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[Senate Hearing 114-291]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-291

 FIELD HEARING ON THE VETERANS CHOICE PROGRAM: ARE PROBLEMS IN GEORGIA 
                   INDICATIVE OF A NATIONAL PROBLEM?

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 21, 2015

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              

                            August 21, 2015
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1

                            REPRESENTATIVES

Collins, Hon. Doug, U.S. Representative from Georgia.............     1

                               WITNESSES

McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans 
  Affairs; accompanied by Dr. James Tuchschmidt, Acting Principal 
  Deputy Under Secretary for Health..............................     5
    Prepared statement...........................................     7
Hoffmeier, Donna, Vice President, VA Services and PCCC Program 
  Manager, Health Net Federal Services...........................    23
    Prepared statement...........................................    25
Jarrard, Stephen, MD FACS, General Surgery/General Medicine, 
  Lakemont, Georgia and Veteran..................................    30
    Prepared statement...........................................    31
Williams, Wayman Duane, Georgia Leadership Fellow, Iraq and 
  Afghanistan Veterans of America (IAVA).........................    32
    Prepared statement...........................................    34
Chacha, Carlos F., SFC U.S. Army (Ret.), Veteran.................    36
    Prepared statement...........................................    37

 
 FIELD HEARING ON THE VETERANS CHOICE PROGRAM: ARE PROBLEMS IN GEORGIA 
                   INDICATIVE OF A NATIONAL PROBLEM?

                              ----------                              

                        FRIDAY, AUGUST 21, 2015

                                        U.S. Senate
                             Committee on Veterans' Affairs
                                                   Gainesville, GA.
    The Committee met, pursuant to notice, at 1:58 p.m., at the 
Continuing Education/Performing Arts Building, Room 108, 
University of North Georgia, 3820 Mundy Mill Road, Gainesville, 
GA, Hon. Johnny Isakson, Chairman of the Committee, presiding.
    Present: Senator Isakson and House Representative Doug 
Collins.

      OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 
                   U.S. SENATOR FROM GEORGIA

    The Chairman. I would like to ask my home Legion Post, Post 
233 in Loganville, GA, to present the colors.
    [Presentation of Colors.]
    The Chairman. Would you join me in the Pledge of 
Allegiance?
    [Pledge of Allegiance.]
    The Chairman. You may be seated. I would like to call this 
meeting of the U.S. Senate Committee on Veterans' Affairs to 
order and let everyone in the audience know this is an official 
meeting of the U.S. Senate and operates under the rules of the 
U.S. Senate. We are grateful to North Georgia University and 
the people of Gainesville, GA, and Hall County for making the 
facility available today. We are very happy to be here.
    We are honored to have my dear friend, the congressman from 
this district, Doug Collins, here and I want him to give his 
welcoming remarks. But before he does, I want to say this. I 
know you all think we have a code where we always brag about 
each other. That is not necessarily true. In this case, I will 
brag about Doug because he has done a marvelous job since he 
was elected to Congress. It has been a pleasure for me in the 
Senate to work with him hand-in-hand on many, many projects. I 
am honored and privileged that he came and chose to be with us 
today at this hearing.
    So, Doug, the show is yours.

   STATEMENT OF HON. DOUG COLLINS, U.S. REPRESENTATIVE FROM 
                            GEORGIA

    Mr. Collins. Well, thank you, Senator. I appreciate that. 
It is always good when you can look across and know that the 
senator from your State is one who serves and has served and be 
a part of that. You being here today shows that commitment and 
bringing the secretary here as well.
    I want to thank our folks who are here, our staffs, our 
witnesses, many of which we have dealt with in our office, and 
the folks who are here today to be a part of this.
    Nothing can be greater in my mind than the issue of taking 
care of our veterans and taking care of people. As a veteran 
myself, as one who is still part of the Air Force Reserve, who 
has served in Iraq, there is nothing higher in my concern than 
to say, ``What are we doing, and why are we doing it?'' and 
also to be transparent about that.
    I want to thank the senator for his chairmanship on the 
Senate side of the VA--also my friendship with Jeff Miller, who 
is his counterpart in the House, who sends his regards as well, 
also to his friends.
    We have got a lot that is happening. Are there a lot of 
questions still left? Yes, there are. Are there a lot of things 
that we still need to do? Yes, there are.
    But I am also proud just to be up here in the 9th District 
of Georgia, up here in Oakwood, in Gainesville, Hall County. 
This is a great place to be from. I just want to welcome those 
who may not be from here. Come back often. We have a lake. 
There are a lot of things for you to be a part of; and just 
know that we care about this area.
    I want to thank the senator for having us here and for 
being a part of this and for the secretary and others who will 
testify. Thank you.
    The Chairman. Let me add a comment. We are all glad the 
lake is full. [Laughter.]
    Mr. Collins. That is exactly right.
    The Chairman. All the local folks know what that means.
    As I said, this is an official hearing of the United States 
Senate Committee on Veterans' Affairs, and I appreciate all of 
you for joining us today. We will operate under the rules of 
the United State Senate. There are a couple of people I want to 
introduce who are in the audience.
    Sam Smith, the DAV Chapter 17 President and Commander, 
welcome and thank you for being here today.
    Give him a big round of applause. [Applause.]
    The Chairman. And the newly elected Commander of the 
Disabled American Veterans of the United States of America from 
the State of Georgia, Moses McIntosh. Where is Moses? 
[Applause.]
    It is always good when your leader is named Moses. I know 
that.
    We are glad to have you here, Moses.
    I want to welcome Secretary McDonald and thank him for 
being here today. He is going to testify in just a minute, and 
I am going to introduce him in just a minute. But before I do, 
I want to make a few points, and then I want to make a few 
gestures if I can.
    The first point is this. The secretary, myself, Congressman 
Collins, and others are aware of an incident that took place 
June the 30th at the Oakwood Veterans Clinic here in 
Gainesville, GA. That is not a subject of this meeting for any 
number of reasons, principally because personnel issues are 
involved.
    We are not allowed, as Members of Congress nor as employees 
of the U.S. Government, to discuss personnel issues in an open 
forum until they are settled, at which time all the information 
is available and accessible to anyone. I just wanted to make 
sure that information was made clear to everyone.
    The purpose of this meeting today is to talk about the 
Veterans Choice Act and having a more veteran-centric Veterans 
Administration. There are two great anniversaries today. 
Actually, one is an anniversary and one is a beginning. This is 
the first year anniversary of the passage of the Veterans 
Choice Program, which passed in August 2014. It began to be 
implemented in November 2014 and is in full force today, 
although there are problems and there are challenges that we 
have to meet, which is why we are here today to find out what 
those are and to talk about what we are going to do to solve 
them.
    But a second great historical thing is happening today. Two 
American women are in Fort Benning, GA, graduating from Ranger 
school, where Secretary McDonald graduated. [Applause.]
    I do not know about you, but after watching the news last 
night with what they can carry on their backs, they can fight 
with me any time they want to fight. I would be happy to have 
them. We are so proud of them and so proud of Fort Benning and 
that installation and so proud, too, that Secretary McDonald 
graduated from Ranger school in Fort Benning, GA. We appreciate 
his service to the country.
    The Veterans Choice Program was an answer by the Congress 
of the United States to a major problem. A year ago, we had the 
Phoenix situation which came forward, where we had veterans who 
had died because they could not get appointments in time to get 
into the hospital. We had problems where consults were 
canceled, where people were being given bonuses for figures 
that were improved that really were not improved. We had 
situations where there was a culture in the VA that was not as 
positive as it should be.
    A number of things happened. One of them was Bob McDonald 
came along, a veteran himself, someone willing to serve, 
someone taking the job to do the job, someone who wanted to put 
the veterans in the center of his life and in the center of the 
VA system. And he has begun the process over the last 12 months 
of changing the culture of the VA, and it is obvious to me, as 
a member of that committee for 11 years in the Congress, that 
that has been the case.
    Also, we passed the Veterans Choice Program, which is a way 
to meet the challenges of the 21st century Veterans 
Administration. With operations in Afghanistan and Iraq, we all 
know we will have more and more veterans coming home to Georgia 
and to America in the years to come, and the pressure on the VA 
will be greater, not less. And the amount of pressure on the VA 
to meet the throughput necessary to see to it that people get 
timely appointments and timely services was going to be--we 
needed a force multiplier, a force multiplier being a way to 
add more productivity and more accessibility for veterans to 
quality health care.
    Veterans Choice program was that answer. We did the very 
best that we could in Congress in 2014 to write a bill that 
worked, that would give the VA more tools and would give the 
veterans more accessibility. But in doing it--anytime you 
create a new entity, you create a few problems, and we have 
been working over the last 12 months to find out where those 
problems were and correct them.
    We have been working also to see what the future of VA 
Choice could really be for our veterans. I think the secretary 
will reflect what I am about to tell you. We all know the 
Veterans Choice Program was the right thing to do. We all know 
the changes we have made and the ones we seek to make will make 
it even better. It will be the force multiplier necessary, not 
to replace VA health care, but to enhance VA health care.
    For anyone in this audience today who thinks that the 
Veterans Choice Program had anything to do with replacing the 
VA, you need to go on home, because it does not. It had to do 
with enhancing the VA, improving the VA, and giving them more 
tools and more arrows in their quiver to see to it that we met 
the needs of our veterans.
    I am delighted today to welcome the secretary of the 
Veterans Administration, Bob McDonald, to this hearing in 
Gainesville, GA. I have already told you he was a Ranger. I 
have already told you--or I did not tell you--he graduated from 
West Point.
    He took this job on at a time when not very many people 
would take on a job like this. But he did it like an Army 
Ranger does. He tackled it, decided he was going to solve the 
problems, gave out his cell phone number to everybody, 
including me, and takes calls at night. He wants to make sure 
that every veteran is at the center of the services of the 
Veterans Administration and has worked tirelessly to see to it 
that that happens.
    I just want to give you one little ancillary story before I 
turn it over to Bob for his testimony. About 3 weeks ago, we 
had a meeting at the VA--what they call at the VA a stand-up. 
Every day, they have a stand-up where all their department 
heads, all their responsible personnel at the VA stand up and 
tell what things they did last week that worked and what things 
they did last week that did not work. They talked about where 
they had successes. They talked about where they had failures.
    Jeff Miller, the chairman of the House Committee, and I 
went along with Ranking Member Blumenthal from Connecticut in 
the Senate and Ranking Member Brown in the House. We sat around 
a round table and watched the stand-up, watched them report on 
the things they were doing that were right and the things they 
were doing that were wrong.
    We also had a heart-to-heart meeting for 3 hours. We were 
about to have to close some facilities because the Veterans 
Choice Act needed some correcting and some technical 
adjustments to be able to move money and make it more fungible 
for veterans' benefits. We had to do some other things in the 
Veterans Administration to see to it that the VA worked better 
and worked quicker, and we only had about 48 hours, if I 
remember, to do it.
    We did it in 48 hours because we locked arms, we sat down 
and decided to agree rather than disagree, and we found the 
solution to the problem. So, today, the VA Choice Program is 
working better, and our veterans are having better access 
because of that day and that meeting. It is that type of can-do 
attitude that the secretary has exhibited that will make the VA 
Choice Program work and will make it work even better in the 
future.
    So, we are here today to talk about a great complement to 
VA health care. That is the Veterans Choice Program. It is a 
privilege and a pleasure for me to introduce a man for whom I 
have gained the utmost respect for all the work that he has 
done and all that he has going to be willing to do to see the 
VA through, Secretary Bob McDonald.
    Welcome. [Applause.]
    I just made my first or second mistake, because Dr. 
Tuchschmidt is here to be his aid to answer the questions he 
can not answer.
    Dr. Tuchschmidt, we are glad to have you here today.
    Give him a round of applause. [Applause.]

     STATEMENT OF HON. ROBERT A. McDONALD, SECRETARY, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR. JAMES 
TUCHSCHMIDT, ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH

