realize putting a network together is difficult. I do know that. 

That is a big deal you are trying to do countrywide. It is a huge 

deal. 

And another question I have, I guess, Mr. Secretary, for you, you 

said about the 40-mile limit. How much would it cost to do that? 

You didn’t mention that. You said it was expensive, but you didn’t 

put a number on it. 


VACREP0180 with DISTILLER
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And, secondly, why are we using the veterans Choice card? This 

was to reduce the backlog, not to just provide service for veterans. 

Why are we going to that pot of money instead of using money the 

VA already has in its budget for that? And that was mentioned, 

and I would like to know why that is going on, because I shouldn’t 

be. 

Mr. GIBSON. I am not sure I understood the last question. 

Why—— 

Dr. ROE. Well, he just said just a second ago that they were funneling the veterans to the Choice program, not to a program that 

already exists for their care outside the VA. 

And, lastly, concerns I have heard over prompt payment—we 

talked a lot about that when we were doing this bill, and prompt 

in the VA in payment is an oxymoron. 

Mr. GIBSON. Which of those questions would you like for me to 

tackle first? 

Dr. ROE. Any of them. 

Mr. GIBSON. I will start from the end, and then probably have 

to ask for a reminder. 

On prompt payment, you are absolutely right. We are historically—as I have said in the past, we pay low and slow. And that 

is a challenge for providers. 

One of the things that Congress did for us, thank you very much, 

is you required us to consolidate our payment processing organization at least into a single reporting channel. We were processing 

payments in 21 different locations—in 21 different organizations in 

77 different locations. We have now consolidated the—at least the 

reporting relationship, and we are now beginning to tackle some of 

the tough issues that were just being worked around in the past, 

and as a result, not providing timely payment to providers. 

Frankly, the situation has been exacerbated by our acceleration 

of referral to care in the community. In the first 4 months of this 

year, the number of claims coming in the door are up 42 percent. 

So not only are they trying to catch up from the past, they are trying to stay ahead of that kind of a bow wave. 

So we are after it in a big way. It bears directly on access to care 

because we have got to have providers out there. 

I would remind you that under Choice, the providers get paid by 

the TPAs, and the stipulated requirement in the contract is 30 

days. 

What is the next question that I need to answer? 

Dr. ROE. My time is expired, but I will submit those to you because there are several important questions I want the answer to. 

And I would like to have this letter submitted for the record. 

Mr. GIBSON. And I would be delighted to answer them. 

The CHAIRMAN. Without objection. 

[The prepared statement of Sloan Gibson appears in the Appendix] 

The CHAIRMAN. Ms. Titus, you are recognized. 

Ms. TITUS. Thank you, Mr. Chairman. 

Mr. McIntyre, you mentioned in your written statement that the 

current rules might require a pregnant veteran to change doctors 

during the course of her pregnancy, and that just kind of draws attention to something that I have been working on to try to be sure 


VACREP0180 with DISTILLER
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that our women veterans get the kind of healthcare services that 

they need. So I would ask you if you have discovered any patterns 

or any trends of differences between men and women who are 

using the Choice program? Any tendencies for women to go outside 

of the VA perhaps more than men for OB/GYN treatment? Can you 

answer some of those questions so we can be sure that women are 

being served by this program as well? 

Mr. MCINTYRE. Yes, ma’am. And thank you for your critical leadership in that area. 

I think it is really early to tell what the patterns are going to 

look at the end of the day. We have got about 42,000 auths for 

Choice that have moved through our fingertips over the last several 

months since this started, and many of them are in—certainly for 

women’s services issues. We could get you a listing of what that 

looks like and what the volume is juxtaposed to other types of services that are being requested. We do have OB/GYNs in the network. 

We also have a responsibility that to the degree that mammograms aren’t available, OB/GYNs aren’t available and the like, and 

they are needed and unavailable in the VA, to actually contact a 

provider on the veteran’s behalf and place them with a provider of 

their choice. 

And then as Secretary Gibson said, to pay within 30 days on average. That is actually what we are doing now. Three months ago 

we were at 90 days. Now we are on average at 30. So we are hitting that speck. 

And the focus on women’s health issues is really, really important to all of us. We appreciate their service, and we look forward 

to collaborating with you, particularly as it relates to Las Vegas on 

that and the other issues in your community. 

Ms. TITUS. I appreciate that, and it is so important because 

many of the VA facilities don’t have a resident OB/GYN, and so we 

want to be sure that they are getting that service. And I especially 

appreciate you saying that you want to collaborate. I heard you 

mention you had been to Las Vegas, but Ms. Hoffmeier said that 

she had been willing to do roundtables with veterans, not just 

meeting with the doctors. And I wonder perhaps you could partner 

with me and we could do a roundtable so we can get the word out 

about the Choice program in—— 

Mr. MCINTYRE. Ma’am, that would be fabulous. You name the 

time, the place, the date, and I will be there. 

Ms. TITUS. And I got a lot of witnesses here. 

Mr. MCINTYRE. Done. And what I will tell you, ma’am, is this. 

It is not the only time I have been to Vegas. 

Ms. TITUS. Well, that is good. We like that too. So—— 

Mr. MCINTYRE. Not for gambling. I have been there not to leave 

money in the economy. I have been there to work, and we have 

been there four times now to meet with the facility and work on 

tailoring the network related to the demands in that market. And 

they are leaning forward and doing what they need to be doing on 

their end on your behalf. 

Ms. TITUS. Great. Thank you. We will set that up. 

Mr. Secretary, I—thank you. It is always a pleasure to see you, 

but before I ask a question, I want to just take a minute to assoVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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ciate myself with the comments that were made in the veterans 

hearing on the Senate side yesterday by Ranking Member 

Blumenthal. He is very concerned, as I am, about taking money 

from the Choice Act to pay for those outrageous overruns in Aurora, and we need to help the veterans in Denver, but we can’t take 

money from a program that you all said you needed, you needed 

this money, to serve all our veterans. And now to just say: Oh, 

well, we don’t really need that $700 million, I don’t think is acceptable, and I would like for the record to show that. 

Also my question, though, is that you mentioned that you all are 

in the process of hiring more than 10,000 medical professionals. 

What my question is—is that to fill a gap, to fill a hole, or to fill 

vacancies, or is that in anticipation of needs of the future? Because 

there is some parts of the country where the veteran population is 

growing, like Mr. O’Rourke’s district, my district. Other places the 

veterans population not so much. 

Could you address that? 

Mr. GIBSON. Of course, yes. In fact, the comment in my opening 

statement was that we had grown net 11,000 medical staff in our 

medical centers over the last 12 months. We are at any point in 

time, and we are right now, the number I am remembering, Jim 

may have a better number, is somewhere on order of 28,000 individual positions that we are working to fill all across VA. That 

number bumped up because of the Choice Act, because of the number of positions that we are working to fill, that were made possible 

by that incremental funding. But in the course of our routine turnover, we see between 8 and 9 percent turnover, substantially less 

than what you see in the private sector in healthcare, but when 

you look at a staff of some close to 300,000, if you are turning over 

8 or 9 percent a year, you are going to have a large number of vacancies open at any point in time. So we are constantly recruiting 

to fill vacancies across VHA. 

Ms. TITUS. Thank you. And we hear a lot about the shortage of 

doctors, but I know there is a shortage of nurses and other technicians as well. So we need to be aware of that problem too. 

Mr. GIBSON. You are absolutely right. Yes, ma’am. We are the 

largest employer of nurses in the country, and that is a vital position for us to ensure that we are effectively recruiting. 

Ms. TITUS. Thank you. 

Thanks, Mr. Chairman. 

The CHAIRMAN. Mr. Huelskamp. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate you 

calling this hearing, as well as your great work on expanding 

choices for our veterans, and I—— 

Mr. Under Secretary, I do appreciate your statement that Choice 

is now the default option for care outside the VA, and I will look 

forward to some description of how you made changes to make certain that happens. 

What I want to ask—a couple things. First of all, I find out in 

this committee we have a lot of differences across our districts, and 

some have more or less providers, but in my Congressional district, 

we have about 70 community hospitals and zero VA hospitals. And 

what I am hearing from those hospitals is a tremendous difficulty 

of getting into—as an approved provider. They can do it for MediVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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care. They certainly can do it for TRICARE. But it is extremely difficult. 

What I would like to ask the TriWest folks is, what does the VA 

need to do to make sure that these community hospitals that want 

to serve veterans get in and become an approved provider? What 

can we do differently? 

Mr. MCINTYRE. Well, I think we should compare notes because 

we have a fairly sizeable network built out in Kansas, and it may 

be that some think they are not under contract because we used 

to do the TRICARE work in the State of Kansas, and they actually, 

in fact, have a network contract to do the work for this work. 

And actually Dr. Tuchschmidt and I discovered that similar problem in Bend, Oregon. Didn’t we, sir? Where someone decided to 

light both of us on fire, and at the end of the day, within a couple 

hours, they were trying to explain why it was that they had mistaken the fact that they actually were under contract. 

So I would look forward to that dialogue. We have a broad footprint in Kansas. If we need to add it, we will definitely make that 

happen, because we are responsible for making sure that the care 

is accessible. 

Mr. HUELSKAMP. And I appreciate that, and maybe it is the folks 

at the VA that are answering the phone, because it is still extremely difficult. We have veterans that are making it through the 

system and getting those choices. As I have talked about again and 

again in this committee, it is usually they talk about hours to get 

to a provider and—when they have a local hospital down the road, 

and they are still not getting the yeses that they need. 

And one of the other things, as far as yeses, I would like the 

Under Secretary to know about this. At Fort Riley, which is in my 

district as well, they are building a brand-new hospital, and there 

are—sometimes they say it takes years for the VA and the DoD to 

come together to agreement, and the CBOC there is a limited primary care. Actually, all the CBOCs are very limited, which I want 

to get to in another question, but I wanted the Under Secretary to 

understand that the folks there would like access. They would—you 

know, they can serve 10 years at Fort Riley. They would like to 

step off the base and turn around and still access the care that 

they have been doing as well. 

So the last question of Mr. Secretary would be in reference to the 

hardship exemption. And how far can you stretch that to meet the 

needs of these veterans of rural communities to get past this artificial 40-mile barrier, and say, Hey, you know what? The CBOCs are 

not offering the care, and it makes no sense to calculate 40 miles 

to a place that doesn’t offer anything other than maybe primary 

care, maybe 4 days a week, maybe 1 day a week, and describe how 

we can expand that and meet those needs? 

Mr. GIBSON. First, very briefly, everywhere I go I find a very 

strong relationship between the local VA and DoD medical facilities. I will make sure—I have not been to Kansas yet, but I will 

make sure that we are working to build that relationship with Fort 

Riley. 

Secondly—the second question is? 

Mr. HUELSKAMP. Hardship exemption, and how we can use the 

current law and still expand beyond this artificial—— 


VACREP0180 with DISTILLER
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Mr. GIBSON. Yeah. Well, the flexibility that I referred to here and 

that we are requesting, the way the language is written right now 

it has to do with a very limited and very narrow geographic barrier. What we are looking for is much broader discretion so that, 

you know, for example, the veteran that you described in your letter that we would be able to, much more liberally, address those 

particular needs for that veteran in terms of the distance traveled 

and be able to rely on the Choice program to fund that. 

I would tell you, part of our challenge here, and I didn’t get a 

chance to answer that part of Dr. Roe’s question, as we run even 

the most conservative assumptions, we are seeing numbers on the 

order of magnitude of $10 billion a year. So just completely open 

the aperture. And—and so part of what we are looking at here as 

an interim solution is the idea that we would have that kind of discretion. And I might say, for example, if a veteran needs a knee 

replacement, then traveling some considerable distance to get that 

knee replacement, maybe that is not unreasonable in order to get 

it done at a VA hospital. What I don’t want to have is that veteran 

having to travel that same distance to get the physical therapy 

done after he has the procedure. 

Mr. HUELSKAMP. And I am out of time, Mr. Under Secretary. 

One last point. And appreciate that. I would ask you to look at the 

hardship exemption to get past this artificial 40-mile barrier as 

well. And as far as your cost estimates, I don’t know if you have 

done the comparison, but I find it hard to believe that you are 

doing it more effective and more cheaply than our TRICARE and 

Medicare system, which is dozens and dozens and dozens, and perhaps hundreds of choices, and in the—in my congressional district, 

very few choices for VA. So that is a comparison I would like to 

see. 

So I yield back, Mr. Chairman. 

The CHAIRMAN. Mr. O’Rourke. 

Mr. O’Rourke. Thank you. 

Mr. Gibson, at one point in your opening statement, you had 

mentioned spending up to $9.9 billion, including Choice on outside 

care. 

