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▶ 0:13:30this oversight hearing for the subcommittee on health will now come to order uh it's not often in Washington DC you start uh very early in the morning shoveling snow uh but thank you all for making it despite the snow um I understand this hearing focused on Community Care has garnered a significant member interest including from committee members who are not on my subcommittee so before we get started in accordance with committee rule 5e I ask unanimous consent that all off subcommittee members be permitted to participate in today's Committee
▶ 0:14:00hearing without objection so ordered as a 24-year army veteran and a health care provider I've seen firsthand the struggles our veterans face and accessing the care they have earned I've also experienced the challenges providers encounter when trying to deliver the care let me make two things perfectly clear at the start of today's hearing veterans should never have to fight through a maze of bureaucracy to get the health care they deserve and providers should not be bogged down by administrative hurdles just to serve
▶ 0:14:31them these two statements shouldn't be considered partisan this subcommittee has received multiple reports regarding delayed referrals cancel appointments um lack of reimbursement and long wait times for treatment that should be available much sooner these aren't isolated incidents these are systemic failures that have real harmful impacts on the everyday lives of veterans and let me also say that I know that the VA is working very hard and very diligently to serve our veterans and
▶ 0:15:01to remedy uh these incidents and it's why today's hearing is so important today is our follow-up to our previous full Committee hearing where we heard directly from veterans and their families about the barriers they experienced in accessing community care but with a new Administration comes New Opportunities and under the leadership of secretary Collins I have total confidence that the VA will course correct the failures of the previous administration to protect Healthcare access for veterans in our last hearing we we saw attempts by some members to shift the
▶ 0:15:31failures of the Biden Harris Administration to thirdparty administrators and providers there was also yet another attempt to propagate the myth that Republicans want to privatize VA let me once again address this falsehood and state the position I chair I share with chairman Bost Community Care is VA care it's designed to supplement va's Direct Care system not replace it the purpose of today's hearing is to provide a refresher on the roles and
▶ 0:16:01responsibilities of the outside providers who are responsible for administering the Community Care Program so that all members of the committee can refocus efforts on holding the right people accountable this is about making sure the Community Care program works for veterans not for bureaucrats in Washington DC so let me spell out who is responsible for what third-party administrators are task with building provider networks and paying claims for services rendered by Community Care providers thirdparty administrators do not
▶ 0:16:31determine veterans eligibility for Community Care they do not authorize referrals and they do not manage the transfer of medical records between VA facilities and Community providers those responsibilities belong to the VA when the VA fails to authorize referrals in a timely manner or delays sending the necessary documentation veterans are the ones that suffer we have heard countless stories from veterans who have waited months for care because their referrals were stuck in the system or who received approval
▶ 0:17:01for care just prior to the expiration of that care veterans who have had to navigate confusing and in inconsistent communication because the VA not the outside providers cannot get it together one of those veterans is my constituent Mr Terry bar Grover a Vietnam veteran battling blood cancer I'd like to take a moment to describe Terry's Community Care experience in his own words they just expect us to know all the rules no one answers the phone or
▶ 0:17:31returns calls we get the feeling the VA does all of this extra work so we'll give up and not use the VA at all and just last night in this morning I had a veteran in my community text me about his experience at the VA with a urinary tract infection caused by a kidney stone we can't allow these issues to persist veterans like Terry and the veterans we all heard from a few weeks ago in this room deserve better they deserve a sister that work A system that works for them
▶ 0:18:02not against them and that's my number one uh priority from my seat as the chairwoman today we'll hear from VA officials and stakeholders about the steps they're taking to improve the administration of community care and Ure that the program operates efficiently and effectively so veterans can get the care they need without unnecessary delays thank you all for being here today I look forward to hearing from our Witnesses on how they can improve the VA Community Care Program for the veterans who rely upon it with that I yield to ranking member brownley
▶ 0:18:32for her opening statement the chair recognizes ranking member brownley thank you madam chairwoman I am glad the subcommittee is holding this hearing today uh prior to last month neither the committee nor the subcommittee had held an oversight hearing on Community Care since July of 2022 uh nearly three years ago when Democrats held the majority I want to acknowledge and make clear at the outset that there will always be a place for Community
▶ 0:19:02Care VA cannot provide all the Care our veterans need on its own this is especially true for women veterans needing specialized Women's Health and maternity care Community Care is an important part of the health care that VA provides but finding the right balance is important and I'm concerned that we have not yet found that balance today I expect we will hear uh some of my colleagues on the other side of the aisle say that VA is restricting veterans access to Community
▶ 0:19:32Care but veterans are now receiving more than 40% of their care in the community versus only about 23% in the year before the mission Act was implemented spending on Community Care has risen sharply over that period of time ballooning to what some have argued is an unsustainable amount and yet in all that time particularly over the last two years our committee and this subcommittee have conducted limited oversight
▶ 0:20:03on one of the most significantly growing segments of the va's budget VA is on track to spend $42 billion on Community Care referrals this fiscal year that shouldn't be a surprising number to everyone in this room as more and more veterans are referred to Community Care every single year but it should be shocking to everyone here that VA is sending that much money out out of the door every year to a community Care Network Network over which VA
▶ 0:20:33and this committee have devoted very little oversight as we will hear from our oig and GAO witnesses there are numerous weaknesses in va's oversight over the performance of its third-party administrators optim and tri West these contractors who we will hear from on the second panel have contracts with VA worth tens of billions of dollars and yet our Witnesses from GAO and oig have detailed in many many reports
▶ 0:21:04that VA needs to perform additional oversight about how they are maintaining their provider networks and whether and whether their providers are properly coordinating veterans care with the VA worse still we don't even know whether patients that are referred to the community are receiving more timely access to care or even high quality Care in the community we don't know because VA has not established sufficient contractual requirements and
▶ 0:21:34metrics through through with it can through through with it it can hold its contractors accountable three weeks ago at a full Committee hearing my colleagues and I had the chance to hear from veterans who had difficulties accessing Community Care Unfortunately The Limited witness list and Hasty organization of that hearing meant that we did not get a chance to hold VA or the third party administrators accountable for these failures nor did we have a chance to discuss them
▶ 0:22:04with the experts at GAO or and oig who have done some excellent work to find room for improvement in the community Care Program I'm glad we have you all here today as I said at the hearing three weeks ago I think there is absolutely room to improve the coordination of Community Care on Monday G GAO published a report about this very topic one that I requested along with some democratic colleagues of mine GAO found that there is
▶ 0:22:35inconsistency and variation across facilities in terms of how long it takes to schedule appointments and that VA lacks a comprehensive National policy that clearly defines roles and responsibilities for local facilities we are rapidly hurdling ahead toward toward a legislative hearing and a markup on chairman boss Comm Community Care legislation beginning less than two weeks from now my colleagues and I have many questions about
▶ 0:23:05the current state of community care that I'm not sure uh can all be answered in this one subcommittee hearing I'm also concerned that chairman Bose bill would could exasperate existing challenges in VA Community Care rather than equipping VA with the resources it needs to properly operate the Community Care Program we already have this committee and the health subcommittee in particular has an obligation to conduct robust oversight over the
▶ 0:23:35health care that VA is providing including through its Community Care Program I'm concerned that the committee's current level of oversight is not sufficient for us to move straight to legislating while this hearing today is an important opportunity to hear directly from vaa opum and tri West I sincerely urge my colleagues to consider what additional over oversight is needed to inform our legislative efforts and with that I thank you and I yield back Madam chair
▶ 0:24:05uh thank you ranking member brownley the chair would also like to acknowledge that the chair of the full committee chairman Bost is here with us today and we will hear from him later I'd like uh now like to introduce the panel one Witnesses testifying before us today we have Dr Steven Braverman Chief Operating Officer of the veterans health administration at the Department of Veterans Affairs accompanying Dr Braverman representing Department of Veterans Affairs is Dr sain yindi chief medical officer office of integrated veteran care also with us today
▶ 0:24:36is Sharon silus director of healthc care for the government accountability office and Dr Julie cak principal Deputy assistant Inspector General for the healthcare inspections for the va's office of Inspector General Dr Braverman you're now recognized for five minutes to deliver your opening statement okay thank you and before I get started I just want to apologize Upfront for any you know coughing or sneezing that occurs during the discussion um but I thought it was really important to be here
▶ 0:25:06with you today so and I want to recognize chairman Bost for joining us so good afternoon uh chairman chairwoman excuse me Miller Meeks uh ranking member brownley and members of the subcommittee thank you for inviting me here today to discuss the Department of Veterans Affairs Community Care Program I'm accompanied by Dr uh sain yende chief medical officer of the office of integrated care uh for or integrated veteran care or IVC it's an honor
▶ 0:25:36to be here representing the veterans Health Administration for the first time as its inaugural Chief Operating Officer I'm responsible for ensuring we continue to live up to the standard the veterans expect and deserve by overseeing operations for va's 18 veterans Integrated Service networks or visions and providing executive leadership and oversight to 34 program offices within the offices of integrated veterans care patient care services and Clinical Services it's a great
▶ 0:26:06responsibility and I bring to bear the same philosophy I've shared with my teams as a leader in the Army and VA a philosophy I call the for Seas to success they are communication care of the veteran customer service and Sense over the last decade our system has been faced with many challenges following my Army re retirement I joined the Edward Hines Jr VA hospital as its director in 2016 frustrations with veteran access to care were at a peak
▶ 0:26:37and employee morale was low employing those forces to success we worked hard to implement the changes necessary to boost morale while keeping veteran Care at the core of every decision we made the 2018 Mission Act passed by this committee gave us the authority to put processes in place to ensure veterans had access to the timely appropriate care in the community when VA was unable to provide it in our Direct Care System since the mission act became law VA
▶ 0:27:07has referred over 5.4 million unique veterans to Community Care Providers encompassing more than 228 million Community Care appointments as with the implementation of any law we've had to make systemic improvements to ensure timely access and build veterans trust in our system while serving as the Director of the VA Greater Los Angeles healthc care system we hired and trained dedicated staff for referring and appointing veterans into Community Care we piloted the va's initial
▶ 0:27:37tele emergency medicine initiative that enabled most veterans to be evaluated without costly emergency room visits and receive appropriate followup on specialty outpatient referrals as needed it's now a national program during my time as the visen 22 director the Phoenix VA became a model for the referral ordination initiative a nurse-led effort to connect veterans eligible for Community Care with the right provider for his or her needs with implementation
▶ 0:28:08of the PCT act Demand on the VA has never been greater since the law took effect nearly 900,000 veterans have enrolled in vaare with even more moving into higher priority groups due in part to the resulting increase in service connected disability ratings The corresponding elimination of co-pays and increased eligibility for traditional Medical Services led to more Reliance on VA care that can't be met in the Direct Care System alone I can confidently say that
▶ 0:28:38we could not meet veteran demand without the partnership and collaboration among our thirdparty administrators and Community Care Providers still challenges remain with care coordination and the veteran and provider experience within the community care program a recent series of oig inspections of visen Community Care programs including my former Network identified several similar findings or recommendations those included strengthening Community Care oversight councils scanning of care documents into
▶ 0:29:08veterans electronic health records and referrals and timely processing of follow-up requests for services based on these findings IVC leaders Vision directors and vha's office of integrity and compliance are working together to execute consistent action plans across the country to address oig's recommendations s prior to joining the VA I served 29 years as a physiatrist in the Army Medical Corps in both academic and operational leadership roles as an army