    Secretary McDonald. Thank you, Chairman Isakson and 
Congressman Collins, for this opportunity to continue our 
public dialog on caring for veterans.
    This is my fourth trip to Georgia as secretary, and what I 
have seen here is representative of what is happening all 
around the country. The Atlanta Regional Benefits Office has 
shrunk its claims backlog by more than 77 percent while also 
improving accuracy. Our cemeteries in Georgia are performing 
record numbers of internments, up 60 percent in the last 5 
years, and our hospitals and clinics are providing more health 
care than ever before to Georgia veterans.
    We recently renewed many of our affiliations with important 
academic partners, such as Emory, Morehouse, and the University 
of North Georgia. And out of these partnerships have come some 
outstanding clinical care and some outstanding medical 
research. Just last week, Dr. Raymond Schinazi was awarded this 
year's William S. Middleton Award, VA's top award for 
biomedical research. Dr. Schinazi has been with Emory for 34 
years and with the Atlanta VA for 29 years, and in that time, 
he has pioneered the development of drugs to treat HIV and 
Hepatitis C.
    Georgia is one of the fastest growing areas in the country 
for veterans seeking VA care. This year, the Atlanta VA has 
seen its numbers of unique patients grow 7.5 percent.
    All around the country, VA has seen demand increase this 
year and in past years as the very large Vietnam era cohort 
moved through the high-need, high-cost, 50 to 65 age range. 
Keeping up with that growth has not been easy. It has put many 
VA employees in the position of having to do more and more, and 
some, unfortunately, responded by doing things they should not 
have, losing sight of what VA is all about.
    VA is in the customer service business. Healthcare is just 
one of nine forms of customer service VA provides. Our goal, 
our vision for the VA in the future, is to be the number 1 
customer service agency in the Federal Government. Our 
Cemeteries Administration already is number 1 in customer 
service, public or private, according to the American Customer 
Satisfaction Index. We aim to bring the rest of the VA up to 
the same standard.
    To do that, we have begun an ambitious transformation of 
VA's organizational culture and business processes called MyVA, 
applying tried and true principles of customer service from the 
public and private sectors. We brought aboard several key 
leaders with broad experience in business. Eleven of my 18 
direct reporting senior executives have joined VA since my 
swearing in. The entire leadership team is as committed as I am 
to making VA number 1 in customer service.
    We are taking action here and throughout VA to hold people 
accountable for their actions with additional training and 
disciplinary actions where appropriate. We are also meeting the 
increase in demand with more of everything available, more 
hours, more space, more people, more productivity, more 
accountability, more transparency, and, of course, more choice.
    We have completed 7 million more appointments this year 
than last. That is 2.5 million at VA and 4.5 million in the 
community. Ninety-seven percent of appointments are now 
completed within 30 days of the veteran's preferred date, 88 
percent are within 7 days, and 22 percent are same-day 
appointments.
    Average wait times for completed appointments are 4 days 
for primary care, 5 days for specialty care, 3 days for mental 
health care. The electronic wait list is down 47 percent, and 
the new enrollee appointment request list is down 93 percent. 
Overall, VA health care providers have increased physician 
productivity 8 percent on a health care budget increase of only 
2.8 percent.
    We are working both harder and smarter, and the result is 
more care for more veterans. But we still have some serious 
challenges. We are burdened with an aging infrastructure. Nine 
hundred VA buildings are over 90 years old, and most are over 
50 years old. These older buildings do not meet today's 
standards for hospital construction and need to be replaced.
    We are also seeing more veterans enrolling for VA health 
care and more enrolled veterans turning to VA for care. Most 
have other choices. Eighty-one percent of veterans have either 
Medicare, Medicaid, TRICARE, or some private insurance. But 
more are choosing VA health care because it saves them money, 
and it is more convenient, and it is often better care than 
they may get elsewhere.
    On average, enrolled veterans rely on VA for just 34 
percent of their care. But if that percentage rises just 1 
percentage point to 35 percent, VA's costs increase about $1.4 
billion. The more veterans come to us for care, the harder it 
is for us to balance supply and demand without additional 
resources. That is a fundamental problem that only Congress can 
help solve.
    Last month, VA was facing a critical shortfall in funding 
for care in the community. Authorizations for care in the 
community were up 44 percent. We are providing so much care in 
the community and also paying so much for the new miracle drugs 
to cure Hepatitis C that we are running out of money.
    So, I appealed to you, Mr. Chairman, and your congressional 
colleagues. You responded by giving me the budgetary 
flexibility to use Choice Program funds for other care in the 
community programs, and I again thank you for that. But that 
flexibility only lasts until the end of this fiscal year. Our 
next fiscal year, October 1, we will be back in the same bind 
of not having the flexibility to allocate funds to pay for the 
care veterans are actually choosing.
    Over 70 line items in our budget are inflexible, meaning I 
can not use that money anywhere else. It is like having 70 
checking accounts for every bill you have to pay, one for food, 
one for clothing, one for gas, et cetera, with no way to move 
funds from one checking account to another. Actually, it is 
worse than that. It is like having separate checking accounts 
for different foods. I can not spend health care funds on 
health care. I can not even spend care in the community funds 
on care in the community.
    We at VA believe in giving veterans a choice, and we are 
committed to making the Choice Program work. Authorizations 
under the Choice Program have gone up steadily in the past 6 
years. But Choice does not cover everything. It is just one of 
seven programs providing care in the community, each with its 
own requirements for participation by veterans and by 
providers.
    We look forward to working with Congress to consolidate our 
various care in the community programs. We need Congress to 
give us permanent flexibility to move funds to accounts that 
fund the care veterans are actually choosing.
    We need Congress to fully fund the president's 2016 budget 
request. The House-proposed $1.4 billion reduction in that 
budget would mean $688 million less for veterans' medical care. 
That's 70,000 veterans going without care. Also, the House 
passed a 50 percent cut in construction despite our aging 
infrastructure. The Senate's proposed reduction of $857 million 
would also hurt, though not as much.
    We have made great progress in the past year. We have 
tackled the access problem and have begun transforming VA's 
organizational culture and business processes to improve care 
for veterans for years to come. But we need Congress to fix 
what only Congress can. Congress defines the benefits veterans 
receive, and Congress appropriates the funds to pay for them. 
Only by balancing the two can VA serve veterans the way 
veterans expect and deserve to be served.
    Thank you for listening, and I look forward to answering 
your questions.
    [The prepared statement of Secretary McDonald follows:]
        Prepared Statement of Hon. Robert McDonald, Secretary, 
                  U.S. Department of Veterans Affairs
    Good afternoon, Chairman Isakson, Ranking Member Blumenthal, and 
Members of the Committee. Thank you for the opportunity to discuss the 
Department of Veterans Affairs' (VA's) provision of health care to 
Veterans and the implementation of the Veterans Choice Program. I am 
accompanied today by Dr. James Tuchschmidt, Acting Principal Deputy 
Under Secretary for Health.
    Caring for our Nation's Veterans, their Survivors, and dependents 
continues to be the guiding mission of VA. Each year, VA works to 
provide timely, high-quality services and benefits to fulfill this 
mission. As we emerge from one of the most serious crises the 
Department has ever experienced, however, we face continuing challenges 
in ensuring that Veterans receive the care they deserve, and indeed 
have earned through their service. But we believe that these challenges 
are surmountable, and we will continue to work with Congress to reach 
resolution and move forward in achieving our mission.
    VA's goal is always to provide Veterans with timely and high-
quality care with the utmost dignity, respect, and excellence. For the 
Veteran who needs care today, VA's goal will always be to provide 
timely access to clinically appropriate care in every case possible. 
However, as we have shared with staff for the Senate and House 
Committees' on Veterans Affairs, users of the Veterans Choice Program, 
whether Veteran, community provider, or VA employee, have identified 
aspects of the law that are challenging. It has also been challenging 
to mobilize the resources and systems required to smoothly implement 
this new Program. We are addressing these challenges and turning them 
into opportunities to improve VA care and services. I look forward to 
discussing the progress we have made thus far in Georgia and the 
Nation.
    More than a year ago--at my Senate confirmation hearing--I was 
charged with ensuring that VA is refocused on providing Veterans ``with 
the high quality service that they've earned.'' I welcomed that 
opportunity. For the last year, I've been working with a great and 
growing team of excellent people to fulfill that sacred duty (11 of 18 
of VA's top leaders are new since my swearing in).
    Because of their hard work, VA has increased Veterans' access to 
care and is projected to have completed approximately seven million 
more appointments over the past year ending May 31, 2015 than last--2.5 
million more at VA, 4.5 million more in the community. While Choice has 
been just a small proportion of that 4.5 million increase in the 
community, it's on the rise, and Choice utilization has doubled from 
May 2015.
    We've expanded the capacity required to meet last year's demand by 
focusing on four pillars--staffing, space, productivity, and VA 
Community Care.
    We have more people serving Veterans. From August 2014 to July 31, 
2015, VHA has increased net onboard staff by over 13,000. This includes 
over 1,100 physicians, 3,500 nurses, 147 psychiatrists, and 294 
psychologists for VHA's clinical care to Veterans. Included in this, 
VHA has hired over 6,400 medical center staff as a direct result of the 
VA Choice Act enacted in August 2014.
    We have more space for Veterans. We activated over 1.7 million 
square feet last fiscal year and increased the number of primary care 
exam rooms so providers can care for more Veterans each day.
    We're more productive--identifying unused capacity, optimizing 
scheduling, heading off ``no-shows'' and late appointment 
cancellations, and extending clinic hours at night and on weekends. 
We're aggressively using technology like telehealth, secure messaging, 
and e-consults to reach more Veterans.
    We're aggressively using care in the community. The Choice Program 
and our Accelerating Access to Care Initiative increased Veteran 
options for care--including Choice--for 36 percent more people than we 
did over the same period last year--a total of 1.5 million individual 
VA beneficiaries.
    In short--we're putting the needs and expectations of Veterans and 
beneficiaries first, empowering employees to deliver excellent customer 
service, improving or eliminating processes, and shaping more 
productive and Veteran-centric internal operations.
    That's MyVA--our top priority to bring VA into the 21st century.
                                outcomes
    Our strategy is paying dividends to Veterans. With the growth in 
Veteran options, we've increased VA Care in the Community 
authorizations--including Choice--by 44 percent since we started 
accelerating access to care a year ago. That's 900,000 more 
authorizations than the previous year. Between the end of June last 
year and the end of June this year, we completed 56.5 million 
appointments--a 4 percent increase over last year, and there were 1.5 
million encounters during extended hours, a 10 percent increase.
    Even with that increase in number of Veterans served, we completed 
97 percent of appointments within 30 days, 92 percent within 14 days, 
88 percent within seven days, and 22 percent same day. For specialty 
care, wait times are an average of five days. For primary care, wait 
times are an average of four days and an average of three days for 
mental healthcare.
    So, we're making verifiable progress for Veterans, and with your 
continued support, VA can be the best customer-service agency in 
Federal Government. Even as we increase access and transform, important 
challenges remain--and there will be more in the future as Veteran 
demographics evolve. It's now clear that the access crisis in 2014, 
prior to the passage of the Choice Act, was predominantly a matter of 
significant mismatch at certain facilities between supply and demand, 
exacerbated by greater numbers of Veterans receiving services.
    That sort of imbalance predicts failure, especially when we promise 
benefits to Veterans without the flexibility to fulfill the 
obligations.
    So a fundamental challenge is that VA is managing budgetary 
resources with the package of benefits and services Veterans have 
earned and been promised by Congress.
    Funding is static--our requirements are fluid, and Veterans' needs 
and preferences for care are dynamic. VHA has averaged over 35,000 new 
enrollments every month.
    We're also seeing more enrolled Veterans come to us for more of 
their care. For example, through June 2014, VHA treated over 5.54 
million Veteran patients. Through June of this year, VHA cared for 5.64 
million enrolled Veterans. This is a 1.7 percent increase in enrolled 
Veteran patients treated compared to an increase of 0.9 percent in 
enrollment for the same time period.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Why? Three reasons:

    1. The growing number of enrollees being adjudicated for service-
connected disabilities are driving significant increases in VA 
utilization;
    2. VA is providing more access to high-quality care--often better 
than available elsewhere; and
    3. Financial incentives make VA the smart choice.

    Let me give you an example: VA provides the best hearing aid 
technology anywhere. Medicare doesn't cover hearing aids, and most 
insurance plans have limited coverage. So choosing VA for hearing aids 
saves Veterans around $4,200.
    Most Veterans have other choices: 81% have Medicare, Medicaid, 
TRICARE, or private insurance. But more Veterans are turning to VA for 
more of their care. Not for all of their care: On average, enrolled 
Veterans rely on VA for just 34 percent of their care. However, if that 
percentage rises just one point, to 35 percent, our costs increase 
about $1.4 billion.
                              beyond 2016
    Services and benefits peak years after conflicts end, and 
healthcare requirements and the demand for benefits increase as 
Veterans age and exit the workforce. So, full funding of the 2016 
budget request is a critical first step in meeting these challenges, 
but we have to look much further ahead for the sake of Afghanistan and 
Iraq Veterans.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    In 1975, just 40 years ago, only 2.2 million American Veterans were 
65 years old or older--7.5 percent of our Veteran population. By 2017, 
we expect 9.8 million will be 65 or older--46 percent of Veterans.
                              2016 budget
    To meet these growing requirements, VA needs the adequate funding 
the President's Fiscal Year 2016 budget request provides. The House-
proposed $1.4 billion reduction to VA's total request, including 
allocation of a Department-wide rescission, means $688 million less for 
Veterans Medical Care--the equivalent of as many as 70,000 fewer 
Veterans receiving care. The Senate's proposed reduction to VA's total 
budget request would be $857 million.
    Further, the House proposal would provide no funding for four Major 
Construction projects and six cemetery projects. Our growing 
requirements are a clear signal that even greater challenges lay ahead, 
and we can't afford to be short sighted. I am greatly concerned the 
House-passed funding bill cuts construction by 50% at a time when 60% 
of our buildings are over 50 years old and general operating rooms 
today must be at least 50% larger than they were about a decade ago.
                           the choice program
    I want to turn to discussing how VA has worked to implement the 
Choice Program, enacted into law in August 2014. As Deputy Secretary 
Gibson testified to the Committee on March 24, 2015, the 90-day 
timeline last year to establish a new health plan capable of producing 
and distributing Veterans Choice Cards, determining patients' 
eligibility, authorizing care, coordinating care and managing 
utilization, establishing new provider agreements, processing complex 
claims, and standing up a call center was particularly challenging. In 
fact we received overwhelming feedback from the marketplace about the 
significant challenges of meeting the law's aggressive timeline. 
Despite the timeline, VA published regulations and launched the 
Veterans Choice Program on November 5, 2014, with a responsible, staged 
implementation and the goal of providing Veterans with the best 
possible care-experience, while also meeting our obligations to be good 
stewards of the Nation's tax dollars. By the end of January, 8.6 
million Veterans Choice Cards had been distributed to Veterans.
    As we have learned in seeking feedback about the Choice Program, 
users of the Program have identified aspects of the law that are 
presenting challenges, resulting in confusion for Veterans, or not 
working for Veterans as well as they need to. We also recognize that 
early utilization of the Choice Program was not as robust as expected 
or hoped. We have been eagerly seeking feedback on the program from all 
our stakeholders--from Veterans, Veterans Service Organizations, our 
employees, and Congress, and we are working diligently to address these 
challenges. To continue our outreach efforts, VA launched a public 
service announcement for eligible Veterans, viewable at: https://
www.youtube.com/watch?v=i9nnsRlX5b8. We hope all parties will share the 
video to aid in education efforts about the Choice Program. We want to 
turn these challenges into opportunities to improve our care and 
services, and I am pleased that we have worked with Congress and 
stakeholders to improve the Program in several ways over the last year.
    As of July 31, 2015, 6,589 unique Veterans residing in Georgia have 
been authorized care under Choice. These Veterans account for 
approximately 8,958 authorizations of which 5,877 have been scheduled 
for appointments.
                  va budget and choice improvement act
    The Department appreciates the VA Budget and Choice Improvement 
Act, which provided essential budget flexibility and authority we need 
to support Care in the Community through September 30, 2015. This 
legislation also made a series of amendments to the Veterans Access, 
Choice, and Accountability Act of 2014 and instituted additional 
requirements to improve access to care and VA's budgeting process.
    The VA Budget and Choice Improvement Act also codified the 
Department's initiative to develop a plan to consolidate all non-
Department provider programs by establishing a single new program, the 
Veterans Choice Program, for furnishing hospital care and medical 
services to enrolled Veterans. By November 1, 2015, VA will submit its 
plan to Congress. On July 29, 2015, VHA established a VA Community Care 
Transition Team with the charge of developing this plan to consolidate 
all VA care in the community for medical services, hospital care, and 
extended care for Veterans into a single ``Veteran Choice Program.'' VA 
is committed to simplifying the confusing array of programs through 
which VA delivers care in the community and appreciates the opportunity 
to rationalize the various statutory authorities and create a unified, 
integrated approach to community care. VA looks forward to working with 
Congress to streamline and improve access to care in the community.
    In addition, the VA Budget and Choice Improvement Act made several 
amendments to the Veterans Choice Program established by section 101 of 
the Choice Act such as:

     Removing the restriction limiting VA to furnishing 
hospital care and medical services to eligible Veterans through the 
Veterans Choice Program for a period of no more than 60 days;
     Removing the restriction that Veterans must have enrolled 
in the VA health care system as of August 1, 2014, to be eligible to 
participate in the Veterans Choice Program;
     Expanding the pool of eligible providers who can furnish 
hospital care and medical services to eligible Veterans through the 
Veterans Choice Program;
     Authorizing VA to enter into agreements with an entity 
that meets established criteria;
     Making eligible for the Choice Program Veterans who cannot 
be seen within the wait-time goals of VHA and those who, with respect 
to care or services that are clinically necessary, cannot be seen 
within the time period determined necessary if such period is shorter 
than the wait-time goals of VHA; and
     Making eligible those Veterans who are seeking primary 
care and who reside more than 40 miles from a VA medical facility that 
is able to provide such primary care by a full-time primary care 
physician.
                               conclusion
    We have made great progress in the last year. As we continue to 
work together to address Veterans' access needs, we are grateful for 
the close working relationship we have had with Congress, particularly 
this Committee, as we make progress in implementing the Veterans Choice 
Program. Mr. Chairman, we will continue to work with Veterans, 
Congress, VA community care providers, VSOs, and our own employees to 
ensure the Choice Program helps us deliver great healthcare outcomes 
for Veterans. Thank you. We look forward to your questions.

