[Senate Hearing 114-291]
[From the U.S. Government Publishing Office]
S. Hrg. 114-291
FIELD HEARING ON THE VETERANS CHOICE PROGRAM: ARE PROBLEMS IN GEORGIA
INDICATIVE OF A NATIONAL PROBLEM?
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
AUGUST 21, 2015
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas Richard Blumenthal, Connecticut,
John Boozman, Arkansas Ranking Member
Dean Heller, Nevada Patty Murray, Washington
Bill Cassidy, Louisiana Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota Sherrod Brown, Ohio
Thom Tillis, North Carolina Jon Tester, Montana
Dan Sullivan, Alaska Mazie K. Hirono, Hawaii
Joe Manchin III, West Virginia
Tom Bowman, Staff Director
John Kruse, Democratic Staff Director
C O N T E N T S
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August 21, 2015
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
REPRESENTATIVES
Collins, Hon. Doug, U.S. Representative from Georgia............. 1
WITNESSES
McDonald, Hon. Robert A., Secretary, U.S. Department of Veterans
Affairs; accompanied by Dr. James Tuchschmidt, Acting Principal
Deputy Under Secretary for Health.............................. 5
Prepared statement........................................... 7
Hoffmeier, Donna, Vice President, VA Services and PCCC Program
Manager, Health Net Federal Services........................... 23
Prepared statement........................................... 25
Jarrard, Stephen, MD FACS, General Surgery/General Medicine,
Lakemont, Georgia and Veteran.................................. 30
Prepared statement........................................... 31
Williams, Wayman Duane, Georgia Leadership Fellow, Iraq and
Afghanistan Veterans of America (IAVA)......................... 32
Prepared statement........................................... 34
Chacha, Carlos F., SFC U.S. Army (Ret.), Veteran................. 36
Prepared statement........................................... 37
FIELD HEARING ON THE VETERANS CHOICE PROGRAM: ARE PROBLEMS IN GEORGIA
INDICATIVE OF A NATIONAL PROBLEM?
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FRIDAY, AUGUST 21, 2015
U.S. Senate
Committee on Veterans' Affairs
Gainesville, GA.
The Committee met, pursuant to notice, at 1:58 p.m., at the
Continuing Education/Performing Arts Building, Room 108,
University of North Georgia, 3820 Mundy Mill Road, Gainesville,
GA, Hon. Johnny Isakson, Chairman of the Committee, presiding.
Present: Senator Isakson and House Representative Doug
Collins.
OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN,
U.S. SENATOR FROM GEORGIA
The Chairman. I would like to ask my home Legion Post, Post
233 in Loganville, GA, to present the colors.
[Presentation of Colors.]
The Chairman. Would you join me in the Pledge of
Allegiance?
[Pledge of Allegiance.]
The Chairman. You may be seated. I would like to call this
meeting of the U.S. Senate Committee on Veterans' Affairs to
order and let everyone in the audience know this is an official
meeting of the U.S. Senate and operates under the rules of the
U.S. Senate. We are grateful to North Georgia University and
the people of Gainesville, GA, and Hall County for making the
facility available today. We are very happy to be here.
We are honored to have my dear friend, the congressman from
this district, Doug Collins, here and I want him to give his
welcoming remarks. But before he does, I want to say this. I
know you all think we have a code where we always brag about
each other. That is not necessarily true. In this case, I will
brag about Doug because he has done a marvelous job since he
was elected to Congress. It has been a pleasure for me in the
Senate to work with him hand-in-hand on many, many projects. I
am honored and privileged that he came and chose to be with us
today at this hearing.
So, Doug, the show is yours.
STATEMENT OF HON. DOUG COLLINS, U.S. REPRESENTATIVE FROM
GEORGIA
Mr. Collins. Well, thank you, Senator. I appreciate that.
It is always good when you can look across and know that the
senator from your State is one who serves and has served and be
a part of that. You being here today shows that commitment and
bringing the secretary here as well.
I want to thank our folks who are here, our staffs, our
witnesses, many of which we have dealt with in our office, and
the folks who are here today to be a part of this.
Nothing can be greater in my mind than the issue of taking
care of our veterans and taking care of people. As a veteran
myself, as one who is still part of the Air Force Reserve, who
has served in Iraq, there is nothing higher in my concern than
to say, ``What are we doing, and why are we doing it?'' and
also to be transparent about that.
I want to thank the senator for his chairmanship on the
Senate side of the VA--also my friendship with Jeff Miller, who
is his counterpart in the House, who sends his regards as well,
also to his friends.
We have got a lot that is happening. Are there a lot of
questions still left? Yes, there are. Are there a lot of things
that we still need to do? Yes, there are.
But I am also proud just to be up here in the 9th District
of Georgia, up here in Oakwood, in Gainesville, Hall County.
This is a great place to be from. I just want to welcome those
who may not be from here. Come back often. We have a lake.
There are a lot of things for you to be a part of; and just
know that we care about this area.
I want to thank the senator for having us here and for
being a part of this and for the secretary and others who will
testify. Thank you.
The Chairman. Let me add a comment. We are all glad the
lake is full. [Laughter.]
Mr. Collins. That is exactly right.
The Chairman. All the local folks know what that means.
As I said, this is an official hearing of the United States
Senate Committee on Veterans' Affairs, and I appreciate all of
you for joining us today. We will operate under the rules of
the United State Senate. There are a couple of people I want to
introduce who are in the audience.
Sam Smith, the DAV Chapter 17 President and Commander,
welcome and thank you for being here today.
Give him a big round of applause. [Applause.]