▶ 0:29:38retiree a federal employee and a deployed veteran I have multiple options for my health care I'm proud to say that I receive all my medical care at VA it's the best care available Madam chair ranking member brownley and members of the committee I look forward to working with you to continue to strengthen our Health Care system and to answering your questions thank you Dr Braverman uh Miss Silas you're now recognized for 5 minutes to deliver your opening statement chairwoman Miller Meeks
▶ 0:30:08ranking member brownley and members of the subcommittee thank you for the opportunity to be here today to discuss va's efforts to ensure veterans have timely access to Healthcare through the Community Care Program although the majority of veterans receiving VA Healthcare still receive their care at VA medical facilities the number of veterans receiving care through the veterans community Care Program has increased greatly in fiscal year 2023 Community Care represented about 40% of all VA healthare in 2018 in an effort to help alleviate
▶ 0:30:38long wait times for Care at VA medical facilities Congress created the most recent version of Community Care the veterans community Care Program expanding access to Providers and Veterans communities since the implementation of the program the veterans Health Administration has made numerous changes to how the program is administered how referrals for appointments for commity care providers are processed and how the agency tracks data and information on the performance of the program my remarks today address findings of recommendations from Seven reports that we have issued since
▶ 0:31:092018 and includes 27 recommendations that we have made to improve the Community Care Program although VA has fully implemented some of those recommendations and taken steps to address others 17 of the 27 recommendations remain open as of 2025 there are a few areas I would like to focus on today where we believe that there are opportunities for VA to continue to make improvements to the Community Care Program first we have long provided oversight of va's appointment scheduling processes and monitoring of weight times
▶ 0:31:39VA has taken some AC actions to address challenges both with scheduling appointments with VA and Community Care Providers such as establishing Timeless standards for appointments VA has also established a timeline standard for when a veterans appointment should occur with a VA provider however VA is still not full implemented our 2018 recommendation to establish a similar Timeless standard for Community providers without a complete picture of how long it takes a veteran to receive care whether that care is
▶ 0:32:09being delivered at the VA or through a community provider it will be continue to be difficult for the VA to know whether it's achieving its goal of providing veterans with timely access to care further we recently issued a report on va's referal coordination initiative this is a new process with the potential to transform the effectiveness of VA medical centers processing of community care referrals and appointment scheduling in our 2025 report we identified challenges with the implementation of the new program including needed
▶ 0:32:39improvements to the program's Direction guidance and performance metrics for example we found that the regional networks and medical facilities did not have guidance that was aligned with policy was evidence-based nor was it timely or consistent resulting in inconsistent implementation of the initiative and potentially impacting VA medical facility staff's ability to effectively serve veterans we made five recommendations based on our findings second I would like to highlight va's oversight of Community
▶ 0:33:09Care contracts and network adequacy oversight of these contracts and effective monitoring of the contractor's network of community providers and their capacity to see veterans contributes to va's ability to provide timely access to care the veterans Health Administration is responsible for measuring the Community Care contractor's performance and including Network out quacy in our August 2024 report we reported weaknesses in va's oversight of these contracts specifically we found that the continued restructuring within within the office responsible for contract oversight
▶ 0:33:40resulted in a lack of clarity and completeness in oversight procedures and roles and responsibilities we made three recommendations to address the deficiencies that we identified we have also found opportunities for VA to better ensure Community Care Program Network adequacy specifically in our 2024 report we found that va's methodology to calculate Network adequacy for Specialty Care through the program does not include all claims in their calculation this raises concerns as to whether VA is fully assessing the adequacy of Community Care contractors
▶ 0:34:10networks as I have highlighted in my remarks and in the statement that we submitted GA will continue to monitor va's actions addressing our open Community Care recommendations we also have ongoing and future audits that will build on our existing body of work in this area including a review of va's medical document exchange with Community providers which we plan to issue this spring especially as VA has seen an increase in enrollment and Reliance on VA health care and the agency prepares for the next generation of Community
▶ 0:34:40Care contracts the Community Care Program will continue to be an important resource for expanded health care options for veterans in ensuring they receive timely access to care a key goal for VA addressing both our outstanding and new recommendations will help VA to provide consistent highquality regardless of where veterans receive their Care thank you and that concludes my statement thank you Miss Silas Dr cak you're now recognized for five minutes to deliver your opening statement thank you Dr Miller Meeks ranking member brownley chairman
▶ 0:35:11Boston subcommittee members I am pleased to discuss the oig's oversight work related to VA Community Care since 2020 we have published over 50 reports that highlight the significant challenges VA faces in ensuring veterans get the care timely and high quality Care in the community since 2020 I apologize since 2020 we have published over 50 reports that highlight the significant challenges VA faces in veterans getting high quality Care in the community my colleagues in the office of healthcare inspections or ohigh
▶ 0:35:41include Physicians nurses pharmacists clinical psychologists and social workers with Decades of clinical experience this expertise allows in-depth review and Analysis of not only Community Care's administrative issues but also a credible perspective on how these issues affect the actual quality of care for Veterans for example ohi's care and the community teams conduct cyclical Vision level reviews to evaluate compliance with vha's community care referral and coordination
▶ 0:36:11processes these reviews intentionally evaluate administrative processes that have direct impact on the healthc care provider's ability to manage and coordinate a patient's care Ohi also conducts inspections to evaluate issues specific to individual episodes of Community Care again through a clinical lens for stakeholders to understand exactly how certain events influence the quality and timeliness of care additionally oig's office of audits and evaluations has conducted multiple National reviews
▶ 0:36:41that highlight issues in Community Care related to contractor oversight VA Staffing it systems and financial management processes this oversight work has informed my testimony before this subcommittee as well as the many briefings we give to committee staff in individual members and VA leaders what we have consistently found can be organized into four areas of concern first veterans may not experience timely and seamless Coordinated Care when they are referred
▶ 0:37:12to the community referrals designated as high- risk must be consistently prioritized requests for additional Services must be acted upon quickly to avoid interruptions to care and results of that care must be appropriately uploaded in a patient 's medical record to ensure care teams have upto-date information and can take action that is needed to do this VHA must further develop administrative processes to get patients to the right provider in a timely manner and then follow
▶ 0:37:42up to ensure veterans received the appropriate care second VHA has an adequate oversight of Community Care Providers and cannot ensure the quality of care that is being provided unlike care provided at VHA the Community Care Program La robust quality assurance processes that monitor monitor the performance of care specific to Veterans such as screenings for suicidal ideation and military sexual trauma as well as realtime oversight of opioid prescribing practices
▶ 0:38:13for example Community Care Providers may not be complying with bha's opioid safety initiative risking the close monitoring of these prescriptions for veterans when VA providers cannot even get timely access to basic clinical documentation detailing a Community provider's Management of a referred veteran any opportunity to monitor that quality or address additional identified needs is lost basic qualifications of community providers must be thoroughly reviewed and verified prior to
▶ 0:38:43joining the Community Care Network third VHA Staffing shortages further undermine community care coordination efforts Reliance on community providers is necessary but as we have seen it does not guarantee veterans will get the timely care care they need VHA must commit adequate Staffing and resources to ensure Community Care is as seamless as it is inous fourth substandard it systems and inaccurate and incomplete data significantly restrict va's ability to manage Community
▶ 0:39:13Care payments VA has a right and an obligation to recover Community Care treatment costs for conditions unrelated to military service from veterans Private health insurers the oig has found that VHA has not enacted effective processes to do this compounded further by the pause of the program Integrity tool which is used to identify billable claims oig teams will continue to conduct meaningful independent oversight to ensure veterans receive the timely high quality care they deserve we look forward
▶ 0:39:43to working with the subcommittee to advance vha's provision of care to Veterans regardless of where it is provided Dr Miller Meeks ranking member brownley and members of the subcommittee this concludes my statement I look forward to your questions uh thank you very much Dr cak uh as is customary customary I'll reserve my uh time until all all of members have had a chance to ask their questions without I now recognize uh our chair of the full committee chairman boss for five minutes for any questions he may have first
▶ 0:40:13I want to thank chairman Dr Miller Meeks uh you know I appreciate your friendship and the continued leadership that you're in that you're due here with the VA uh it puts veterans front and center and thank you for that you know as chairman I am deeply committed to our shared mission of improving delivering the care and services to our nation's veterans you've all heard me say it before and I'm going to say it again VA built not
▶ 0:40:43for VA bureaucracy but for the veterans themselves and we have to remember that that's why last month I held a hearing to learn what veterans and their family members think about the witnesses put their trust in the VA and the Bure bureaucracy burned them in process uh Mr douly an army veteran of 20 years described his experience with VA saying I was treated like I
▶ 0:41:13was asking for charity and not treated as a disabled veteran that was trying to receive life-saving treatment Miss uh loir a former VA employee who tragically lost her son stated I believe my child would still be here today if the VA had lived up to promise and the promises that they were that were made to him Miss Diamond a Navy veteran struggled with access
▶ 0:41:44appropriate Community Care shared um and she shared this VA must stop its uh practice of rationing inpatient mental health care based on arbitrary seemingly thoughtless guidelines you would think that these testimonies would be sufficient for anyone to realize that VA Community Care reforms are needed some members wanted another
▶ 0:42:14hearing to talk about the community care and accuse us of not conducting oversight on the community care this statement is inaccurate let me say that again these statements are inaccurate last Congress and I want to be very clear that all members hear this last Congress we held nine hearings nine hearings that focused on Community Care and for someone to say we did we aren't focused on it we held
▶ 0:42:44nine hearings now I don't expect Congress this Congress to be any different last week I and 10 co-sponsors introduced access Act because veterans have earned access to timely and Quality Health care whether in the VA at home or in the community the access act would codify care access standards give veterans a
▶ 0:43:14say in their choices and provide access to Urgent mental health Residential Care the VA Mission Act passed in 2008 18 with overwhelming by pardon some support like the mission act the access act does nothing to privatize VA now let me say that again the VA Mission act like the aess ACT does nothing
▶ 0:43:44to privatize VA and anyone who suggests s otherwise based on how they feel or how their party feels needs to put a pair of glasses on and read the bill make no mistake the access act embodies the committee's position Community Care is VA Care Community Care is VA Care Community Care is not a
▶ 0:44:15substitute but an essential extension of va's mission now I look forward to working with my good friend uh Mr SEC the secretary Doug Collins he and I've have been friends a long time and we're going to focus on VA and it's only Mission that's caring for our veterans that's our only Mission so now my question Dr
▶ 0:44:45Braven what is the Trump Administration doing to ensure that veterans are at the center of every VA uh chairman Bost I think the most important answer to your question is that that's already the guidance from secretary Collins and it's guidance that we all have and all believe in in regards to the decision making that was
▶ 0:45:15also something that I put in my original opening statement that as I've gone through my VA career um those decisions really are made with the best interest of the veterans at heart and we will continue to do that um for every decision that we make along the way I look forward to helping you achieve that not only with the new secretary but everybody that's involved I hope that that is submission of everyone uh there at the VA and know that uh we're going to be working together to make that happen Madam chair I yield
▶ 0:45:45back my time expired uh thank you very much chair Bost I now recognize ranking member brownley for five minutes for any question she may have uh thank you madam chair Dr bra and it's really good to see you um congratulations on your assignment here in Washington I just have to say that I've worked with Dr Braverman very closely over the years um and he's done really terrific work um in the Los Angeles Medical uh Center but for all of visen 22