    The Chairman. Thank you, Mr. Secretary. I will tell you 
what; I will make a deal with you. I will work on giving you 
more fungibility and flexibility. I want you to respond--I had 
a letter sent to you about any publications you had put out on 
implementing Choice within the VA to get to me by July 31. I 
did not get all the answers I needed to get. So, when you get 
back, if you will get me all those answers to that letter, I am 
going to do the best I can to get you all the flexibility I 
can.
    Secretary McDonald. I sure will, sir.
    The Chairman. That is a fair deal, is not it?
    Secretary McDonald. It is a fair deal.
    The Chairman. You know, 2 years ago, in 2013, we held a 
field hearing just like this one at Georgia State University. 
The Clairmont Road VA Hospital had gone through a terrible 
situation where three veterans had committed suicide, one of 
them in the hospital itself while as a patient, and two others 
because the appointments were not timely and were not kept 
timely. Leslie Wiggins came in to be the new director of the 
hospital.
    Stand up, Leslie. She deserves a big hand. [Applause.]
    The VA brought Leslie Wiggins in to take over the operation 
of that hospital after we discovered and then disclosed through 
our hearing the problem with mental health coverage. I want to 
compliment you on the numbers--about timely appointments being 
kept in mental health, which has greatly improved. Are we where 
we need to be nationwide on mental health accessibility in the 
VA? If not, what do we need to do to get there?
    Secretary McDonald. We are not where we need to be, and we 
are not where we need to be as a Nation. As I have often talked 
about, Mr. Chairman, VA is the canary in the coal mine for 
American medicine. American medicine is not producing enough 
mental health professionals; though, as you know, we are 
recruiting. I have been to over a dozen medical schools myself, 
recruiting mental health professionals and primary care 
physicians. There is a shortage in the country. But we are 
making great progress.
    One of the things that excites me the most is the progress 
that only VA can make. I will give you an example. The other 
day, I met with a group of our researchers and doctors who have 
developed an algorithm--call it a Monte Carlo simulation--where 
we are now starting to see some evidence that we might be able 
to predict suicide.
    This would be a breakthrough, and only the VA, with an 
integrated health care system that has 40 years of medical 
records for most of our veterans in advance, can put that kind 
of algorithm together. We have published it in medical 
journals, and I am hopeful we can validate it. That would be 
not only a great benefit to all veterans, but a great benefit 
to the American public.
    The Chairman. We had a hearing in the Committee, as you 
will recall, back a few months ago on the situation in Tomah, 
WA--I mean, Tomah, WI----
    Secretary McDonald. Yes.
    The Chairman [continuing]. With the over-prescription of 
opiates. Yesterday, I happened to be at the CDC with Dr. Tom 
Frieden and Senator Perdue from Georgia. Over-prescription of 
opiates is becoming a nationwide problem in the United States. 
It is estimated that enough opiates were prescribed last year 
in America for 15 percent of the population to have a full 
year's supply at any one given point in time, which is entirely 
too many.
    What is the VA doing to get out of this candy store 
attitude of giving out opiates for mental health problems and 
getting back to a more disciplined prescription process?
    Secretary McDonald. Well, first of all, the situation in 
Tomah should have never happened. We had a situation there 
where we were not providing the kind of oversight that was 
necessary, and we had one person doubling in two roles, which 
was not providing the proper oversight.
    Second, we have a national effort to reduce the number of 
opiates that we use, a national program. One of the great 
things about the VA that we are able to do, unlike many other 
health care systems, is we try other alternatives. We are the 
number 1 user of acupuncture in the country. Yoga has been 
proven to be successful with some people in reducing their 
opiate level and equine therapy in our West Bedford, MA, 
location shows promise.
    These are therapies that are allowing us to prove positive 
results that are allowing us to reduce medication. Maybe I will 
ask Jim to comment a little bit more on the program, the 
national program.
    Dr. Tuchschmidt. We agree completely. We have been looking 
at our policies and our procedures and have really begun to put 
a program in place to educate our providers--kind of what we 
call academic detailing--about appropriate use of opioids in 
the clinical setting. I think this use of complementary and 
alternative medicine as a way of helping people live with 
chronic pain is something that we really embrace.
    Secretary McDonald. Mr. Chairman, this goes to your point 
of why a VA is so necessary. Those alternative uses of 
treatment are not available as readily in the private sector.
    The Chairman. Well, that is part of my point. There are 
almost 9 million VA beneficiaries. Is that not correct? Did not 
we send out almost 9 million Choice cards?
    Secretary McDonald. Yes, sir.
    The Chairman. That is a huge census from which to draw a 
lot of pretty predictable results and pretty predictable 
outcomes. But there are a lot of people who think that opiates 
have become the biggest problem in our society today. The 
signature injuries of Afghanistan and Iraq are PTSD, TBI, and, 
obviously, limb injuries. But if we are over-prescribing 
opioids to mask the problems of TBI and PTSD, we are only 
postponing a suicide that some day probably will happen. So, I 
encourage you to continue to work on that as hard as you can.
    Secretary McDonald. Mr. Chairman, I could not agree with 
you more. I know Jim could not, either.
    Also, I just wanted to make you aware, in case you did not 
know, that Monday we are holding a traumatic brain injury 
summit in Washington, DC. This is one of the things I have 
wanted to do for some time, because I want to use the convening 
authority of the VA, you know, the largest medical system in 
the country, to bring together the country's experts on 
traumatic brain injury, whether it is the NFL, the NHL, whether 
it is police officers, firefighters--bring everybody together, 
share the information, and put together a research program 
which is guided so that we do not have redundant pieces of 
research going on.
    We are looking forward to doing that next week. It is 3 
days--I think it is--next week, and we hope to provide some 
benefit, not only to veterans, but to the American people from 
it.
    The Chairman. I have one more question. After that I am 
going to turn to Doug for his questions, then I will probably 
have a follow-up. My question is this: in the second panel--
which you will hear their testimony in just a little bit, and I 
have read the statements that they submitted--in almost every 
case, there are concerns about the commitment within the VA to 
the Choice Program and concerns about the information on Choice 
really getting to the veteran.
    You will hear some testimony where veterans will tell you 
they really did not know how to utilize Choice. In some cases, 
utilizing Choice was more cumbersome and difficult.
    Is there a person in your employ in the VA in Washington 
that is principally responsible for communicating the Choice 
Program throughout the VA system to its employees?
    Secretary McDonald. Well, ultimately, I take responsibility 
for that. If you find any failures in the Choice Program, it 
would be my accountability or my fault. But what we have done 
is we have set up Choice experts in every single VA operation, 
so you do not have to come all the way to Washington. Leslie 
has one here in her shop. We have them throughout the system. 
The idea would be that they would be the experts to help you 
navigate the system.
    Jim, do you want to comment?
    Dr. Tuchschmidt. Sure. You know, I think we have done a lot 
to try to educate our staff, because, ultimately, our staff are 
the best resource we have to explain the Choice Program to our 
patients. We have done Web training. We have sent out printed 
material. People have access to printed material in the waiting 
rooms and at the clerk's desk which they hand out. Every 
facility has, quite frankly, one or more Choice champions who 
we have focused and concentrated on to be able to answer those 
questions.
    I think that there is no doubt that in a program as, kind 
of, complex as this is, making sure that 9.2 million veterans 
actually understand the program and how to use it has clearly 
been a challenge. I think that we have tried through outreach 
efforts, mailings, our Web site, which we recently revamped, to 
make the resources available to veterans so that they can get 
the information that they need. Yet, we know we need to do a 
better job of that.
    Secretary McDonald. Mr. Chairman, may I introduce Gary 
Compton, who is the Choice champion here in Atlanta?
    Gary?
    The Chairman. Hi, Gary.
    Secretary McDonald. So, if anybody in the room has any 
questions on Choice, you can contact me or Gary.
    The Chairman. While Gary is here, let me make a comment. 
You know, every good leader assumes principal responsibility 
first. You answered the question by saying, ``If you have got a 
problem, it is my responsibility.'' But, quite frankly, you 
have 314,000 employees in VA health care. It is the second 
largest agency in the Federal Government. If you are the only 
person we have to count on to get Choice implemented, we are in 
deep trouble. [Laughter.]
    The Chairman. Mr. Compton? Is that correct?
    Mr. Compton. Yes.
    Secretary McDonald. Gary Compton.
    The Chairman. Are there a lot of Gary Comptons around the 
country?
    Secretary McDonald. There is a Gary Compton in every VA 
facility.
    The Chairman. Well, let me make a suggestion. I am being as 
sincere as I can be on this.
    Secretary McDonald. Sure.
    The Chairman. After you finish your TBI summit next week, 
we probably ought to have a summit with all your Mr. Comptons 
around the country, because I think you will hear from Doug and 
you will hear from some of the people about to testify that the 
big missing link in the chain is everybody in the VA knowing 
what to communicate to the veteran, so that the veteran has an 
easy way to find out how to get it.
    My best example is this--and I am not advertising for Bank 
of America, but I happen to have a Bank of America credit card. 
I happened to open my bills last night, and I got a letter from 
Bank of America that was six pages long and in small print and 
said, ``Your credit terms have changed.'' I threw it away. It 
was too intimidating. It was too much to read. I know we all 
get those types of mailings.
    We need a simple system where veterans have an easy way to 
access the information in terms of what their choices are. I 
have love to see us have a summit in Washington with all the 
Mr. Comptons of your agency to see what we can do to improve 
the communication from the VA offices and CBOCs and hospitals 
to the veteran beneficiaries.
    Secretary McDonald. We will do that.
    Dr. Tuchschmidt. If I could, I will just add that we have--
there is the toll free number available. We also updated our 
Web site and we just recently added a live chat to that. So, if 
you go onto that Web site, and you can not find what you are 
looking for, you can talk in a chat session with somebody real-
time.
    The Chairman. You know, I am sorry that you mentioned that 
for this reason. I tried to go to the site last--is that the 
You Tube site?
    Dr. Tuchschmidt. No.
    The Chairman. That is not. You had a You Tube site in your 
printed comments. I could never get it to come up. But we will 
work on that after the meeting. That may have been the 
operator, too, you know.
    Congressman Collins?
    Mr. Collins. Thank you, Mr. Chairman.
    I want to start off similar to the senator. Mr. Secretary, 
I know you would not probably be aware of this, but it goes 
back to issues that the senator just hit on: communication and 
the delays that seem to come in.
    One of the issues we have in our office is a tort claim on 
the medical malpractice--waited for 180--you know, the 180-day 
wait. The case was supposed to be decided on July 26, 2015. On 
July 29, the gentleman received a letter--and we received an 
opinion--that said a second medical opinion would be needed. We 
are outside of the window. Again, it just looks more like a 
delay. If it was going to be denied, it would be denied, and 
that is OK, because there is a court route to take.
    I wanted to bring this to your attention. I know there has 
been some communication even as late as this morning. But this 
is the kind of issue that bothers folks.
    Secretary McDonald. I know that. I mean, customer service 
is what we have got to improve. And, you know, when I came to 
the VA, what I discovered was the second largest department in 
government--that I felt everybody was looking inward. That is 
typical. When you have a catastrophe or you have a crisis in an 
organization, people turn inward.
    A leader's job is to turn them outward, get them out in the 
field. That is why I have been to over 200 VA sites. That is 
why I have demanded the town hall meetings. It is why we have 
had open houses. It is why we have had media days. We have got 
to open everything up, let people in, hear the criticism, and 
then work to improve customer service.
    We have employed help from people like Disney, Starbucks, 
Ritz Carlton. We have put in place a new veteran experience 
officer. That is his only job. So, we are working very, very 
hard. But it is going to take time, because all you need is one 
situation out of 340,000 employees where something goes wrong, 
and that is the one that customer remembers.
    Mr. Collins. Exactly. And I think one of the things, Mr. 
Secretary, as we deal with this is you are having to build a 
hill back up. I appreciate the attitude that you have had. I 
think if we go back to the start of the Choice Program when, 
yes, VA sent out 9 million letters to folks; the problem, as I 
have talked to veterans, is that many of them--it would not 
have applied to them.
    All of a sudden, they got a letter that really did not 
apply to them. They began to have questions that they can not 
get answered. They get frustrated. They think they are being 
denied a benefit or something that they really did not have a 
chance to get to start with. Again, it is sort of like we are 
catching up here and----
    Secretary McDonald. And even since those letters, we have 
changed the definition of 40 miles.
    Mr. Collins. Exactly.
    Secretary McDonald. And some of those letters arrived 
around the holidays with all the catalogs.
    Mr. Collins. Exactly. Well, the changes--the chairman has 
already said we are out of here at 4 o'clock. We are not going 
to discuss the 40-mile definition at this point. I think the 
thing that concerns me--and for my office--when I came to 
Congress, following folks like the senator who has been in both 
houses, it was still amazing to me, having a familiarity with 
the system, that I have people in my office whose sole job is 
to have to deal with veterans who should be getting services 
without having to go to their congressman or their senator. 
They should not have to. I should have them being able to 
research new ideas. OK? [Applause.]
    I appreciate that, and I say that from a positive aspect. I 
am not saying--and before my staff believes I am running them 
out of a job, that is not what I am doing. I have plenty of 
things for them to do.
    But when two-thirds of their caseload is VA, and two-thirds 
of their caseload is a lack--basically, it boils down to a lack 
of trust. It goes back to something you said, that I want to 
hear your comments on, because I know, speaking as a Member of 
Congress, you asked for flexibility, which I think is 
understandable.
    Given the track history--and I am not going to say you are 
a part--you are trying to change that--there should be some 
understanding that that is why budgets are there. There can be 
some issues, and I know Senator Isakson--the chairman is going 
to work on that. But, my question is how can we address the 
flexibility issue but also assure that--one, we are seeing from 
the outside bills that we passed to dismiss employees who are 
not doing what they should be doing, when there was actually 
some pushback from VA to even pass that bill. Those are the 
kinds of things that--how do you do that? [Applause.]
    Secretary McDonald. Well, first of all, we are holding 
people accountable. Since I have been secretary, more than 
140,000 employees have been terminated. Over the previous year 
before I was sworn in, it was about 100,000--110,000 that were 
terminated. So, we are holding people accountable. I mean, you 
have got a citizen here in Georgia who faces 5 years in jail 
and $250,000 for each count if found guilty. So, this is 
accountability.
    At the same time, in VHA, nobody received a bonus for 2014. 
I took a lot of heat for that. And nobody was rated outstanding 
in the SES ranks in 2014. I would venture to say we have the 
best distribution of ratings of any government agency for SES 
employees--I would be happy to show it to you--and I would say 
equal to the best companies in the private sector. I know 
because I used to run one.
    So, we are holding people accountable. Accountability is a 
lot more, though, than just firing people. Accountability is 
also about praising people who do a good job.
    Mr. Collins. I agree.
    Secretary McDonald. We are trying to do more of that. And 
accountability is about having a culture where people self 
report. I was pleased, as I told you earlier this morning, that 
Dublin self reported that they had some problems at their 
consults. I was pleased that Dayton self-reported. When we get 
to the point where people are self reporting, that means they 
are fixing the system that they are working on; that is a good 
thing and that is a good culture.
    Mr. Collins. Mr. Secretary, I agree. I think one of the 
things I--from my perspective Ms. Wiggins and her staff--I see 
them sitting in front--have been outstanding in that regard, to 
at least get us answers. Frankly, what I like about them is 
that they will tell me, ``I do not like it any more than you 
do, Congressman.'' I am sure that you love to get those memos 
in which there are some questions.
    You brought up an interesting issue, because it was 
popularly reported, and this was actually--it was not popularly 
reported. It was in the newspaper in Atlanta. The gentleman----
    Secretary McDonald. Do not believe what you read in the 
papers.
    Mr. Collins. No, I never have on myself. But, the gentleman 
in that situation you brought up--yes, he is facing charges 
now, but he was transferred from Augusta to Atlanta. His own 
attorney said it was because he needed a change of scenery. He 
did not need a change of scenery. He needed to be in jail.
    Secretary McDonald. I am unfamiliar with that detail. All I 
know is the investigation carried on. It was carried on 
thoroughly. It went to the FBI, the Department of Justice, and 
he is facing 50 charges.
    Mr. Collins. We will look forward to those----
    Secretary McDonald. I----
    Mr. Collins. I appreciate it, Mr. Secretary. I am just 
reflecting--I have been in front of four town halls this week, 
and VA was part of every one of them. Senator Isakson knows 
that as well. It was the first question this morning in 
Hiawassee, GA, on Sunrise.
    I want to turn a little bit, and from a positive 
standpoint, ask how do we go from the Choice plan that we have 
put into action, what are some of those obstacles, and how do 
we fix it? One of those issues that I hear about a lot right 
now is how do we get--and I would like for you to address the 
challenges of finding and including outside VA providers, 
because I know in Atlanta--and we talked about the mental 
health issue--there is just simply no providers to be able to 
step forward. What is the perspective helping to fill that gap 
right now?
    Secretary McDonald. The ultimate answer is to go to one 
consolidated Choice Program. Right now, we have, as I said in 
my remarks, seven different ways of veterans getting care 
outside the VA. It is so complex that our employees do not get 
it and veterans do not get it. And the complexity also deals 
with the kind of service available in each one and the 
reimbursement rates.
    When I went to Montana with Senator John Tester, all the 
providers were complaining to me about all of the other six 
programs, except one, ARCH; it was because ARCH had the highest 
reimbursement rates for people in Montana. What we have got to 
do is get all of those seven different programs down into one, 
and if we do that, I am convinced we are going to be able to 
get--and get it at the right rate, the Medicare rate--we are 
going to get more and more people in that program rather than 
cherry picking their own program, which is what is happening 
today.
    Mr. Collins. I appreciate that. I think one of the things 
we will hear in the second panel--and you have heard as well--
is, one, there seems--and this goes to the Health Net issue--
there seems to be by a lot of the folks who have to contact our 
office that we are going to hear directly from one in just a 
little bit--that Health Net seemed to add a layer of 
bureaucracy that cuts off even the stilted communications. Many 
times that was happening and unclear. I would like--and I am 
not going to ask this specifically----
    Secretary McDonald. Well, we have got to eliminate that 
bureaucracy.
    Mr. Collins. So, I think that is what I want to hear. 
Again, I am not sure why adding a bureaucracy to help do this 
actually was encouraged or started in this position of Health 
Net and others. Address that issue, because there seems to be 
communications where you call one--``Well, we never heard from 
the VA.'' The VA says ``We never heard from Health Net.'' 
Health Net goes back and forth. We are going to hear about this 
in a minute, so I would just like to hear your discussion on 
it.
    Dr. Tuchschmidt. I think that the Choice Act, as it was 
written, is very complicated. We put it together in 90 days, 
which was a challenge. I would suggest that it is not designed, 
either legislatively or in its implementation, in a way that 
really meets, I think, the customer service standards that we 
want either for veterans, quite frankly, or for providers.
    We have been working on the plan that you all charged us 
with to submit by November 1 to really not only consolidate 
these programs, but to say, ``How do we put this together in a 
way that really makes sense, that improves the business 
processes, and makes it easier for everybody to be able to 
access care outside of the VA facilities?''
    This month we are bringing together a roundtable of 
industry experts to talk to them about how they do this, about 
where the industry is going, both in terms of managing quality 
and appropriateness of utilization. I am confident that the 
proposal we bring you in November is going to address a lot of 
these issues.
    Mr. Collins. My last question--and, Mr. Chairman, I 
appreciate the indulgence in the Senate and the House in 
working together.
    The Chairman. Absolutely.
    Mr. Collins. There is an issue--one of the first things--I 
was excited about your appointment because you brought the 
business acumen from running a successful organization outside 
that cut through what a lot of us have to deal with in the 
Federal Government. And there are a lot of areas. It is not 
just VA. It is everywhere. We have good people at our clinics, 
we have good people at our hospitals, and I never want it to be 
understood that the problems of a few reflect the problems of 
all. That is something we do not need to have happen.
    The issue, though, comes up in some things that I have 
heard from our--and I have toured along with the senator the 
facilities in Georgia, and there are some simple things that 
seem to be, from a Congress perspective, in the contracting, 
purchasing--simple things, where you have--I know in Atlanta 
there was an issue of a simple fixing of a part that cost--I 
want to say $17,000--and it took them 3 to 6 months to order 
the part while at the same time we are serving veterans on 
paper plates, costing more than the part.
    It is my understanding that that could be fixed at your 
desk. If that is not true--and some of these other areas of 
contracting, where we just seem to be redundant--what can we do 
in Congress to fix that? And if it can be fixed at your desk, 
what is being done to fix what were perceived as common-sense 
issues?
    Secretary McDonald. That is actually part of our 
transformation that we call MyVA, which is the overall 
transformation we are trying to make of the VA. There are five 
strategies. Number 1 is to put the veteran at the center of 
everything we do, and start measuring veteran satisfaction for 
the first time.
    Number 2, improve the employee experience. If you check, 
the best customer service companies in the world also are the 
best companies to work for. That is not an accident. You know, 
you have no hope of caring for the veteran unless your 
employees are happy and have a good experience.
    Number 3--and this speaks to your point--is to improve our 
internal support services. Our acquisition, our logistics, our 
human resources, our recruiting, our hiring--these are all 
system that are broken. We have got teams of people now working 
to change them, working with the private sector to learn how 
best to do them; the changes are underway.
    Number 4, quickly, is create a culture of continuous 
improvement. We are teaching employees Lean Six Sigma, which is 
a technology that engages employees and helps them change the 
systems they work on.
    Number 5 is creating strategic partnerships. There is a lot 
of good will in this country for veterans, and we are engaging 
partners to help us--as the chairman said, as force multipliers 
to help us. We did not do that in the past.
    We have put together a plan that is about 55 pages long. If 
you do not have it, we will make sure you get it. We have been 
through it with the Committee, and we have a couple of Members 
of the Committee who are doing a deep dive with us who have 
business experience. We are making good progress.
    Mr. Collins. Well, Mr. Secretary, I appreciate the answers. 
There is still a lot that we could talk about. We are 
continuing to get this. It is not going to be something that 
goes away, and I think that trust factor that you talked about 
is both from a congressional perspective and from a department 
level as well. There is a lot of distrust there.
    So many times, for us, in either house--to ask for 
flexibility, to ask for trust--we are going to have to earn it. 
I think those are the things we are doing. I appreciate your 
answers.
    Mr. Chairman, I yield back. [Applause.]
    The Chairman. Mr. Secretary, would you repeat for me how 
many people you said you disciplined in your first year as 
secretary?
    Secretary McDonald. Well, we have terminated over 140,000.
    The Chairman. When you say you terminated, does that mean 
they took early retirement or were transferred?
    Secretary McDonald. No, this is--they may have been in 
probationary period, and we ended the probationary period, or 
they left, or they were disciplined. I do not know how many 
retired. I would have to check those numbers.
    The Chairman. But is not it true that it is almost 
impossible for you to fire somebody under the current law? 
[Applause.]
    There is a good ending to this question, by the way.
    Secretary McDonald. The actual number fired is 1,800.
    The Chairman. I beg your pardon?
    Secretary McDonald. The actual number of fired is 1,800.
    The Chairman. But it is very difficult to do.
    Secretary McDonald. You know what? I have done it in the 
private sector and I have done it in the public sector, and I 
would tell you it is, in some ways, easier to do in the private 
sector, because what happens in the private sector oftentimes 
is you cut a deal with the employee, so you are able to buy 
them out. You can not do that in the public sector.
    The other thing that happens in the public sector is that 
the due process is baked into the process, whereas due process 
in the private sector only happens if the employee chooses it, 
right, because they take you to court. So, it is a little bit 
different in the public and private sectors, but I would not 
argue that that is an excuse for not being able to deliver good 
customer service.
    The Chairman. The Rubio-Ayotte bill is pending in the 
Senate. Is that not correct?
    Secretary McDonald. It is, and we have said we are against 
any bill that differentiates VA from any other department of 
government. You know, I have got gaps I am trying to fill. I am 
hiring 1,100 new doctors. I am hiring 4,000 new nurses. You 
have given us a chance to hire people under the Choice Act.
    We can not hire the people when Members of Congress are 
going to somehow differentiate the VA versus other departments 
of government. That does not cause people in government to want 
to work for the VA. So, I am against that bill because it 
differentiates us. I think I have the tools I need to hold me 
accountable if I do not deliver. I think I have the tools I 
need.
    The Chairman. Well, I ran a lot smaller company than 
Proctor & Gamble. I had 250 employees and 1,000 agents. You had 
125,000, if I am not mistaken.
    Secretary McDonald. That is correct.
    The Chairman. But the ability to manage your workforce and 
have positive incentives as well as accountability measures in 
which you held people accountable is a wonderful way to run a 
business versus where you do not have that. So, I would suggest 
not wanting to be treated like any other government agency--
different from any other agency is a good statement to make. I 
understand that. I think it is also critical to understand that 
we have had some unique problems within the VA that we need to 
try to deal with.
    Secretary McDonald. Mr. Chairman, let me explain something. 
When I came to the VA, and I got the relative rating of the SES 
employees from the previous year, everyone was rated 
outstanding and above average, right? That is not 
accountability.
    The Chairman. That is self reporting.
    Secretary McDonald. That is not accountability. So, what 
did I do, right? As I told you, nobody in VHA was rated 
outstanding. Nobody in VHA is getting a bonus for the year that 
their secretary resigned. That is accountability.
    Accountability is not only firing. Accountability is giving 
people the rewards for their performance that they have earned. 
And I think I can--I am doing that. I do not think I can do 
that; I am doing that. Now, the SES Association did not like it 
very much, but that is what we did.
    The Chairman. Well, we are proud of what you are doing. One 
last comment I will make for the benefit of the audience 
because I heard them clap--that VA employee is under a criminal 
indictment now?
    Secretary McDonald. Yes, sir.
    The Chairman. From Augusta. That took place because as 
chairman of the Committee, we wrote the Department of Justice 
and asked them to investigate. We brought DOJ into the agency, 
and I think that got the attention of everybody around the 
country that we are going to look that hard, because if you 
manipulate consults or you manipulate medical information, 
which was the case with this Augusta person, it could be a 
criminal offense. In this case, it was a criminal offense, and 
they are subject to imprisonment.
    You do not want to send anybody to jail, and you do not 
want to fire anybody. But if everybody does not think you have 
a standard to live up to, they will always sink to the lowest 
common denominator and never the highest. I learned that a long 
time ago. [Applause.]
    Secretary McDonald. Mr. Chairman, there are 180 other 
people being investigated right now, and I am very certain that 
the FBI will be involved in some of those 180. This story has 
not been written yet. I mean, we still have many, many chapters 
to go, and it will have an impact on the culture.
    Mr. Collins. I have a clarification. When I made this 
comment earlier when we were talking about firings, you used 
the number 140,000, and then you were just handed a note of 
1,800.
    Secretary McDonald. No, no, no.
    Mr. Collins. Is it 140,000 that were let go, or 1,800 that 
were fired?
    Secretary McDonald. I am sorry. I did not mean 140,000. I 
meant 1,400. Over 1,400 have been terminated; yes, have been 
terminated. That means not just fired, but that means 
terminated. Let me get back to you with the exact number.
    Mr. Collins. OK. There is a numbering issue there, and if 
you will get back to me--because something right there is not 
making sense.
    Secretary McDonald. We will get back to you. But, yes, it 
is 140,000 losses--terminations, 1,800 of which have actually 
been fired.
    Mr. Collins. Of the 140,000--OK. A termination and a firing 
for a lawyer is very close.
    Secretary McDonald. Well, a termination could be for poor 
performance. A termination could be during your probationary 
period; you have had poor performance, and----
    Mr. Collins. But that is not retirement.
    Secretary McDonald. No, that is not a retirement.
    Mr. Collins. That is not a ``I am leaving my job.''
    Secretary McDonald. These are not all retirements.
    Mr. Collins. But, they are also not ``I am just coming in 
and quitting.''
    Secretary McDonald. That is correct.
    Mr. Collins. Or would this number include folks who just 
say, ``I got a better job somewhere else. I am leaving.''
    Secretary McDonald. Probably.
    Mr. Collins. So, that would include----
    Secretary McDonald. I would think it would, yes, sure.
    Mr. Collins. OK. We need to get better clarification 
numbers on that.
    Secretary McDonald. But I can tell you that our retention--
--
    Mr. Collins. Oh, I understand completely. But we will get 
better clarification.
    Mr. Chairman, thank you for that clarification.
    The Chairman. Because 140,000 is one-third of your total 
employees, if you have 314,000 employees?
    Secretary McDonald. Yes.
    The Chairman. Check on those numbers.
    Secretary McDonald. I am.
    The Chairman. I am not good at numbers, so I am not going 
to--but we will check on them and get the right information to 
all of you.
    Let me thank the secretary. Dr. Tuchschmidt, thank you too 
for being here. I hope you are going to stay for the second 
panel, because I think the second panel is going to be very 
informative in both a positive and a constructive way, So, I 
hope you will stay for that.
    Secretary McDonald. I am sorry. Mr. Chairman, can I correct 
the record now?
    The Chairman. Yes, sir. The record is to be corrected.
    Secretary McDonald. 1,755 employees have been terminated--
1,755 is the number that have been terminated.
    The Chairman. 1,755. That makes more sense. Thank you, Mr. 
Secretary. Thank you for cutting your vacation short to come to 
Georgia. We appreciate it very much.
    Secretary McDonald. Thank you very much.
    The Chairman. I would like to ask our second panel to come 
forward, if you will set up the table.
    We are very fortunate to have a distinguished second panel 
on our Veterans Choice hearing today, and I want to urge 
everybody to listen closely. I have read the testimony of each 
of these individuals. It is very informative, and it will 
answer or illuminate or enlighten some of the questions you 
have heard us ask the secretary.
    First and foremost is Ms. Donna Hoffmeier, Vice President 
of VA Services with Health Net Federal Services.
    We are delighted that you are here today and thank you for 
what you do.
    Dr. Stephen Jarrard, Provider and Veteran, lives in Rabun 
County, GA, which is a place I love very much.
    We are glad to have you here today.
    Dr. Wayman Duane Williams, Georgia State Leader of the Iraq 
and Afghanistan Veterans of America, thank you for your service 
to the country.
    And Carlos with the best name in the world--Chacha.
    Is that right? I would love to see you dance, Carlos. You 
would be good, I know. We are delighted to have you here today. 
Your story is compelling, and we appreciate it very much.
    We will call on Ms. Hoffmeier first.