The Chairman. And the newly elected Commander of the
Disabled American Veterans of the United States of America from
the State of Georgia, Moses McIntosh. Where is Moses?
[Applause.]
It is always good when your leader is named Moses. I know
that.
We are glad to have you here, Moses.
I want to welcome Secretary McDonald and thank him for
being here today. He is going to testify in just a minute, and
I am going to introduce him in just a minute. But before I do,
I want to make a few points, and then I want to make a few
gestures if I can.
The first point is this. The secretary, myself, Congressman
Collins, and others are aware of an incident that took place
June the 30th at the Oakwood Veterans Clinic here in
Gainesville, GA. That is not a subject of this meeting for any
number of reasons, principally because personnel issues are
involved.
We are not allowed, as Members of Congress nor as employees
of the U.S. Government, to discuss personnel issues in an open
forum until they are settled, at which time all the information
is available and accessible to anyone. I just wanted to make
sure that information was made clear to everyone.
The purpose of this meeting today is to talk about the
Veterans Choice Act and having a more veteran-centric Veterans
Administration. There are two great anniversaries today.
Actually, one is an anniversary and one is a beginning. This is
the first year anniversary of the passage of the Veterans
Choice Program, which passed in August 2014. It began to be
implemented in November 2014 and is in full force today,
although there are problems and there are challenges that we
have to meet, which is why we are here today to find out what
those are and to talk about what we are going to do to solve
them.
But a second great historical thing is happening today. Two
American women are in Fort Benning, GA, graduating from Ranger
school, where Secretary McDonald graduated. [Applause.]
I do not know about you, but after watching the news last
night with what they can carry on their backs, they can fight
with me any time they want to fight. I would be happy to have
them. We are so proud of them and so proud of Fort Benning and
that installation and so proud, too, that Secretary McDonald
graduated from Ranger school in Fort Benning, GA. We appreciate
his service to the country.
The Veterans Choice Program was an answer by the Congress
of the United States to a major problem. A year ago, we had the
Phoenix situation which came forward, where we had veterans who
had died because they could not get appointments in time to get
into the hospital. We had problems where consults were
canceled, where people were being given bonuses for figures
that were improved that really were not improved. We had
situations where there was a culture in the VA that was not as
positive as it should be.
A number of things happened. One of them was Bob McDonald
came along, a veteran himself, someone willing to serve,
someone taking the job to do the job, someone who wanted to put
the veterans in the center of his life and in the center of the
VA system. And he has begun the process over the last 12 months
of changing the culture of the VA, and it is obvious to me, as
a member of that committee for 11 years in the Congress, that
that has been the case.
Also, we passed the Veterans Choice Program, which is a way
to meet the challenges of the 21st century Veterans
Administration. With operations in Afghanistan and Iraq, we all
know we will have more and more veterans coming home to Georgia
and to America in the years to come, and the pressure on the VA
will be greater, not less. And the amount of pressure on the VA
to meet the throughput necessary to see to it that people get
timely appointments and timely services was going to be--we
needed a force multiplier, a force multiplier being a way to
add more productivity and more accessibility for veterans to
quality health care.
Veterans Choice program was that answer. We did the very
best that we could in Congress in 2014 to write a bill that
worked, that would give the VA more tools and would give the
veterans more accessibility. But in doing it--anytime you
create a new entity, you create a few problems, and we have
been working over the last 12 months to find out where those
problems were and correct them.
We have been working also to see what the future of VA
Choice could really be for our veterans. I think the secretary
will reflect what I am about to tell you. We all know the
Veterans Choice Program was the right thing to do. We all know
the changes we have made and the ones we seek to make will make
it even better. It will be the force multiplier necessary, not
to replace VA health care, but to enhance VA health care.
For anyone in this audience today who thinks that the
Veterans Choice Program had anything to do with replacing the
VA, you need to go on home, because it does not. It had to do
with enhancing the VA, improving the VA, and giving them more
tools and more arrows in their quiver to see to it that we met
the needs of our veterans.
I am delighted today to welcome the secretary of the
Veterans Administration, Bob McDonald, to this hearing in
Gainesville, GA. I have already told you he was a Ranger. I
have already told you--or I did not tell you--he graduated from
West Point.
He took this job on at a time when not very many people
would take on a job like this. But he did it like an Army
Ranger does. He tackled it, decided he was going to solve the
problems, gave out his cell phone number to everybody,
including me, and takes calls at night. He wants to make sure
that every veteran is at the center of the services of the
Veterans Administration and has worked tirelessly to see to it
that that happens.
I just want to give you one little ancillary story before I
turn it over to Bob for his testimony. About 3 weeks ago, we
had a meeting at the VA--what they call at the VA a stand-up.
Every day, they have a stand-up where all their department
heads, all their responsible personnel at the VA stand up and
tell what things they did last week that worked and what things
they did last week that did not work. They talked about where
they had successes. They talked about where they had failures.
Jeff Miller, the chairman of the House Committee, and I
went along with Ranking Member Blumenthal from Connecticut in
the Senate and Ranking Member Brown in the House. We sat around
a round table and watched the stand-up, watched them report on
the things they were doing that were right and the things they
were doing that were wrong.
We also had a heart-to-heart meeting for 3 hours. We were
about to have to close some facilities because the Veterans
Choice Act needed some correcting and some technical
adjustments to be able to move money and make it more fungible
for veterans' benefits. We had to do some other things in the
Veterans Administration to see to it that the VA worked better
and worked quicker, and we only had about 48 hours, if I
remember, to do it.