▶ 0:46:16and really appreciate your leadership and seeing through the seach in my district uh as well so so thank you for that um Mr Braverman um um secretary Collins just informed the committee today that um VA doesn't expect to award a Next Generation Um of Community Care Network contracts might be two to three more years before um before they're ready to do that so obviously the current optiman TriWest contracts
▶ 0:46:47are set to expire so in his letter he said uh that in that in the previous uh Administration there were delayed key programmatic decisions what were those delayed key programmatic decisions well I I think um the basics to that is that as we are going through um the requirements process to identify and the decisions to identify what needs to be in these contracts
▶ 0:47:17uh we want to make sure that they're done according to acquisition standards and that's what we will be doing um moving forward so the timeline that was identified in the letter that you received um is you know based on us committing to moving as quickly as possible to making those decisions and being able to uh award the next set of contracts um by the summer of
▶ 0:47:472027 thank you and I agree with uh your remarks as well that Community Care is really important and what Tri West and optim do is critically important those contracts are very important um certainly GAO has identified um areas where we can improve those contracts and identified a lack of formal Lessons Learned um a process of that um um in the current for the past and
▶ 0:48:18current Community Care uh contracts so I I just you know maybe today is not the right day to talk about it but I want to talk about what what we have learned what we do you do you really think let me get to this question do you think that we need to include in their contracts our ability to have stronger oversight in terms of you know the weight times issue and other things like that that built in so that there have been a lot of recommendations I think that we could make the contracts um better
▶ 0:48:48and I believe that they perform well I just want to make sure that we're trying to find what the right balance here is between VA care and Community Care and to really find that out we need a lot more data to to make some I think rather tough decisions so we we absolutely want to work together with the next um contractors to make sure that that partnership identifies ways in which we can really focus on the quality of care that's being delivered
▶ 0:49:19um within or by the contractors by the third party administrators um to be able to um Ensure that we have a way to communicate um what those weight times are what those capabilities are network adequacy taking a look at those areas uh for improvement that have been identified um in the you know from the current contract Administration and building on those to make requirements that will enable us to improve those
▶ 0:49:49I'll actually uh yield here to um Dr yend a moment who has some more specific information on the kinds of things that we're looking at appreciate that question um I I would just say we have a lot of lessons learned within our Legacy contract and uh based on input from both oig and goo while we can't discuss acquisition specific issues today we would just like to reassure this committee that we are focusing for next Generation on better
▶ 0:50:19approaches to return medical documents are more robust I don't have much time so if you can't really talk about it I just would like to move on thank thank you um so in terms of just uh Community Care scheduling and care coordination um by the VA uh in this process do you do you think that that we need to do a better job abely now is tracking that at my level um to identify what the weit times are and then also focus on uh
▶ 0:50:49integration as we reassess what our whole um IVC organization is going to look like moving forward and this whole um uh uh offer to employees for um you know to uh the the buyout for uh leaving the organization and so forth a lot of that I think most of it has been resented now so I'm worried about what those people who are prepared and ready to take it and now that has that offer has been
▶ 0:51:21rescinded well I I in the VA um we have been been um very proactive in identifying uh exemptions from the hiring freeze and exemptions from participation or exclusions from participation in the Deferred resignation program which accounts for more than 90% of the uh employees that work within our um field Hospitals and Clinics so that I think that um for the most part our ability to
▶ 0:51:51care for our veterans is uh pretty much preserved and I think we'll be able to continue to move forward um this is a anxious time for all of our federal employees and we'll continue to work with them to to move forward thank you thank you ranking member brownley the chair now recognizes Dr Murphy for five minutes for any questions you may have thank you Mr chairman I want to say thank you to all our Witnesses today you know I just I have to reiterate the Chairman's comment about community care I just don't
▶ 0:52:22understand the rationale of beating up on it we don't have enough doctors in the VA we have to to refer our other patients out into the community and making that a seamless process rather than just beating on the fact that Community Care is here with us is is in my opinion just ridiculous it's a waste of time and it's just something that the committee doesn't need to do it's just insult after insult as a community care provider myself it's just ridiculous that we have it um you know we we've come before this committee I've been on this committee now for 5 years and I just come
▶ 0:52:52up and I've hear this heard the same Litany of excuses excuses that has gone on and the same story about delayed care especially in the community and I'm hopeful that with new leadership coming in and actually with the uh the tenor of what's going on in Washington DC that we actually get back to not only serving the people of the country but the veterans who uh served us so dearly um let me ask just a couple of questions Dr crak I just you know I'm I'm in awe of all the things that you you spoke about
▶ 0:53:22your your testimony highlighted some reported delays in the processing of Community Care referrals even for veterans with serious conditions and we had a I had a constituent here at our last meeting that was still waiting 9 months to get a referral um what changes do you believe concrete changes something that actually not to be talked about that needs to be done should the VA Implement to to prevent these serious delay delays occurring especially ones with time sensitive things like cardiac disease or Cancer
▶ 0:53:52Care thank you I think um the most important thing is clear policy on prioritizing the very Specialties you're describing that we would be automatically considered high risk and then internal oversight that ensures that Frontline staff are following through consistently on those policies and practices and we've seen that's not happening yeah you know I people say that we want to privatize the VA in certain ways I think the private the actions of the Healthcare Community in the private World should be
▶ 0:54:22mimicked because it's it's a it's a tone within our VA that there's no expediency to this and again with new leadership coming in I think there will be now a different tenor of expediency follow-up question what happened at the Buffalo VA um ra the staff raised concerns but the leadership didn't do anything about it What mechanisms now should be in place to hold the VA leaders responsible when they ignore or dismiss staff with concerns about patient safety so as we've said in much of our
▶ 0:54:52testimony and in our reports it is clearly defined Ro R and responsibilities that will establish the authority that we are all looking for if you know it is your job to follow up and make sure that your staff are performing certain activities and they are not then you need to have the authority to hold them accountable if you're still not getting where you need to go you need to know to go the level above and that is just not consistently happening well I think it needs to and there needs to be accountability I think that's if one word is describing
▶ 0:55:22the tenor in the country right now it's called accountability we know that delaying care changes outcomes period everybody knows especially in Cancer Care you're delayed in diagnosis delayed in treatment your outcome is worse Dr Braverman when veterans face delays in care due to administrative failures within the VA um what processes regarding um their lost referrals miscommunications delayed authorizations what accountability measures are in place or need to be in place that staff
▶ 0:55:52and leadership are responsible for these failures again accountability meaning the uh in the word imper the imperative there one of the things that we have to do is identify the why for when these things happen and is it a matter of failure to execute failure to oversee uh or just um making errors because the processes aren't clear once we have that information at hand we can fix the processes if that's
▶ 0:56:23what's going on um and then hold leaders accountable for failure to take actions when information is the VA um aware of something just called a basic root cause analysis sen Sentinel events yes sir okay so in my world where we've had those if God forbid there was a sentinel event where some patient was injured didn't get the care Etc there is an action team that goes in there and that's then a zero recurrent event it is deemed to be not to ever occur
▶ 0:56:53again and sadly enough we we've heard this Litany of five years I have anyway of these same things being done over and over and over again last four years scandal after scandal after Scandal and I don't think we made one inch of progress towards getting better care more efficient care for our VA we should not be hearing these stories stories occur sure mistakes happen because we're in a Human Institution but the fact that these are recurring and over and over again with no improvement is athema
▶ 0:57:23to what this committee should be all about thank you m mam chairman I'll yeld back thank you Dr Murphy the chair now recognizes representative sheris McCormack for 5 minutes for any question she may have thank you chairwoman Miller Meeks and ranking member brownley for holding this hearing today the VA has faced persistent issues with Staffing clinical and administrative positions essential for managing veterans community care reports from the GAO and vaig reveal challenges including unreliable
▶ 0:57:54data for Staffing Assessments in consistent Staffing practices across facilities and inadequate Staffing tools facility facility leaders lack the authority to enforce recommended Staffing levels and some question whether the suggested numbers are too high these ongoing Staffing challenges impact the effective administration of community care for our veterans I'm deeply concerned that this problem will be further exacerbated by President Trump recent executive order to freeze Federal
▶ 0:58:24Federal workforces Dr braveman what is your plan to ensure that the VA medical facility has the staff necessary to coordinate veterans care within the community care program so the secretary has made it clear that we are going to have the staff required in order to do our mission which is basically taking care of veterans is there a plan as of right now so as of right now there is in that we have these exemptions against the hiring frees uh for the people that
▶ 0:58:54are necessary in order to coordinate that care in order to you tell us some of the exemptions um I have a i all of the medical support assistance uh the nurses the team that's associated with the provision and scheduling of these are on the exemption list um there's I don't know the exact number of occupations that are you know um on that list but we certainly can provide that list to you thank you
▶ 0:59:24um my second question is since the enactment of the mission act the veterans at the veterans community care program has grown exponentially straining the budget of the VA and threatening the ability of the VA to provide Direct Care to our veterans in fact the VA is on track to obligate 42 billion in FY 2025 for the Community Care Program up from 14.3 billion before the enactment of the mission act if this UNS unsustainable Trend continues the VA will be unable
▶ 0:59:54to fulfill its for four core missions one of which is to serve a back stop a back stop for emergencies if hurricanes that affect my constituents in Florida immensely Dr yid would you agree that it is important for the VA to achieve all of its four key missions who was that referred to oh Dr Yen Yen okay sorry sorry uh yes absolutely uh congresswoman we do agree
▶ 1:00:25with you uh and just to be clear we believe that Community Care is an important part of vaare and we will continue to support when veterans are eligible for Community Care that they get the their offered Community Care and Veterans obviously will have the choice to determine whether they want to uh stay in the VA or choose community care but specifically what I was asking is that do you believe that there will be a negative impact to Veterans who are trying to the VA is supposed
▶ 1:00:55to be the back stop for emergency care like hurricanes with this exponential amount Rising consistently is there a concern for you um we are not aware of any direct impacts on our fourth Mission uh due to Community Care increase uh but we can definitely take that back and uh give you some more details would you agree that the rapid growth of spending on the Community Care Program would potentially affect VI's ability to achieve its fourth Mission especially the fourth mission that I guess we already discussed
▶ 1:01:25that um my next concern then would be what would you propose that we could do that would kind of merge and um subside the rising number of Community Care PE Community Care uh so Congressman I just want to be clear over here our sort of our principles when we discuss care with the care options with the veterans are if the veteran is not eligible for Community Care we our staff
▶ 1:01:55should be offering those options to the veterans and then if the veteran chooses to stay in the VA then they would get their care in the VA but if they are choosing to go into the community we should be able to offer that care in the community having said that everyday VA facilities are trying to build capacity within the direct care system to offer more and more services a good example of this is Residential Treatment programs we have increased capacity for beds within our VA direct care system and that's how
▶ 1:02:25we are offering more VA care in the current system but we just want to be clear we don't believe these are competing uh we want to make sure we follow the law in this particular case thank you ield back thank you representative sherff L McCormack the chair now recognizes representative uh van Orton for five minutes for any questions he may have thank you madam chair uh thanks for having us here today uh I'm the I'm the longest serving and listed member of the United States military to ever get elected