What year were you talking about, and what was the amount for 

Choice specifically? 

Mr. GIBSON. Well, we are—what I am talking about is on the 

pace that we are on right now, I expect that we are going to spend 

close to $10 billion on care in the community. 

Mr. O’ROURKE. By what date? 

Mr. GIBSON. Pardon me? 

Mr. O’ROURKE. By what date? 

Mr. GIBSON. This fiscal year. 

Mr. O’ROURKE. Okay. 

Mr. GIBSON. This fiscal year between October 1 of 2014 and September 30 of 2015. This fiscal year that we would spend just under 

$10 billion. The challenge that we have is, for a whole bunch of 

reasons, many of which are internal, some of which we are challenged around in terms of flexibility provisions and things like 

that, the majority of that has been coming out of our—out of our 

traditional VA community care budget. We cannot sustain that. 


VACREP0180 with DISTILLER
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So part of what Jim was describing earlier about—about shifting 

to make Choice the default option, that is—no pun intended—that 

is not a choice. We have no alternative but to do that, because otherwise we won’t be able to refer veterans to care in the community. 

And without additional flexibility, there will be other instances 

where we would otherwise have referred the veteran to care in the 

country but we don’t have the dollars to pay for it. 

Mr. O’ROURKE. So having said that, and then you also said in 

your opening remarks that you wanted to rationalize Choice and 

community into one channel. 

Mr. GIBSON. Yes. 

Mr. O’ROURKE. And a request for flexibility. Is the logical conclusion of that that you would just merge those programs into one? 

And do we need Choice? Should all this go through PC3? Should 

all of PC3 go through Choice? Do we just need one program? 

Mr. GIBSON. Let me, if I may, take one moment, and then I 

want—because there is context for the answer. 

I mention in my statement that we had reviewed with the staff, 

and we are delighted to do that with members, an array of alternatives that we have been looking at to just basically saying 40 

miles from wherever you can get the care. They have to do with 

limiting it to certain services, limiting it to certain priority groups, 

and—and then doing some different things in terms of pay structures. 

One of the alternatives that I think is particularly interesting 

and warrants careful consideration is the idea, and this affects 

other parts of the Federal Government that—let me back up. 

VA care—the veterans who we are providing care to right now, 

81 percent have either Medicare, Medicaid, TRICARE, or some 

form of private insurance. And so part of what we are seeing as we 

cost out this $40 billion from where you can get the care is a material shift out of Medicare and other primary payers into VA because we don’t have the co-pay levels that you find in these other 

programs. So one idea is you eliminate that economic distortion in 

the veteran’s decision. You make, for example, Medicare the primary payer. You use VA as—to indemnify the veteran up to their 

Medicare co-pay, and all of a sudden, you have done something to 

give real choice to the veteran, and, frankly, more efficiently for the 

taxpayer, so that the taxpayer is not paying twice for the same 

kind of care. 

And the base question I am answering here is? 

Mr. O’ROURKE. Well, I was asking about whether the logical conclusion of this is that we are merging the two programs. But I also 

want to get a question to Mr. McIntyre. 

Mr. GIBSON. But as you go to that kind of a scenario, then you 

step back from that and you ask yourself: How do you optimally 

organize to execute that? 

Mr. O’ROURKE. Yes. 

Mr. GIBSON. And I still think it is one single channel. 

Mr. O’ROURKE. Yes. 

Mr. GIBSON. We can’t operate in five or six or seven channels. 

Mr. O’ROURKE. So, Mr. McIntyre, tell me how to read these numbers. Since November, El Paso VA has referred 165 veterans 

through Choice and that same time period referred 4,600 veterans 


VACREP0180 with DISTILLER
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through the PC3 contract. What conclusion should I draw, what 

questions should I be asking related to that? 

Mr. MCINTYRE. The conclusion you should draw with the thirdhighest volume in our geographic space is that it is working. We 

have gaps in performance. There are differences between the two 

contracts and requirements to providers that need to get streamed 

out, but the fact of the matter is that the care that is not accessible 

in the VA facility in El Paso is being delivered downtown. And we 

are now talking about how do we grow the mental health backbone 

together to make sure that we can deliver on that, and that is why 

I was there 2 weeks ago. 

Mr. O’ROURKE. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you very much. 

Mr. Gibson, it wasn’t too many years ago that Florida started a 

lottery program, and the selling point of the lottery program was 

the funds that would be derived from that program would be used 

to supplement education in Florida. The fear was that it wouldn’t 

supplement it, that the base funds would go away. Well, that is 

what has happened. Let me assure you there is a $6 billion item already in your 

budget for outside fee care. We are not going to let the Choice Program become the lottery funding source for the Department of Veterans Affairs. I got the letter. I am checking now to see on where 

some of the money has been diverted, and I can assure you that 

this committee is not going to let the Department purposely delete 

the funds. I just want to make that very clear. It was designed to 

supplement. It wasn’t designed to replace. And I am not asking for 

a response. I am just making sure you know where we are coming 

from, and I think you already know that. 

But in your testimony today and in letters that you have sent to 

us, you have very cautiously woven in some issues that are more 

management issues than they are budgetary issues. And we will 

reach a conclusion, may not be the one you like, but we are all 

going to make sure that the veterans get to use the Choice Program in a way that it was intended so that it is successful. 

Mr. Coffman, you are recognized—— 

Ms. BROWN. Mr. Chairman. 

The CHAIRMAN [continuing]. But you cannot use the word ‘‘Denver’’ one time. 

Mr. COFFMAN. Aurora, Mr. Chairman, Aurora. 

The CHAIRMAN. Okay. 

Mr. COFFMAN. Thank you. 

Ms. BROWN. I had a question. 

Mr. COFFMAN. Thank you, Mr. Chairman. We won’t talk about 

that construction project today. 

But let me just say, in Colorado, 9NEWS, one of our local TV stations, did an analysis over the first 4 months and found that there 

were only 403 veteran Choice appointments scheduled while there 

were 183,000 appointments scheduled through the VA system. It 

seems like that there is underutilization, and what can we do? And 

I think you have expressed some things today. 

But let me go on to another one because maybe you have addressed that, but you can elaborate on that. There is a neurologist, 


VACREP0180 with DISTILLER
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a physician, actually a surgeon that I met with in Colorado who 

does the followup work on this. When people have Parkinson’s, 

there is a procedure whereby there is I think deep brain stimulation to try and stabilize them. And they are having to go to San 

Francisco for that procedure from Colorado where we can do it in 

Colorado. 

Under your new definition of the 40 miles, will veterans have the 

option of staying in Colorado to get that treatment with a provider 

that is reimbursed under the Medicare rate, or will they have to 

go to San Francisco to get that procedure done? 

Mr. GIBSON. I am going to give you a very honest and direct answer: I don’t know. The easy answer would just be for me to say 

yes. I think I know the procedure that you are describing. 

Mr. COFFMAN. Right. 

Mr. GIBSON. I have been to San Francisco. I have seen the impact that that has. It is a very, very specialized procedure and one 

that we have developed some exceptional in-depth experience with. 

At a clinical level, I think that is part of where that decision winds 

up being made. If we are looking at the individual patient acknowledging the hardship of travel, looking at the ability to deliver comparable care in the community, then I suspect that is one where 

we would look at it and say that is a hardship to travel that far 

for that treatment and therefore we ought to do it here locally. 

On the other hand, if we saw material differences in relation to 

that specific veteran and the capability, the relevant capability, we 

might look and say we think it is better for this veteran to be able 

to make that trip. That is an honest answer. 

Mr. COFFMAN. Mr. Secretary, Deputy Secretary Sloan Gibson, 

9NEWS again did a story about a veteran who had to go to Albuquerque, New Mexico, a 200-mile trip, to get—let’s see, he didn’t. 

So it is $160 worth of travel expenses that he was reimbursed and 

it was for an x-ray he needed that the cost of which was evaluated 

at $160, at least by the investigative reporter. I mean, when we 

talk about the cost, how are we rationalizing that? 

Mr. GIBSON. That is a perfect example of where we have got to 

use common sense. It makes absolutely no sense, first of all, for the 

hardship on the veteran to make a trip of 150 miles or whatever 

it was to get an x-ray. For heaven’s sakes, that is just not thinking 

straight. And being able to provide the kind of flexibility and set 

the context inside the organization to make those kinds of decisions 

locally I think is where we wind up taking better care of veterans 

and, frankly, doing the better thing for taxpayers. 

Mr. COFFMAN. Okay. Going back to the issue about the extraordinary travel expenses to send somebody from Colorado to San 

Francisco to get a procedure, so it is your view that if there is no 

qualitative difference in terms of offering the procedure in terms of 

cost savings, that it ought to be done under the Choice Program in 

Colorado. Am I correct in that? 

Mr. GIBSON. You know, the guideline that I hope, and part of 

what Bob and I both are trying to do, and this is a challenge culturally inside the organization, is move us to more principle-based 

approach to making decisions instead of rules-based. And so what 

I would like is that person on the ground looking and saying: What 

is the right thing for veterans and the best thing for taxpayers 


VACREP0180 with DISTILLER
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here. And if that means having the veteran stay there in Colorado, 

then that is the decision that we ought to be making. 

Mr. COFFMAN. And let me just follow up very quickly. They are 

also being sent to San Francisco to do routine things in terms of 

followup such as periodically, I guess, these, when they do the deep 

brain stimulation, the batteries have to be changed out. I don’t 

know the medical lexicon associated with that. But they are going 

to San Francisco for that, and it seems like the followup care certainly could be done in the State of Colorado. 

Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Thank you. 

Ms. Rice. 

Ms. RICE. Thank you, Mr. Chairman. 

Mr. McIntyre, Ms. Titus asked a question specifically about 

treatment for women. The question I have is that you suggest review of the 60-day authorization limitation? 

Mr. MCINTYRE. Yes, ma’am. 

Ms. RICE. So you gave two examples of a situation that I am sure 

we do not want veterans—really, who would want to have to go 

through that kind of midstream change in terms of treatment when 

you are talking about serious health issues. So can you just expound on that a little bit more and how you would fix that? 

Mr. MCINTYRE. Well, I think the fix is probably going to have to 

be made by all of you, at least from the standpoint of giving us the 

flexibility that doesn’t currently exist in the law. The way the 

Choice law was drafted was designed to make sure that there was 

appropriate utilization, not overutilization, and in the drafting of 

that, there was a 60-day limitation put on how long an authorization for care could be. 

So if you are a person who has cancer, you are probably getting 

care for more than 60 days. If you are a person who is pregnant, 

you are probably getting care for more than 60 days. If you are a 

person that is going through radiation oncology, you are probably 

getting care for more than 60 days. And I could go on and on as 

a nonclinician. 

And your position is not unique, and that is that that doesn’t 

make a lot of sense. And so I think stepping back, all of us, you, 

the VA, ourselves, to try and figure out what is clinically rational 

and what adjustments are made in order to make that work. 

Ms. RICE. So what would the solution be? 

Mr. MCINTYRE. Because today what happens is, if we receive 

someone to deliver care, then we contact a provider, we send them 

the request for an appointment, we send the authorization along 

with that request for an appointment and all the rules that they 

have to follow, and then they get that person for care. And 60 days 

later they have to present them back to us, we have to go back to 

the VA, under the current rules, to make sure that it is okay to 

continue to deliver care in the community. 

As Secretary Gibson said, it is not rational and it doesn’t make 

any sense. And so I think we just need to lean forward and figure 

out how to adjust that. We are certainly willing to do our part 

when you do your part. 

Ms. RICE. Well, tell me what our part is. 

Mr. MCINTYRE. It would be adjusting the requirement. 


VACREP0180 with DISTILLER
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Ms. RICE. So it is a language adjustment. 

Mr. MCINTYRE. It is a language adjustment. And Dr. 

Tuchschmidt might even have thought about this as a clinician in 

terms of what is needed. 

Dr. TUCHSCHMIDT. Yes. So we totally support this change. There 

are a number of changes that I think we are prepared to come forward with here shortly asking for changes in the way the Choice 

Program works. One of these is the 60-day authorization, and I 

think the issue is clear about continuity of care beyond the 60-day 

period. 

So what normally happens in the industry, quite frankly, is that 

there is an authorization for an episode of care as opposed to 60 

days. So that episode of care, if you are being referred to an obstetrician for your prenatal care and delivery, obviously is not a 60- 

day episode of care. It is a much longer period of time. If it is for 

the radiation therapy, it is for a course of therapy, it is not for 60 

days. 

And so I think what we would like to see happen is that that 60- 

day window, quite frankly, just get taken out and that we manage 

this by authorizing episodes of care and using, quite frankly, industry standard utilization management criteria that we use internally and that we have provided to the TPAs. 