We did it in 48 hours because we locked arms, we sat down
and decided to agree rather than disagree, and we found the
solution to the problem. So, today, the VA Choice Program is
working better, and our veterans are having better access
because of that day and that meeting. It is that type of can-do
attitude that the secretary has exhibited that will make the VA
Choice Program work and will make it work even better in the
future.
So, we are here today to talk about a great complement to
VA health care. That is the Veterans Choice Program. It is a
privilege and a pleasure for me to introduce a man for whom I
have gained the utmost respect for all the work that he has
done and all that he has going to be willing to do to see the
VA through, Secretary Bob McDonald.
Welcome. [Applause.]
I just made my first or second mistake, because Dr.
Tuchschmidt is here to be his aid to answer the questions he
can not answer.
Dr. Tuchschmidt, we are glad to have you here today.
Give him a round of applause. [Applause.]
STATEMENT OF HON. ROBERT A. McDONALD, SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR. JAMES
TUCHSCHMIDT, ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
Secretary McDonald. Thank you, Chairman Isakson and
Congressman Collins, for this opportunity to continue our
public dialog on caring for veterans.
This is my fourth trip to Georgia as secretary, and what I
have seen here is representative of what is happening all
around the country. The Atlanta Regional Benefits Office has
shrunk its claims backlog by more than 77 percent while also
improving accuracy. Our cemeteries in Georgia are performing
record numbers of internments, up 60 percent in the last 5
years, and our hospitals and clinics are providing more health
care than ever before to Georgia veterans.
We recently renewed many of our affiliations with important
academic partners, such as Emory, Morehouse, and the University
of North Georgia. And out of these partnerships have come some
outstanding clinical care and some outstanding medical
research. Just last week, Dr. Raymond Schinazi was awarded this
year's William S. Middleton Award, VA's top award for
biomedical research. Dr. Schinazi has been with Emory for 34
years and with the Atlanta VA for 29 years, and in that time,
he has pioneered the development of drugs to treat HIV and
Hepatitis C.
Georgia is one of the fastest growing areas in the country
for veterans seeking VA care. This year, the Atlanta VA has
seen its numbers of unique patients grow 7.5 percent.
All around the country, VA has seen demand increase this
year and in past years as the very large Vietnam era cohort
moved through the high-need, high-cost, 50 to 65 age range.
Keeping up with that growth has not been easy. It has put many
VA employees in the position of having to do more and more, and
some, unfortunately, responded by doing things they should not
have, losing sight of what VA is all about.
VA is in the customer service business. Healthcare is just
one of nine forms of customer service VA provides. Our goal,
our vision for the VA in the future, is to be the number 1
customer service agency in the Federal Government. Our
Cemeteries Administration already is number 1 in customer
service, public or private, according to the American Customer
Satisfaction Index. We aim to bring the rest of the VA up to
the same standard.
To do that, we have begun an ambitious transformation of
VA's organizational culture and business processes called MyVA,
applying tried and true principles of customer service from the
public and private sectors. We brought aboard several key
leaders with broad experience in business. Eleven of my 18
direct reporting senior executives have joined VA since my
swearing in. The entire leadership team is as committed as I am
to making VA number 1 in customer service.
We are taking action here and throughout VA to hold people
accountable for their actions with additional training and
disciplinary actions where appropriate. We are also meeting the
increase in demand with more of everything available, more
hours, more space, more people, more productivity, more
accountability, more transparency, and, of course, more choice.
We have completed 7 million more appointments this year
than last. That is 2.5 million at VA and 4.5 million in the
community. Ninety-seven percent of appointments are now
completed within 30 days of the veteran's preferred date, 88
percent are within 7 days, and 22 percent are same-day
appointments.
Average wait times for completed appointments are 4 days
for primary care, 5 days for specialty care, 3 days for mental
health care. The electronic wait list is down 47 percent, and
the new enrollee appointment request list is down 93 percent.
Overall, VA health care providers have increased physician
productivity 8 percent on a health care budget increase of only
2.8 percent.
We are working both harder and smarter, and the result is
more care for more veterans. But we still have some serious
challenges. We are burdened with an aging infrastructure. Nine
hundred VA buildings are over 90 years old, and most are over
50 years old. These older buildings do not meet today's
standards for hospital construction and need to be replaced.
We are also seeing more veterans enrolling for VA health
care and more enrolled veterans turning to VA for care. Most
have other choices. Eighty-one percent of veterans have either
Medicare, Medicaid, TRICARE, or some private insurance. But
more are choosing VA health care because it saves them money,
and it is more convenient, and it is often better care than
they may get elsewhere.
On average, enrolled veterans rely on VA for just 34
percent of their care. But if that percentage rises just 1
percentage point to 35 percent, VA's costs increase about $1.4
billion. The more veterans come to us for care, the harder it
is for us to balance supply and demand without additional
resources. That is a fundamental problem that only Congress can
help solve.
Last month, VA was facing a critical shortfall in funding
for care in the community. Authorizations for care in the
community were up 44 percent. We are providing so much care in
the community and also paying so much for the new miracle drugs
to cure Hepatitis C that we are running out of money.
So, I appealed to you, Mr. Chairman, and your congressional
colleagues. You responded by giving me the budgetary
flexibility to use Choice Program funds for other care in the
community programs, and I again thank you for that. But that
flexibility only lasts until the end of this fiscal year. Our
next fiscal year, October 1, we will be back in the same bind
of not having the flexibility to allocate funds to pay for the
care veterans are actually choosing.