▶ 1:02:55to to Congress in the history of the nation I get all my healthc care through the VA and I love the VA I want everybody to go to the VA who served our country I get these rocking glasses in Lacrosse I also get seen in toma but when I say I get all of my health care at the VA I mean also at crossing rivers Hospital in PRI Wisconsin when they I can't get an appointment um so again I I can't stress enough that Community Care is is Veterans Administration care because the check is coming from there um
▶ 1:03:25so I just want because I was an listed guy this why I want to show you something here these These are the recommendations that were made by Miss silas's office and your reports are fantastic 50 reports is a lot um okay so and these are the things that the VA hasn't done so if you look at them sideways they look like they're just about exactly the same thickness don't they so if we have the the GAO working hard working hard sorry
▶ 1:03:56I was list guy it almost came out and Miss uh Dr croak working hard and over years and years since 2018 they gave you this stuff you have 18 out of the 21 haven't been done so this is this is this is a it is endemic and I've learned this as a chair of the subcommittee for Economic Opportunity that we seem to keep going in these circles you know what I mean we got the government account accountability
▶ 1:04:26office we got the IG doing stuff and then it goes to the VA and it just falls into a hole we forget about it for a while and then another report you said you did 50 reports ma'am 50 reports if you're by volume to take the amount of recommendations in those 50 reports and showed us what was not acted on in any of those reports what do you think that ratio would be there's got to be how many recommendations there in 50 reports a lot uh there's hundreds of recommendations and so the scale like
▶ 1:04:56how many you think the Veterans Affairs Administration has not acted on I would be much more comfortable getting that number back to formally listed math I'm okay with that um the point being this there is zero accountability at the Veterans Affairs Administration doctor I'm glad you're coming in and I'm glad secretary Collins is here but there's zero accountability at the Veterans Affairs Administration and I don't have hopefully this will change I I don't have any confidence I mean zero
▶ 1:05:26confidence in the Veterans Affairs Administration to be able to plant itself even out of a wet paper sack because I've seen it to the tunes tune of billions and billions and billions of dollars of waste one example is the electronic GI Bill the estimate from the guys at the VA that it was going to cost $25 million you know what they're up to million from a $25 million estimate and Mr sure MC cormack we had
▶ 1:05:56this uh hearing the other day about the electronic service record wow I mean it's shocking I mean they're up to like $50 billion they think it's going to take to implement from a$6 billion initial estimate okay that's unacceptable so I mean I it begs the question Miss Silas and Miss cury I you know why do you guys even exist if you're doing this and I mean high quality work if it's not going to be acted on so this is
▶ 1:06:26more of an encouragement you know senior enlisted to you're probably a colonel or something when you got out yes I was okay there you go so this is your senior listed adviser to the incoming Colonel your your your command broken and it needs to be fixed and it won't be fixed until you hold people accountable like you would in the military the Veterans Affairs Administration has to stop acting on a long series of suggestions and those shouldn't be suggestions we we got to figure out a way to empower
▶ 1:06:57you to hold people accountable that don't follow the findings in your reports um and nothing's going to change until that happens so I I I don't really have a question I just I'm offering you encouragement I want to thank you ladies for your exceptional work and if you ever need anything um I'm really good at yelling people I can do that all day long um just reach out to my office and I'll scream at at them on the phone for you is that good yes thank you all right thanks Colonel I yield back uh I would Echo that uh about representative van Orton and thank
▶ 1:07:27you very much representative van Orton the chair now recognizes Dr Conway for 5 minutes for any questions he may have uh thank you madam chair and thank you uh ladies and gentlemen for presenting yourself to us today I um I I suspect there is going to be broad agreement on this committee that Community Care is is VA care and is necessary and um but of course uh the devil's in the details and the implement of course we uh must
▶ 1:07:57as we always do have cost concerns um as part of our deliberations um it's been noted uh the rise in the use of Community Care uh and so to Dr braveman and perhaps Mr Andy may want to chime in as well uh do you have a concern about the growth of the Community Care Program and what that might mean for the Direct Care Program because what we also know is what's in our notes and has been said here at that this day as is that veterans certainly want the Direct Care
▶ 1:08:27Program to continue they want to have uh receive their health care there and numerous reports show that the quality of care delivered there is um better than you're going to get out in the private sector so do you have a concern about the growth of the Community Care Program and the potential negative impact on the D Direct Care program within the VA thank you for the question the the way I would answer that is first off to make sure
▶ 1:08:57that we have a direct care system that um provides to the best of our ability the needs for all of the veterans so that um their initial justification for care and availability for care is maximized within our system and then continue to use the community care as that partner as vaare as many folks have identified that before um we are venturing on a productivity
▶ 1:09:28and efficiency initiative in order to try to maximize um the ability to provide care in the direct care system which will then pardon me just do do you have a concern about the direct care system being able to function in a way that meets uh the demand and desires of the veteran Community I think uh this committee um that the Direct Care Program uh thrives and is there for the veterans well into the future I I I don't have concern about the ability to do that
▶ 1:09:59um as long as Congress identifies the and approve resources that we need uh to make that happen thank you um my next question is for Dr croak uh you know one of the things that we're seeing in our notes which is concerning to me when you look at the sort of schematic they lay out for referrals getting them done getting people moved uh through a system to get uh care um one of the things that was noted is that there is a disconnect between what's in the veterans
▶ 1:10:29administration's regulations around referrals and then timeliness there and what the actual practice is uh when they get out in the community setting now in your um investigations you actually go to the thirdparty providers tpas and others to look at their their processes as well as the ones in the VA or no we look exclusively at va va exclusively does anybody look at the processes and and um in these in the third party Community we don't have that authority to look at don't have that Authority
▶ 1:11:00well let me um let me bounce back to Dr then so um is there a a as you think about this next cont the current contract or perhaps the next contract um recognizing and first I'll ask you you can agree or disagree do you recognize there's a mismatch between what the VA rules are about referral and getting in the timeliness and what actually happens uh in practice when people are referred to the community do you agree that there's a mismatch
▶ 1:11:30there I would agree that we have these set of standards that are identified in the VA access standards and we don't have those same standards in the community care and so that's a that sounds I mean am I right then that that's a Contracting problem the way the contracts are drafted um to uh direct the operations of the vendors that is optim and what is it Tri West and others who are providing Community Care is that is that part of the problem here with this this disconnect and people not getting timely care uh on in the
▶ 1:12:01community I'll let you respond to that um you're right in a current contract we don't have that requirement but I would just add that from our standpoint Community Care is a partner when vaare option is not available and so if we like that's a back stop and these are some of the challenges within the US Healthcare system so we had to work within those confines well it sounds like it might be a Contracting issue and I do wonder whether or not I mean if contracts
▶ 1:12:32not supposed to change them but it is there a way to well let's just say that I'm for myself and maybe there'll be others that disagree or agree with me uh that we need to look more carefully at the contracts the current contracts what remedies we might have within the current contracts if people are not adhering to the contracts and then certainly if we when we Rec contract that we take care to make sure there's a match between what we're requiring and what they actually do I thank you Madam chair thank you very much Dr Conway
▶ 1:13:02uh the chair now recognizes representative hamaday for five minutes for any questions he may have thank you Madame chairman as a veteran I'm deeply troubled by reports of systemic delays veterans face accessing care through the va's Community Care Program as mentioned earlier we had a few weeks ago really heard tragic stories I mean it's quite an emotional hearing of so many failures with in the VA system and referrals to the Community Care Program now despite reforms VA mismanagement continues to put bureaucracy over timely
▶ 1:13:32Health Care using dishonest wait time metrics excessive appointment cancellations and barriers to Community Care referrals the VA fails on its most basic Mission caring for those who served my question will focus on identifying specific actions to streamline care access veterans deserve accountability transparency and flexible care options we must focus on empowering veterans through Healthcare Choice my first question is for Miss silus what main factors Drive
▶ 1:14:03continued barriers to Community Care access um there's a number of barriers um in terms of uh getting timely access to the Community Care Program when is that the process with NVA to um determine eligibility for the program to um uh identify providers in the community that are available to see Veterans for care um the process itself there's a lot of back and forth in discussing the options with the veteran
▶ 1:14:33um find identifying the provider availability and then working on an appointment um scheduling time that works for both and so there's a lot of back and forth that can go on during that time it's the nature of the process um sometimes when there's this back and forth and there may be challenges in contacting the veteran to get their preferences of times and availability and maybe those appointments um slots may get picked up by other patients not even in a
▶ 1:15:04veteran in VA care and so there's a constant juggle of doing that um within the process itself um I think one of the other issues is that um veterans are competing with other patients out in the community for these appointment slots and we know just in general um in the healthcare industry that it's difficult to find providers there's a shortage of providers and so when you're working in that environment and the VA is responsible for ensuring
▶ 1:15:34that these veterans get timely care those create a lot of challenges for them would codifying access standards into law help Ure access I think establishing and this goes back to our 2018 recommendation that we made um where we recommended VA establish a standard for when receive care in the community right now there is a standard for when an appointment is scheduled for the veteran in the community which is great for holding
▶ 1:16:04the VA staff accountable for meeting that standard but we don't have a similar standard for when the veteran actually receives care in the community and we've had conversations with VA officials during our followup on these recommendations to see what actions they've taken and there are concerns that they do not have any control over the community provider schedules in their capacity to see veterans and so I do believe by establishing and fulfilling our recommendation of establishing a standard for receipt of
▶ 1:16:34care it will at least help VA to better monitor whether or not veterans are getting timely access to care and it would actually provide an indicator to see if they are actually meeting their goal of providing timely care and that leads me to Dr bman so why hasn't the VA complied with using the date requested versus the patient indicated dates to ensure the accurate weight times that Miss Isis just uh noted okay I'm going to refer
▶ 1:17:05that to Dr yend because he's more familiar with the specifics oh our weight time calculations uh start from the time the services requested so if a primary care physician request A cardiology appointment uh that's when Time Zero starts and that's how we calculate our weight times at least in the last few years um so it is not from the clinically indicated date as you're referring to it just seems like there's a mismatch I think what we need is to know what the actual wait time
▶ 1:17:35is and not what's most convenient for the VA um that's something that's been a frustration for so many people if I can just clarify Congressman Time Zero which is when the primary care physician request at appointment is the most proximal time that cannot be fudged that's when the request is made by by the primary care physician I know when people have used clinically indicated date as you're referring to that there may be ways to change that but in general we start calculating
▶ 1:18:05weight times from the point uh that request for service has been made so I I would just submit to you that there is usually no way to change that time and that's a very conservative estimate to look at weight times my time is up I yield back thank you representative hamay the chair now recognized is Dr Morrison for 5 minutes for any questions she may have thank you madam chair for holding this hearing and thanks to the witnesses for being here today I've enjoyed this discussion I think we've all learned
▶ 1:18:36a lot um you know as one of the five Physicians serving on the subcommittee I'm deeply committed to working with my colleagues on both sides of the aisle to ensure that our veterans receive the highest standard of care and as an OBGYN I'm especially focused on making sure our women veterans get the quality care that they um have earned and deserve last week I had the opportunity to visit the Minneapolis VA uh and learn about its new women's uh veterans clinic that is scheduled open next year we're lucky
▶ 1:19:06in the Twin Cities our VA is pretty well equipped to meet the needs of our women veterans but we know this isn't the case everywhere across the country in parts of the country where Women's Healthcare isn't as readily available we need to take extra care to ensure that Community providers are filling those gaps um Miss Silas and its most recent report on women veterans which was actually I believe in 2016 the GAO found that improving oversight of the Community Care Program is essential to improving Health Care for Women veterans and we know this because