Ms. RICE. Okay. 

Deputy Secretary Gibson, just one question. So we can hear individual stories that some of us might hear from constituents of ours, 

and they are very compelling, but those, unfortunately, seem too 

few and far between. Seems to me like the veterans service organizations might actually be privy to more stories that might be more 

instructive as to how you address a persistent problem. 

So does the VA regularly and have you been—I think I know the 

answer to this—reaching out to the VSOs to ensure that we are not 

waiting just to get into a situation like this to hear about the horrible story of a handful of people. 

Mr. GIBSON. We are at various levels in the organization, from 

Bob McDonald and I, all the way down to folks in medical centers, 

are regularly meeting with VSOs. I think I am partly responsible 

for Bob’s cholesterol level back there because we have breakfast together as often as we do. So it is, yes, we do that very closely. 

As we do things with Choice, for example, the original letter that 

we sent out, before we sent it out, we gave it to the VSOs to get 

feedback. We are getting ready to send another mailer out. We got 

great feedback from the VSO on things to address and things to 

fine-tune that they are hearing from their members aren’t clearly 

communicated. So that is a routine part of our approach. 

Ms. RICE. Great. Thank you all very much. 

Mr. GIBSON. Yes, ma’am. 

Ms. RICE. I yield back, Mr. Chairman. Thank you. 

The CHAIRMAN. Thank you. 

Dr. Wenstrup, you are recognized. 

Dr. WENSTRUP. Thank you, Mr. Chairman. 

I appreciate all of you taking on these very complicated issues, 

but I do think that with a lot of perseverance, we have a chance 

to do some great things here. 


VACREP0180 with DISTILLER
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First question I have, Mr. McIntyre, do you know offhand what, 

say, the top five physician services are that are being referred out? 

Mr. MCINTYRE. Through Choice? 

Dr. WENSTRUP. Yes. 

Mr. MCINTYRE. It would be physical therapy. 

Dr. WENSTRUP. Physician. Physician. 

Mr. MCINTYRE. Physician services? 

Dr. WENSTRUP. Yes. 

Mr. MCINTYRE. It would depend on market, and it would depend 

on what is the gap at the VA market by market by market. 

Dr. WENSTRUP. I guess I was looking for more what your—— 

Mr. MCINTYRE. The average? The Secretary may be able to answer that. 

Mr. GIBSON. I think primary care is the biggest item. 

Dr. TUCHSCHMIDT. Yes. 

Mr. GIBSON. By far. 

Dr. WENSTRUP. At some point for the record, if you could give me 

what you think are the top 5 or 10. 

Mr. GIBSON. We can give you that breakdown. 

The other thing that I think we are going to see over a period 

of time is those referrals into primary care oftentimes are going to 

lead to a specialty care. 

Dr. WENSTRUP. Another referral. 

Mr. GIBSON. And so while we see primary care up here right 

now, primary care may move down as some of the other specialties 

move up. 

Dr. WENSTRUP. That makes sense to me, especially if you have 

more primary care doctors at the VA, they would refer directly to 

a specialist rather than the other way around. 

So at TriWest, you manage claims and payment, correct? 

Mr. MCINTYRE. Yes, sir. 

Dr. WENSTRUP. Okay. But the administrative rules and requirements are set by the VA? 

Mr. MCINTYRE. Correct. 

Dr. WENSTRUP. As far as paperwork? 

Mr. MCINTYRE. Correct. 

Dr. WENSTRUP. Okay. So who does the non-VA provider get their 

check from? Do they get it from TriWest or they it from the VA? 

Mr. MCINTYRE. We pay the provider after the provider returns 

the medical documentation of the encounter to us so that the VA 

can put it in the consolidated medical record for the veteran. And 

then the VA pays us 

Dr. WENSTRUP. So you pay them before the VA pays you? 

Mr. MCINTYRE. Correct. And on average, we are now doing that 

in 30 days. 

Dr. WENSTRUP. Okay. Very helpful. 

Now, how does that system compare to other networks that you 

might be managing as far as the paperwork? That is my key issue. 

Because one of the complaints is the VA paperwork is so much 

tougher, so it deters some docs from wanting to be providers. 

Mr. MCINTYRE. You know, there are some requirements that are 

a bit more extensive than they might be under other programs. 

Probably the biggest challenge that we have is that there is a different set of requirements for PC3, which predated Choice, and for 


VACREP0180 with DISTILLER
25 

Choice itself, and the need to harmonize those two things is pretty 

important, both for the provider, for the provider’s staff, for the veteran, for our staff, and also for the VA staff. 

Dr. WENSTRUP. Because we are looking for ways that can streamline things that aren’t necessarily related to care and get people 

taken care of, and so it sounds like there is some room for improvement there that we can work on, and I appreciate that. 

Is there a capability for a non-VA doctor to directly contract with 

the VA? 

Mr. MCINTYRE. The way it works is that to the degree that we 

don’t have a network provider available—and we have 100,000 now 

in our network, we will probably have somewhere between 125,000 

to 130,000 when we are done tailoring networks—if we can’t meet 

that need that way, then we have a responsibility, based on the instructions that you gave to all of us, to go and seek a provider in 

the community that would be willing to serve that veteran. So if 

there is one in a market, we still have a responsibility. 

Dr. WENSTRUP. Great. 

Mr. MCINTYRE. Secondly, if the person walks in with an individual provider’s name, that is the place we start. 

Dr. WENSTRUP. Has the SGR fix been helpful in recruitment, 

considering that it is Medicare rates and now there is some stability to the Medicare rate? 

Mr. MCINTYRE. We have been fairly successful in recruiting providers. The other side of it is that we are now opening up the aperture and allowing providers across our geographic expanse to actually identify that they are interested in taking care of veterans 

under Choice at the Medicare rate. 

Dr. WENSTRUP. One of the things that I wanted to ask you, Mr. 

Gibson, you mentioned about RVUs increasing. Do you think that 

is because of increased productivity or better documentation in increasing the RVUs or a combination? 

Mr. GIBSON. I think it is probably a combination. We have been 

increasing our focus on productivity. We have built some internal 

tools to help us do that. That is part of the overall discipline that 

we are trying to impose on the organization. Once you start focussing on something, you are probably getting better reporting. But 

when you look at the increase in completed appointments, you realize that there is more work being completed here. 

Dr. WENSTRUP. At some point—I am about out of time—but I 

would like to address further what we are spending, the total cost 

per RVU in our system, and I know we have talked about that before. 

Mr. Chairman, I yield back 

The CHAIRMAN. Ms. Brownley, you are recognized 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

Mr. Secretary, I think we all know that there is a difference in 

reimbursement rates between the fee basis care, the PC3, and the 

Choice Act. We know that. And you had mentioned in your testimony that it is somewhat problematic with regards to the Choice 

Act. And it is true that Choice is the least of the reimbursements 

to providers of those three programs. It is not the least? 

Mr. GIBSON. PC3 is actually typically negotiated at below Medicare rates. 


VACREP0180 with DISTILLER
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Ms. BROWNLEY. PC3 is. 

Mr. GIBSON. It is, yes. 

Ms. BROWNLEY. Okay. 

Mr. GIBSON. So you have got individual authorizations or other 

contracts that may be at Medicare or may be a little above Medicare, PC3 below, and then Choice at Medicare. And obviously you 

can surmise the signals that is sending to the provider community. 

Ms. BROWNLEY. Well, that is what I was trying to kind of drill 

down a little bit more and following up on Dr. Wenstrup. If the 

Medi-Cal or Medicare rate is less, then is that going to drive in 

terms of having the providers that we need to access the program? 

Mr. GIBSON. One of the challenges that we are going to have as 

we move to that single network and I think we become predominantly Medicare based is, particularly in rural markets, our ability 

to attract providers in rural and highly rural markets at Medicare 

rates. That I expect will be a challenge. We know that is a difficulty already because we already experience that in our other VA 

care, and that will be one of the areas where I think ultimately we 

are looking for some modicum of flexibility. 

Ms. BROWNLEY. Very good. I think it was you that mentioned 

some of the positive impacts on the Choice Act or what we have 

done is to extend office hours at various facilities. I know in my 

district our veterans are screaming for extended hours with our 

CBOC and we haven’t accomplished that. So I am just wondering 

if you have some kind of data to show where we are providing 

those extended hours and where we are not. 

Mr. GIBSON. As a matter of fact, we have got very detailed data 

all the way down at least to the medical center level. I don’t know 

if I have got it all the way down to the CBOC level. When you look 

at the last year, we are up slightly over 10 percent in total extended hours, 2 years we are actually up almost 27 percent in extended hours care. So it is really one of the things that we are trying to emphasize, but we can focus on the specific outpatient clinic 

that you are referring to. 

Ms. BROWNLEY. Well, that would be great. And I am just interested in what the VA is doing to continue to drive that to. I mean, 

the goal would be that wherever it is needed, and maybe it is not 

needed everywhere, but wherever it is needed, that we do have 

those extended hours. 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWNLEY. And then last. We provide, I think, in terms of 

the wait time data and number of appointments for VA care, we 

have those statistics and it is given to us on a pretty regular basis. 

In your comments you talk about Phoenix and Denver and Fayetteville, you mentioned those. But I am wondering if you have consistent data for all of the facilities across the country for the Choice 

Act in terms of how we are doing. It is very hard to measure. We 

get a lot of this anecdotal feedback, but it is really hard to actually 

know how we are doing center by center by center. 

Mr. GIBSON. In fact, we do have that detailed data down to the 

facility level for Choice. As you might expect, it is still a very small 

fraction of the total activity. And so part of our challenge is really 

what we are in the process now is basically diverting. Folks are 

used to doing business the way they do. 


VACREP0180 with DISTILLER
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First of all, veterans are confused by this, providers are confused 

by this, and our internal staff are used to doing care in the community the way they have always done care in the community. Notwithstanding communication and hours of training and everything 

else, we still have people that are ingrained in their old habits. 

And so what we are in the process of doing right now is shifting 

that over. 

We are looking at access writ large and assessing how we are improving access and then underneath that how we are using the different tools that we have, VA community care being one of those 

broadly and Choice being a part of that. Choice has got to become 

a dramatically larger segment of that care in the community that 

we are delivering. 

Ms. BROWNLEY. And I heard what the chairman said with regards to your concept of trying to merge all of these programs. If 

we were going to do that, is the tool that you need is simply budget 

flexibility or does it go beyond that? 

Mr. GIBSON. I think ultimately it likely would involve some kind 

of budget flexibility because right now we have got two different 

buckets of money. But I am just presuming that there would be 

other legislative relief that we would need in the process of trying 

to consolidate what are today six or seven different channels 

through which we provide care in the community. 

Ms. BROWNLEY. So the Choice Act being underprescribed, what 

is being overprescribed in terms of your budget? 

Mr. GIBSON. I would say our traditional VA care. PC3, it is still 

a new program, and it is still a very small percentage. It is really 

our traditional. As I mentioned in my statement, we have been referring veterans for care in the community for years. Folks are 

used to doing that a certain way. There are providers that they are 

used to referring their patients to on a routine kind of basis. And 

so that is what is being overutilized. 

The requests that the chairman was alluding to earlier was really one where from our perspective Choice was designed to help accelerate access to care, to make care in the community more available to veterans. That is precisely what we have been trying to do. 

We have just been using traditional channels to accomplish that as 

opposed to being able to get all the system and veterans and providers in place to do it through Choice. 

Ms. BROWNLEY. Thank you. 

I yield back, Mr. Chairman 

The CHAIRMAN. Dr. Abraham. 

Mr. ABRAHAM. Thank you, Mr. Chairman. 

Mr. Secretary, going back to Dr. Roe’s line of questioning on 

what you described as the slow—— 

Mr. GIBSON. Paying low and slow. That is you say down South. 

Mr. ABRAHAM. I would add no pay in certain districts in Louisiana that I am familiar with. And you said you have had 42 percent increase in claims. We understand that. And I understand 

that you are trying to consolidate the payment system. But objective data, since we have done this, I mean, we have got clinics in 

my district that are owed well over $1 million, and they have, unfortunately, to their chagrin, turned veterans away, not that they 


VACREP0180 with DISTILLER
28 

want to, but they just can’t afford to see them. What is the time 

now as to payment of that claim? 

Mr. GIBSON. Great. Thanks for the question. 

What VA historically tried to manage to was to pay 80 percent 

of claims within 30 days. 

Mr. ABRAHAM. But that is not happening. 