Over 70 line items in our budget are inflexible, meaning I
can not use that money anywhere else. It is like having 70
checking accounts for every bill you have to pay, one for food,
one for clothing, one for gas, et cetera, with no way to move
funds from one checking account to another. Actually, it is
worse than that. It is like having separate checking accounts
for different foods. I can not spend health care funds on
health care. I can not even spend care in the community funds
on care in the community.
We at VA believe in giving veterans a choice, and we are
committed to making the Choice Program work. Authorizations
under the Choice Program have gone up steadily in the past 6
years. But Choice does not cover everything. It is just one of
seven programs providing care in the community, each with its
own requirements for participation by veterans and by
providers.
We look forward to working with Congress to consolidate our
various care in the community programs. We need Congress to
give us permanent flexibility to move funds to accounts that
fund the care veterans are actually choosing.
We need Congress to fully fund the president's 2016 budget
request. The House-proposed $1.4 billion reduction in that
budget would mean $688 million less for veterans' medical care.
That's 70,000 veterans going without care. Also, the House
passed a 50 percent cut in construction despite our aging
infrastructure. The Senate's proposed reduction of $857 million
would also hurt, though not as much.
We have made great progress in the past year. We have
tackled the access problem and have begun transforming VA's
organizational culture and business processes to improve care
for veterans for years to come. But we need Congress to fix
what only Congress can. Congress defines the benefits veterans
receive, and Congress appropriates the funds to pay for them.
Only by balancing the two can VA serve veterans the way
veterans expect and deserve to be served.
Thank you for listening, and I look forward to answering
your questions.
[The prepared statement of Secretary McDonald follows:]
Prepared Statement of Hon. Robert McDonald, Secretary,
U.S. Department of Veterans Affairs
Good afternoon, Chairman Isakson, Ranking Member Blumenthal, and
Members of the Committee. Thank you for the opportunity to discuss the
Department of Veterans Affairs' (VA's) provision of health care to
Veterans and the implementation of the Veterans Choice Program. I am
accompanied today by Dr. James Tuchschmidt, Acting Principal Deputy
Under Secretary for Health.
Caring for our Nation's Veterans, their Survivors, and dependents
continues to be the guiding mission of VA. Each year, VA works to
provide timely, high-quality services and benefits to fulfill this
mission. As we emerge from one of the most serious crises the
Department has ever experienced, however, we face continuing challenges
in ensuring that Veterans receive the care they deserve, and indeed
have earned through their service. But we believe that these challenges
are surmountable, and we will continue to work with Congress to reach
resolution and move forward in achieving our mission.
VA's goal is always to provide Veterans with timely and high-
quality care with the utmost dignity, respect, and excellence. For the
Veteran who needs care today, VA's goal will always be to provide
timely access to clinically appropriate care in every case possible.
However, as we have shared with staff for the Senate and House
Committees' on Veterans Affairs, users of the Veterans Choice Program,
whether Veteran, community provider, or VA employee, have identified
aspects of the law that are challenging. It has also been challenging
to mobilize the resources and systems required to smoothly implement
this new Program. We are addressing these challenges and turning them
into opportunities to improve VA care and services. I look forward to
discussing the progress we have made thus far in Georgia and the
Nation.
More than a year ago--at my Senate confirmation hearing--I was
charged with ensuring that VA is refocused on providing Veterans ``with
the high quality service that they've earned.'' I welcomed that
opportunity. For the last year, I've been working with a great and
growing team of excellent people to fulfill that sacred duty (11 of 18
of VA's top leaders are new since my swearing in).
Because of their hard work, VA has increased Veterans' access to
care and is projected to have completed approximately seven million
more appointments over the past year ending May 31, 2015 than last--2.5
million more at VA, 4.5 million more in the community. While Choice has
been just a small proportion of that 4.5 million increase in the
community, it's on the rise, and Choice utilization has doubled from
May 2015.
We've expanded the capacity required to meet last year's demand by
focusing on four pillars--staffing, space, productivity, and VA
Community Care.
We have more people serving Veterans. From August 2014 to July 31,
2015, VHA has increased net onboard staff by over 13,000. This includes
over 1,100 physicians, 3,500 nurses, 147 psychiatrists, and 294
psychologists for VHA's clinical care to Veterans. Included in this,
VHA has hired over 6,400 medical center staff as a direct result of the
VA Choice Act enacted in August 2014.
We have more space for Veterans. We activated over 1.7 million
square feet last fiscal year and increased the number of primary care
exam rooms so providers can care for more Veterans each day.
We're more productive--identifying unused capacity, optimizing
scheduling, heading off ``no-shows'' and late appointment
cancellations, and extending clinic hours at night and on weekends.
We're aggressively using technology like telehealth, secure messaging,
and e-consults to reach more Veterans.
We're aggressively using care in the community. The Choice Program
and our Accelerating Access to Care Initiative increased Veteran
options for care--including Choice--for 36 percent more people than we
did over the same period last year--a total of 1.5 million individual
VA beneficiaries.
In short--we're putting the needs and expectations of Veterans and
beneficiaries first, empowering employees to deliver excellent customer
service, improving or eliminating processes, and shaping more
productive and Veteran-centric internal operations.
That's MyVA--our top priority to bring VA into the 21st century.
outcomes
Our strategy is paying dividends to Veterans. With the growth in
Veteran options, we've increased VA Care in the Community
authorizations--including Choice--by 44 percent since we started
accelerating access to care a year ago. That's 900,000 more
authorizations than the previous year. Between the end of June last
year and the end of June this year, we completed 56.5 million
appointments--a 4 percent increase over last year, and there were 1.5
million encounters during extended hours, a 10 percent increase.