▶ 1:19:36many women's specific procedures like mammograms maternity care and Gynecology are not always available at the VA and as you know GAO issued a priority recommendation that the VA include performance metrics for access to these women's specific procedures in its Community Care contracts rationale being that it would give VA mechanism to work with the third party administrators to ensure Network adequacy for Women's Health this recommendation was closed in 2023 but did VA ever actually incorporate any performance metrics into its
▶ 1:20:06Community Care contracts um thank you for the question um no they did not um they created a dashboard to monitor access to care for women's veterans care um and well that is a a good tool to monitor access um family access to care um having contract requirements or performance metrics in a contract would have a higher level of accountability in place
▶ 1:20:36um and to do that you would have to do a contract modification which is never popular with the existing contracts but there is a window now as VA is gearing up for the next generation of Community Care contracts for VA to take that into consideration that's great news and you answered my next question so thank you um Dr bman thank you for being here today my question for you is why didn't VA choose to follow the GAO recommendation and modify its Community Care contracts to implement
▶ 1:21:06these performance metrics for Women's Health which as we know disproportionately referred to community providers unfortunately I can't answer the why didn't we because I wasn't there um but we're going to take all of the recommendations that we're hearing here and and identify how they can be incorporated in the next set of contracts that's great um so it sounds like you're open to considering this recommendation for future Community Care contracts
▶ 1:21:36we're we're open to everybody's good ideas and uh some of that will be in the request for information as we move forward through the process as well I appreciate that thank you sir um Dr croak oig's done a lot of excellent work identifying the any efficiencies in the community Care Program when it comes to getting medical records from Community providers back to VA in your observation what are the biggest challenges facing VA and how would you recommend that we chip away at them um it's an incredibly
▶ 1:22:07discouraging but real quality of care issue um for the providers who refer their patients to the community there are delays in receiving those documents there are delays in uploading those documents and there are um issues with uploading those documents to the correct space in the medical records where P providers can access the results easily again um I would go back to the oversight of these functions making sure that Frontline staff understand clearly what their responsibilities are and that there is
▶ 1:22:37continuous supervisory oversight to ensure those are happening um consistently thank you for that answer I yield my time back thank you madam chair thank you very much Dr Morrison the chair now recognizes representative K King Hines for five minutes for any questions she may have thank you chair and thank you to all of our Witnesses for making it out here today I know it's the storm is uh the winter storm is not for me from the coming from the islands so I'm
▶ 1:23:07from the Northern Mariana Islands and there are hundreds uh of veterans facing extreme limitations when accessing Health Health Care Professionals and resources in the Northern Mariana Islands for context there are three islands with permanent populations tinian Roa and sipan with roughly 47,000 people covering these regions on a part-time basis is one Doctor Who is contracted to treat veterans only two days a week and one nurse if a veteran
▶ 1:23:37lives in tinian or Roda they must travel to cpan to visit these two Health Care Professionals costing hundreds of dollars in air airfare alone not to mention lodging meals Grand ground transportation and other expenses the VHA will occasion Ally send specialty care doctors to the northern Marianas but only once every other couple of months if a veteran from the maranas needs more advanced Specialized Care from Veterans Affairs directly the nearest
▶ 1:24:07VA hospital is in Honolulu these veterans including many who are older and living on fixed income must pay out of pocket to travel for care and then wait often too long to receive their reimbursements our communities have long been working to establish a commity based outpatient clinic or a COK but the threshold is a thousand and because of the lack of care and access to care whether it be direct or community- based care we just see these veterans
▶ 1:24:38return home only to leave to look for adequate qu adequate care somewhere else and I'm sitting here and I'm listening to you know my colleagues argue about whether or not direct care or Community Care is the most viable solution and then I'm listening to miss Silas and Miss covc talk about just the issues and the challenges with both um with both situations and I'm sitting here having to go back home on a monthly basis and talk to Veterans who one are
▶ 1:25:08killing themselves two are dying because they don't have any service at all um and I say that to go on record because to often people from the territories are not hurt in terms of their needs being met and so um I thought it was important that you all hear that directly from me um listen I I get how expensive healthc care can be right we the challenge is not just for our veterans we have
▶ 1:25:38we have challenge to access to care healthcare for for non Veterans as well and so you know what would it take basically for the for the VA to provide any type of service for our veterans that would provide some of this uh would provide some of our people the relief that they're Desperately Seeking okay um congresswoman I have to admit that I don't know much about the program that you're
▶ 1:26:08describing and I will get some more information and get back to you I will refer you to a GAO report that was published in May 2024 and I think that's the problem right is that too often um we leave these territories behind and too often is where these territories that these soldiers you know we're basically like a soldier producing Island and in 10 or 20 years from now our whole entire Island's population would be nothing but vets yet we have to deal
▶ 1:26:39with all these restrictive regulations one size fits-all regulations that may work here but obviously it's not working here because we're arguing about Direct Services or Community you know Community Access Services right and so um if you can just please please take note of that and let's try to figure out how to make the situation better also I have one more question um so we had one um one BHA administrative specialist whose duties included assisting patients in securing appointments
▶ 1:27:09with part-time with a part-time physician or nurse she recently retired in 2023 and her position has been vacant since then um can you please help us out in terms of making sure that we fill that position as soon as possible she's the only person that provides a direct Lifeline to our veterans and she is badly needed one person it's all we have all right if I can just add to what dran said places like Alaska
▶ 1:27:40Pacific Islands have unique challenges that are different from the rest of the country and we realize that sometimes the solutions have to be different creative yes yeah and we work closely with TriWest our TPA Partners in those Reg so we'll commit to looking into this as a followup from this hearing and appreciate the opportunity to look into it thank you I appreciate it the gentlewoman uh yields thank you uh representative uh King Hines I now yield myself uh
▶ 1:28:10five minutes to ask questions uh and I'm as I've listened to uh the dialogue which I think is very helpful to do um other questions have Arisen as we've gone through this so Dr crak you mentioned some metrics that are required for care within the VA but not for care within the community and I found that interesting because one of the things that you addressed was opioid prescribing and so as a person who's provided Community Care and as a veteran
▶ 1:28:40for every doctor that's out in the community you have to access and go to the prescription drug monitoring program of your state and you're required in order to get your license to have familiar it and continuing education on prescription drug monitoring so before you can prescribe a medication you have to go to the prescription drug monitoring especially if it's opioid so have you actually looked at what's required for Physicians within the community that may be the same standard as what
▶ 1:29:10the VA is requesting um they might very well be the same standard based on the state requirements for the license however we have done work that has discovered there um wasn't documentation or even a reference to a pdmp query or a urine drug screen within the community when we were trying to verify that those so you haven't access the pmdp or gone to the state to see if it's access correct okay thank you and then I was I was listening to the dialogue over waiting times and although I may not
▶ 1:29:41have a a difficulty with that being part of a contractual obligation as I listen to it and heard that we don't have a standard so a a veteran tries to make an appointment for a VA they either can't get an appointment within 30 days or sometimes they're called back on the 29th day of 30 days to extend the timeline and or they're greater than 40 miles away so if a veteran could not
▶ 1:30:11get an appointment within 30 days and they want to access community care but let's say the appointment at the VA is 6 weeks away the appointment in Community Care is 8 weeks away isn't the standard then the veteran isn't it up to the to decide which waiting time they prefer or not prefer and if they you know they can get an earlier appointment at a VA they can decide whether or not they want to travel the distance or in our case our um Veterans Affairs uh will arrange transportation so
▶ 1:30:41isn't the standard the veteran isn't there a standard in place now it's okay dror y you can just talk louder um so you're absolutely right uh that is exactly what the referal coordination team should be doing is presenting that information to the veteran and Veteran should be making that choice and the veteran chooses VA we are very happy to support if the veteran chooses opts out and goes to the community then we'll make sort of make sure the veteran gets care in the yeah and if if the if there is a holdup
▶ 1:31:12in the amount of time from which a veteran requests community care but the authorization is not given to the community care provider so then they can't request to make or they can't make an appointment that then will lead to further delays um additionally I'm got to find my document here so I apologize I've got all these papers because I've completely changed my testimony um since I've been on this committee I've heard one insult after another hurled at VA Community
▶ 1:31:42Care and my Democrat colleagues with all due respect and the Biden Administration have described Community Care as inferior to vaare and certainly argued that it's more expensive and as I said I'm not only a veteran but a community provider I know that you know Community Care is ordinarily excellent care just like Care at the VA is ordinarily excellent care and many cases it's specialty care that's not available at the VA or at a distance that's you know manageable miss silus your testimony
▶ 1:32:12also suggests that Community Care is often more affordable than in-house care your written testimony States and I'm going to quote because I think it's important VA documentation shows that Community Care represented about 40% of all VA Healthcare and fiscal year 2023 according to VHA the department spent about 26.7 billion on this care in the same year out of a total of 1266 20 1286 billion appropriated for all VA
▶ 1:32:42Healthcare by my math 40% of the va's healthcare is community care but community care costs less than 25% of the VA Healthcare budget do you agree that community care is more cost effective than VA care I would have to see the details of the the budget um but what the facts that you're stating are in the our report and in the statement and this question may be rhetorical and you may not be able to answer it especially Dr Braverman who is new
▶ 1:33:13in this position um but the important question to answer to ask would be especially uh Dr Braverman you mentioned the packed Act and the stress of the act act on to um being able to deliver Care at the VA system what would the cost to the VA be of all of the Care currently provided in the community so we know that it was 26 billion in 20123 what would the cost be to the VA
▶ 1:33:44itself so I agree that's somewhat rhetorical based on the information that I have the one thing that I would identify in the calculations here is that um we do have a lot of fixed costs that are not directly related to rvus and so the uh the actual calculation of what it costs for you know the direct care system for a per patient visit um is um more difficult to identify yeah and as is the cost to community
▶ 1:34:14providers as well so I would wholeheartedly agree uh thank you all so much on behalf of the subcommittee I want to thank you for joining us today you are now excused and we'll wait for a moment as the second panel comes to the witness table thank you so
▶ 1:34:52much e
▶ 1:35:55it'll be off
▶ 1:36:26thank you very much that's my signal um uh before I introduce uh panel two witnesses I would also like to acknowledge that the ranking member of the full committee uh representive Tano is here with us as well and we will hear from him later I'd now like to introduce the panel to Witnesses testifying before us today we have Dr Scott Krueger Army veteran and physician Virginia oncology Associates Dr Dave McIntyre president and CEO Tri
▶ 1:36:56West Healthcare Alliance uh Mr Ed Weinberg president and CEO optim serve and Mr Chris faraji president of well hiive Dr Krueger you're now recognized for five minutes Madam chair before we begin I have a I have a a point of parliamentary inquiry so recognized uh may have state my inquiry um both the house rules and our committee rules require non-government witnesses to submit a truth and testimony form these forms
▶ 1:37:26include a question about whether the witness is quote a fiduciary including but not limited to a director officer advisor or resident agent of any organization or entity that has an interest in the subject matter of the hearing end quote has come to my attention that both Mr Weinberg and Mr McIntyre indicated under their truth and testimony forms that they are not fiduciaries of their organizations my my inquiry is this madam chairwoman did the majority advise the witnesses
▶ 1:37:56about this form and instruct them to indicate that they were not fiduciaries of their organizations um so if not does the chairwoman find that these two witnesses who are CEOs of the third-party administrators who manage va's Community Care Network and hold at least $70 billion in VA contracts that they are not fiduciaries who have an interest in the subject matter of this hearing I think it's important to hear from the people that are third