Mr. GIBSON. Historically, that happened in most VISNs, but 

VISN 16 was one that chronically underperformed, because I used 

to have the VISN director in my office repeatedly before she retired 

and before we consolidated all this stuff about that very issue. In 

part because of the feedback that we have received from you and 

other Members in the Louisiana delegation, we have focused very 

intensively on VISN 16 and specifically on the Louisiana market. 

I can tell you in VISN 16, that 80 percent standard that I was 

referring to, in the month of December in VISN 16, 35 percent of 

claims were within 30 days. 

Mr. ABRAHAM. Okay. 

Mr. GIBSON. Today that number, I think it is 78 percent are 

within 30 days. 

Mr. ABRAHAM. Okay 

Mr. GIBSON. In New Orleans per se it is now at 85 percent, still 

not where it needs to be. 

The other thing I would mention very quickly is, and this is part 

of bringing management focus at an enterprise level to this activity, you never would have organized this way to do this kind of 

work ever. It is crazy. 

We are now focussing on issues, and one of the things we learned 

is that the industry standard is actually 90 days, 90 percent within 

30 days, but it is on clean claims. So my question was, so what percent of our claims are clean? Sixty. Forty percent of our claims 

don’t have authorizations matched up with them. That then sends 

us back into process improvement, to figure out how we drive process improvement so that we have got a higher percentage of the 

claims coming in the door that are clean so that we can process 

those timely. We are after it. 

Mr. ABRAHAM. Okay. It sounds like we are making some 

progress. 

Mr. GIBSON. We are after it. 

Mr. ABRAHAM. Quick question on Hep C. 

Mr. GIBSON. Yes, sir. 

Mr. ABRAHAM. Certainly, ethically and morally, as a physician, 

I know it is much better to treat the disease than the symptom. 

Mr. GIBSON. Yes, sir. 

Mr. ABRAHAM. And certainly it is more financially advantageous 

to treat the disease, certainly when you are talking about a Hepatitis C patient. 

You said there were $660 million shifted to the Hep C program. 

I guess my first question is, where did that money come from? And 

secondly, how much more money are we talking about knowing, if 

you do know to date, how many veterans are testing positive for 

Hep C, and how much money are you anticipating, more than the 

$660 million, needing? 

Mr. GIBSON. Yes. We moved $688 million. We moved it from VA 

care in the community because we expected VA care in the commuVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

VACREP0180 with DISTILLER
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nity to be shifting those costs to over into Choice. That hasn’t happened, as we have described. 

At the current rate of new starts for Hep C between now and the 

end of the year, we will need $400 million in order to be able to 

close that gap at the current rate. And that is an urgent issue for 

us. 

I think the intermediate-term discussion really has to do with 

what is the requirement that we all, Congress and VA, agree that 

we will manage to. We have today in our records 136,000 Hepatitis 

C Active veterans and some additional amount that we expect are 

Hep C positive that aren’t in the inventory. 

I think, frankly, the requirement we should be managing to is to 

reach functional zero among veterans that are Hep C positive by 

the end of fiscal year 2018. And I think then you step back, you 

look at the cost associated with doing that over a 3-year period of 

time. But that to me is the discussion that we should be having 

among ourselves, agree on the requirement, and then it is basically 

we are into executing. 

Because the challenge that we run into is you pick a dollar 

amount and you wind up in a situation where you are denying a 

veteran, who is Hep C positive, who comes to see you, he is ready 

for treatment, he is not abusing alcohol, he is not abusing substances, and he wants the treatment. And if you have managed to 

a number, you can’t provide it. I don’t want to put our clinicians 

in that position. You wouldn’t want to be in that position. 

Mr. ABRAHAM. Right. Okay. 

Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Ms. Kuster. 

Ms. KUSTER. Thank you, Mr. Chairman. 

And thank you to our panel. 

I want to follow up on a visit that I had last week to White River 

Junction Hospital in Vermont serving most of my district in New 

Hampshire. First of all, things are going well. I was very, very impressed, particularly with the mental healthcare. I had a tour of a 

really outstanding drug and alcohol treatment facility that I wish 

we could have for my constituents across the district. And I am 

pleased to see our veterans getting good care. I had a presentation 

on telemedicine that was fascinating and is very helpful. 

What I learned from the folks there is that they actually have 

a preference for the way they were doing business, and I think you 

just made a reference to this. They were providing community care 

as they saw the need, both travel and the appropriateness of care 

in the community. 

And one of the issues that we talked about that was preferable 

under the previous program was the medical record and the relationship between the provider at the VA and the community provider where the VA was personally engaged in setting up that care. 

They were able to make a call the day before the appointment to 

make sure that the vet received the care. They made a followup 

call, how did it go, do you have any questions, is there anything 

you need from us. They got the record electronically in a way that 

was timely, and so that when they came for their next visit at the 

VA, the VA was aware of the care that they had had. 


VACREP0180 with DISTILLER
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And so I am happy to work with you. I think, in a bipartisan 

way, there are folks that want to work with you to make this work. 

But that is my question, is how can we do better on the transfer 

of the medical record and, again, just being veteran focused to 

make sure they get the care they need? 

Dr. TUCHSCHMIDT. I am glad to hear that story because that is 

a really exciting good news story I think there. 

I think we have a lot of work to do. We have been traditionally 

a closed kind of HMO model, much like a Kaiser Permanente, 

where we can coordinate care, we can coordinate some of those 

handoffs. And if you look, we have bought more and more care out 

in the community over—well, really going back since about 2006, 

2007, with this year turning out to be probably a banner year. 

The challenge we now have is doing what I think you are talking 

about, is how do we really, if we are getting care outside the system and we have more of an open system, how do we really coordinate that care and manage that care on behalf of veterans, and 

how do we empower veterans with the right information and tools 

to make wiser decisions for themselves in that environment? 

I think we have a lot to learn, quite frankly. I think all of American healthcare is trying to figure out how to do this. We have a 

lot to learn. I think that we have really good partners to try and 

do this. And Dave may want to talk about some of the new portal 

stuff that you are opening up. 

But I think ultimately it is about communicating back and forth 

with us: How do we exchange information without having to fax 

and Xerox and all that other kind of stuff and use more of an electronic environment? 

Ms. KUSTER. Great. 

Mr. MCINTYRE. One of the gaps that we discovered in Phoenix 

as we and the VA got together to evaluate what went well and 

what didn’t go well as we moved through August 17 was that the 

pipes that we had set up didn’t allow for the efficient movement 

of information or the effective movement of information. 

So prior to that time most of the medical records from the community care were not getting back to the VA even though they 

were buying the care directly. One of our obligations and Health 

Net’s obligations was to actually make sure that that happens. We 

built it in before we pay the provider. So there is an incentive to 

return it. So we got a lot of this back. It went into a portal. And 

what we discovered was that the VA staff found a very labor-intensive process that did not work. 

So we and they sat together in a room with a black belt group 

that actually helped them redesign what those tools were going to 

look like. We are rolling those out starting the 26th of May, right 

after Memorial Day. And so we are revamping the entire process, 

and every geographic space we are responsible for will now get a 

rearchitected approach to how that works. 

Dr. TUCHSCHMIDT. And just in 10 more seconds, I think ultimately the ideal situation is if we had computable data moving 

back and forth, if we had the ability to exchange information between electronic record systems in the private community with our 

system. I think the state of the art across American healthcare is 

just not there yet to do that in a consistent and reliable way. 


VACREP0180 with DISTILLER
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Ms. KUSTER. Well, from what we have heard in this committee, 

it can’t be any harder than trying to exchange it with DoD. So 

thank you very much. 

Thank you, Mr. Chair. I yield back. 

The CHAIRMAN. Mr. Costello. 

Mr. COSTELLO. Thank you, Mr. Chairman. 

We are here to talk about the Choice Act, and obviously attendant with the Choice Act is making sure that there is accountability 

with the Choice Act. So Deputy Secretary Gibson, I want to ask 

you this question. According to an April 22, 2015, report, reported 

in the New York Times, the VA has not successfully fired anyone 

at all for wait time manipulation, which continues to be a source 

of frustration for many. Is it too hard to fire VA employees who 

have committed wrongdoing? 

Mr. GIBSON. As I come into this organization from the private 

sector, what I find is it is hard to hire and it is hard to fire, and 

I think that is the case all across the Federal Government. I would 

tell you that we use, have used and continue to use every authority 

that we have at our disposal to be able to hold people accountable. 

But as we take actions, those actions, by law, have to be able to 

withstand an appeal. 

Mr. COSTELLO. So mindful that there were 110 VA medical facilities who have maintained secret lists, what you are saying is that 

the actions that are ongoing within the VA are intended to root out 

those who have committed intentional wrongdoing relative to data 

manipulation? 

Mr. GIBSON. Yes. There were actually 113 sites that were 

flagged. 

Mr. COSTELLO. Very good. 

Mr. GIBSON. And when they were flagged, it didn’t mean that 

there was wrongdoing. It meant that there was something in the 

data in the survey that raised a question. A very large number of 

those were ultimately cleared by the IG, and we send a letter, a 

bill of clean health to those organizations so that they and their 

congressional delegation can become aware of that. 

Others, the IG comes back with some questions, and we send in 

an investigative team where there are those particular questions, 

and there have been individuals where accountability actions have 

been taken, everything from a letter of reprimand up to removal. 

It is a relatively small number. There are dozens of additional of 

those that are either still with the IG or are still in the process of 

being investigated internally, and we are going to continue to pursue it until we have gotten through every single one of them. 

Mr. COSTELLO. Let me direct your focus now to AIBs. Now, the 

Philly VARO serves about 800,000 veterans, including some in my 

congressional district. The IG report came out. Now, they have 

impaneled an AIB to more closely scrutinize it and I hope name 

names and start restoring some accountability to identify who did 

wrongdoing. 

There have been AIBs appointed in a number of different—we 

can go to Denver, Wisconsin, Virginia—in instances where the AIB 

has not operated as effectively as it should, I am going to put it 

kindly. How do we go about explaining how those mistakes occurred? Do you think the AIB process is inherently flawed? How 


VACREP0180 with DISTILLER
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do we make sure that moving forward the AIBs are performing at 

a high level with the expertise needed and with the independence 

needed to make sure that when findings are made there are no 

concerns that things are still being swept under the rug? 

Mr. GIBSON. Yes. That is a great question. That was and still is 

a fundamental concern that I had in my earliest time, in my time 

as the acting secretary. 

Mr. COSTELLO. And does that still persist? 

Mr. GIBSON. That is why I set up the Office of Accountability Review. My perception is that VA was in the habit of not exercising 

appropriate accountability actions in the wake of mismanagement 

or wrongdoing. That is a generalization, but it was one that I held 

and still believe generally that that had been the case in the organization. 

We set up the Office of Accountability Review in order to create 

that level of independence as part of recalibrating the organization’s accountability action. So every senior executive investigation, 

every senior leader investigation, and those that are of particular 

note wind up being managed by the Office of Accountability Review. They appoint the AIB. And on any senior executive issue I 

am the deciding official. That is how I ensure that we are taking 

appropriate action in relation to the misconduct. 

Mr. COSTELLO. To the appointment of the AIB or to the AIB’s 

findings? 

Mr. GIBSON. The Office of Accountability Review appoints the 

AIB and we ensure that we have got individuals that are independent of the organization where the alleged activity has occurred. The Office of Accountability Review charges that AIB. And 

on a senior executive, I am the deciding official to ensure—— 

Mr. COSTELLO. So if an AIB is with a broad brush doing an investigation and as part of that investigation you have senior officials that may be the subject of inquiry, you are signing off on it 

to make sure that you have the expertise and the independence 

sufficient to do the investigation. 

One final question. Puerto Rico VA, there is a report indicating 

that a potential whistleblower was threatened with fines of up to 

$20,000 for leaking information. Are you familiar with this generally? 

Mr. GIBSON. I am generally familiar with it, and I have directed 

the Office of Accountability Review to dig in. 

Mr. COSTELLO. And you can appreciate how important it is for 

VA employees across the country to have assurances that whomever, if this threat did in fact happen, that it needs to be dealt with 

swiftly because it is the intimidation element here that shuts down. 

In Philly VARO, you have some whistleblowers that will not come 

forward but channel their whistleblowing through another whistleblower who is willing to step up based on the fear of retaliation. 

Mr. GIBSON. Bullying, retaliation, intimidation is absolutely unacceptable, and I send that message, Bob sends that message every 

opportunity that we get. The other thing that I have messaged 

across the organization is we will not change the culture of VA unless we hold people accountable, and that is why this gets as much 

of my time and attention as it does. 

Mr. COSTELLO. Thank you. I yield back. 


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The CHAIRMAN. Ms. Brown. 