Even with that increase in number of Veterans served, we completed
97 percent of appointments within 30 days, 92 percent within 14 days,
88 percent within seven days, and 22 percent same day. For specialty
care, wait times are an average of five days. For primary care, wait
times are an average of four days and an average of three days for
mental healthcare.
So, we're making verifiable progress for Veterans, and with your
continued support, VA can be the best customer-service agency in
Federal Government. Even as we increase access and transform, important
challenges remain--and there will be more in the future as Veteran
demographics evolve. It's now clear that the access crisis in 2014,
prior to the passage of the Choice Act, was predominantly a matter of
significant mismatch at certain facilities between supply and demand,
exacerbated by greater numbers of Veterans receiving services.
That sort of imbalance predicts failure, especially when we promise
benefits to Veterans without the flexibility to fulfill the
obligations.
So a fundamental challenge is that VA is managing budgetary
resources with the package of benefits and services Veterans have
earned and been promised by Congress.
Funding is static--our requirements are fluid, and Veterans' needs
and preferences for care are dynamic. VHA has averaged over 35,000 new
enrollments every month.
We're also seeing more enrolled Veterans come to us for more of
their care. For example, through June 2014, VHA treated over 5.54
million Veteran patients. Through June of this year, VHA cared for 5.64
million enrolled Veterans. This is a 1.7 percent increase in enrolled
Veteran patients treated compared to an increase of 0.9 percent in
enrollment for the same time period.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Why? Three reasons:
1. The growing number of enrollees being adjudicated for service-
connected disabilities are driving significant increases in VA
utilization;
2. VA is providing more access to high-quality care--often better
than available elsewhere; and
3. Financial incentives make VA the smart choice.
Let me give you an example: VA provides the best hearing aid
technology anywhere. Medicare doesn't cover hearing aids, and most
insurance plans have limited coverage. So choosing VA for hearing aids
saves Veterans around $4,200.
Most Veterans have other choices: 81% have Medicare, Medicaid,
TRICARE, or private insurance. But more Veterans are turning to VA for
more of their care. Not for all of their care: On average, enrolled
Veterans rely on VA for just 34 percent of their care. However, if that
percentage rises just one point, to 35 percent, our costs increase
about $1.4 billion.
beyond 2016
Services and benefits peak years after conflicts end, and
healthcare requirements and the demand for benefits increase as
Veterans age and exit the workforce. So, full funding of the 2016
budget request is a critical first step in meeting these challenges,
but we have to look much further ahead for the sake of Afghanistan and
Iraq Veterans.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In 1975, just 40 years ago, only 2.2 million American Veterans were
65 years old or older--7.5 percent of our Veteran population. By 2017,
we expect 9.8 million will be 65 or older--46 percent of Veterans.
2016 budget
To meet these growing requirements, VA needs the adequate funding
the President's Fiscal Year 2016 budget request provides. The House-
proposed $1.4 billion reduction to VA's total request, including
allocation of a Department-wide rescission, means $688 million less for
Veterans Medical Care--the equivalent of as many as 70,000 fewer
Veterans receiving care. The Senate's proposed reduction to VA's total
budget request would be $857 million.
Further, the House proposal would provide no funding for four Major
Construction projects and six cemetery projects. Our growing
requirements are a clear signal that even greater challenges lay ahead,
and we can't afford to be short sighted. I am greatly concerned the
House-passed funding bill cuts construction by 50% at a time when 60%
of our buildings are over 50 years old and general operating rooms
today must be at least 50% larger than they were about a decade ago.
the choice program
I want to turn to discussing how VA has worked to implement the
Choice Program, enacted into law in August 2014. As Deputy Secretary
Gibson testified to the Committee on March 24, 2015, the 90-day
timeline last year to establish a new health plan capable of producing
and distributing Veterans Choice Cards, determining patients'
eligibility, authorizing care, coordinating care and managing
utilization, establishing new provider agreements, processing complex
claims, and standing up a call center was particularly challenging. In
fact we received overwhelming feedback from the marketplace about the
significant challenges of meeting the law's aggressive timeline.
Despite the timeline, VA published regulations and launched the
Veterans Choice Program on November 5, 2014, with a responsible, staged
implementation and the goal of providing Veterans with the best
possible care-experience, while also meeting our obligations to be good
stewards of the Nation's tax dollars. By the end of January, 8.6
million Veterans Choice Cards had been distributed to Veterans.
As we have learned in seeking feedback about the Choice Program,
users of the Program have identified aspects of the law that are
presenting challenges, resulting in confusion for Veterans, or not
working for Veterans as well as they need to. We also recognize that
early utilization of the Choice Program was not as robust as expected
or hoped. We have been eagerly seeking feedback on the program from all
our stakeholders--from Veterans, Veterans Service Organizations, our
employees, and Congress, and we are working diligently to address these
challenges. To continue our outreach efforts, VA launched a public
service announcement for eligible Veterans, viewable at: https://
www.youtube.com/watch?v=i9nnsRlX5b8. We hope all parties will share the
video to aid in education efforts about the Choice Program. We want to
turn these challenges into opportunities to improve our care and
services, and I am pleased that we have worked with Congress and
stakeholders to improve the Program in several ways over the last year.
As of July 31, 2015, 6,589 unique Veterans residing in Georgia have
been authorized care under Choice. These Veterans account for
approximately 8,958 authorizations of which 5,877 have been scheduled
for appointments.
va budget and choice improvement act
The Department appreciates the VA Budget and Choice Improvement
Act, which provided essential budget flexibility and authority we need
to support Care in the Community through September 30, 2015. This
legislation also made a series of amendments to the Veterans Access,
Choice, and Accountability Act of 2014 and instituted additional
requirements to improve access to care and VA's budgeting process.