 STATEMENT OF DONNA HOFFMEIER, VICE PRESIDENT, VA SERVICES AND 
       PCCC PROGRAM MANAGER, HEALTH NET FEDERAL SERVICES

    Ms. Hoffmeier. Thank you, Mr. Chairman. Chairman Isakson, 
Representative Collins----
    The Chairman. Pull the microphone real close. Almost 
swallow it. You have to almost get it that close.
    Ms. Hoffmeier. I appreciate the opportunity to testify on 
Health Net's administration of the Veterans Choice Program.
    The Chairman. I am going to interrupt you once more--is 
there a sound person in the room? If you can ratchet it up a 
little bit, I would appreciate it. She is hard to hear.
    Try it again. I am sorry.
    Ms. Hoffmeier. 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 health 
care administrators of government programs for the military and 
veterans communities. We are dedicated to ensuring that our 
Nation's veterans have prompt access to needed health care 
services and continue to believe there is great potential for 
the Choice Program to help VA deliver timely, coordinated, and 
convenient care to veterans.
    From the start of the Choice Program, Health Net has worked 
collaboratively with VA to implement Choice and to identify and 
address process and policy gaps or needed improvements. In 
Georgia, we have made nearly 7,500 Choice appointments for 
veterans and currently have over 400 in the process of being 
appointed. Another 1,000 cases are either awaiting 
documentation from VA or contact by the veteran to initiate 
care.
    Our provider network team works closely with the VA medical 
centers to develop a provider network tailored to meet the 
needs of Georgia's veterans. Our Choice provider registry 
includes 5,700 providers and 21 hospitals, including a number 
of large health care systems. Through these large health care 
systems, we are able to provide access to an even greater 
number of physicians who are affiliated with these 
organizations.
    Our network in Georgia also includes several dedicated 
psychiatric hospitals and 14 federally qualified health 
centers. We continue to conduct outreach to providers with 
which VA has longstanding relationships, including VA 
affiliates and preferred providers.
    Implementation of any new program is always challenging, 
particularly when the change is significant and the 
implementation period is very condensed. The very limited 
implementation period for Choice did not afford VA time to 
develop necessary policy and process guides, nor did it allow 
us the time to develop operational processes, make needed 
system changes, and to effectively hire and train the staff 
needed to support a program of this size and complexity.
    We only had about 30 days of close collaboration and 
planning with VA before going live, which is an extremely 
aggressive implementation period by any standard. There clearly 
have been bumps in the road with the accelerated rollout of 
Choice--delays in eligibility information being made available, 
confusion over program details and inconsistent expectations, 
incorrect and sometimes conflicting information provided to 
veterans. These bumps have understandably caused a level of 
veteran frustration.
    While issues are common with the startup of any new 
program, many of the challenges with Choice to date are the 
result of inadequate development and transition time. We are 
working very closely with VA to address these challenges and, 
more importantly, to develop solutions for these challenges.
    For example, we are working with VA currently to streamline 
the process for receiving eligibility information on veterans, 
which has been one of the biggest sources of frustration for 
veterans. VA is phasing in a new eligibility process for wait 
list eligible veterans that will provide the Choice contractors 
with much more timely access to eligibility information.
    To address challenges with incorrect information being 
provided, we have initiated additional training for all 
customer service representatives. And we have also deployed 
senior, very experienced operational and training experts to 
directly oversee that training.
    We continue to work with VA to set realistic timelines for 
new initiatives and program changes. Since the start of Choice, 
the number of changes have been fast and frequent. We fully 
support VA making changes to increase the use of the Choice 
Program, but it is essential that adequate time be allocated so 
we can retrain our people and execute the change effectively. 
When timeframes are pushed to unrealistic levels, mistakes 
happen. It is just a reality.
    We continue to advocate for the creation of process and 
policy manuals that clearly articulate program procedures and 
expectations. This will help ensure consistent application of 
Choice across the board with both contractors and all VA 
facilities.
    To ensure veterans have ready access to community care, 
providers must be willing to participate in the Choice Program. 
Widespread adoption by community providers requires the 
elimination of unnecessary impediments. We are currently 
working with VA to identify those impediments and to, 
hopefully, get those impediments removed.
    In closing, I would like to thank you, Chairman Isakson, 
for your leadership in ensuring our Nation's veterans have 
prompt access to needed health care services. Working together 
with VA 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.
    [The prepared statement of Ms. Hoffmeier follows:]
 Prepared Statement of Donna Hoffmeier, Program Officer, VA Services, 
                    Health Net Federal Services, LLC
                        a history of partnership
    I appreciate the opportunity to testify at today's field hearing on 
Health Net's implementation and administration to date of the Veterans 
Choice Program.
    Health Net is proud to be one of the largest and longest serving 
health care administrators of government and military health care 
programs for VA and the Department of Defense (DOD). Health Net's 
health plans and government contracts subsidiaries provide health 
benefits to more than five million eligible individuals across the 
country through group, individual, Medicare, Medicaid, TRICARE, and VA 
programs.
    For over 25 years, in partnership with DOD, Health Net has served 
as a Managed Care Support Contractor in the TRICARE Program. Currently, 
as the TRICARE North Region contractor, we provide health care and 
administrative support services for three million active-duty family 
members, military retirees, and their dependents in 23 states. We also 
deliver a broad range of customized behavioral health and wellness 
services to military servicemembers and their families, including 
guardsmen and reservists. These services include the worldwide Military 
and Family Life Counseling (MFLC) program, which provides non-medical, 
short-term, problem solving counseling, rapid-response counseling to 
deploying units, victim advocacy services, and reintegration 
counseling.
    As an established partner of VA, Health Net has collaborated in 
supporting Veterans' physical and behavioral health care needs through 
Community Based Outpatient Clinics (CBOCs), the Rural Mental Health 
Program, PC3 Program, and the Choice Program. We also have supported VA 
by applying sound business practices to achieve greater efficiency 
through claims auditing and recovery and claims re-pricing. It is from 
this long-standing commitment to supporting the military and Veterans 
communities that we offer our thoughts on the role of Choice in 
augmenting VA's ability to provide eligible Veterans with timely access 
to needed health care services.
                        the evolution of choice
    In August 2014, with the leadership of this Committee, Congress 
passed and the President signed into law the Veterans Access, Choice, 
and Accountability Act of 2014 (VACAA, Public Law 113-146, ``Choice 
Act''), which directed the establishment of a new program to better 
meet the health care needs of Veterans. The law directs the 
establishment of a Veterans Choice Card benefit that allows eligible 
Veterans who are unable to get a VA appointment within 30 days of their 
preferred date or the date medically determined by their physician; 
reside more than 40 miles from the closest VA health care facility 
(there are different mileage rules for some states, such as New 
Hampshire and Hawaii); or face other specific geographic burdens in 
traveling to a VA facility to obtain approved care in their community 
instead.
           Health Net's Contracted Choice Regions 1, 2, and 4
 (includes 13 of 21 VISNs with 90 VA medical centers in all or part of 
    37 states; Washington, DC; Puerto Rico; and the Virgin Islands)