Ms. BROWN. Thank you, Mr. Chairman. And before I begin, I 

want to make a couple of quick announcements. First of all, May 

26, the opening of the Orlando VA hospital. Is that correct? 

Mr. GIBSON. It is, yes, ma’am. 

Ms. BROWN. Okay. Good. So I have heard it here and I am going 

to be down there, so it better open. 

And the next thing is on May 29 is when I am planning on going 

to Denver. So any of the members that would like to go with me 

on the 29th, that is my date, because I really want to see the facility and really get a on-hands, in-person update on it. 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN. So that is May 29. 

And before I just begin my questioning, also I just want the 

chairman to know that I voted for the Florida lottery and that was 

the worst vote I have ever taken in my life, and I regret that one. 

Now, on to the questioning. Thank you, Ms. Hoffmeier, for coming to Jacksonville. I thought that was extremely helpful. Not only 

did we meet with the veterans, but we also met with the stakeholders and various community leaders and organizations to get a 

clear understanding of the Choice Program. 

Some of the veterans were saying that the program wasn’t working. Well, the program just started. And one of the things that we 

in Congress demanded, that we sent a Choice card to all of the veterans, whether they was eligible or not. And so that created some 

confusion. And can you address that first? Both of you. 

Ms. HOFFMEIER. Thank you again, Ms. Brown, for the opportunity to attend the meetings with you in Jacksonville. They were 

invaluable. 

I think there is no question that there has been a lot of confusion 

created by the card. Actually, we heard that, as you just said, firsthand at the meeting and that was probably one of the most helpful 

discussion points with veterans after the meeting. 

I was asked yesterday a question at the Senate VA Committee 

hearing that, to be honest with you, threw me a little bit at first 

but it was whether I had any credits cards. And the reason that 

was asked was because with a credit card you receive, about a fourpage set of rules in teeny, tiny print once a year, and what do most 

people do with that? Unfortunately, they throw it out. It is too hard 

to read. 

And one of the things that we worked very collaboratively with 

VA on at the beginning in mailing the cards out was trying to 

make sure we designed the envelopes and the letters so it was very 

clear it was official mail and that a veteran would read it. But that 

may not have been the case in every case. And I think one of the 

things that we need to continue to do together is to try to make 

it very easy for veterans to understand the program, and we need 

to do more outreach and more education, and really would welcome 

more opportunities like the one we had in Jacksonville with you. 

So thank you for that. 

Ms. BROWN. Thank you. 

Dr. Gibson, the article came out in the paper several times that 

my Jacksonville clinic or vet service is one of the worst in the country. And so I have had many meetings with veterans. And I needed 


VACREP0180 with DISTILLER
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to know the definition of what is the worst in the country. And of 

course, it is not the service at the VA. Once they get in there, they 

think it is the best. It is actually getting in there. 

And when we built the clinic, it was already overflowing. And 

that has happened throughout the country because now that we 

have this new awareness, then more veterans are coming forward 

and we have got to figure out how to serve them. And I guess it 

is a little bit of confusion on all of our parts. 

Mr. GIBSON. Yes, ma’am. As I alluded to generally in my opening 

statement, what we are finding in instance after instance is we 

take a step, make a major investment to improve access to care, 

and we get a disproportionate response and additional demand. 

That is telling us that there is pent-up demand among veterans for 

additional care at VA. I think clearly that was the case in Jacksonville. 

I will tell you, one of my points of frustration. I visited Gainesville, Florida, on the 26th of June. It was on that day that I directed that the team there, that has responsibility for the Jacksonville outpatient clinic, to go find space in the community so that we 

could expand access to care and get additional providers. We are 

hoping—we are hoping—to be able to see veterans in that space in 

August. 

And I am told that that is at light speed as we have worked 

through the acquisition process associated with being able to go 

lease 20,000 square feet of space. And so that is not responsive to 

the needs of veterans. 

I would tell you, it hasn’t come up. We are talking about Choice, 

we got 27 leases that were authorized in the Choice Act. On average, we are saying right now it is going to take us 5 years to activate those facilities. That is unacceptable. That is not responsive 

to the needs of veterans. 

We have been doing Lean Six Sigma on that process to try to figure out how we accelerate it, and maybe we have trimmed 4 or 5 

months off. That is not acceptable. We have to find a better way 

to do that in order to meet the needs of veterans 

Ms. BROWN. What I want to know is what is it that we can do. 

You talked about flexibility. We need to know exactly what kind of 

flexibility that you have had. Because I have talked to some of our 

stakeholders. For example, you said UF Shands, they want to be 

partners. All 400 of their physicians have signed up for the Choice 

Program. I mean, we have a hospital right there, right next to it 

that can provide additional space. And trying to get the Choice 

with the community, the other program that is already in place, 

and what is the difference between the two? I mean, why is it that 

we can’t speed it up? 

Mr. GIBSON. We will actually be providing specific language that 

support each of the individual requests that I have identified in my 

opening statement, and that includes that kind of flexibility that 

would allow us to be able to utilize Choice for a lot of that care. 

Ms. BROWN. Last thing. I mean, the Denver issue we are discussing and trying to figure out how we are going to come up with 

the flexibility because we don’t need to leave Denver without the 

funding source that they need. But many Members have said: Well, 

we don’t want to take the money from the Choice Program. And I 


VACREP0180 with DISTILLER
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certainly don’t want to take it from the $5 billion that we have gotten to provide additional physicians, additional clinics, or whatever 

we need. 

And you say: Well, Denver is not my area. Our responsibility on 

this committee is for veterans all over the country. And so we have 

got to work to figure out how we are going to meet these extremely 

challenging areas of—— 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN [continuing]. Funding these other facilities that are 

almost ready, but the cost overruns. And when we say cost overruns, was that a realistic cost in the beginning? 

Mr. GIBSON. I think all the evidence indicates that it was not. 

Ms. BROWN. You got an answer to my question, though? 

Mr. GIBSON. Well, the answer is, yes, we have to find a way to 

pay for that. In prior years I would tell you there would have been 

much more flexibility inside VA. We are doing everything we can, 

Hepatitis C, access to care in the community, additional hiring, accelerating hiring, trying to improve access to care. This is not the 

time where we can go find $700 million sitting on the sidelines 

somewhere. There are no easy answers. 

If we are permitted to access the $5 billion, we will get the minor 

construction programs into the 2017 budget, we will work all those 

nonrecurring maintenance items into the 2017 and the 2018 budget 

to the extent that the budget amount will allow us to do that, so 

that it is not an open-ended delay in those particular projects. But 

we are out of alternatives in terms of finding a place to cover that 

cost. 

Ms. BROWN. Well, let me again thank you for your service and 

all of you all for your testimony this morning. 

Mr. GIBSON. Yes, ma’am. 

The CHAIRMAN. Mr. Lamborn. 

Mr. LAMBORN. Thank you for the consideration. 

Mr. McIntyre, before I ask a question of you, I just want to say 

that you used to provide care in Colorado. And I want to commend 

you. You had an excellent reputation, your whole organization, and 

you did an exemplary job. So thank you. 

Mr. MCINTYRE. Thank you, sir. 

Mr. LAMBORN. I know that you pay the providers in your network promptly, it sounds like. But my question isn’t that, but how 

promptly are you paid by the VA so that you in turn can pay the 

providers in your network? 

Mr. MCINTYRE. Well, we are paying the providers with our funds, 

and then we seek to gain reimbursement from the VA. 

I would say at this point it is actually working reasonably well. 

And it takes a little while to get the gears moving. You have to 

make sure when you are establishing something new that you have 

stress tested whether the paper that is being submitted is worthy 

of payment. So you have got that issue on their side, they have 

done an appropriate job at that. But we have payment streams 

that are starting to move. 

And I think, based on what we have seen so far, we will hit a 

rhythm. And I am pretty confident that if we face a problem in 

that space, given what we are responsible for, that the Deputy SecVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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retary and the team underneath him would be very focused because that is what they have demonstrated today. 

Mr. LAMBORN. Do you have a timeframe you could give us? 

Mr. MCINTYRE. Timeframe for? 

Mr. LAMBORN. On how quickly you are reimbursed? 

Mr. MCINTYRE. I could pull some information for you. I don’t 

have it at the top of my fingertips. 

We do have a few spaces where we have got some arrears, but 

those things are being attended to. The challenge is that some of 

this has to run through each VA medical center given the uniqueness of some of these programs. 

Mr. LAMBORN. Okay. 

Mr. MCINTYRE. We are in good shape. 

Mr. LAMBORN. All right. Thank you. 

Now, Mr. Gibson, I am going to ask you about an unrelated matter, because I am going to take advantage of the fact that you are 

here in front of us today. So you may not be 100 percent prepped 

on this, but I am sure it is something you are following. 

Mr. GIBSON. I will give it a try. 

Mr. LAMBORN. Earlier this week there was an article in the Wall 

Street Journal and it talked about the computerized disability assessments. And it said that there was a high error rate, because 

probably in the desire to save time. But anyway, the result was 

there was less human interaction. The reviewer wasn’t allowed or 

the program didn’t accommodate individual comments that may 

help give a more rounded picture, a more complete picture of the 

disability. So what is your response to that article in the Wall 

Street Journal? 

Mr. GIBSON. Since I have been busy preparing and testifying 

these last couple of days, I haven’t had the chance to do the deep 

dive on that issue. That is tomorrow. I would tell you, as I am recalling, the person that was quoted in the article had left VA in 

2012, had worked at VA for many years, and I suspect the context 

within which that person had experienced claim processing was one 

of a paper-based process where you had individuals sitting and 

turning every single page. 

Our duty to assist means that the claims raters are basically 

looking at every single piece of evidence that sits in that file. Part 

of what we have done here is gone through a paradigm shift in 

terms of how we operate and harnessing automation to be a tool 

for individuals to be able to make well-informed decisions. It is not 

to take information out of their hands, it is to make the information more readily available. They still have the obligation to review 

all the evidence in the file when they are making that particular 

decision. 

Now, having said all that, I will do the deep dive starting tomorrow so that I can understand more substantively if there is a particular part of the VBMS system that this individual was making 

reference to so that I can understand what the specifics are. 

Mr. LAMBORN. Okay. Thank you. I think everyone would agree, 

we want those assessments to be as accurate as possible. 

Mr. GIBSON. Absolutely. 

Mr. LAMBORN. Not too low or not too high. I mean, it has to be 

accurate. 


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Mr. GIBSON. Doing the right thing for veterans and being good 

stewards of taxpayer resources. It is both at the same time. And 

if we are granting disability when there is not an entitlement for 

that, we are not doing the right thing for the taxpayer. 

Mr. LAMBORN. Mr. Chairman, maybe we can hear more about 

that at one of our future hearings. Thank you, and I yield back. 

The CHAIRMAN. Thank you very much. We appreciate the first 

panel. 

I would read one thing out of the Choice Act law that says that: 

It is the sense of Congress that the Veterans Choice Fund is a supplement but distinct from the Department of Veterans Affairs’ current and expected level of non-Department care currently used by 

the Department’s medical care budget. Congress expects that the 

Department will maintain at least its existing obligations of nonDepartment care programs in addition to but distinct from the Veterans Choice Fund for each of the fiscal years 2015–2017. 

Mr. GIBSON. And I am very familiar with that provision, and my 

interpretation of that language has always been that the idea was 

don’t let VA use Choice money instead of using money for other 

care in the community programs and then take and divert those 

funds someplace else. We have done exactly the opposite. We have, 

in effect, overused care in the community. 

The CHAIRMAN. I appreciate it very much, but while I agree with 

the desire to manage to requirement, you have a budget, and there 

have been decisions made within that budget that busted the budget. You are trying to backfill that budget now by extracting from 

one fund and then talking about using the Choice Program as the 

default program, which sounds great. But when you are pulling 

money out of the other program that was supposed to be supplemented it is going to drain the money out of the Choice Program 

much quicker than it was originally intended. 

So while I appreciate the magical accounting that your folks have 

figured out, that is not the intent of Congress. And we will work 

with you in the budget on Hep C. I get it. But somebody was asleep 

at the switch on the request. I mean, $100 million, then it goes to 

$600 million, that is almost like the Aurora hospital at 350 to 1.75. 

Somebody has got to get better at forecasting. And I know you and 

the Secretary are working very diligently—— 

Mr. GIBSON. We are. 

The CHAIRMAN [continuing]. In order to correct that, so this is 

not aimed specifically at you, but maybe to the bean counters within the Department that are trying to find the dollars. But this is 

not a place to look. 

And I appreciate very much everybody being here today. We 

have got a second panel to go to. So thank you very much. 

Mr. ABRAHAM. [Presiding.] Appreciate you guys being here. 