The VA Budget and Choice Improvement Act also codified the
Department's initiative to develop a plan to consolidate all non-
Department provider programs by establishing a single new program, the
Veterans Choice Program, for furnishing hospital care and medical
services to enrolled Veterans. By November 1, 2015, VA will submit its
plan to Congress. On July 29, 2015, VHA established a VA Community Care
Transition Team with the charge of developing this plan to consolidate
all VA care in the community for medical services, hospital care, and
extended care for Veterans into a single ``Veteran Choice Program.'' VA
is committed to simplifying the confusing array of programs through
which VA delivers care in the community and appreciates the opportunity
to rationalize the various statutory authorities and create a unified,
integrated approach to community care. VA looks forward to working with
Congress to streamline and improve access to care in the community.
In addition, the VA Budget and Choice Improvement Act made several
amendments to the Veterans Choice Program established by section 101 of
the Choice Act such as:
Removing the restriction limiting VA to furnishing
hospital care and medical services to eligible Veterans through the
Veterans Choice Program for a period of no more than 60 days;
Removing the restriction that Veterans must have enrolled
in the VA health care system as of August 1, 2014, to be eligible to
participate in the Veterans Choice Program;
Expanding the pool of eligible providers who can furnish
hospital care and medical services to eligible Veterans through the
Veterans Choice Program;
Authorizing VA to enter into agreements with an entity
that meets established criteria;
Making eligible for the Choice Program Veterans who cannot
be seen within the wait-time goals of VHA and those who, with respect
to care or services that are clinically necessary, cannot be seen
within the time period determined necessary if such period is shorter
than the wait-time goals of VHA; and
Making eligible those Veterans who are seeking primary
care and who reside more than 40 miles from a VA medical facility that
is able to provide such primary care by a full-time primary care
physician.
conclusion
We have made great progress in the last year. As we continue to
work together to address Veterans' access needs, we are grateful for
the close working relationship we have had with Congress, particularly
this Committee, as we make progress in implementing the Veterans Choice
Program. Mr. Chairman, we will continue to work with Veterans,
Congress, VA community care providers, VSOs, and our own employees to
ensure the Choice Program helps us deliver great healthcare outcomes
for Veterans. Thank you. We look forward to your questions.
The Chairman. Thank you, Mr. Secretary. I will tell you
what; I will make a deal with you. I will work on giving you
more fungibility and flexibility. I want you to respond--I had
a letter sent to you about any publications you had put out on
implementing Choice within the VA to get to me by July 31. I
did not get all the answers I needed to get. So, when you get
back, if you will get me all those answers to that letter, I am
going to do the best I can to get you all the flexibility I
can.
Secretary McDonald. I sure will, sir.
The Chairman. That is a fair deal, is not it?
Secretary McDonald. It is a fair deal.
The Chairman. You know, 2 years ago, in 2013, we held a
field hearing just like this one at Georgia State University.
The Clairmont Road VA Hospital had gone through a terrible
situation where three veterans had committed suicide, one of
them in the hospital itself while as a patient, and two others
because the appointments were not timely and were not kept
timely. Leslie Wiggins came in to be the new director of the
hospital.
Stand up, Leslie. She deserves a big hand. [Applause.]
The VA brought Leslie Wiggins in to take over the operation
of that hospital after we discovered and then disclosed through
our hearing the problem with mental health coverage. I want to
compliment you on the numbers--about timely appointments being
kept in mental health, which has greatly improved. Are we where
we need to be nationwide on mental health accessibility in the
VA? If not, what do we need to do to get there?
Secretary McDonald. We are not where we need to be, and we
are not where we need to be as a Nation. As I have often talked
about, Mr. Chairman, VA is the canary in the coal mine for
American medicine. American medicine is not producing enough
mental health professionals; though, as you know, we are
recruiting. I have been to over a dozen medical schools myself,
recruiting mental health professionals and primary care
physicians. There is a shortage in the country. But we are
making great progress.
One of the things that excites me the most is the progress
that only VA can make. I will give you an example. The other
day, I met with a group of our researchers and doctors who have
developed an algorithm--call it a Monte Carlo simulation--where
we are now starting to see some evidence that we might be able
to predict suicide.
This would be a breakthrough, and only the VA, with an
integrated health care system that has 40 years of medical
records for most of our veterans in advance, can put that kind
of algorithm together. We have published it in medical
journals, and I am hopeful we can validate it. That would be
not only a great benefit to all veterans, but a great benefit
to the American public.
The Chairman. We had a hearing in the Committee, as you
will recall, back a few months ago on the situation in Tomah,
WA--I mean, Tomah, WI----
Secretary McDonald. Yes.
The Chairman [continuing]. With the over-prescription of
opiates. Yesterday, I happened to be at the CDC with Dr. Tom
Frieden and Senator Perdue from Georgia. Over-prescription of
opiates is becoming a nationwide problem in the United States.
It is estimated that enough opiates were prescribed last year
in America for 15 percent of the population to have a full
year's supply at any one given point in time, which is entirely
too many.
What is the VA doing to get out of this candy store
attitude of giving out opiates for mental health problems and
getting back to a more disciplined prescription process?
Secretary McDonald. Well, first of all, the situation in
Tomah should have never happened. We had a situation there
where we were not providing the kind of oversight that was
necessary, and we had one person doubling in two roles, which
was not providing the proper oversight.