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    As background on VA's approaches to delivering non-VA care, VA 
developed the PC3 Program to provide eligible Veterans access to health 
care through a comprehensive network of community-based, non-VA medical 
professionals. In September 2013, Health Net was awarded a contract for 
three of the six PC3 regions. These regions include 13 of 21 Veterans 
Integrated Service Networks (VISNs) and 90 VA medical centers in all or 
part of 37 states; Washington, DC; Puerto Rico; and the Virgin Islands. 
In October 2014, VA amended our PC3 contract to include several 
components in support of the Choice Act. These components included 
production and distribution of Choice Cards; establishment of a Choice 
call center to answer Veterans' questions about the Choice Program and 
to verify eligibility; appointing services for eligible Veterans with 
Choice-eligible community providers; and claims processing. Since VACAA 
required implementation by November 5, 2014, we worked collaboratively 
with VA and TriWest (the contractor for the other three PC3/Choice 
regions) to develop an implementation strategy with extremely 
aggressive timelines. This ambitious schedule allowed minimal time to 
hire and train staff and to reconfigure our systems for the new 
program, which contains many requirements that differ from PC3 and 
therefore have to be tracked and recorded separately. Despite the fast-
paced implementation schedule, on November 5th, Veterans started to 
receive their Choice Cards and were able to call in to the toll-free 
Choice telephone number and speak directly with a customer service 
representative about the Choice Program.
    On April 24, 2015, VA published a second interim final rule that 
changed the way VA measures distance for purposes of determining 
eligibility. VA now considers the distance a Veteran must drive to the 
nearest VA medical facility, rather than the straight-line of geodesic 
distance to such a facility. This change resulted in an expansion in 
the number of Veterans eligible for the Choice Program.
    Most recently, on August 4, 2015, Congress passed a number of 
improvements to the Choice Program through H.R. 3236--Surface 
Transportation and Veterans Health Care Choice Improvement Act, which 
became Public Law 114-21. These program improvements include expansion 
of eligibility for Veterans, expansion of the pool of providers 
eligible to participate, clarification of wait times, removing the time 
limit on an episode of care, and modification of the distance 
requirement. The new law also requires VA to develop a plan to 
consolidate all non-VA care programs by establishing a new, single 
program to be known as the ``Veterans Choice Program.'' We commend the 
Committee for working to address some of the unintended limitations 
contained in the original legislation.
                        engaging collaboratively
    From the start of discussions on implementation of VACAA, the VA 
Chief Business Office, Contracting Office, and senior VHA officials 
have worked closely with both contractors to establish priorities, 
provide policy guidance, and develop process flows. As the Choice 
implementation progresses, more policy and process items continue to be 
identified. We are working closely with VA and TriWest to ensure that 
key policy or process items are addressed quickly; doing so is 
essential to program performance and effectiveness.
                  building the choice provider network
    A key component to the success of Choice is acceptance by community 
providers. To provide Veterans with timely access to care in their 
communities, Health Net proactively recruits providers to Choice. Since 
the implementation of Choice, we have collaborated with VA medical 
centers and actively reached out to providers and professional 
associations to build a network. Highlights of our efforts to build a 
robust provider network are summarized below.
     highlights of health net's choice provider network development
     Sent outreach letters to 22,264 TRICARE contracting 
entities to encourage providers to register for participation in the VA 
Choice Program; these entities represent anywhere from 156,000 to 
200,000 community providers
     Sent outreach letters to the 7,650 vendors on the VA 
Nomination Report that have not yet joined the VA Choice Program
     Participated in joint VA Medical Center and Provider 
Meetings to encourage key VA Medical Center vendors to register for the 
VA Choice Program; as needed, Health Net staff are assisting large 
organizations register their multiple locations
     Conducted outreach to all 280 VA Affiliates to encourage 
participation in the VA Choice Program
     Participated in a presentation to the AAMC on the VA 
Choice Program; scheduled to participate in calls with AHA and AMA to 
present similar information regarding VA Choice Program to their 
membership
     Contacted all VA Medical Center Hepatitis C preferred 
vendors to encourage participation in the VA Choice Program; Health Net 
is making outreach calls to all PC3 contracted, VA Choice Participating 
and Registered Gastroenterology and Infectious Disease providers to 
determine if they treat Hepatitis C patients
     Used the American Liver Foundation directory to identify 
community providers who treat Hepatitis C patients; all providers not 
already eligible for the VA Choice Program will receive telephonic 
contact asking them to join the VA Choice Program

    In Georgia, our provider network team works closely with the VA 
medical centers in VISNs 7 and 8. We have developed an extensive 
provider network to meet the needs of Veterans receiving care at the 
three VA medical centers in Georgia: Charlie Norwood VA Medical Center 
(Augusta); Atlanta VA Health Care System (Decatur); and Carl Vinson VA 
Medical Center (Dublin). From January 31, 2015, through July 31, 2015, 
our Choice provider network in Georgia grew from 3,084 providers to 
5,677 providers--an increase of 84 percent in six months.
    Our Choice network in Georgia currently includes 21 hospital 
providers, including large health care systems such as Saint Joseph's 
Candler Health System (Savannah), Southeast Georgia Health System 
(Brunswick), Southern Regional Medical Center (Riverdale), Doctors 
Hospital (Augusta), and Coliseum Medical Center (Macon). Through these 
large health care systems, we are able to provide access to an even 
greater number of physician specialists who are affiliated with these 
organizations. Recognizing the high demand for mental health services, 
our Choice network also includes dedicated psychiatric hospitals, such 
as Southern Crescent Behavioral Health System, Saint Simons by the Sea, 
and Summit Ridge Hospital. Provider counts for the top 10 specialties 
in our Choice network are shown in the table below.

 
------------------------------------------------------------------------
                                              Choice Provider Count in
       Top 10 Provider Specialties          Georgia As of July 31, 2015
------------------------------------------------------------------------
Chiropractic.............................                           358
Physical Therapy.........................                           344
OB/Gyn...................................                           260
Optometry................................                           257
Surgery--Orthopedic......................                           201
Surgery--General.........................                           191
Podiatry.................................                           181
Cardiovascular Disease...................                           173
Ophthalmology............................                           171
Dermatology..............................                           116
------------------------------------------------------------------------

    In building the Choice network, we recognize the importance of 
collaborating with providers where VA medical centers have established 
relationships. For example, we initiated a strong effort to integrate 
federally Qualified Health Centers (FQHCs) in our network. We are 
working very closely with VHA's Office of Rural Health on this effort, 
and participated with VA at the National Rural Health Association 
annual conference and National Association of Community Health Centers 
webinar. To date, we have been very successful and have contracted 14 
FQHCs as Choice providers in Georgia, as shown in the table below.

                                  Federally Qualified Health Centers in Georgia
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Christ Community Health Services                         J.C. Lewis Primary Health Care Center
Coastal Community Health Services                        Oakhurst Medical Centers
Community Health Care Systems                            Palmetto Health Council
Curtis V. Cooper Primary Health care                     St. Joseph's Mercy Care Services
Diversity Health Center                                  Southside Medical Center
East Georgia Health care Center                          Southwest Georgia Health care
Four Corners Primary Care centers                        Valley Health care System
----------------------------------------------------------------------------------------------------------------

        increase in choice program utilization--results to date
    Since the inception of the Choice Program in November 2014, 
workload volume has dramatically increased. In the 37 states that 
Health Net supports in Regions 1, 2, and 4, monthly call volume has 
grown from an average of 27,000 calls in November 2014 to over 202,000 
calls in July 2015. Correspondingly, the monthly volume for appointment 
authorizations has grown significantly, from 1,800 authorizations in 
November 2014 to almost 29,000 authorizations in July 2015. VISNs 7 and 
8 account for about 7 percent of the authorizations.
                 program challenges and recommendations
    Implementation of any new program is challenging, particularly when 
the change is significant and the implementation period is condensed 
into a very short timeframe. The very limited implementation period for 
Choice did not afford VA time to develop necessary policy and process 
guides, nor did it allow for us to make needed system changes, develop 
business processes and work flows, and effectively hire and train the 
number of staff to support a program of this size and complexity. There 
clearly have been bumps in the road with the accelerated rollout of 
Choice--delays in eligibility information being available, confusion 
over program details, and incorrect or sometimes conflicting 
information provided to Veterans. These bumps have understandably 
caused a level of Veteran frustration. While issues and challenges are 
common with the startup of any new program, many of the challenges with 
Choice to date are the result of inadequate development (e.g., in terms 
of program policies and procedures) and transition time.
    While the collaboration with VA since the start of the Choice 
Program has been solid, there is still considerable work that needs to 
be done with regard to the development of policy and process guides or 
manuals. Having clear policies and procedures in place is essential to 
ensuring that everyone understands the program requirements--VA staff, 
contractor staff, and Veterans. Well-designed program policies and 
procedures also ensure consistency across the country. In addition, 
more work remains to be done to adequately train staff, conduct 
provider outreach, and enhance Veteran education.
    There currently are multiple options for non-VA care including 
Choice, PC3, local agreements/direct contracts, individual 
authorizations (``Fee''), other national contracts (e.g., dialysis), 
and Project ARCH. Each option has different reimbursement levels, 
different requirements for community providers (e.g., requirements for 
return of medical documentation, credentialing, etc.), and different 
``administrators'' (VA Medical Center non-VA care staff, VA contracting 
staff, PC3/Choice contractors). These various options create enormous 
confusion with non-VA (community) providers, Veterans, VA Medical 
Center staff, and contractor staff.
    We commend this Committee for directing VA to develop a plan for 
consolidating all non-VA care programs. Of note, consolidating options 
into one approach that minimizes VA-unique requirements for community 
providers should have a very positive impact on the willingness of 
community providers to participate in Choice and ultimately, enhance 
Veterans' access to care. As VA moves forward with the plan, we offer 
the following considerations:

    1. The consolidated plan and implementation strategy must clearly 
define the program and VA policies and procedures.
          Adequate Transition Time: Transition timelines must 
        allow for adequate implementation, staffing, and training.
          Clear Program Policies and Manuals: Development of 
        policy and operations guides or manuals that provide clear 
        instruction to all parties--VA medical centers, contractors, 
        Veterans, and Congress--on how the program is to operate, is 
        essential. For example, such policies and manuals might 
        address: what services are/are not covered by VA; rules for 
        eligibility, authorizations, and return of medical 
        documentation to ensure consistency for Veterans and providers; 
        reimbursement requirements for proper payment of provider 
        claims; and systems rules outlining integration between VA and 
        contractors, security requirements, and details for reporting 
        requirements.
    2. Unnecessary impediments to community provider participation must 
be eliminated.
    The most common complaint from providers is the administrative 
burden of complying with requirements that exceed those of commercial 
or even other government programs such as Medicare. Removing these 
requirements will remove impediments to provider participation and 
offer Veterans greater choice.
          Streamline Medical Documentation Requirements: 
        Medical documentation requirements are not consistent with 
        commercial/community standards. VA requirements for medical 
        documentation are often more detailed than the accepted 
        standard of practice in commercial health care. For example, 
        PC3 and Choice require specific elements, short timelines, and 
        provider signatures. VA asks for more documentation and more 
        specific detail than is typically provided in private sector 
        health care, such as provider social security numbers. In 
        addition, many of these requirements are not required for the 
        other non-VA care programs.
          Timely Medical Claims Payment: Delays in payment of 
        medical claims are often due to issues with the return of 
        medical documentation. Providers are not paid until medical 
        documentation is returned and accepted by VA. This delays 
        payments to providers who have already legitimately provided 
        the services and complied with the requirements to return 
        medical documentation. Continued delays in payment will result 
        in dwindling community provider participation and access 
        problems could return.
          Consistency in Reimbursement: There is a need for a 
        consistent methodology for the reimbursement rate 
        determination. The amounts paid to providers should be equal to 
        the amount paid under the Medicare program. When there is not a 
        Medicare rate, the payment should follow the state's prevailing 
        rates instead of VISN- or VA Medical Center-specific rates.
          Modifications to Scheduling Process to Reduce No-
        Shows: There is a high level of appointment no-shows in the 
        community. Currently, we are required to schedule appointments 
        for Veterans we are unable to reach by phone, and then notify 
        these Veterans of their appointment by mail. This process 
        increases Veteran no-show rates and causes frustration with 
        community providers. Community providers have no ability to 
        bill VA for these no-shows, nor can providers bill the Veteran 
        a fee. This process also creates frustration for VA Medical 
        Center staff because Veterans show up for VA appointments that 
        may have been canceled due to a community appointment being 
        scheduled through Choice. More importantly, Veterans may not 
        receive needed care in a timely manner. Modifying this process 
        would reduce community provider reluctance to participate. We 
        currently are working with VA on such a modification.
          Improve the Process for Follow-Up for Authorizations: 
        Timely follow-up on requests by community providers for 
        additional clinically appropriate care is essential. Choice 
        services are authorized for an ``episode of care.'' Once an 
        episode of care is complete, additional authorizations are 
        necessary, even for follow-on care that is normally considered 
        standard of practice. VA is addressing this issue and progress 
        has been made already to ensure timely approval of requests for 
        additional services. We appreciate VA working collaboratively 
        with us to address this challenge.
                     committed to veterans' choice
    In closing, I would like to thank the Committee for its leadership 
in ensuring our Nation's Veterans have prompt access to needed health 
care services. We believe there is great potential for the Choice 
Program to help VA deliver appropriate, coordinated, and convenient 
care to Veterans. We are committed to continuing our collaboration with 
VA and TriWest to ensure Choice succeeds in providing Veterans with 
timely access to care when VA is unable to provide it. Working 
together, and with the support and leadership of this Committee, we are 
confident that the Choice Program will deliver on our obligation to 
this country's Veterans.

    The Chairman. Thank you, Ms. Hoffmeier.
    Dr. Jarrard?