Joining us on the second panel is Darin Selnick, Senior Veterans 

Affairs Advisor for the Concerned Veterans for America; Carlos 

Fuentes, Senior Legislative Associate for the National Legislative 

Service of the Veterans of Foreign Wars of the United States; Roscoe Butler, the Deputy Director for Healthcare for the Veterans Affairs and Rehabilitation Division of the American Legion; Joseph 

Violante, Legislative Director for the Disabled American Veterans; 


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and Christopher Neiweem, the Legislative Associate for the Iraq 

and Afghanistan Veterans of America. 

Thank you for all being here. 

Mr. Selnick, we will start with you. You have 5 minutes, sir. 

STATEMENT OF DARIN SELNICK, SENIOR VETERANS AFFAIRS 

ADVISOR, CONCERNED VETERANS FOR AMERICA; CARLOS 

FUENTES, SENIOR LEGISLATIVE ASSOCIATE, NATIONAL 

LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF 

THE UNITED STATES; ROSCOE G. BUTLER, DEPUTY DIRECTOR FOR HEALTHCARE, VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION; JOSEPH A. 

VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR, DISABLED 

AMERICAN VETERANS; AND CHRISTOPHER NEIWEEM, LEGISLATIVE ASSOCIATE, IRAQ AND AFGHANISTAN VETERANS 

OF AMERICA 

STATEMENT OF DARIN SELNICK 

Mr. SELNICK. Chairman Miller, Ranking Member Brown, and 

members of the committee, I appreciate the opportunity to testify 

at today’s hearing on the Choice program, and thank you for your 

leadership in ensuring that veterans get the quality healthcare 

they deserve. 

Today, true choice in veterans healthcare remains out of reach 

for most veterans. Like a mirage in the desert, as you move closer, 

it recedes into the horizon. 

Our assessment is that the Choice program has been unsuccessful and is not a long-term solution. As such, we have developed recommendations for comprehensive reform through the bipartisan 

Fixing Veterans healthcare Task Force. The current rules pertaining to Choice do not represent real choice. Instead, they require 

veterans to obtain approval from VA before they are able to make 

a choice. Veterans should not have to ask for permission to select 

their healthcare provider. 

VA implementation of the Choice program has been a failure. For 

example, the Associated Press has reported ‘‘GAO says veterans’ 

healthcare costs a high risk for taxpayers.’’ The number of medical 

appointments that take longer than 90 days to complete has nearly 

doubled, and that only 37,000 medical appointments have been 

made through April 11. 

Last fall, CVA commissioned a national poll of veterans. The result showed 90 percent favored efforts to reform veterans 

healthcare; 88 percent said eligible veterans should be given the 

choice to receive medical care from any source they choose; 77 percent want more choices, even if it involved higher out-of-pocket 

costs. 

Choice and competition are the bedrock of today’s healthcare system. We choose our healthcare insurance provider and primary 

care physician. healthcare organizations provide quality and convenient care because they know if they don’t, they will lose their 

patients to someone else. In order to fix the VA healthcare system, 

both choice and competition must be injected into the system. 

VA has recognized this when they said, ‘‘Evaluation options for 

potential reorganization that puts the veteran in control of how, 


VACREP0180 with DISTILLER
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when, and where they wish to be served. Unfortunately, veterans 

do not have that control, and will not under the current VA 

healthcare system. VA needs a 2015 healthcare system. We believe 

the Veterans Independence Act is a roadmap and solution to do 

just that. This roadmap was developed by the Fixing Veterans 

healthcare Task Force, co-chaired by Dr. Bill Frist, former Senate 

majority leader, Jim Marshall, former Congressman from Georgia, 

Avik Roy of the Manhattan Institute, and Dr. Mike Kussman, 

former VHA Under Secretary. 

We first developed 10 veteran-centric core principles that serve 

as the guiding foundation. These principles included: The veteran 

must come first, not the VA. Veterans should be able to choose 

where to get their healthcare. Refocus on and prioritize veterans 

with service-connected disabilities and specialized needs. VA 

should be improved and thereby preserved. Grandfather current 

enrollees. And VHA needs accountability. 

To implement these principles, we laid out three major categories 

of reform and nine policy recommendations: 

First, restructure the VHA’s independent government chartered, 

nonprofit corporation. And power to make decisions of personnel, 

IT, facilities, partnerships, and other priorities; second, give veterans the option to seek private healthcare coverage with their VA 

funds; third, re-focus veterans healthcare and those service-connected injuries to VA’s original mission. The key policy recommendations included separate the VA’s payer and provider functions into separate institutions. 

Establish the veterans health insurance program as a program 

office in VHA. Establish the Veterans Accountable Care Organization, VACO, as a non-profit government corporation fully separate 

from VA. Preserve the traditional VA health benefit for enrollees 

who prefer it, while offering an option to seek coverage from the 

private sector through three planned choices. 

VetsCare Federal. Full access to the VACO integrated healthcare 

system with no changes to benefits or cost sharing. VetsCare 

Choice. Select any private healthcare insurance plan legally available in their State financed through premium support payments. 

And VetsCare Senior. Medicare eligible veterans can use their 

VA funds to defray the cost of Medicare premiums and supplemental coverage. Lastly, create a VetsCare Implementation Commission to implement the Veterans Independence Act. 

We retained the services of HSI to conduct the physical analysis. 

HSI determined a properly designed version of these policy recommendations is likely to be deficit neutral. 

In order the fix veterans healthcare, we must always keep in 

mind what General Omar Bradley said in 1947. ‘‘We are dealing 

with veterans, not procedures. With their problems, not ours.’’ 

That is why we urge you to use the Veterans Independence Act 

roadmap to develop the legislative blueprint that will finally fix 

veterans’ healthcare. Veterans must be assured that they will be 

able to get the quality and convenient healthcare they deserve. In 

this mission, failure is not an option. We are committed to overcoming any and all obstacles that stand in the way of achieving 

this important mission. We look forward to working with the chairVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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man, ranking member, and all members of this committee to 

achieve this shared mission. 

Thank you. 

[The prepared statement of Mr. Selnick appears in the Appendix] 

Mr. ABRAHAM. Thank you, Mr. Selnick. 

Mr. Fuentes. 

STATEMENT OF CARLOS FUENTES 

Mr. FUENTES. Chairman Abraham and Ranking Member 

O’Rourke, thank you for the opportunity to present the views of the 

men and women of the VFW and our auxiliaries. 

The VFW has continued to play an integral role in identifying 

new issues the Veteran Choice Program faces, and recommending 

reasonable solutions. 

Yesterday we published our second report evaluating this important program which made 13 recommendations to ensure that the 

program accomplishes its intended goal of expanding access to 

healthcare for America’s veterans. 

Our initial report identified a gap between the number of veterans who are eligible for the program and the number of veterans 

who were given the opportunity to participate. 

Our second report found that VA has made progress in addressing this issue. Thirty-five percent of second survey participants 

who believed they were eligible were given the opportunity to participate. That is a 16 percent increase from our initial survey, yet 

we continue to hear from veterans who report that schedulers they 

speak to are unaware of the program or unsure how it works. For 

30 day-ers, participation hinges on VA staff informing them of their 

eligibility. The lack of system-wide training for frontline staff has 

resulted in veterans receiving dated or misleading information. VA 

must continue to improve its processes and training to ensure all 

veterans who are eligible have the ability to receive healthcare in 

their communities. 

Our second report also validated that veterans are satisfied with 

their VA healthcare experience if they receive timely access. 90 

percent of survey participants who received care within 30 days reported that they were satisfied with their VA healthcare experience. Satisfaction dropped to 67 percent for participants who waited longer than 30 days. 

The 40-mile standard used to establish geographic-based eligibility for the Veterans Choice Program does not properly account 

for the diversity of the veterans’ population. Thirty-six percent of 

veterans enrolled in the VA healthcare system live in rural areas. 

Many of them are required to travel more than 40 miles for general 

goods and services. On the other hand, some urban veterans live 

within 40 miles of a VA medical center, but are required to travel 

several hours for their care. 

Our second report found that a commute time standard, based on 

population densities, would more appropriately reflect the travel 

burden veterans face when accessing VA healthcare. 

Section 201 of the Choice Act mandated 12 independent assessments of the VA healthcare system. One of those being carried out 

by the Institute of Medicine will evaluate how VA measures wait 

times; however, none of them evaluate the 40-mile standard. ConVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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gress and VA must commission a study to determine what is an appropriate measure for the geographic burden that veterans face 

when traveling to VA medical facilities. 

As the future of the VA healthcare system and its purchased care 

model are evaluated, it is important to recognize that the quality 

of care veterans receive from VA is significantly better than what 

is available in the private sector. Moreover, many of the VA capabilities cannot be duplicated or properly supplemented by private 

sector healthcare systems, especially for combat-related mental 

health conditions, blast injuries AND service-related toxic exposures, just to name a few. With this in mind, VA must continue to 

serve as the initial touch point and guarantor of care for enrolled 

veterans. 

Although enrollment in the VA healthcare system is not mandatory, and despite more than 80 percent of the veterans having 

other forms of healthcare coverage, more than 6.5 million veterans 

choose to rely on their earned VA healthcare benefits and are, by 

and large, satisfied with the care they receive. 

Moving forward, the lessons learned from the Veterans Choice 

Program should be incorporated into a single systemwide non-VA 

care program with veteran centric and clinically driven access 

standards which afford veterans the option to receive care from the 

private sector if VA is unable to meet those standards. 

More importantly, non-VA care must supplement the care veterans receive from VA medical facilities, not replace it. Ideally, VA 

would have the capacity to provide timely access to direct care to 

all the veterans it serves. We know, however, that VA medical facilities continue to operate at 150 percent capacity and may never 

have the ability to expand care to deliver direct care to all the veterans it serves. VA must continue to expand capacity based on 

staffing models for each healthcare specialty and patient density 

thresholds. 

However, VA cannot rely on building new facilities alone. When 

thresholds are exceeded, VA must use leasing and sharing agreements with other healthcare systems when possible, and purchased 

care when it must. 

Mr. Chairman, this concludes my testimony. I am prepared to 

take my questions you or the committee members may have. 

[The prepared statement of Mr. Fuentes appears in the Appendix] 

Mr. ABRAHAM. Thank you, Mr. Fuentes. 

Mr. Butler, you have 5 minutes. 

STATEMENT OF ROSCOE G. BUTLER 

Mr. BUTLER. Chairman Abraham, Ranking Member O’Rourke 

and distinguished members of the committee, on behalf of our National Commander Michael Helm and the 2.3 million members of 

the American Legion, we thank you for this opportunity to testify 

regarding the American Legion’s views of the progress of the Veterans Choice Program. 

The American Legion supported the Veterans Access Choice and 

Accountability Act of 2014 as a means of addressing emerging 

problems within the Department of Veterans Affairs. VA’s wait 

times for outpatient medical care had reached an unacceptable 


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level nationwide as veterans struggled to receive access to timely 

healthcare within the VA healthcare system. It was clear that swift 

changes were needed to ensure veterans could access healthcare in 

a timely manner. As a result, the American Legion immediately 

took charge by setting up veterans benefit centers, or VBCs, in big 

and small cities across the country to assist veterans in need and 

their families as a result of the systemic scheduling crisis facing 

the VA. 

The American Legion VBC’s charge is to work firsthand with veterans experiencing difficulties in obtaining healthcare or having 

difficulties in receiving their benefits. 

On November 7, 2014, VA rolled out the Veterans Choice Program, and after 6 months, it is clear the program falls short of the 

initial projections from the CBO. According to the VA’s latest daily 

Choice metrics dated March 31, 2015, there were approximately 

51,000 authorizations issued for non-VA care since implementation 

of the Choice program, with about 49,000 appointments scheduled. 

When you compare those numbers to the over 8 million Choice 

cards issued, one would ask, why did VA issue so many Choice 

cards? 

Nevertheless, the American Legion is optimistic that the recent 

rule changed by VA eliminating the straight-line rule and using 

the actual driving distance will allow more veterans access to 

healthcare under the Veterans Choice Program. The American Legion also believes if VA were to move forward with the 40-mile rule 

change to only include a VA medical facility that can provide the 

needed medical care or services, everyone would see increases in 

utilization and access to non-VA healthcare. 

The American Legion applauds the Senate for unanimously passing an amendment reminding the Department of Veterans Affairs 

that they have the obligation to provide non-VA care when it cannot offer that same treatment at one of its own facilities that is 

within the 40-mile driving distance from the veteran’s home. 

We now call upon the House to take up H.R. 572, the Veterans 

Access to Choice Care Act, and ensure its swift passage. Let’s get 

the bill to the President’s desk and make sure we are taking care 

of our rural veterans. 