Second, we have a national effort to reduce the number of
opiates that we use, a national program. One of the great
things about the VA that we are able to do, unlike many other
health care systems, is we try other alternatives. We are the
number 1 user of acupuncture in the country. Yoga has been
proven to be successful with some people in reducing their
opiate level and equine therapy in our West Bedford, MA,
location shows promise.
These are therapies that are allowing us to prove positive
results that are allowing us to reduce medication. Maybe I will
ask Jim to comment a little bit more on the program, the
national program.
Dr. Tuchschmidt. We agree completely. We have been looking
at our policies and our procedures and have really begun to put
a program in place to educate our providers--kind of what we
call academic detailing--about appropriate use of opioids in
the clinical setting. I think this use of complementary and
alternative medicine as a way of helping people live with
chronic pain is something that we really embrace.
Secretary McDonald. Mr. Chairman, this goes to your point
of why a VA is so necessary. Those alternative uses of
treatment are not available as readily in the private sector.
The Chairman. Well, that is part of my point. There are
almost 9 million VA beneficiaries. Is that not correct? Did not
we send out almost 9 million Choice cards?
Secretary McDonald. Yes, sir.
The Chairman. That is a huge census from which to draw a
lot of pretty predictable results and pretty predictable
outcomes. But there are a lot of people who think that opiates
have become the biggest problem in our society today. The
signature injuries of Afghanistan and Iraq are PTSD, TBI, and,
obviously, limb injuries. But if we are over-prescribing
opioids to mask the problems of TBI and PTSD, we are only
postponing a suicide that some day probably will happen. So, I
encourage you to continue to work on that as hard as you can.
Secretary McDonald. Mr. Chairman, I could not agree with
you more. I know Jim could not, either.
Also, I just wanted to make you aware, in case you did not
know, that Monday we are holding a traumatic brain injury
summit in Washington, DC. This is one of the things I have
wanted to do for some time, because I want to use the convening
authority of the VA, you know, the largest medical system in
the country, to bring together the country's experts on
traumatic brain injury, whether it is the NFL, the NHL, whether
it is police officers, firefighters--bring everybody together,
share the information, and put together a research program
which is guided so that we do not have redundant pieces of
research going on.
We are looking forward to doing that next week. It is 3
days--I think it is--next week, and we hope to provide some
benefit, not only to veterans, but to the American people from
it.
The Chairman. I have one more question. After that I am
going to turn to Doug for his questions, then I will probably
have a follow-up. My question is this: in the second panel--
which you will hear their testimony in just a little bit, and I
have read the statements that they submitted--in almost every
case, there are concerns about the commitment within the VA to
the Choice Program and concerns about the information on Choice
really getting to the veteran.
You will hear some testimony where veterans will tell you
they really did not know how to utilize Choice. In some cases,
utilizing Choice was more cumbersome and difficult.
Is there a person in your employ in the VA in Washington
that is principally responsible for communicating the Choice
Program throughout the VA system to its employees?
Secretary McDonald. Well, ultimately, I take responsibility
for that. If you find any failures in the Choice Program, it
would be my accountability or my fault. But what we have done
is we have set up Choice experts in every single VA operation,
so you do not have to come all the way to Washington. Leslie
has one here in her shop. We have them throughout the system.
The idea would be that they would be the experts to help you
navigate the system.
Jim, do you want to comment?
Dr. Tuchschmidt. Sure. You know, I think we have done a lot
to try to educate our staff, because, ultimately, our staff are
the best resource we have to explain the Choice Program to our
patients. We have done Web training. We have sent out printed
material. People have access to printed material in the waiting
rooms and at the clerk's desk which they hand out. Every
facility has, quite frankly, one or more Choice champions who
we have focused and concentrated on to be able to answer those
questions.
I think that there is no doubt that in a program as, kind
of, complex as this is, making sure that 9.2 million veterans
actually understand the program and how to use it has clearly
been a challenge. I think that we have tried through outreach
efforts, mailings, our Web site, which we recently revamped, to
make the resources available to veterans so that they can get
the information that they need. Yet, we know we need to do a
better job of that.
Secretary McDonald. Mr. Chairman, may I introduce Gary
Compton, who is the Choice champion here in Atlanta?
Gary?
The Chairman. Hi, Gary.
Secretary McDonald. So, if anybody in the room has any
questions on Choice, you can contact me or Gary.
The Chairman. While Gary is here, let me make a comment.
You know, every good leader assumes principal responsibility
first. You answered the question by saying, ``If you have got a
problem, it is my responsibility.'' But, quite frankly, you
have 314,000 employees in VA health care. It is the second
largest agency in the Federal Government. If you are the only
person we have to count on to get Choice implemented, we are in
deep trouble. [Laughter.]
The Chairman. Mr. Compton? Is that correct?
Mr. Compton. Yes.
Secretary McDonald. Gary Compton.
The Chairman. Are there a lot of Gary Comptons around the
country?
Secretary McDonald. There is a Gary Compton in every VA
facility.
The Chairman. Well, let me make a suggestion. I am being as
sincere as I can be on this.
Secretary McDonald. Sure.
The Chairman. After you finish your TBI summit next week,
we probably ought to have a summit with all your Mr. Comptons
around the country, because I think you will hear from Doug and
you will hear from some of the people about to testify that the
big missing link in the chain is everybody in the VA knowing
what to communicate to the veteran, so that the veteran has an
easy way to find out how to get it.
My best example is this--and I am not advertising for Bank
of America, but I happen to have a Bank of America credit card.