STATEMENT OF STEPHEN JARRARD, MD, FACS, GENERAL SURGERY/GENERAL 
           MEDICINE, LAKEMONT, GEORGIA AND A VETERAN

    Dr. Jarrard. Mr. Chairman, Congressman, Mr. Secretary, Mr. 
Deputy Under Secretary, Committee staff, and fellow panelists, 
thank you for the opportunity to appear before you here today 
on behalf of Georgia veterans, one of this great State's most 
valuable natural resources.
    I feel qualified to provide some input within my scope, as 
I am both a health care provider and a veteran. I served in the 
Army on active duty as both an infantry officer and then a 
surgeon. During my medical school and training, I was always 
honored to work in VA medical facilities to include Mountain 
Home, TN, and Augusta, GA.
    It is an honor to be a veteran, but more of a personal 
honor to me to earn their trust, establish a bond with them as 
a physician, and help take care of them. As a provider, it is 
never a bother to attend to their needs, and I only hope our 
Nation never loses that perspective about her sons and 
daughters who have sacrificed and served both now and in the 
past.
    On that note, I would commend the Veterans Administration 
for recognizing a problem in the care of our veterans and 
coming up with a good program to help solve that problem. 
Especially in rural areas, like Rabun County, GA, where I 
practice medicine, Veterans Choice gives our veterans good 
options to get safe and quality care in a timely manner. Health 
Net seems to have good oversight and management and does a good 
job coordinating this care and seeing it through to completion, 
which is no small task.
    Also, tying reimbursement to Medicare rates is not unfair, 
and I believe that most providers would want to be a part of 
this system and help the VA to care for these veterans. I did 
personally find that it was easy to register and become part of 
the database and, therefore, to become an option in the 
Veterans Choice Program.
    I have not yet personally carried an encounter through to 
completion, so I cannot speak to those parts. But I look 
forward to that and trust that it will be organized and smooth.
    I would also commend Health Net, Ms. Hoffmeier, as your 
provider information materials have been both useful and 
informative.
    Many providers and veterans remember a former cumbersome 
system in both appointments for veterans and management and 
reimbursement for providers. That memory will need to fade and 
be proven past.
    We would all like it to be better, and I again appreciate 
the chance to provide two specific recommendations to that end. 
I believe the program could benefit from wider publicity and 
efforts to register more providers. This information also needs 
to be kept very current for the veterans on the Web site.
    When I put my own zip code into the provider search area, I 
saw a list of many of my colleagues who really do not know 
about the program or their contact information is out of date 
or not correct. More effort should be made to publicize through 
provider channels, such as State medical associations, 
specialty organizations, and even county medical societies. And 
I will pledge to do this through our own local Stephens and 
Rabun County Medical Society. I consider it a patriotic duty to 
help with this program, and I know that many of my Georgia 
medical colleagues would regard it the same way if they knew 
more about it.
    Another thing I think would help is to recognize those 
providers who have stepped up and accepted the Veterans Choice 
responsibility and are actively participating and caring for 
veterans under this program. Perhaps some kind of recognition 
symbol or logo that they could publicize in their own marketing 
materials or on their social media outlets.
    This should be something that veterans could easily 
identify with and look for to know that this provider is 
approved by the VA and could be an option in their spectrum of 
care should they need it or if they just feel more comfortable 
staying closer to home and having a more local provider.
    Again, sir, it is an honor to have the opportunity to 
participate in this valuable discussion regarding the care of 
our veterans. As they in their past and current service 
represent the strength of our national fiber, none of us deny 
the priority they deserve, and it is a privilege to still serve 
by assisting on their health care team.
    Thank you very much. [Applause.]
    [The prepared statement of Dr. Jarrard follows:]
Prepared Statement of Stephen Jarrard, MD FACS, General Surgery/General 
                      Medicine, Lakemont, Georgia
    Mr. Chairman, Congressman, Mr. Secretary, Mr. Deputy Under 
Secretary, Committee Staff, and Fellow Panelists, Thank you for the 
opportunity to appear before you here today on behalf of Georgia 
Veterans--one of this Great State's most valuable natural resources. I 
feel qualified to provide some input, within my scope, as I am both a 
Healthcare Provider and a Veteran. I served in the Army on Active Duty 
as both an Infantry Officer and then a Surgeon. During my Medical 
Schooling and Training, I was always honored to work in VA Medical 
Facilities, to include Mountain Home, TN and Augusta, GA. It is an 
honor to be a Veteran, but more of a personal honor to earn their 
trust, establish a bond with them as a Physician, and take care of 
them. I consider them my brothers and sisters, and therefore they are 
family. It is never a bother to attend to their needs--and I only hope 
our Nation never loses that perspective about her Sons and Daughters 
who have sacrificed and served both now and in the past.
    On that note, I would commend the Veteran's Administration for 
recognizing a problem in the care of our Veterans and coming up with a 
good program to help solve that problem. Especially in rural areas, 
like Rabun County, GA where I practice medicine--Veteran's Choice gives 
our Veterans good options to get safe and quality care in a timely 
manner. Health Net seems to have good oversight and management, and 
does a good job coordinating this care and seeing it through to 
completion--no small task. Also, tying reimbursement to Medicare rates 
is not unfair, and I believe most providers would want to be a part of 
this system and help the VA to care for these Veterans. I did 
personally find that it was easy to register and become part of the 
database and therefore to become an option in the Veteran's Choice 
program. I have not yet personally carried an encounter through to 
completion, so I cannot speak as much about ease of use, but I look 
forward to that and trust it will be organized and smooth. I would also 
commend Health Net, Ms. Hoffmeier, as your Provider information 
materials have been very useful and informative.
    However, we would all like it to be better, and I again appreciate 
the chance to provide two specific recommendations to that end.
    I believe that the program could benefit from wider publicity and 
efforts to register more providers. This information also needs to be 
kept current. When I put my own zip code into the provider search 
area--I saw a list of many of my colleagues who don't really know about 
the program, or their contact information was out of date or not 
correct. More efforts to should be made to publicize through provider 
channels such as State Medical Associations, Specialty Organizations, 
and even County Medical Societies (and I will do so through our local 
Stephens-Rabun County Medical Society). I consider it a patriotic duty 
to help with this program, and I know many of my Georgia medical 
colleagues would regard it the same way if they knew more about it.
    Another thing that I think would help is to recognize those 
providers who have accepted the Veteran's Choice responsibility and are 
actively participating and caring for Veterans under this program. 
Perhaps some kind of recognition symbol or ``logo'' they could 
publicize in their own marketing materials or social media outlets. 
This should be something that Veterans could identify with and look for 
to know that this provider is ``approved by the VA'' and could be an 
option in their spectrum of care should they need it or if they just 
feel more comfortable staying closer to home and having a local 
provider.
    Again, Sir, it is an honor to have the opportunity to participate 
in this valuable discussion regarding the care of our Veterans. As they 
and their past and current service represent the strength of our 
National fiber--none of us deny the priority they deserve and it is a 
privilege to still serve by assisting in their health care. Thank you 
very much.

    The Chairman. Thank you.
    Dr. Williams?

STATEMENT OF WAYMAN DUANE WILLIAMS, GEORGIA LEADERSHIP FELLOW, 
            IRAQ AND AFGHANISTAN VETERANS OF AMERICA

    Dr. Williams. Chairman Isakson, Congressman Collins, on 
behalf of Iraq and Afghanistan Veterans of America and our 
nearly 400,000 members and supporters, over 11,000 of whom 
reside in Georgia, I want to thank you for this opportunity to 
share our views with you today. IAVA was one of the leading 
veterans organizations involved in the early negotiations on 
the VACAA, and we took an active role in advocating for its 
passage.
    My remarks will focus on where we have been, where we are, 
and where we are going with the Choice Program based on the 
experiences of those using the Choice Program in Georgia. The 
general information and personal experiences I would like to 
present were gathered through a combination of: (a) recent data 
reported by the Atlanta VA medical center; (b) preliminary 
analysis of member responses to the IAVA national member 
survey; and (c) my own personal interactions with local IAVA 
members.
    The population of veterans enrolling for VA care is growing 
quickly, as you know, and Georgia is no different. This growth 
comes with a huge increase in demand, and I would rather go 
with numbers rather than percentages. In 2014, the Atlanta VA 
ended the year having seen 96,000 patients. But by the time we 
got to 15 July, the Atlanta VA had seen 100,000 patients.
    By comparison, most other VA medical centers service 50,000 
to 60,000 veterans a year. Most VA health providers serve 1,200 
patients annually. But here in north Georgia at the Atlanta VA, 
our physicians and nurse practitioners and PAs are seeing 1,300 
to 1,400 patients annually. Thus, our concern in Georgia is 
that we must have both specialty and primary care providers to 
match this population growth, especially our female veterans.
    The Choice Program can be a great boost to providing this 
support with proper foundation and education. The Atlanta VA 
medical center is referring correctly to Choice, and right now 
there are over 35,000 veterans who can not be seen inside of 30 
days, but they have been referred to the Choice Program.
    Even before the Choice Program came to fruition, the VA 
experienced challenges with meeting the demand for health care. 
The three VA medical centers in Georgia have made significant 
improvements over the past 3 years in improving customer 
service, thanks in large part to changes in local leadership. I 
would like to commend Ms. Leslie Wiggins, our Atlanta VA 
medical center director, who has been particularly responsive 
in holding employees accountable.
    But we understand work needs to be done. We are at a point 
where access to care and customer service really do have to be 
differentiated.
    Preliminary analysis of IAVA's most recent member surveys 
show that on a national level, 54 percent of the respondents 
still do not know what Choice is; 95 percent of those 
respondents have never used a Choice card; 43 percent indicated 
that one of the reasons for not using the Choice card was 
because they do not know how to use it; and of the 5 percent of 
the respondents who did use the Choice card, 40 percent of them 
had a very negative experience.
    In my personal interaction with local IAVA members, I have 
found that those who were able to use the Choice card were very 
happy. However, the program has been challenging for some 
veterans to successfully use. I would like to highlight the 
experience of one recently demobilized Army Reserve veteran and 
her frustration with trying to use the Choice Program for an 
orthopedic problem that required an orthopedic consultation.
    The consultation was ordered by her primary care provider 
in April, and the Atlanta VA did not have any available 
appointments until August, thus making her eligible for use of 
the Choice Program. But then over 2 months and six calls to the 
Choice appointment line and one call to the local VA OEF 
coordinator and finally the call to the Choice Program manager, 
they said they just could not get authorization for her to be 
seen.
    The end result was that she saw an orthopedic surgeon at 
the Atlanta VA on Monday. Her response to me at the end was, 
``I give up on Choice.''
    Based on the observations, I would like to make a few 
recommendations that the Congress and the VA should consider in 
order to get the program operating at its fullest potential. 
Those recommendations include strengthening the training for 
the Choice Program for all parties involved. For VA employees, 
such as the non-VA care coordinators who are primarily 
interacting with the veterans seeking care and the contract 
care provider, provide the referral technology training so that 
they have hassle free scheduling.
    Finally, I recommend that there be some sort of reviewing 
and streamlining of the operational process by which the Choice 
Program is implemented. We understand that this is a new 
program, and the change in VA culture to a more veteran-
centered care is highly welcome. Contracted care for our 
veterans must also keep the veteran at this center-of-service 
philosophy.
    IAVA is committed to remaining actively engaged with 
veterans making use of the Choice Program and advocating for 
the best access to care for our veterans. This includes but is 
not limited to IAVA's role in consolidation of the numerous 
care in the community programs into one simple and easy to 
understand program, as mandated by the law.
    We appreciate the hard work of Congress. We appreciate the 
hard work of our VA and our partners in the veterans community, 
and we understand that we will continue to work together for 
the success of this program.
    Mr. Chairman, I sincerely appreciate the Veterans' Affairs 
Committee's work on this issue and your invitation to us to 
participate in this, and we stand ready to assist the Congress 
and the department to achieve the best results for health care 
for our veterans.
    Thank you for your time and attention, and I will be happy 
to answer questions.
    [The prepared statement of Dr. Williams follows:]
Prepared Statement of Wayman Duane Williams, Georgia Leadership Fellow, 
                Iraq and Afghanistan Veterans of America
    Chairman Isakson, Ranking Member Blumenthal, and Distinguished 
Members of the Committee: On behalf of Iraq and Afghanistan Veterans of 
America (IAVA) and our nearly 400,000 members and supporters, over 
11,000 of whom reside in Georgia, thank you for the opportunity to 
share our views with you at today's hearing The Veterans Choice 
Program: Are Problems in Georgia Indicative of a National Problem.
    IAVA was one of the leading veterans organizations involved in the 
early negotiations on the Veterans Access to Choice and Accountability 
Act (VACAA) and took an active role in advocating for its passage. This 
is a highly complex law that the Department of Veterans Affairs (VA) is 
continuing to effectively implement in order to ensure veterans are not 
left waiting unacceptable lengths of time to receive health care 
services.
    My remarks will focus on where we've been, where we are currently, 
and where we're going with the Choice Program based on several 
experiences of those utilizing the VA Choice Program in Georgia. The 
general information and personal experiences I would like to present 
were gathered through a combination of recent data reported by the 
Atlanta VA Medical Center to the medical center veteran advisory board 
on July 15, 2015, preliminary analysis of member responses to the IAVA 
national member survey, and my own personal interactions with local 
IAVA members.
    The population of veterans enrolling in VA medical centers is 
quickly growing, and in Georgia this is no different. With this growth 
comes increased demand and this is challenging capacity. The Atlanta VA 
Medical Center is particularly fast growing: FY 2014 ended with a total 
enrollment of 96,000 unique veterans with chronic care problems, and by 
July 15, 2015 this same type of enrollment was at 100,000. Most VA 
medical centers provide service to 50,000 to 60,000 veterans with 
chronic care problems and most VA health providers serve 1200 patients 
annually, but the North Georgia VA providers see 1,300 to 1,400 
patients. Thus our concern in Georgia is that we must have both 
specialty and primary care providers to match this population growth. 
The Choice Program can be a great boost to providing this support with 
the proper foundation and education to properly. However, according to 
the August 18, 2015 report provided to the Medical Center Veterans 
Advisory Board by the Atlanta VA Medical Center's quality management 
team, there are 35,000 veterans waiting for longer than 30 days for 
either a Choice provider or their VA appointment.
    Even before the Choice Program came to fruition, the VA experienced 
challenges with meeting capacity and providing customer service at the 
same time. The three VA medical centers in Georgia have made 
significant improvements over the past three years in improving 
customer service thanks in large part to changes in local leadership. 
Leslie Wiggins, the Medical Center Director of the Atlanta VA Medical 
Center, has been particularly responsive in holding employees 
accountable, but work remains to be done. We are at a point where 
access to care and customer service cannot be confused.
    Preliminary analysis of IAVA's most recent member survey shows that 
on a national level, fifty-four percent of the respondents still do not 
know about the Choice program, ninety-five percent of respondents have 
never used a Choice card, and nearly half (forty-three percent) 
indicated that one of the reasons for not using a Choice card was 
because they did not know how to use it. Of the 5 percent of 
respondents who did use the Choice program, 40 percent had a negative 
or very negative experience.
    In my personal interactions with local IAVA members, I found that 
those who were able to use the Choice Program were happy with the 
service. However, the program has been challenging for some veterans to 
successfully utilize. I would like to highlight one particular 
experience of a recently demobilized Army Reserve veteran and her 
frustrations utilizing the Atlanta VA Medical Center and Choice Program 
for a joint concern that required orthopedic consultation. The 
consultation was ordered by her primary care provider in April, but the 
Atlanta VA Medical Center did not have any available appointments until 
August, thus making her eligible to use the Choice Program. Over the 
course of two months and six calls to the Choice Program appointment 
line and one call to the local VA OEF Coordinator, no record of the 
consultation could be found in the system. The end result of her calls 
was a recommendation from a Choice Program manager to maintain her mid-
August appointment at the Atlanta VA Medical Center. Her response to me 
at the end of describing this process was, ``I give up on Choice.''
    Based on the experiences I've witnessed in Georgia, I would like to 
make a few recommendations that Congress and the VA should consider in 
order to get the program operating at its fullest potential. These 
recommendations include: strengthening the training for the Choice 
Program for all parties involved, to include providing clear and 
concise information to each veteran eligible for the Choice Program on 
how to utilize the Choice services, to VA employees such as the Non-VA 
Care Coordinators who are primarily interacting the veterans seeking 
care and the contracted-care provider and their network to ensure 
hassle-free scheduling. Additionally, I recommend reviewing the 
operational process by which the Choice Program is implemented for each 
veteran to ensure a streamlined and timely delivery of care with a 
defined point of contact and customer service support system that 
veterans can use to resolve issues with scheduling appointments.
    This is a new program, and the change in VA culture to more 
veteran-centered care is a new, and welcome, focus. Contracted care of 
our veterans must also keep the veteran at the center of their service 
philosophy. IAVA is committed to remaining actively engaged with 
veterans making use of the Choice Program and advocating for the best 
access to care for those veterans. This includes, but is not limited 
to, IAVAs role in the consolidation of the numerous Care in the 
Community programs into one simple and easy to understand program 
mandated by law.
    We appreciate the hard work of Congress, the VA, and our partners 
in the veteran community. We must continue to work together and keep 
all communication active between all stakeholders.
    Mr. Chairman, I sincerely appreciate the Veterans' Affairs 
Committee's hard work in this area, your invitation to all us to 
participate in this important hearing, and we stand ready to assist 
both Congress and VA Secretary Bob McDonald to achieve the best results 
for the Choice Program now, and in the future.