During a recent visit last month to examine the healthcare system in Puerto Rico, the American Legion learned that VA staff had 

been mistakenly telling veterans that no one on the island is eligible for healthcare under the Veterans Choice Program because 

there is no medical facility that is further than 40 miles from anywhere on the island. The American Legion is concerned that as a 

result of inadequate training, there could be staff at many VA 

healthcare facilities who failed to receive proper training as a result, and are communicating incorrect information. 

While VA has issued a number of fact sheets and press releases, 

VA has not issued a single national directive and supporting handbook which sets forth VHA policy and operational procedures on 

the Choice program. VA failure to issue such national policies and 

procedures and tie them to existing VHA policies and procedures 

contribute to inconsistencies in implementation and staff failure to 

understand key principles of the program. Fact sheets and press 

releases are great, but they are not VHA policy and procedures. 


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In fiscal year 2014, VA spent $7 billion on national—on non-VA 

care. Many of VA’s non-VA care and programs are mandated by 

different program offices and VA central office, and some of the 

programs are handled outside of VA’s fee basis claims processing 

systems. 

VA should streamline its current purchased care model to incorporate all of non-VA’s care programs into a single integrated program. 

Thank you again, Mr. Chairman, ranking member. I appreciate 

the opportunity to present The American Legion’s views and look 

forward to answer any questions you may have. 

[The prepared statement of Mr. Butler appears in the Appendix] 

Mr. ABRAHAM. Thank you, Mr. Butler. 

Mr. Violante. 

STATEMENT OF JOSEPH A. VIOLANTE 

Mr. VIOLANTE. Chairman Miller, Ranking Member Brown, and 

members of the committee, on behalf of DAV and our 1.2 million 

members, all of whom were wounded, injured, or made ill from 

their wartime service, thank you for the invitation to testify on 

progress of the temporary Choice program. While it is too early to 

reach definite conclusions about this program, we are beginning to 

see some early lessons. Utilization of Choice program is lower than 

expected, and that can be attributed to a number of factors. 

First, since the crisis erupted last spring, VA has used every 

available resource to increase its capacity to provide timely care. 

That probably has shifted some of the demand away from Choice. 

Second, VA was slow in rolling out Choice cards and in educating 

its staff, and that confusion continues to discourage some veterans 

today. 

Finally, some veterans simply prefer to use VA. 

Mr. Chairman, we understand that desire to quickly fix the 

Choice program and to overhaul how VA provide care inside the 

system and in the community. But it could be a tragic mistake to 

rush towards permanent, systematic solutions with unknown consequences that would gamble with something as important as—to 

veterans as VA healthcare system. That is why the Choice Act 

mandated a commission to carefully study and work towards consensus recommendations on how best to reform VA. 

Recently, DAV, VFW, the American Legion, IAVA, and other 

VSOs signed a joint letter calling on Congress to give the commission enough time to do its job properly. And once the commission 

issues its final report, then allow sufficient opportunity for stakeholders in Congress to engage in a debate worthy of the men and 

women who served. 

For more than 150 years, going back to President Lincoln’s solemn vow ‘‘to care for him who shall have borne the battle,’’ the VA 

healthcare system has been the embodiment of our National promise. Yet you have heard one proposal today from the CVA witness 

calling for VA to become just another Choice among healthcare providers. But if you actually read their report and look behind their 

poll-tested sound bites, you can clearly see what they are intending 

is for VA to be privatized and downsized. And under their proposal, 

VA could even be eliminated if that is what the market chooses. 


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But for millions of veterans, the most seriously disabled, there is 

only one choice for receiving the specialized care they need, and 

that is a healthy and robust VA. Although VA provides comprehensive medical care to more than 6 million veterans, VA’s primary 

mission is to meet the unique specialized healthcare needs of the 

Nation’s 3.8 million service-connected disabled vets. If VA was 

privatized, downsized, or eliminated, as the CVA proposal could 

lead to, would the civilian healthcare system actually be able to 

provide timely access to specialized care that disabled veterans require? 

Even if all disabled—service-disabled veterans were dispensed in 

the civilian healthcare system, they would be just 1.5 percent of the 

total adult population. Does anyone truly believe that a marketbased private sector healthcare system would provide the focus and 

resources necessary to ensure the highest standards of specialized 

care for this small minority in the same way that VA does? 

Mr. Chairman, we can and must do better for the men and 

women who have sacrificed so much for our freedom. 

In DAV’s written testimony, we have outlined a framework for 

how to rebuild, restructure, realign, and reform the VA healthcare 

system. We need to rebuild VA’s capacity to provide high-quality, 

patient-centered care, restructure non-VA care programs to ensure 

timely and seamless access, realign VA’s healthcare services to 

meet the needs of the next generation of veterans, including women 

veterans, and reform VA’s management with greater transparency 

and true accountability. 

Mr. Chairman, this framework is not intended to be a final or 

detailed plan, nor could it be at this point. But it offers a pathway 

forward to a future that would keep the promise Lincoln so eloquently laid out. 

That concludes my testimony. I would be happy to answer any 

questions. 

[The prepared statement of Mr. Violante appears in the Appendix] 

Mr. ABRAHAM. Thank you, Mr. Violante. 

Mr. Neiweem. 

STATEMENT OF CHRISTOPHER NEIWEEM 

Mr. NEIWEEM. Thank you, Chairman Abraham, Ranking Member 

O’Rourke, and distinguished members of the committee. 

On behalf of Iraq and Afghanistan Veterans of America and our 

nearly 400,000 members and supporters, thank you for the opportunity to share our views with you at today’s hearing, assessing the 

promise and progress of the Choice program. 

IAVA was one of the leading veterans organizations involved in 

the early negotiations on the Veterans Access to Choice and Accountability Act as it was being drafted and the breadth of its final 

language was debated. This is a highly complex law that the Department is continuing to work to effectively implement in order to 

ensure veterans are not left waiting unacceptable lengths of time 

to receive healthcare services. 

My remarks will focus on the experiences of utilizing the VA 

Choice program IAVA members have recently reported by way of 

survey research. Additionally, I will provide recommendations ConVerDate Aug 31 2005 13:30 Jul 21, 2016 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 Y:\98-636.TXT PAT

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gress and the Secretary must consider in order to get the program 

operating at the height of its potential. 

These recommendations include legislative clarification of the eligibility criteria for assessing the Choice program; strengthening 

training guidelines for VA schedulers charged to explain the eligibility criteria to veterans; and active engagement with veteran organizations to more broadly identify a comprehensive strategy and 

plan for delivering non-VA care in the future. 

In examining the current criteria for determining which veterans 

are eligible to use the Choice program, those who must wait longer 

than 30 days for an appointment and those who live more than 40 

miles from a VA medical facility, more statutory clarity is required. 

Veterans are all too frequently reporting they are unsure if they 

are eligible for Choice, and VA has, in some cases, been inconsistent in communicating whether or not a veteran can access it in 

individual cases. 

Over one-third of IAVA members have reported they do not know 

how to access the program. This is compounded by reports that, in 

some case, VA scheduling personnel are not explaining eligibility 

for Choice to veterans and are then offering appointments off the 

grid of the 30-day standards, and sometimes, much later. I know 

because I had experienced it myself just last month at the VA medical facility here in DC. 

The Secretary must continue to engage VA front-facing scheduling personnel with ongoing and evolving training standards so 

when veterans call the VA, they hang up the phone with the correct or best answer that explains their Choice eligibility. The VA 

has improved in this area, but with so many veterans still confused 

about Choice and eligibility nearly 9 months after the program’s 

birth, training criteria must be strengthened and maintained to get 

it right. 

Congress should aid in the Department’s implementation efforts 

by clarifying in law that the 40-mile criteria must relate specifically to the VA facility in which the needed medical care will be 

provided. 

The frustrating example that has surfaced is one of a veteran 

that requires specialized care in a VA facility outside of 40 miles, 

but through strict interpretation of current VACAA law is ineligible 

for participation because a local CBOC may be geographically near 

the veteran’s address, notwithstanding that facility cannot provide 

the required care. 

One of our members illustrated one of these cases with the following statement. ‘‘Because there is a CBOC in my area, I was denied. The clinic doesn’t provide any service or treatment I need for 

my primary service-connected disability. The nearest medical center in my network is 153 miles away.’’ 

Congress must provide much-needed clarity and work with VA to 

eliminate cases like those just described. However, VA’s action to 

step up to fix the initial ineffectiveness of the 40-mile rule calculations under regulation as it related to geodesic distance versus 

driving distance is encouraging. That regulatory correction was 

much needed, and we applaud the Secretary for leading to make 

that change happen. 


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VHA’s statistics on Choice utilization among the veteran population as of this month state there have been nearly 58,863 authorizations for care, and nearly 47,000 appointments for care. This 

data verifies that veterans are out and they are using the program, 

and VA is making progress to implement what is clearly a complex 

and historic mandate relating to the punishment of veterans 

healthcare now and in the years to come. 

IAVA is committed to remaining actively engaged with veterans 

making use of Choice care so we can keep current on the veteran 

experience. We are mindful that with thousands of appointments 

for care being concluded, there will inevitably be thousands of 

unique experiences we want to know about to gauge the satisfaction that these veterans are having with the program. The satisfaction of the veterans utilizing Choice, the cost of the care purchased 

outside of VA facilities, and understanding issues that come up 

along the way will allow us to better identify the scope and role of 

the concept Choice plays in the future. 

We appreciate the hard work of Congress, the VA, and the veteran community, and recognize we have to stay focused on improving veteran healthcare delivery in the short term and long term. 

Robust discussion on the scope and cost of maintaining healthcare 

networks is complicated and multi-layered, which is why our last 

recommendation is simple. We must continue to work together and 

keep communication active among all relevant stakeholders. 

Mr. Chairman, we sincerely appreciate your committee’s hard 

work in this area. We also sincerely appreciate Chairman Miller’s 

recently introduced Veterans Accountability Act, which we strongly 

support, your invitation to allow us to participate in this important 

hearing, and we stand ready to assist Congress and Secretary Bob 

McDonald to achieve the best results for the Choice program now 

and in the future, and happy to answer any questions you or members of the committee may have. 

[The statement of Mr. Neiweem appears in the Appendix] 

Mr. ABRAHAM. Thank you, Mr. Neiweem. 

I have a question for the entire panel, and I will start with you, 

Mr. Selnick, and we will go down the line. 

There are some serious concerns regarding the training the VA 

and the TPA staff have received during the Choice program. Moving forward, what are your recommendations for the VA and the 

TPAs to improve their training efforts for the Choice program? 

Mr. SELNICK. Yes. Thank you, Mr. Chairman, for that question. 

I used to work at the VA, and when I was at the VA for several 

years, I headed up the VA Learning University, which was the department-wide—first-ever department-wide education training. We 

did the first-ever strategic plan for VA. 

VA has never fully implemented that strategic plan, and it strategically changed where it located its department-wide training 

over at HR. And so one of the problems is this whole training 

mechanism is faulty and does not work well. 

I know they have been trying to improve that, but VHA has always had a poor record in terms of overall training developments 

and a lack of ability to go ahead and be flexible in terms of the way 

it does its training. Having worked at a number of healthcare organizations and understanding how important the flexibility and the 


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ability to change your training and update your training as needed 

as new situations come, VHA just does not have the inherent capability to do it. It needs to revitalize and update its strategic plan, 

and it needs to develop the flexibilities in concert with its EES, the 

VHA training system in concert with VA—to be able to take care 

of flex needs such as the Choice program. 

Mr. ABRAHAM. Mr. Fuentes. 

Thank you, Mr. Selnick. 

Mr. FUENTES. So getting more than 300,000 staff members on 

the same page is going to be difficult, and we understand that, you 

know. But it is unacceptable that veterans continue to receive misleading information, or even dated information. 

You know, we do commend VA for recognizing this issue, and I 

have to commend Dr. Tuchschmidt for being very receptive to all 

of our recommendations and being willing to listen to them even 

though he may not like what we are saying. And we have been informed that they are in the process of rolling out mandatory training for all VHA staff and specialized training for scheduling and fee 

basis staff. And that second part, I think, is the most important 

part. Because the scheduling staff and that frontline staff are the 

ones who are really interacting with the veterans, and they are the 

ones who really need to know the intricacies and nuances of the 

program. 

You know, I don’t think they are there yet, but with support from 

the leadership, which they have, I feel that they can get there. 

Mr. ABRAHAM. Mr. Butler, do you have a comment? 

Mr. BUTLER. The key to training is making sure you have articulated, defined policies and operational procedures. Those are the 

nucleus and the basis for VA staff to use and to educate staff members on the functions and roles of a program. 