▶ 1:38:26party administrators since we're talking about Contracting and that's one of the questions that has been brought up yeah my my question relates to the uh the truth and testimony form which non government Witnesses must fill out and it's important for us to know whether or not uh it is accurate that they are not fiduciaries it's something that we require of all our non-government Witnesses they said said that they're not fiduciaries we asked them to fill out and disclose the form and
▶ 1:38:56they correctly filled out and disclosed on the form okay um it's your not thank you we're now going to hear from our Witnesses Dr Krueger you're recognized for five minutes thank you chairwoman Miller Meeks ranking members Brown and to Caden distinguished members of the committee thank you so much for the opportunity to testify today on the department of entrance program of Community Care Medicine on behalf of my practice Virginia oncology associate and a member of the US oncology Network this is one of
▶ 1:39:26the largest networks of integrated community-based oncology care in the United States I'm Scott Krueger and I'm a practicing medical oncologist and hematologist and medical director of Virginia oncology Associates I've had the privilege of providing care to many of our nation's veterans through the CCP and I appreciate the subcommittee's attention to the critical role this program has in providing care the highest quality and the best quality of care to our veterans the CCP has helped Bridge care
▶ 1:39:57gaps however there are significant challenges that must be addressed to enhance its Effectiveness for veterans with complex medical conditions like cancer timely access to Cancer Care is critical many veterans experience significant delays in receiving authorizations for Community Care which can be to particularly detrimental for patients requiring time sensitive treatments in my area it can take take more than four to six months to get an approval for a mamogram and a breast
▶ 1:40:27biopsy and that's due to the ineffective communication with the office of Community Care furthermore coordination between the VA and the community provider is often lacking resulting in fragmented access to medical records treatment plans and followup care this lack of data sharing can lead to incomplete medical histories duplicated tests and procedures and in some cases delaying transm in cruical biopsy results CT scans MRI scans
▶ 1:40:57and other vital data just delays the care even more these challenges in coordination and communication are further compounded by the inefficiencies faced by the third-party administrators tpas are struggling with the high case loads that cause delayed responses and administrative strain for both providers and patients although tpas have provided our practice with the liaison to ease in some of these communication barriers we still struggle to reach the Community Care
▶ 1:41:27office effectively regarding reimbursement and financial stability we used to face significant delays in receiving reimbursements from the VA over five years for a payment of one particular claim we actually had five years of no non-payments for all claims so unfortunately when you don't pay your bills it discourages people like myself from taking care of Pat patients and we want to take care of the VA patients I'm a cell phone and Veteran
▶ 1:41:58and we want that to happen it's difficult for the veterans because frequently they encounter difficulties n navigating the complexities of the CPP including eligibility requirements scheduling coordinating care between the VA and Community providers for instance I saw an elderly woman in her 70s who was sent to me for an evaluation of a blood cancer of course I was only allowed to see her I could not do a CBC I could not look at her blood I wasn't allowed to order any
▶ 1:42:28testing when I saw her she had had a stroke she could not walk she had skin breakdown and she had signs of dementia although I was authorized one clinical visit I tried to arrange for her to have home care with physical therapy occupational therapy Wound Care and Rehabilitation I set it up with two different home health care agencies the VA did not approve any of the agencies and after two months and then four months so far she still hasn't had any
▶ 1:42:59care so I have a few recommendations for and basically we need to enhance the effectiveness of our communication firstly I I would recognize that we need a better referral a process to help expedite and implement the standardized guidelines and timeliness for approvals this would streamline operations and reduce delays in service secondly improving care
▶ 1:43:30coordination is crucial this can be achieved through sharing of medical records and the use of effective communication between our platforms as Community Partners were committed to collaborating with the VA to ensure our veterans receive the care that they deserve Additionally the efficiencies of the tpas can be enhanced by establishing clear performance benchmarks and accountability measures this will ensure that the tpas operate effectively and contribute positively to
▶ 1:44:00the program furthermore timely and fair reimbursement or Comm for the community providers is essential because they won't participate if if there's a financial strain on their own practice lastly we must strengthen and provide education and navigational resources for the veterans to help them better understand their care more efficiently and ensuring that they receive the best possible care I briefly want to say and know I've listened to this first group of testimonies and it would be so much
▶ 1:44:30easier if you just say Okay Dr Krueger please take care of my patient here's six months you can order your test you can order your chemotherapy you can order your biopsy and I will treat that veteran and get them treated clearly efficiently and do a great job the current system makes me go through so much red tape before I can even start part a month and a half has gone by so I really want to thank you for the opportunity of testifying today look forward to answering your
▶ 1:45:00questions and I think the subcommittee has the right idea we have to put the veteran in the center in order to strengthen the program our job is to work together to help the veteran to get them get the care they need thank you thank you very much Dr Krueger Mr McIntyre you're now recognized for five minutes for deliver in your opening statement thank you thank you m'am chairman Miller Meeks ranking member brownley and distinguished members of the health subcommittee is a privilege
▶ 1:45:31to testify before this subcommittee today on behalf of all associated with TriWest health care allines for me this is a return to this witness table having been here multiple times in the last 10 years to those members who have not yet had a chance to meet I look forward to doing so soon and working closely with you on things that matter including in the maranas and in my home state of Arizona I ask that
▶ 1:46:01my written state may be entered into the record established nearly 30 Years Ago by a group of nonprofit health plans and two University Hospital Systems our sole purpose since then has been supporting VA and DOD and meeting the health care needs of the military and veterans community communities in our geographic area of operation nearly all who work for TriWest either serve this country
▶ 1:46:31or their families served we began our work in support of va a couple of months before the crisis of access in care in our home town of Phoenix hit the media armed with a mature and robust network from our 18 years of work for the dod we quickly went to work to support the VA in eliminating the backlogs in needed care well it's been quite a journey the last decade
▶ 1:47:02today we serve in support of va through the Community Care Network program across a geographic space that spans 14 States and the Pacific compromising re uh comprising regions four and five and our network has delivered more than six 5 million Community Care appointments in support of va today we have the privilege of supporting VA
▶ 1:47:32and serving the needs of nearly 4.7 million veterans through our network of over 300,000 credential Community Care Providers offering VA and VA access to care um at over 750,000 provider locations each day day they deliver between 12,500 and 16,27 needed appointments
▶ 1:48:02spanning all areas especially and we pay their bills in three days to an accuracy rate in excess of 99% we've been working a number of initiatives collaboratively with VA in our markets to demonstrate the art of the possible through a tighter partnership um to strengthening VA and allowing them to fully leverage us for the benefit of veterans that reside in their area
▶ 1:48:33and I think of two markets that highlight that promise The Valley in Texas and Montana as they're leading the way second we're working with many of the visions and vses in our area responsib who have a responsibility to try and make things more efficient in terms of how we're doing our work all with an eye towards how do we do appointment scheduling more effectively between us and what provider changes
▶ 1:49:03need to be made that impact care delivery in a positive way fourth many more collaborative initiatives have been underway in our geographic area of responsibility all with the goal of effective refinement to our Collective performance in fact next week we and the VA team are gathering for two days to discuss what we want to add to our Collective list in our further request to improve
▶ 1:49:34Collective performance lastly I would like to thank this committee um and the leadership for your focus on fixing once and for all the rule that forces us um to reject provider claims that arrive six months after the date of service rather than allowing 12 months as is the case for tri care Medicare Medicaid and the private insurance Market it is beyond
▶ 1:50:04time that this gets fixed and that we execute properly and promptly the change once it is long we're proud of the progress that we have made together over the past decade and it's been painful for many of us but we have made progress yet we all know that work remains to achieve our true potential of delivering fully for this generation's Heroes and as we know this committee is focused on the refinements necessary
▶ 1:50:35to ensuring that what was envisioned in the year-long bipartisan effort that led to the passage of the mission Act and the authorities and resources that have followed in the Years sense is going to be delivered on from all of us associated with tri West look forward to doing our part in collaborating with this committee to respond to those adjustments believed necessary to achieve our Collective potential so that the nation's Heroes their families
▶ 1:51:05caregivers and survivors receive that which should we owe them thank you Mr McIntyre um we have votes at 4:30 so I'm going to remind our witnesses to be within their five minute time frame I'm also going to remind all members that I will be gabbling them out at the 5minute interval interval I thank you Mr Weinberg you are now recognized for 5 minutes to deliver your opening statement chairwoman Miller Meeks ranking member brownley ranking member Tano uh and distinguished members of the subcommittee good afternoon and thank you for the opportunity to
▶ 1:51:36discuss optim seres role as the third party administrator for the vacn program in regions 1 two and three where we've been supporting veterans choice and access to care for nearly six years as a combat veteran retired army officer and the proud father of a soldier I have a deep understanding for the sacrifices made by our nation's veterans and their families I am deeply connected to our purpose and I'm also committed to the successful uh the success of the
▶ 1:52:06entire VA Health ecosystem but I certainly can't do it alone at optim serve I'm humbled to be surrounded by 5,000 great Americans many of whom have served in the armed forces or in the VA or as military spouses and caregivers through the vacn program we have the privilege of supporting nearly 6 A5 million veterans across 36 States Washington DC the us at Virgin Islands and Puerto Rico and we are making a difference
▶ 1:52:36with our robust network of providers nearly 2.4 million credentialed care sites we have facilitated over 159 million veteran care visits since we started healthc care delivery in 2019 we also know that building the provider network is only half the story it's the maintaining of the network for our veterans that really matters and our success in sustaining the network is in large part due to adjudicating and paying provider claims in
▶ 1:53:06seven days on average far exceeding the requirements set forth by the VA another critical factor in our success story is the collaborative relationships that we've developed throughout the veteran Community we enjoy strong relationships with with VA at every level to ensure veterans have access to the right care whenever and whenever they need it meeting at least monthly with each of our 109 VA medical centers and Visions in our regions we hold quarterly program management
▶ 1:53:37review meetings with VA central office to ensure proper oversight we do in-person updates and engagement with our military and veteran service organizations and we have consistently worked with Congress ensuring that you and your staff receive quarterly updates on the important work that we are leading one of the many ways we manage these relationships is through veteran experience officers who provide boots on the ground support at each VA Medical Center and through our provider Advocates
▶ 1:54:07who work between VA and Community providers to ensure veteran care needs are being met at optim serve we remain purpose oriented by keeping the veteran at the center of everything that we do while the total numbers of our impact are interesting I always remind my team to focus on the power of one each phone call every Pharmacy transaction every response to a VA staff member that's where the magic happens and while we are laser focused on our stated
▶ 1:54:37requirements we also seek ways to help the VA system work better for everyone one such area is in medical records retrieval while we fulfill our obligations of educating providers on medical record return policies we don't stop there we have developed mechanisms for VA staff and providers to escalate if they are not receiving their records back in a timely manner additionally we collaborate with VA leadership to identify ways we can improve existing processes for
▶ 1:55:07example we are actively engaged in a visin One Pilot with the goal of improving the exchange of medical record documentation between Community providers and the VA I am deeply grateful for the opportunity to share optim seres unwavering dedic dedication to Veterans through the V vacn program we look forward to our ongoing collaboration with the VA with this subcommittee and all of the partners that we work with we are making a difference and my belief is that we will