    Thank you for your time and attention, I am happy to answer any 
questions you may have.

    The Chairman. Thank you, Dr. Williams.
    Mr. Chacha?

     STATEMENT OF CARLOS F. CHACHA, SFC USA (RET), VETERAN

    Mr. Chacha. Thank you, Mr. Chairman. Mr. Chairman, 
Honorable Doug Collins, thank you for allowing me to speak.
    I like Choice. I want to tell you when I got the little 
card that said Choice, I said, ``Wow, I can go to my doctor 
next door, down the street in 10 to 15 minutes and I will be 
good.'' Came to find out that is not a fact.
    Choice is a good program. What I found out, based on my 
experience with Choice and dealing with Choice, is that, 
basically, the right hand does not talk to the left hand. 
Somebody got a dog and pony show, and we are better off. Simple 
as that.
    I understand--I think they have got three different 
databases. You got the people who you call--and they had a 
number--and ask for an appointment. They are located in one 
part of the United States. Then you have somebody who will make 
an appointment, in my case, for a rheumatologist, someplace in 
Kansas City, another place, another State. Then, if I want a 
colonoscopy, that will be in another State.
    Their system, their database, does not talk with each 
other. If I called Choice right now and I say, ``I need to know 
when is my appointment for a rheumatologist,'' they might be 
able to tell me. But if I say, ``I need to know when my 
colonoscopy is going to happen,'' they need to go to another 
database or I need to talk to somebody else.
    It is frustrating. It frustrates me as a person that I had 
to call, and the person at the other end either is not properly 
trained, or they do not care about us. I had to ask to talk to 
a supervisor. I talked to a supervisor who told me I am not 
authorized to have a colonoscopy, even though my primary care 
doctor sent a request to Choice, and they receive it in Choice 
in April 2015.
    It seems to me that some of the papers get lost because 1 
minute, they have everything they need. They have got the 
authorization from the VA. They have got the doctor's name, and 
everything is good. The next minute, they can not find 
authorization, and we have to start all over again. We are 
reinventing the wheel.
    We do not need to do that. We need to have one system, and 
everybody needs to be properly trained. We need to have 
managers and supervisors that care. I have found three people 
that I was able to talk to, and they cared for us. The rest of 
the people, in the seven or eight times I talked to them--they 
really did not care about me--as simple as that. I was just a 
number.
    It took me almost 4\1/2\ months to finally get my 
rheumatologist appointment. It was this week. I am going to see 
a doctor for a colonoscopy the 31st of this month. The paper 
was submitted on April 30, and now we are in August. So, I am 
just now getting those appointments.
    You might not believe it, but the only reason I am getting 
those appointments is because I stir up congressional. Why do I 
need to stir up congressional for something that is supposed to 
be there for us? [Applause.]
    We put ourselves out there for everybody here to be a free 
person. I did my time. Now it is time for me to get it back. 
Please just get one database, one--and better training.
    Thank you, Mr. Chairman. I appreciate your help.
    [The prepared statement of Mr. Chacha follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
    