Prior to my position at the American Legion, I was the deputy 

director for policy for VA. And so in that area, you have to make 

sure that when Congress enacts a law, VA develops regulations, 

there are supporting policies in place to ensure that staff in the 

field understands the role, the functions, and the procedures for 

any new law that has been enacted. Without appropriate policies 

and procedures, that can lead to miscommunication among staff 

and senior leaders. 

So, one of the important elements, as I stated in my testimony, 

is that VA has not issued any national policies or handbooks that 

define the operational role and procedures of the Choice program. 

And it also hasn’t linked those policies and—linked anything to any 

other existing policies and procedures. So while you issue fact 

sheets and press releases, that is great. But VA needs to look at 

what are the guiding policies and procedures that they need to provide to field staff so that staff can use that information as a guide 

for training their staff. 

Mr. ABRAHAM. Okay. Thank you. 

Mr. Violante, real quickly. 

Mr. VIOLANTE. Yes. I would associate myself with the comments 

made by my colleague from VFW, and just add, I think one of the 

biggest problems right now are there too many programs out there 

that have too many criteria that have to be met. And I think it 

should be simplified. I think we have heard it from both the first 


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panel and this panel that, you know, there should be one program 

for outside non-VA care, and it should be simplified. 

Mr. ABRAHAM. Thank you. 

Mr. Neiweem, real quick. 

Mr. NEIWEEM. Yes, Mr. Chairman, I will just be more brief. 

First and foremost, the vast majority of VA employees do a really 

great job when they have the right tools. I would associate myself 

with Mr. Butler specifically. A training guideline or a memo that 

can be very brief that could be in their office space. If A, here. If 

B, here, so that every single VA scheduler says the same thing getting off the phone, and try to create a memo with just that basic 

information in front of them. 

Mr. ABRAHAM. Okay. Thank you. Good answers. 

All right. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you very much. 

You know, first I would like to note that Deputy Secretary Sloan 

Gibson is still here with us, and he is listening to your testimony 

right now as the other participants in the last panel are, and I 

think that is important in demonstrating the VA’s commitment to 

not just listening and responding to us, but listening and responding to you. So I appreciate you being here, Mr. Gibson. 

Mr. Fuentes, you, I understand, were working on the Senate side 

during the development of the Choice Act, and so you may be able 

to shed light on a question that I think was raised by the chairman 

of the full committee concerning budgeting. And the CBO when 

they were scoring the Choice Act assumed that these funds would 

be fully consumed bill early fiscal year 2016. Early fiscal year 2016 

could be, you know, anytime in the next, you know, 6 to, let’s say, 

12 months. And yet so far we have only obligated $500 million. 

Any light you can shed on the miscalculation there? 

Mr. FUENTES. Yes, sir. I did have the distinct pleasure of working for then-Chairman Sanders at the time. 

I think the projections on utilization were over-calculated. I 

mean, VA was given 3 months to implement this very complex program. We are not surprised that there were many issues, to commend VA and TriWest and Health Net, they have been really fixing 

the problems as they go. I think that participation definitely needs 

to improve. The number of veterans eligible also needs to be improved, because we know that there are certain issues with the 

standard. I mean, the VFW is committed to ensuring that that 

standard serves the best interest of veterans, and we know that it 

doesn’t right now. In terms of wait times, veterans are waiting too 

long. 

Mr. O’ROURKE. I am sorry to interrupt you. I just—I wanted to— 

I understand that we are all trying to fix it, I am just wondering 

how the mistake was made in the first place in terms of projecting, 

but it may have to be a question answered at another time. 

I want to follow up on another thing that you said, which was, 

the need to look at leasing and sharing facilities with other providers in the community. 

Could you expand on that. 

Mr. FUENTES. So you need to have an innovative look at how to 

expand capacity. You know, we have learned from many of VA’s 

mistakes that building facilities and large facilities is not always 


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the best solution. When Fort Riley, Kansas is building facilities, 

then the local VA should say: Well, you know, what? We don’t have 

the capacity to provide, women-specific services. DoD, MTFs you 

have been doing that for quite some time. Can we rely on you to 

meet that need for our veterans? 

Same thing with Indian Health Services in Alaska. They are 

doing a great job of doing that, but in other areas where they are 

present, we can expand on that, but also, sharing agreements. Denver was originally supposed to be a shared facility with the medical 

with the school. 

Mr. O’ROURKE. Right. And would you expand that to include private hospitals? 

Mr. FUENTES. Yes. Better use of affiliated hospitals and hospitals 

across the street as well. 

Mr. O’ROURKE. Not just DoD and other public services, but private hospitals. 

All right. I think that is important, and I wanted to give Mr. 

Violante a chance to perhaps expand on his comments. I feel like 

you almost presented us with a false choice of privatizing or eliminating VHA, or just doing better with the mandate that we already 

have. But I am struck by the fact that we have 28,000 open positions within the VA, that wait times, despite the crisis following 

Phoenix, or at least the attention to the crisis that existed prior to 

the news about Phoenix, but in almost the year since then, wait 

times have not improved at the VA. To me, it is really clear that 

we owe it to veterans to try some things that might be uncomfortable, that may carry some risk with them. 

I am not suggesting eliminating the VHA, but wanted to get your 

comments on what the threshold for experimentation might be, 

whether we can try pilot projects, for example, to see if we can’t 

work better with private providers in the communities. Love for 

you to respond to that. 

Mr. VIOLANTE. And, again, I don’t think DAV has a problem with 

using private providers. My concern is where—where the report 

that CVA put out could possibly lead VA. I mean, we believe that 

no veteran should wait too long or travel too far, no enrolled veteran in VA healthcare. VA needs to be able to address their needs 

in the community if need be. My only concern is that if we are providing—and, again, whether you call it Choice or purchased care, 

you know, ARCH, or PC3, VA needs the ability to do that. It is just 

a matter of how they go about doing it and where that choice lies. 

Mr. O’ROURKE. Thank you. 

Thank you, Mr. Chairman. 

Mr. ABRAHAM. Well, thank you again, gentlemen, for being here 

and for your patience. It has been some very good testimony. The 

committee may submit more questioning and we would ask for 

your expedience in answering those if so submitted. 

If there are no further questions, you are now excused. I ask 

unanimous consent that all members have 5 legislative days to revise and extend their remarks and include extraneous materials. 

Without objection so ordered. I would like to, once again, thank all 

of you here. 

This hearing is now adjourned. 

[Whereupon, at 12:40 p.m., the committee was adjourned.] 


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APPENDIX 

PREPARED STATEMENT OF CHAIRMAN JEFF MILLER

Thank you all for joining us for today’s oversight hearing, ‘‘Assessing the Promise 

and Progress of the Choice Program.’’ 

We have two full witness panels ahead of us so I will keep my opening remarks 

short in the interest of time. 

The Choice program was created last summer to address an unparalleled access 

to care crisis at the Department of Veterans Affairs (VA). 

Six months after it was first implemented, the program has successfully linked 

thousands of veterans with quality healthcare in their home communities. 

We can all be proud of that and I applaud VA and the two Choice program Third 

Party Administrators (TPAs)—Health Net Federal Services and TriWest Healthcare 

Alliance—for their initial efforts to quickly implement the program and their ongoing efforts to make it work well for the veterans who need it. 

That said, the implementation and administration of the Choice program has been 

far from perfect and many veterans are still waiting too long and traveling too far 

to receive the health care they need. 

There are many reasons for this—a lack of outreach to veterans who may be eligible, a lack of training for front-line VA and TPA staff, a lack of urgency on the part 

of many VA medical facilities who continue to adhere to their old ways of doing 

business—and I could go on. 

During today’s hearing we will discuss how to eliminate impediments to greater 

veteran and provider participation in the Choice program and how to ensure VA and 

TPA staff are properly trained and seamlessly coordinated to respond to veteran and 

non-VA provider questions and ensure the timely delivery of care. 

We will also begin discussing where VA goes from here. 

The Choice program is just one of many ways VA provides care outside of the Department’s walls. 

All too often VA’s numerous purchased care programs and authorities operate in 

conflict with one another—using different eligibility criteria, different programmatic 

requirements, and different reimbursement rates to achieve the same goal. 

That does not serve VA, American taxpayers, or—most importantly—veterans and 

their families. 

As was stated many times last year, business-as-usual is not an option. 

Congress has consistently met the Administration’s budget requests for the Department of Veterans Affairs and, as a result, VA’s total budget has increased by 

seventy-three percent [73%] since 2009. 

In comparison, veteran patients have increased by only 32% since 2009. 

Yet, VA has not and cannot fully meet the needs of the entirety of their patient 

population. 

This illustrates clearly that VA’s failures are not a matter of money, they are a 

matter of management. 

There is no one way forward, but there can also be no mistaking that, by challenging VA’s failing status quo approach to purchased care, we find ourselves at a 

crossroads of opportunity that never existed before. 

I am encouraged by and in agreement with the numerous testimonies today that 

emphasize the need to build a coordinated managed care system that incorporates 

VA care along with needed community options and resources. 

While working to improve the Choice program today, we must all prepare for the 

Choice program of tomorrow—one that brings the universe of non-VA care together 

under one umbrella so that the care our veterans receive is more efficient and effective, regardless of where it takes places. 

However, I look forward to working with veterans, VA, veteran service organizations, and all other interested stakeholders on this effort, beginning with your statements this morning. 


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PREPARED STATEMENT OF CORRINE BROWN, RANKING MEMBER

Thank you, Mr. Chairman, for calling this hearing today. As you know, it has 

been about 9 months since the President signed the Veterans Access, Choice and 

Accountability Act into law. This hearing is one in a series of hearings designed to 

follow the progress and ability of the VA to provide healthcare to veterans in the 

twenty-first century. 

I am sure we can all agree the VA provides the best healthcare for returning veterans in this country. However, we all know that there are challenges to this mission and the recognition that VA cannot do it all. 

The Choice Program offers eligible veterans access to healthcare that they may 

not have had in the past. One of this Committee’s highest priorities is to ensure 

that veterans receive the highest quality healthcare in a timely manner and in a 

safe environment. For those veterans who choose to use the Choice Program, I want 

to make sure that this is happening. 

Mr. Chairman, VA has served the special needs of returning veterans for 85 years 

and has expertise in providing services that address their unique healthcare needs, 

including prosthetics, traumatic brain injury, Post Traumatic Stress Disorder 

(PTSD), and a host of other veterans specific injuries. My focus continues to be on 

ensuring that Veterans Affairs retains the ultimate responsibility for the healthcare 

of our veterans, regardless of where they choose to live. The VA is the best system 

we have to serve the health care needs of the veterans returning from war. We cannot allow circumstances that would render the system unable to serve the very veterans it was built to serve. 

The DAV, in its submitted testimony, says ‘‘Although the VA today provides comprehensive medical care to more than 6.5 million veterans each year, the VA systems’ primary mission is to meet the unique, specialized health care needs of service-connected disabled veterans. To accomplish this mission, VA health care is integrated with a clinical research program and academic affiliation with well over 100 

of the world’s most prominent schools of health professions to ensure veterans have 

access to the most advanced treatments in the world.’’ I believe that says it all. 

I look forward to hearing from the Deputy Secretary today and all the witnesses 

to learn how the VA can better treat those veterans who have given so much in defending the freedoms we all hold so dear. 


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STATEMENT OF DANNY BREEDING

Nice seeing you again this past Monday in Morristown. Per our conversation regarding the Veterans Choice Card, all I have heard from our local veterans in Hawkins County ‘‘its a joke’’. Personally I called the toll free number and was told by 

a lady that the area I lived was not ‘‘programmed’’ in. I was told to call back in 

7–10 days to check if information was available. This was in December after the 

October roll out. 

I have also heard from a few veterans that they were told because residing in the 

immediate Rogersville area, we had a VA facility, and they could attend there. (after 

obtaining their own appointment) They were referring to our CBOC, which only has 

a primary care physicians are in our OBOC. 

Hearing other disgruntled stories through The Tennessee Department of Veterans 

Affairs quarterly training, I must agree with my fellow veterans I serve, the program is a joke indeed. Some common sense needed to be implemented before this 

program was rolled out . . . .mainly the miles issue and of course realizing the difference between a CBOC and a VA Medical Center. 

Bill, I use the VA Health Care pretty much exclusively, I’ve only good things to 

say about my treatment. I’m just thankful I haven’t had to depend on The Choice 

Card for care. With my Service Connected PTSD, I would probably make a fool of 

myself! 

Regards, and my best to you and Congressman Roe, 

Danny Breeding 

VSO/Hawkins County 

Æ 


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