▶ 1:55:37always be better together thank you again for the opportunity to be here today and I look forward to your questions thank you Mr Weinberg Mr fr you are now recognized for 5 minutes to deliver your opening statement chairwoman Miller meek ranking member brownley and distinguished members of the subcommittee thank you for the opportunity to speak to you today my name is Chris fragi and I'm the president of well hiive we're a healthcare software company dedicated to modernizing the va's approach to Community Care scheduling our technology isn't
▶ 1:56:08theoretical it's real it's proven and it's successful it was purposely built to address the va's long-standing inefficiencies and scheduling ensuring veterans receive the care from the right provider at the right time this is why VA contracted with us in 2023 to deliver this technology Nationwide the issues we're tackling is one we all recognize veterans are patiently waiting to get the care they need right now scheduling a VA Community Care appointment is like booking a flight before Expedia
▶ 1:56:38or Tri velocity even existed imagine needing to fly across the country but instead of searching online you have to call each Airline separately you're waiting on hold you're checking availability one by one repeating this process until you finally find the flight that works that's exactly how the VA Community Care scheduling system works today medical support assistants also known as msas have a hard job they spend hours making calls waiting for responses and manually piecing
▶ 1:57:08together the appointment availability while veterans are waiting this is where things change with the external provider scheduling it allows schedulers to instantly see real-time appointment availability across multiple provider groups in the community and book on the spot no more phone tag no more unnecessary delays just fast efficient scheduling that ensures veterans get the care they need when they need it and we know it works at sites using EPS MSA schedulers book
▶ 1:57:38up to four times as many appointments per day compared to the outdated manual methods but the most compelling proof comes from those from the front lines one scheduler calls EPS a godsend saying before I spent hours tracking down appointments now I see them instantly the time saved is making a world of difference for veterans another shared before EPS I would schedule an appointment only to find out later that the provider wasn't available forcing me to reschedule
▶ 1:58:09now I know exactly when and where the veteran can be seen un avoiding unnecessary delays EPS is directly reducing weight times the current average weight to schedule V Community Care appointment is 31 days with EPs and even without the critical Integrations into systems like hsrm or console toolbox that weight drops by 33% and in some locations the Improvement is even more dramatic for example Columbia South Carolina
▶ 1:58:40their weight times have dropped by 52% and Dallas Texas the weight times have fallen by 46% so yet despite these results EPS remains optional this means means many schedulers are still relying on outdated methods and even at sites where EPS is fully available more than half the appointments are still booked manually we are encouraged by the direction of this Congress the new Administration and secretary Collins who has made it clear to the commitment to ensuring veterans receive the care they
▶ 1:59:10deserve we at well hiive stand ready to work side by side secretary Collins Congress VA to ensure an aggressive roll out of eps technology isn't the op IAL bureaucracy is the solution is simple let's just cut through the red tape and let's fully integrate EPS into the va's mission across the country before concluding I'd like to briefly address some of the comments from the first panel there is obviously a pattern
▶ 1:59:40of scheduling that is inherent into the conversations of today's questions Miss silus mentioned some of the nuances that these schedulers and veterans are facing when they're not able to have that information at their fingertips they're waiting they don't know they'll get back to them they make these telephone calls and they also made a comment about the veterans competing with non Veterans for these appointment slots but what the EPS well hiive platform has been able to do is provide and equip these schedulers with that information so that
▶ 2:00:10hey if if there is a provider that doesn't have availability they're going to see it but if the provider does have availability they'll also be able to see it so they're not wasting time calling providers that do not have availability in the first place so you know and and another point that I would like to make with my remaining time is that you know from Dr Morrison you had made mention of women's health we're really excited because this week we were able to activate and provide mammograms um where they can now be scheduled so it's not just providers
▶ 2:00:40but it's mammograms and in addition to that we also have Imaging I thank you very much for the time and I look forward to your questions uh thank you very much Mr fragi I now recognize ranking of the full committee representative Tano for 5 minutes for any questions he may have thank you madam chair for this courtesy um uh I I have a question for both Mr McIntyre and Mr Weinberg you are both paid capitated rates that are calculated on the basis of how many veterans are directed to your networks
▶ 2:01:10so that means the more veterans referred to you the more you're paid is that right M McIntyre we are paid in administrat just answer the question the more more you're the more they're referred to you the more you're paid is that right yes yes Mr Weinberg Congressman we get paid if there's a paid C it's a very simple question the more veterans are referred to you the more you're paid is that right that's correct for than do either of you conduct assessments of the quality of care delivered by specific providers
▶ 2:01:41in your networks yes yes we do you do uh and you make this information available to Veterans make the information available the VA Mr Weinberg we as well make it available to the VA well I I'm going to tell you that VA facilities are regularly rated on quality measures and this public is provided to veterans in the public um I find it extremely hard to believe that you actually do these assessments since you do not require your network providers to
▶ 2:02:11return medical records to you or the VA I heard about all the pilots but and in general you do not require this so I don't know how you could be assessing the quality of care what would you be even using to assess the quality of care either one of you have a Mr Mr Weinberg well thanks for the question uh what I would probably start with is we've got a credential Network so quality starts with verification of state license it also uh board certifications education so we do verify
▶ 2:02:41that with all of our providers well thank you very much for that but I don't believe it's the kind of rating and assessment that VA does um I know that United Healthcare Group has plenty of EXP experience reviewing medical records when it is is deciding whether to pay a claim or make a patient prove medical necessity and it astounds me that there is no conditioning of payment on the return of records for veterans community care um do you conduct audits to identify whether or not your network providers are opportunistically billing
▶ 2:03:12VA for additional services or requesting additional authorizations rather than referring veterans back to VA for Coordinated Care uh Mr McIntyre thank you for the question sir um when we started the work do you actually do audits regularly systematically of your of your network yes we do you do Mr Mr Weber Mr Weinberg please can we claim my time Congressman we not only audit but we are audited by independent external Auditors quarterly and those data are
▶ 2:03:42all provided back i' would be interested in knowing whether there's any opportunistic billing Mr Weinberg this question is for you how many veterans currently enrolled in United Healthcare groups Medicare advantage plans are also receiving care through va's Community Care Program Congressman I appreciate the question I don't know the answer to how many well thank you I would hope that you would get that answer back to the committee within a week we'd be happy to do that uh United Healthcare Group operates one of the largest Medicare Advantage Programs in the country so it is
▶ 2:04:12collecting premiums for veterans uh and through its Optimum Sub sub through its Optimum subsidiary is collecting payments from VA under the Community Care Program veterans uh received the care once but United Healthcare ostensibly is getting paid twice do you think the federal government and taxpayers are overpaying because of this double billing practice thank you for the question Congressman no I don't I believe that veterans have choices for their health care and they've earned the right to use
▶ 2:04:42the VA as well as any other benefit they've it's really nonresponsive to my question because it's really about the double billing United Healthcare is receiving Medicare Advantage premiums but yet they're also being uh you're also receiving money uh from the Community Care Program uh and my question was isn't that double billing Congressman we we don't view it that way we view it as the administrative fees that we need to manage both programs I well Mr Mr McIntyre just because you found a loophole to collect from both Medicare
▶ 2:05:12Advantage and VA for the same veterans care doesn't make it right it makes it a taxpayer funded windfall for your company at the expense of veterans and American people um Mr Mr wber how much uh uh how much revenue does optim United Healthcare Group and tri well for both of you how much does it does it generate from the community care pro contracts over the past year five years or the entire time you've held the Community Care contracts Mr McIntyre I'll be glad to get to you that
▶ 2:05:43information congressman and I'd say that Mr Weinberg we used to require uh how much money would you say um Congress can you repeat the question uh how much money have your contracts generated uh from from the Community Care Program I mean if you want the specific number Congressman I would prefer to come back to you with that for the record okay uh tens of billions of dollars I would say yes and I would also re remind you sir that many of those dollars are pass through dollars
▶ 2:06:13so they are paying the provider directly they're not coming back to the thank I you back thank you the gentleman's time has expired the chair now recognizes represent Tom for 5 minutes for any questions you may have thank you madam chair now as I sit here in this committee and other committees and on the VA I'm deeply concerned by my Democrat colleagues attempt to scapegoat Community Care Providers caused by VA mismanagement I feel as if too often some of our colleagues are focused on protecting the bureaucracy and not veterans
▶ 2:06:43care as outlined in the staff memo titled on most alarming aspects of va document review efforts to mitigate Community Care aim to trap veterans in a broken VA system limiting choice and access now Madame chair at this time I ask unanimous consent to insert our staff memo into the the hearing record no objections so rather than attacking Partners trying to serve veterans we must identify solutions to cutting
▶ 2:07:13bureaucratic red tape and Empower veterans through accountable flexible care options they deserve nothing less now my question is for my fellow arizonan Mr McIntyre during covid you took over appointment scheduling responsibilities from the VA correct yes sir and could resuming centralized scheduling uh improve access used to do the things that were to the right of the lineer debarkation and the VA did the work to the left
▶ 2:07:44and that worked um the current system could be refined but that worked the second thing that we did is we did not back in the day pay a provider's claim until they submitted their medical records and we paid the claims in days and Congress felt that it was problematic because some providers were complaining about uh that requirement
▶ 2:08:14but 85% of the doctors were providing the medical records to the system um under that approach what obstacles have you faced building robust provider networks due to burdensome VA administrative barriers we haven't faced uh problems in the development of network because of that it's maintaining this uh Network that's challenging and we're working together
▶ 2:08:44with the VA to try and make sure that those challenges are addressed in the markets where we face them so it seems like you guys are working together right now we're trying okay on both sides that's good to hear now Mr Weinberg what specific steps can the VA take to improve the referral process Congressman great question um I do believe that a lot of what I heard on panel one in that discussion was on point um we're talking about standards not standardization I think we're we're reminding
▶ 2:09:15ourselves that Healthcare is local um and I believe that there's got to be accountability in the system so we need to measuring we need to be tracking and we need to be holding folks accountable thank you I yield back thank you representative Hamad the chair now recognizes Dr um excuse me representative brownley ranking member brownley for five minutes thank you madam chair um Mr Weinberg um I was concerned to read in uh Dr Krueger's testimony that the reimbursement rates his practice uh receives are often lower
▶ 2:09:45than those offered by Medicare um is optim reimbursing providers that are lower than Medicare rate congresswoman thank you for the question uh we do follow the uh strict adherence of the payment rates that are given to us by the VA primarily for medical care that would be in line with CMS oh but the mission clearly states that it you must be paid by Medicare rate so I'm just making sure that that's what you're paying so Mr Krueger do is that inconsistent with
▶ 2:10:15what you understand so the problem is uh the VA initially and this has been happening happening for about the last seven years it got better about two years ago basically didn't pay any claims for over five years with multiple submissions and multiple fights between our local VA and the VA and Salem when eventually it was paid they were paying it on the current rates when they approved the bill I even though the treatment was done four years ago
▶ 2:10:46I see so the drugs then so it it that has smoothed out it it has smoothed out okay and so I'm so again maybe you're clarifying a question another question that I had because Mr McIntyre is saying that he he's providing a three-day turnaround um on reimbursements and you were saying sometimes it's out to five years so there was a lot of inconsistency there but you're saying now that that reimbursement process has improved significantly it's improved significantly
▶ 2:11:16over the last six months what has helped significantly was we've been giving liaison that we can talk to an opt them and they are helpful with the billing but they don't really get involved with ordering the care for the patient that's up to the VA Community office thank you so um to optim and tri West we you know in the in the first panel we talked about the contract uh the delay in the contract uh possible additions to a a