    The Chairman. Well, thank you for your personal story. I 
would ask, were all of your attempts to make those appointments 
through Health Net?
    Mr. Chacha. Yes, sir, the 1-800 number.
    The Chairman. I would like to ask Ms. Hoffmeier: Can you 
address what he just said?
    Ms. Hoffmeier. Mr. Chairman, as I said, we know that there 
have been challenges from the beginning, and I have gone 
through and seen some of the input on his record, only when we 
discovered the case just this week. Some of it is based on the 
eligibility process that we discussed, so we can only authorize 
care for cases where we actually have the eligibility 
information and a consult, and then a contact by the veteran.
    But then there are also--I mean, I will not make excuses 
for mistakes. There have been a number of mistakes made. There 
is no question. I completely agree with the recommendation for 
adequate training, which was one of the comments I made in my 
testimony.
    The challenge that we have had is there have been so many 
changes made so quickly that we are retraining our staff every 
week. You can not expect there not to be mistakes when rules 
are changed almost on a weekly basis and we have to retrain and 
ensure we have everything in our scripts within the system. 
Staff are supposed to follow the scripts. But when the process 
is modified frequently, the reality is it is hard to keep the 
training up to date.
    We are addressing a number of the specific concerns. I 
would like to mention some of the improvements we are making to 
address a couple of the things that Mr. Chacha mentioned, which 
is the regional nature of our appointing process.
    We are in the process--we had used for the patients in our 
community care program an approach we referred to as regional 
pods. We had a team that was dedicated to each VISN so they got 
to know that area, and they made all the appointments for that 
area. Choice has grown so fast that we have not had the time to 
put the pods in place. We are moving to that model; it will 
take time with the volume that we are seeing with Choice.
    We also are opening operational centers throughout our 
regions. We do have a number of locations throughout our 
regions already, but earlier this week, I visited one in VISN 8 
we are building and looking to staff; it will include a 
significant staff in VISN 8. We will end up with staff that are 
dedicated to each VISN that will get to know the specific 
geography, the providers in that VISN, and that should help 
facilitate the process considerably.
    We also are putting more nurses up front so that we have 
nurses looking at the authorizations right off the bat. One of 
the things that is a challenge is that not every consult looks 
the same. Sometimes, with the consults that we receive, it 
takes a lot of work to go through the consult and figure out 
what exactly is required--what service is required.
    For the more complex consults, we are having nurses review 
them to try to make sure that we can clearly identify what is 
needed up front, and that will get the process started more 
quickly. For the rheumatology issue, I can tell you I know part 
of the problem was provider acceptance. I think I talked about 
this at the May hearing in Washington. It is a new program, 
which we have had a lot of hesitation by community providers, 
particularly the harder to find specialties.
    It is a new program. As the secretary testified, there are 
so many options right now with VA that providers can 
participate in. There are direct authorizations, local 
agreements, there is Choice, there is PC3, there is ARCH, and 
providers are very confused. They are picking and choosing 
which program they participate in, and certain specialists have 
said, ``We are going to wait and see how Choice works before we 
sign up.'' So, we did have some problems getting 
rheumatologists on board.
    All of those are items that we categorize; and we meet 
every day to work through each of these issues. As a veteran 
myself, I do not like hearing these problems any more than 
anybody else in this room does. But, it is an unfortunate 
reality of an extremely aggressive timeline that has not 
provided ample time for training.
    The Chairman. You know, listening to Mr. Chacha, I was 
reminded of my youth. My father believed in corporal 
punishment, and I can always remember right before I got a 
spanking, he said, ``Now let this be a learning experience to 
you.'' I did not get nearly as many spankings after that, I can 
tell you.
    Your story should be a learning experience, both for 
Secretary McDonald as well as Health Net as well as Congressman 
Collins and myself. Really, that amount of time, that amount of 
misdirection, that amount of disconnect really should not 
happen.
    Now, you are correct in some of the reasons why it 
happened. We are fixing the Choice Program on the run. But, 
really, there ought to be a way to learn from your experience 
to fix those problems that exist within the system so the 
veterans do not go through this frustration.
    By example, you said one of your difficulties is 
establishing eligibility. Right?
    Ms. Hoffmeier. We do not establish eligibility.
    The Chairman. No, no--finding out if they are eligible or 
not.
    Ms. Hoffmeier. Right.
    The Chairman. How do you find that out right now?
    Ms. Hoffmeier. Currently the process is that VA transmits a 
file to us. It is a very large file, and we get the file at 
different timings. So, we receive mileage eligible veteran 
files on a weekly basis and wait list eligible veterans on a 
daily basis----
    The Chairman. Let me interrupt. So, everybody in the 
audience--the mileage is 40 miles or more out?
    Ms. Hoffmeier. Correct.
    The Chairman. You got a verification on that, number 1, 
right?
    Ms. Hoffmeier. Yes, sir.
    The Chairman. The timing is 30 days or more delay for the 
appointment. Is that correct?
    Ms. Hoffmeier. The wait list, yes.
    The Chairman. Now beyond that, what other eligibility 
requirements do you have to have?
    Ms. Hoffmeier. Those are the eligibility requirements for 
Choice. What we have to get is the eligibility information from 
VA that is passed to us in these files.
    The process involves first the VA medical center uploading 
this information somewhere internally at VA. Then there is a 
different office at VA that takes that information and then 
transmits it to us.
    The Chairman. But why would it--excuse me for interrupting. 
But why would it take a file this thick--that was your 
reference--to determine whether somebody lived 40 miles or more 
away from a clinic or could not get an appointment within 30 
days?
    Ms. Hoffmeier. The eligibility file just comes to us from 
VA. The reason that file is so significant--it is records from 
across all of our regions. So, it is not for one individual. 
That is all of the veterans in our region. VA provides us with 
updates in these files. It is all transmitted electronically to 
us.
    That is one of the improvements that VA is working on right 
now, which we are very excited about, to be honest, because one 
of the things that has been a real challenge for even the VA 
medical centers to understand. The VA medical centers have a 
very, very good source of information--they call it the VA 
Viewer--that provides simple, easy to follow information on 
what the veteran is eligible for, what care they need.
    We do not have access to that. So, instead, it goes through 
this complicated process. This new process that is being put in 
place by VA will include not giving us access to the Viewer, 
but sharing that information with us directly from the VA 
medical center level, so we get it almost in real time.
    It is being rolled out in phases, so VA is starting first 
with a subset of veterans that are eligible, because they need 
to do some system reconfiguration in order to make it work, and 
we need to also be able to test it. We have started that, 
actually. I think that will make a huge difference in what I 
call the runaround.
    I mean, it has been a runaround in many cases for veterans, 
because they will call us, and we do not have the eligibility 
information. By contract, we cannot do anything without that 
information.
    The Chairman. Well, this story is one of the reasons we 
have hearings exactly like this so we can find out the real 
story about what is going on out there. Now I have got to ask 
you this. If I heard Mr. Chacha correctly, the referral he got 
from Health Net for rheumatology was a rheumatologist in Kansas 
City. Is that right?
    Mr. Chacha. No. The person who was handling my 
rheumatology----
    The Chairman. They lived in Kansas City.
    Mr. Chacha. They were in Kansas City.
    The Chairman. But the rheumatologist was in Georgia.
    Mr. Chacha. Yes.
    The Chairman. Well, that is good. I was really worried you 
were getting referred to Kansas City.
    Mr. Chacha. No, no.
    The Chairman. Dr. Jarrard, let me ask you a question. You 
said you have not completed your first consult. Is that right?
    Dr. Jarrard. That is correct.
    The Chairman. So, you have not been reimbursed by VA for 
any services you offered under Choice. Right?
    Dr. Jarrard. Not yet, sir.
    The Chairman. Are you aware that under Choice, it is the 
secondary payor if there is any other insurance coverage, and 
your veteran would have to pay a copayment when you saw him?
    Dr. Jarrard. Yes, sir. As I said, the Health Net 
information is very adequate and thorough. I was aware that if 
the other insurance is primary, there may be a copay according 
to whatever that insurance company requires for that visit.
    The Chairman. As a physician and as a veteran, would you 
think it was a disincentive to use Choice if you knew you could 
go to the Clairmont Hospital and get it paid for through 
regular VA payment without a copayment, but if you got referred 
within Choice, you would have to make a copayment and you would 
be secondary?
    Dr. Jarrard. Yes, sir. But I think you would have to figure 
out the amount of time it may take you to get seen at that VA 
facility, and some veterans may feel that way. But, in general, 
I would say the answer to your question is yes.
    The Chairman. Well, that is a great way that you answered 
the question. I commend you on that answer, because the 
circumstances do dictate. I mean, if you are in emergency care 
or you are ill, you are going to go wherever you can get the 
service, and that is going to dictate the situation. If you 
have some flexibility, it might be different.
    But one of the reasons I brought it up--we have been 
talking with Secretary McDonald and his staff--when we passed 
the Choice Act we created some unintended consequences.
    Right, Secretary McDonald?
    Secretary McDonald. Yes, sir.
    The Chairman. One of them is the one I just illuminated, 
where there are different sets of circumstances for the 
physician to be reimbursed, depending on which avenue they 
attract in terms of services, which is a problem the veteran 
should not have to worry about, quite frankly, in my judgment. 
So, I wanted to bring that out.
    The last thing I want to ask you as a practitioner--and I 
do have a place in Rabun County, yet I hope I do not ever need 
to see you, but if I do, I am glad that we met under good 
circumstances.
    Dr. Jarrard. Yes, sir.
    The Chairman. But if I needed to see you, and I made an 
appointment for next Monday, and I did not show, would you bill 
me for not showing? Or do you have a 24 hour notice, or do you 
have a fine for not showing? Tell me what your practice is.
    Dr. Jarrard. Well, sir, my personal philosophy on that as a 
practitioner in Rabun County is I would never do that to my 
people, regardless. But under the Health Net rules----
    The Chairman. I am going to come see you. [Laughter.]
    Dr. Jarrard [continuing]. Under the Health Net rules, that 
is disallowed, meaning no veteran can be charged for a missed 
appointment, nor can the VA or Health Net be charged for a 
missed appointment.
    The Chairman. Well, the reason I bring it up--we are 
looking at an omnibus approach to solving some of the technical 
problems with Choice and VA health care. Some of the ones we 
have already talked about--some tweaks that need to be done one 
way or another. But, you know, in the private sector--one of 
the problems in getting doctors to participate in Choice is 
that if you can not be reimbursed when somebody does not show, 
or you can not have a penalty for somebody not showing, then it 
costs them money to have an appointment unfilled that they made 
24 hours out.
    Would it be unreasonable if somebody used Choice to make 
sure the veteran understood that if they made the appointment 
and did not show, there would be a $35 fee for not showing? 
Does that bring about more accountability on the veterans, from 
the veterans' standpoint? I am asking you tough questions, I 
know.
    Dr. Jarrard. It possibly could, as long as they were 
informed ahead of time and knew that. Where you will see most 
of those policies about charging for no-show appointments is in 
urban areas. Doctors are very busy. They have a full schedule. 
If someone no-shows without prior notice, that slot could have 
been filled by someone else that is waiting longer to get an 
appointment.
    In your rural areas where these veterans are most likely to 
live, out away from the VA medical center or the VA clinic, you 
do not find those policies as much. But, I would only say that 
that was fair if veterans knew ahead of time that that was the 
policy, and that they would be willing to take that risk. Now, 
I believe--and I want this to become a really good thing.
    And, sir, I am sorry for the experience that you had.
    Mr. Chacha. I understand.
    Dr. Jarrard. I am glad we are here today to talk about it, 
to get it fixed.
    I want this to be such that that veteran is so happy to get 
that appointment and to get some care under the system that 
they would not want to be a no-show. I believe that most of 
them would be grateful. That was my experience working in VA 
medical centers in various places in the country while in 
training, that it was very pleasant that the veterans that you 
took care of were always grateful.
    That is something you do not always see. It is like money 
in your pocket when that happens. It is like extra pay.
    The Chairman. Absolutely. It is very rewarding.
    Dr. Jarrard. I hope that happens.
    The Chairman. After all they have sacrificed for us, the 
least we can do is provide the best quality service to them.
    Dr. Williams, thank you for mentioning women veterans. You 
know, it is ironic--I was sitting here thinking when you did 
that--people are forgetting that pretty soon, women veterans 
are going to be 10.2 percent of those eligible for VA health 
care, and it is growing dramatically because of Afghanistan and 
Iraq. Today, two female Rangers are being inducted in the U.S. 
Army at Fort Benning, which is indicative of what is happening 
to our military.
    I appreciate your standing--and one of the things I have 
said as chairman of the Committee is I want to make sure that 
we look forward in the future, understanding that our clientele 
in terms of veterans health services is going to change. There 
needs to be a focus on all services and on services that are 
particular to women and particular to men. Your advocacy is 
very much appreciated.
    You said 54 percent of your members do not know about 
Veterans Choice. Right?
    Dr. Williams. Yes, sir. According to the survey, that is 
what we got back. It was a little surprising to us, but it is 
what it is.
    The Chairman. Well, everybody that has testified has 
referred to a lack of clear understanding on who is eligible 
and who is not, and there are an awful lot of veterans who have 
told us one way or another that when they try to find out, it 
is very cumbersome and very difficult.
    Your organization has done a great job of sending us a lot 
of things we ought to do that are very well thought up and we 
have done some of them. I would hope your organization would 
think outside of the box and be a voluntary resource for me and 
the Committee to make recommendations to us about how we could 
better communicate from the VA to the veterans on what Choice 
is, whether or not they are eligible, and make it in a seamless 
way that would make it easier for them, because 54 percent is 
inexcusable.
    We have implemented a very large and very comprehensive 
program in a very short period of time. But we did it to make 
it easier for the veteran. If 54 percent do not even know about 
it, then we are not doing our job. There ought to be some 
better way that we can reach the veteran. The VSOs can be an 
important help in doing exactly that. So, I appreciate your 
testimony very much. Work on that as a project for me if you 
would.
    Dr. Williams. Yes, sir.
    The Chairman. Mr. Chacha, you have got a colonoscopy coming 
up?
    Mr. Chacha. Yes, sir.
    The Chairman. It is worth waiting for, I will tell you. 
[Laughter.]
    That is one thing you can delay as long as you want to.
    Mr. Chacha. That is right.
    The Chairman. I am just teasing.
    Mr. Chacha. Mr. Chairman, if I may, can I touch on one 
point?
    The Chairman. Please.
    Mr. Chacha. I know some people are going to be upset about 
this, but----
    The Chairman. Speak closely into the microphone.
    Mr. Chacha. Some people might get upset about what I am 
going to say, but the facts are the facts. I talked to a couple 
of doctors, trying to find one to be my doctor, like a 
rheumatologist or a GI, so I can go get my colonoscopy.
    They explained to me the reason why they would not accept 
somebody from Choice or the VA, although this is hearsay, what 
I was told from these physicians and from these offices was 
because the VA is taking 6 months to 1 year to pay the doctors 
for seeing a veteran. Now they are turning--anybody that has 
anything to do with the VA, they turn away because they are 
afraid they are not going to get paid and they cannot stay in 
business.
    The Chairman. Well, I am glad that you mentioned that, 
because we all--I see some nodding heads from some of the 
professionals in the room. Prompt payment is a problem, and if 
there is any--I know the secretary is here and some other folks 
from the VA. The more reliable the reimbursement system for the 
veterans is, the more doctors are going to want to participate 
in it. I think that is a good point to make.
    I do not know that we have a longitudinal--enough time yet 
in the program to know if that is endemic to the program or if 
it is just an anomaly. But that is something that is going to 
expand our--I guess Ms. Hoffmeier might agree with that. Am I 
correct?
    Ms. Hoffmeier. That is one of the top reasons we hear from 
providers for not participating in Choice--that they have had 
experiences in the past that have been less than positive with 
being reimbursed. We are paying the Choice providers for the 
care, but it does take time to rebuild that confidence that 
they will be paid in a timely manner.
    VA is doing a great job of working collaboratively, though, 
with us to address that. So, when we hear that from providers, 
we work it through our VA contacts, who are working to try to--
you know, if there are still outstanding bills, to get those 
bills resolved and to improve that perception of payment. That 
really is a very important point.
    I would like to comment on the no-show issue. That is 
another significant issue we hear, and it may be the urban 
providers, as Dr. Jarrard mentioned, but it is an issue with a 
number of them, because right now, unfortunately, the way it is 
structured, we are not allowed to call veterans. Veterans must 
call us to initiate the appointment.
    Once we schedule the appointment, we follow up with the 
veteran to let the veteran know they have an appointment. If we 
cannot reach the veteran, we are required by our contract to 
send them a letter telling them when their appointment is 
scheduled to occur.
    What we are finding is that there is a high volume of no-
shows because we are not actually reaching the veteran live. We 
are sending a letter. VA is working to change that as well, and 
I think once we get that process changed, that will reduce the 
number of no-shows and it may become less of a problem. But 
today, it is a problem for provider participation.
    The Chairman. Thank you very much.
    Congressman Collins?
    Mr. Collins. Mr. Chacha, you wanted to follow up very 
quickly?
    Mr. Chacha. Yes. When they are talking about the 
appointments, appointments are made by Choice, and I have been 
told by Choice that they cannot call my house and leave me a 
message in my voice mail because of HIPAA or something like 
that. They cannot tell me----
    The Chairman. Because of HIPAA?
    Mr. Chacha. Yes, sir. They use that for everything.
    The Chairman. You can blame Congress on that.
    Mr. Chacha. I mean, I just answer the questions, OK. But 
that is what I have been told. I missed two appointments with 
my rheumatologist because the appointments were made and I was 
never contacted about it.
    The Chairman. That seems like a solvable problem, having 
recently gone to a physician and signing a HIPAA release on 
whether they could call and leave a message on my voice mail. 
Could there be some procedure when you sign up to become 
eligible for VA health care that there would be a sign-off 
where they could give the authorization to leave a message on a 
voice mail or with another party? I am kind of directing this 
to some of the VA staff. We ought to look at that.
    Secretary McDonald. There is, Mr. Chairman. But the 
question is about how pervasive can that be. In other words, 
would you do it once and have a particular--the way HIPAA is 
written--and we can work together on this--is that it has to be 
very, very specific to an instance. But, you know, again, it is 
law so we would have to change the law.
    The Chairman. I told you it was a congressional problem. 
Maybe we will make it an opt-in versus an opt-out type of 
situation. Excuse me for interrupting. Go ahead.
    Secretary McDonald. Something to make it easier for the 
veteran.
    The Chairman. Right.
    Mr. Collins. I appreciate the chairman talking about that, 
because I just left a doctor and I had to sign a who could be 
notified form, which stays in my file. I mean, it is for my 
doctor, my general practitioner. So, I am not sure that there 
is that much limitation in it. You can actually do that. It is 
something we can work on.
    Secretary McDonald. We are talking about different 
providers here.
    Mr. Collins. Yes, different providers. We could get a 
signature for different things. I mean, it is a signature.
    I want to start positive. My mom always told me to start 
positive. I have been sitting here, frankly, a little 
frustrated.
    Dr. Jarrard is one who serves in the 9th District. But 
also, for those who may not know, he takes not only his medical 
practice seriously, but his commitment to his education. He 
serves on my Academy Board and helps put young men and young 
women into our academies, which over and above any time that he 
gives in service, not only to the medical community, but to the 
Academy Board. I wanted to say thank you for what you do. We 
have got a lot of good folks going in, and you are a big part 
of that.
    Dr. Williams, as well, from my service, in that what you 
are doing is providing the missing link that is discussed a 
lot, but I think it is almost like that storm, Mr. Chairman, 
coming. We know the storm is coming with Iraq and Afghanistan 
veterans and others that may in the near future; we are talking 
about it. It is a good conversation, but we have got a lot of 
instructional internal problems that are going to have to be 
fixed in this regard.
    Mr. Chacha, of course, is from my area, and we have been 
working on your case, which, unfortunately, you have made my 
classic case--why did you have to call me to get this solved? 
Mainly because of the many, many days that you had to wait, 
which leads me to a question that the chairman brought up.
    I do not mean to be--I am just asking a question. Ms. 
Hoffmeier, I do not believe you answered the chairman's 
question. He said there were two eligibility issues, to which 
you talked about files being sent over, and that they are this 
thick, or they--that is a whole different line--but there are 
two basic eligibilities for Choice. Why is that so difficult?
    I apologize, but if you are going to tell me about file 
transfer again, just say, ``You know, I really do not have a 
good answer.''
    Ms. Hoffmeier. No, the simple answer--and I apologize if I 
did not express it clearly--is we must have confirmation from 
VA of the eligibility. We do not determine the eligibility. I 
understand what the rules are very clearly, the two types of 
eligibility. But if we do not have something from VA that shows 
us that veteran is authorized under one of those two 
eligibility categories, we are not allowed to act on that.
    Mr. Collins. So, I may have asked the question--and the 
chairman or whoever may say this is--when VA reaches out to 
you, they are asking for you to give an appointment. They 
should have already researched eligibility requirements and 
never called you unless they have determined eligibility. 
[Applause.]
    I am wondering--are we getting stuck semantically here? I 
am beginning to wonder. I appreciate what you are trying to do, 
but I am not sure why VA would even send you a file if they 
were not eligible for Choice.
    Ms. Hoffmeier. Well, I think part of it is you have to go 
back to--first off, I think the chairman, or maybe it was even 
you--mentioned early on at the very beginning that almost 9 
million cards were sent out. The vast majority of the veterans 
were not eligible for the program.
    Mr. Collins. I apologize for interrupting, but please hear 
me because I am really trying to understand this. Can VA just 
send Health Net--and the secretary or somebody else maybe might 
have to help, and I apologize--can they just send you any 
veteran's file? Yes or no? Because if I went into the system, 
if I took my DD214 and I went into the system, can they just 
send----
    Ms. Hoffmeier. The whole file?
    Mr. Collins. Send the file for any reason, for whatever? 
Can they just say, ``You know, we are going to send Doug's file 
to Health Net?''
    Ms. Hoffmeier. No.
    Mr. Collins. So, the reason they would send a file to 
Health Net, if I am tracking here, is because you are eligible 
for the Choice Program. I am not sure why there is the 
disconnect at are you eligible or not. If you get the file from 
the VA, they are eligible. [Applause.]
    I am not sure why we are even--I mean, this is----
    Ms. Hoffmeier. No. I absolutely agree with you, and I feel 
your frustration.
    Mr. Collins. Then why is that a stopping----
    Ms. Hoffmeier. I am telling you what----
    Mr. Collins. Why do we stop there? Why do we stop at 
eligibility?
    Ms. Hoffmeier. Because the contract requires us to wait for 
that eligibility file. We are not allowed, by contract, to act 
based on a VA medical center telling us the veteran is 
eligible----
    Mr. Collins. I understand that.
    Ms. Hoffmeier [continuing]. Or even them sending us the 
consult.
    Mr. Collins. This is frustrating for me, because, frankly, 
I do not want to seem completely disagreeable here, but you 
just added to my frustration. I do not expect you to take a 
call from the VA and they say, ``Oh, by the way, they are 
eligible.'' When you get the file, they are eligible. I think 
that is where the disconnect is coming in; where Mr. Chacha and 
many others are saying, ``Why do we start at eligibility?'' 
because then we get into the other issues of--and let me share 
some quotes here.
    I have asked my staff on many occasions, ``What are some of 
the things that you hear?'' They tell me, ``The VA has not sent 
your records.'' ``You are not in the system.'' ``You are 
approved, but we are still waiting on other paperwork.'' We go 
to other issues of folks who come to us, and if we are getting 
stuck on eligibility, it is no wonder we are waiting 100 days, 
talking to three different people--``I have your file'' or ``I 
do not have your file.''
    Ms. Hoffmeier, frankly, I am just going to leave it alone 
at this second, except to say this. I can not get to these 
other issues of why they can not get appointments if we have an 
answer for eligibility that, frankly, I would have to say, 
would possibly make sense to no one in this room. If we can not 
get the eligibility part down, that you get a file and they are 
eligible--not a call, not a ``Hey, why do not you ask them?'' 
But when you get the file, they are eligible. That should never 
be an excuse anymore.
    I know the chairman and I have discussed making this 
bureaucratically as easy as possible. But as the secretary said 
earlier, we are working to cut out the bureaucracy here. If we 
get stuck there, I am not sure which way we go.
    So, Mr. Chairman, there is a ton more that we could ask. 
But this is part of the reason you are having this hearing. 
This is part of what we are seeing, frustration-wise.
    But from Health Net's perspective, there are a lot of other 
issues about your training, your weekly training and your 
turnover. I understand that. But there is a statement you made 
earlier, that mistakes are just a reality; OK, and it happens 
in a system. But mistakes that are not learned from are costing 
our veterans. We have got to stop this. And having a discussion 
on who is eligible or not is not really going to be a helpful 
discussion.
    I appreciate you, Mr. Chacha. You worked with my office. I 
will let you continue to work with my office, that I think 
there are some good things to come.
    Mr. Chacha. We are here for you, sir.
    Mr. Collins. Thank you for what you are doing.
    Mr. Chairman, with that, before we close, I want to yield 
back to you for follow up.
    The Chairman. Well, you know, these hearings are important 
for the reason that you learn what is going on in reality. Doug 
and I work in Washington, DC, which is the devil's workshop, 
and sometimes it is not the real world.
    If we have gained nothing from this hearing today except 
this one factoid that we can work on--because, really, as I was 
listening to Doug--and I had asked the question and then 
listened to Ms. Hoffmeier--why would a veteran seek a Choice 
appointment? Because he could not get one within 30 days at 
Clairmont, or because he lived more than 40 miles away? Those 
are the two prerequisites, other than his being a veteran, or 
her being a veteran.
    Why does it take a file for somebody who is not a veteran 
to try to determine that? Why does it take some--if we could 
just simplify that process, so when a veteran made the call, in 
a seamless time period, they could say, ``He is eligible'' or 
``She is eligible'' or ``She is not''. We could solve what--you 
could have solved your problem, Mr. Chacha.
    Mr. Chacha. Yes.
    The Chairman. We could have solved most of the other 
problems that are mentioned.
    Mr. Chacha. Four months ago.
    The Chairman. I know the devil is in the details, and 
Members of Congress tried to solve a lot of problems in August, 
yet we created a lot of problems with the Choice program. But 
we created a lot of opportunities as well. For all the horror 
stories that we talk about in here, there are veterans who have 
gotten services who would not have gotten them had they been 
under the laws of 2014 or 2013 or 2012 or 2011. We are moving 
in the right direction.
    Secretary McDonald is trying to steer the ship of VA in 
very difficult waters, and he is doing a good job of that. We 
are not where he wants to be yet. We are not where I want to be 
yet. But we are moving in the right direction.
    Leslie Wiggins at the Clairmont Hospital has done a 
remarkable job of turning that facility around, attitudinally 
as well as service-wise, and I am grateful for that. A lot of 
the things that have improved at that hospital are things we 
learned from the last field hearing we had in Atlanta in 2013.
    These are very worthwhile, and all of you coming today and 
being a part of this--I am very appreciative. To each of our 
panelists, thank you.
    Secretary McDonald, who cut his vacation short--I know his 
wife is waiting on him in Orlando right now--thank you. Thank 
you to all your staff that came.
    But, the people who really deserve a large amount of 
credit--Doug's staff and my staff, who do the hard work, the 
people that you call when you can not get the VA to respond, 
though we try to be responsive--they are all here today. I want 
to thank them for taking their time and all they do to provide 
services.
    To our host today in Hall County, Gainesville, GA, near the 
lake that is full, I want to turn it over for closing remarks 
to Congressman Collins.
    Mr. Collins. Well, thank you, Senator, again. It is great 
to have a partnership. And for those who have watched the 
media, there is a picture that goes around almost every time--
Senator, you are in the paper a lot more than I am. But there 
is always this picture of the senator speaking, and there is 
this tall guy behind him. I am pleased to be that tall guy when 
we are in Augusta together, because it has been a good time 
and----
    The Chairman. That was at a VA hospital.
    Mr. Collins. It was at a VA hospital. It shows the 
commitment that the senator has as chairman and also we have in 
our congressional office to ask the questions that, 
unfortunately, sometimes are not easy. But there are questions 
that we get all the time.
    I do want to say thanks again to our staffs and also to 
North Georgia. This is my alma mater--the University of North 
Georgia. I know Kate Maine. I see her up in the top--and Dr. 
Jacobs.
    Also we do have a fellow, one that works in public life, 
and that is Senator Butch Miller who is here from--Senator 
Miller from our great county up here in Hall. Thank you for 
being here.
    Thank you, panelists.
    Mr. Secretary, although Gainesville is great, I know 
Orlando is better because your wife is there. Thank you for 
coming.
    The Chairman. Would you please join me and rise as we 
retire the colors? We will stand adjourned after the colors are 
retired.
    [Retiring of Colors.]
    [Whereupon, at 3:48 p.m., the hearing was adjourned.]
      

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