▶ 2:11:46future contract um would you have any issue in terms of transparen y around weight times um within Community Care I believe personally that there needs to be accountability and transparency on both sides with regard to wait times and currently in our area for last year um it was an average seven days to schedule once the appointment request was given by VA
▶ 2:12:17an average of 20 days to be seen and an average of 15 days to be seen at the date preferred by the veteran right so I mean but what we would like to see is really you know on sort of a monthly basis to know what what's happening in direct care with the VA and what their weight times are and what your weight times are not so much the averages over you know a long period of time but you that would not be a problem we know we
▶ 2:12:47had talked about years ago the longitudinal look at this and you need to be doing that you and Mr Weinberg do you agree or congresswoman I would agree we do provide hundreds of deliverables to the VA which would include um you know performance for our Network adequacy the only other thing I would add is that I I think it's essential if we're talking about access and choice for veterans they need to be able to see those data so they can make the most Choice it is clear
▶ 2:13:17to me that this EPS system that has been describe today um is music to my ears honestly I I think we need to do a a a lot of Technology outside of the VA um to bring it in but it seems as though this could be a huge Improvement in terms of Community Care scheduling although it's optional so who did the VA decide that it was just going to be optional not or did you decide that it should
▶ 2:13:47be op optional I'm I'm trying to understand why can't be Universal across the board because it seems like it really would improve that process sorry was that question to me well I think it needs to be to well I can answer it I mean it's it's not it's actually not coming from the vendor it's not coming from the tpas it's it's coming directly from VA uh the VA okay so it's VA that is theyve not no there's not been any sort of uh directive to
▶ 2:14:17be able to use this um for optim and tri West you have an VA to make it optional that that would be preferable to you no ma'am and would Dr krger would would um Physicians or pH providers have a problem putting out their schedules in Ether for us that would be a little bit of a challenge because different oncologists specialize in different areas a vendor may not know that basically
▶ 2:14:47if they send us a consult they will get an answer in 48 hours hours all oncology is seen within 24 hours of the appointment all hematology is seen within three days that's y back sorry didn't thank you if you have other questions please submit them in writing we'll make sure that they're uh answered the CH Cher now recognizes representative uh King Hines for five minutes for any question she may have thank you chair I just have one quick question for Mr McIntyre since you provide or provide coverage for the Marianas
▶ 2:15:18yes ma'am I know that access to health care just for the average ordinary citizen is is a challenge because of the amount of providers that are available out there whether it be mental health or any type of of care what can can you just share a little bit if you're having challenges with ensuring that you have an adequate pool of providers to be able to provide um you know the care that we're trying to give to Veterans for your
▶ 2:15:48area in the country me um I made two visits to tenan and Roda and the maranas and um we have the providers in that Community under contract but as you well stated it's important to make sure that there's a footprint at some of those places like tinin that doesn't have health care to be able to allow circuit Riders to come in and out of
▶ 2:16:18that area to meet the needs versus people traveling and um so we look forward to working with you and with the VA to pick up a topic that we worked on five years ago okay we'll we'll speak offline we'll have the office reach out thank you forward to it it I back chair uh thank you representative uh King Hines the chair now recognizes Dr Morrison for five minutes for any question she may have thank you madam
▶ 2:16:48chair and thank you to the witnesses for being present to answer our questions today during the first panel I think you may have heard me ask Witnesses from VA and GAO uh about including performance metrics that would track access to women's specific procedures and Community Care contracts since Women's Care healthc Care is disproportionately referred to the community we need to make sure that our community providers are delivering this essential care uh and they indicated that they thought it would be an effective way to improve Care for Women veterans Mr Weinberg
▶ 2:17:18and Mr McIntyre what do you think about this sort of contractual requirement in TPA contracts congresswoman thank you for the question again I I think that transparency is uh is really kind of rule of the day here I think that the more we know and the more veterans know the better choices they'll be able to make agree and I think tracking standards and making sure that we're being transparent about where we are DRS oppos the standards makes a lot of sense
▶ 2:17:49appreciate that thank you gentlemen um back to the two of you again um we know that Community Care is an essential piece of the puzzle but we also know that in general veterans prefer VA care uh in part because many VA providers are veterans themselves and understand the military and Veteran experience um you I've trained at a VA during my early medical career um and I can tell you that even those of us who aren't veterans are still required to take military cultural competency
▶ 2:18:19trainings in airia of other trainings that are sensitive to Veterans needs do you know what percentage of your network providers have completed optional uh trainings on military military cultural competency Suicide Prevention and opioid safety congresswoman thank you for the question while I don't know the exact percentage what I can tell you is that we do have a pretty robust Suite of training offerings to include a partnership we've just formed with psych armor who offers additional ones
▶ 2:18:50the other thing that I think is really important as we think about incentivizing providers to take the trainings is to actually start to offer cus and so we've done that with a couple of courses now one for opioids and the other one on suicide prevention and we've got a few others in the queue as well we also have a similar Suite of products and content to include VA provided content and we've been uh working with sty armor for five or six years um I would say
▶ 2:19:20that that in the area of opioid training the question is did the providers need to take VA specific training or is it sufficient to use their state licensure requirement which is uh required of all of them so I think to the last panel it'd be worth all of us taking a look at what reality is and what's occurring in that place thank you
▶ 2:19:51and then one final question uh Mr Weinberg these same trainings that all VA providers are required to take are optional but available through opum right that's correct congressman is there a way for a veteran to know if one of your providers has completed trainings about suicide prevention in that Spirit of transparency at this time there isn't we we aren't required to transmit those level of data over in our provider data file but I think it's a great point and it's something that we would be willing to to talk through
▶ 2:20:21um if it becomes a requirement from the VA I think it again gives more transparency to the veteran as they're making their choice appreciate that and thank you for your service I yield back thank thank you very much uh Dr Morrison I now recognize myself for five minutes Dr Morrison thank you for that excellent question I'm going to pose to the VA uh that I would also like to see the VA stats on how many veterans ask if a the VA provider has completed and done VA specific care whether it's op opioid suicide prevention mental
▶ 2:20:51health or any of the other variety of things that uh continually get brought up in this hearing as a difference again being a veteran who doesn't access VA care and I prefer to get my care in the community uh and a community provider uh we want the best care for veterans where veterans are um and Mr fr I'm going to actually go to you first because the reason you're here is actually the point that ranking member brownley made so given the success of external provider scheduling program or EPS
▶ 2:21:22do you believe EPS should be adopted across all Visions to eliminate the inconsistent care scheduling veterans currently experience thank you for the question I absolutely believe that it should be rolled out across the country and have that Equitable care so that there are veterans that don't AR aren't able to experience EPS because it's not live in their sites and so they're not being able to take advantage of the efficiencies that the platform is already doing today for the sites that do have it by decreasing we times allowing the schedulers
▶ 2:21:52to be even more productive and I have no fiduciary in interest in you or your product but however would such a scheduling platform be beneficial even within the VA system for scheduling appointments I'm sorry what was that would it be beneficial even within the VA not just in community care to schedule such a platform to schedule appointments yes that's correct uh we actually did a pilot in uh January of 2023 where we actually integrated into Vision 7 and 8 with 15 instances of Vista and we were able to demonstrate to
▶ 2:22:22be able to see across those Vista instances and be able to compare that availability with those providers and the goal would be to then add on the Community Care Network to be able to give you that apples apples comparison which the comment that you made earlier about it's up to the veteran if you want to have in the VA care or community care because they're both at the point where it's their they further R right so being able to have that so thank you for saving me that was a big faux PA I'm never supposed to ask a question I don't know the answer to and I didn't know the answer to that question so thank you
▶ 2:22:52that it worked out well for us uh Dr Krueger could you share some of the difficulties you have experienced with sending and receiving medical records to VA so thank you sending we do send the records I don't know where they go to but we do fax them that's the only way we're supposed to send them our communication systems and computers do not talk to the VA in terms of receiving records the VA in my community says that we are their last priority
▶ 2:23:23and they will get around to it when they can so the difficulty that I have of taking care of patients is that if I have to do a CAT scan the VA determines where it's going to be I don't know where it's going to be I don't know where to get the results I have to wait for the VA to tell me it's been done and to give me the results very difficult if I find out it's been done at one of the military hospitals and I'm told it's a hip of breach even though I'm the one who ordered it it's really the VA who ordered it I can't get the results
▶ 2:23:54U thank you very much for that so it sounds like there's some work we have to do on both ends on the medical records uh and also to have interoperability which may be beneficial rather than uh faxing uh Mr Weinberg how do delete de excuse me how do delays I know it was do Dr Braverman who had the cold but I'm the one that's uh stuttering how did delays and VA referral authorizations impact your ability to provide timely care for veterans yeah Madam chair thanks for the question um you know
▶ 2:24:24one of the things that we try to do is make sure that there's as much coordination between us in the VA as possible I I go back to my statements about relationships at the central office level Vis level VA Medical Center office to include sitting down and doing Network adequacy meetings every single month and so you know the impact for me it's not about our organization it's really about the veteran and so what we what we're trying to do is help make that go as fast as possible thank you bu back ranking member brownley would you like to make any closing
▶ 2:24:55remarks brief but I I think that this has been an important meeting um and I'm glad you have called it I think we still there's still a lot uh for us to learn and to understand and I now that we have a delay in this contract I I hope that we can take the time to think about what can be included in the contract to impove improve services for our veterans um I think this EPS system I
▶ 2:25:26I think is could should you know be Universal across the board and if it can be internal within the VA I think we need to do that I mean this could be a huge huge Improvement if just by doing this but I think you know we still need a lot I think we still need more hearings and um and a deeper understanding of where the right balance is this is what I continue to say over and over and over again in these is hearings as the the right balance between Community
▶ 2:25:56Care and VA care and you know where is that where is that balance I took offense to Dr Murphy saying that I'm being critical always continuing to be critical about Community Care that's quite the opposite I I I believe that the Community Care is an essential part which I even said in my opening comments but Community Care is essential um uh to the success of the VA and providing services to our veterans uh when they need it and where they need it so I just think that
▶ 2:26:26we've got to be clear about the direction that we're going in and trying to find that right balance I mean I would wonder from really the the two um uh two providers here optim and and tri West if you had a huge increase a very significant increase um in uh patients you know over a period of time is that something that you could actually handle I I I I you know I don't
▶ 2:26:56know if if you that thank you but that's a question that I would really like to have answered and I'll yield back thank you very much ranking member brownley I'd like to thank everyone for their participation in today's hearing and for the great discussions we've had on this important topic I also would say I would be happy to um accommodate ranking member brownley on having more hearings on Community Care and on this topic because as I stated earlier our veterans biggest barrier to receiving the care
▶ 2:27:26they deserve should not be the VA itself today's hearing reinforced the importance of the clear roles and responsibilities within the community care program and the need to focus on solutions that work for veterans such as what we heard today with Mr Fran welive uh and it focuses on the veterans and not on the people who run the system I look forward to working uh with secretary Collins and the VA Dr Braverman especially to ensure the highquality care is delivered to our veterans the complete written statement
▶ 2:27:56of today's witnesses will be entered into the hearing record I asked unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous material hearing no objections so ordered I thank all members uh and the witnesses for their attendance and participation today the hearing is now adjourned e