I happened to open my bills last night, and I got a letter from
Bank of America that was six pages long and in small print and
said, ``Your credit terms have changed.'' I threw it away. It
was too intimidating. It was too much to read. I know we all
get those types of mailings.
We need a simple system where veterans have an easy way to
access the information in terms of what their choices are. I
have love to see us have a summit in Washington with all the
Mr. Comptons of your agency to see what we can do to improve
the communication from the VA offices and CBOCs and hospitals
to the veteran beneficiaries.
Secretary McDonald. We will do that.
Dr. Tuchschmidt. If I could, I will just add that we have--
there is the toll free number available. We also updated our
Web site and we just recently added a live chat to that. So, if
you go onto that Web site, and you can not find what you are
looking for, you can talk in a chat session with somebody real-
time.
The Chairman. You know, I am sorry that you mentioned that
for this reason. I tried to go to the site last--is that the
You Tube site?
Dr. Tuchschmidt. No.
The Chairman. That is not. You had a You Tube site in your
printed comments. I could never get it to come up. But we will
work on that after the meeting. That may have been the
operator, too, you know.
Congressman Collins?
Mr. Collins. Thank you, Mr. Chairman.
I want to start off similar to the senator. Mr. Secretary,
I know you would not probably be aware of this, but it goes
back to issues that the senator just hit on: communication and
the delays that seem to come in.
One of the issues we have in our office is a tort claim on
the medical malpractice--waited for 180--you know, the 180-day
wait. The case was supposed to be decided on July 26, 2015. On
July 29, the gentleman received a letter--and we received an
opinion--that said a second medical opinion would be needed. We
are outside of the window. Again, it just looks more like a
delay. If it was going to be denied, it would be denied, and
that is OK, because there is a court route to take.
I wanted to bring this to your attention. I know there has
been some communication even as late as this morning. But this
is the kind of issue that bothers folks.
Secretary McDonald. I know that. I mean, customer service
is what we have got to improve. And, you know, when I came to
the VA, what I discovered was the second largest department in
government--that I felt everybody was looking inward. That is
typical. When you have a catastrophe or you have a crisis in an
organization, people turn inward.
A leader's job is to turn them outward, get them out in the
field. That is why I have been to over 200 VA sites. That is
why I have demanded the town hall meetings. It is why we have
had open houses. It is why we have had media days. We have got
to open everything up, let people in, hear the criticism, and
then work to improve customer service.
We have employed help from people like Disney, Starbucks,
Ritz Carlton. We have put in place a new veteran experience
officer. That is his only job. So, we are working very, very
hard. But it is going to take time, because all you need is one
situation out of 340,000 employees where something goes wrong,
and that is the one that customer remembers.
Mr. Collins. Exactly. And I think one of the things, Mr.
Secretary, as we deal with this is you are having to build a
hill back up. I appreciate the attitude that you have had. I
think if we go back to the start of the Choice Program when,
yes, VA sent out 9 million letters to folks; the problem, as I
have talked to veterans, is that many of them--it would not
have applied to them.
All of a sudden, they got a letter that really did not
apply to them. They began to have questions that they can not
get answered. They get frustrated. They think they are being
denied a benefit or something that they really did not have a
chance to get to start with. Again, it is sort of like we are
catching up here and----
Secretary McDonald. And even since those letters, we have
changed the definition of 40 miles.
Mr. Collins. Exactly.
Secretary McDonald. And some of those letters arrived
around the holidays with all the catalogs.
Mr. Collins. Exactly. Well, the changes--the chairman has
already said we are out of here at 4 o'clock. We are not going
to discuss the 40-mile definition at this point. I think the
thing that concerns me--and for my office--when I came to
Congress, following folks like the senator who has been in both
houses, it was still amazing to me, having a familiarity with
the system, that I have people in my office whose sole job is
to have to deal with veterans who should be getting services
without having to go to their congressman or their senator.
They should not have to. I should have them being able to
research new ideas. OK? [Applause.]
I appreciate that, and I say that from a positive aspect. I
am not saying--and before my staff believes I am running them
out of a job, that is not what I am doing. I have plenty of
things for them to do.
But when two-thirds of their caseload is VA, and two-thirds
of their caseload is a lack--basically, it boils down to a lack
of trust. It goes back to something you said, that I want to
hear your comments on, because I know, speaking as a Member of
Congress, you asked for flexibility, which I think is
understandable.
Given the track history--and I am not going to say you are
a part--you are trying to change that--there should be some
understanding that that is why budgets are there. There can be
some issues, and I know Senator Isakson--the chairman is going
to work on that. But, my question is how can we address the
flexibility issue but also assure that--one, we are seeing from
the outside bills that we passed to dismiss employees who are
not doing what they should be doing, when there was actually
some pushback from VA to even pass that bill. Those are the
kinds of things that--how do you do that? [Applause.]
Secretary McDonald. Well, first of all, we are holding
people accountable. Since I have been secretary, more than
140,000 employees have been terminated. Over the previous year
before I was sworn in, it was about 100,000--110,000 that were
terminated. So, we are holding people accountable. I mean, you
have got a citizen here in Georgia who faces 5 years in jail
and $250,000 for each count if found guilty. So, this is
accountability.
At the same time, in VHA, nobody received a bonus for 2014.
I took a lot of heat for that. And nobody was rated outstanding
in the SES ranks in 2014. I would venture to say we have the
best distribution of ratings of any government agency for SES
employees--I would be happy to show it to you--and I would say
equal to the best companies in the private sector. I know
because I used to run one.
So, we are holding people accountable. Accountability is a
lot more, though, than just firing people. Accountability is
also about praising people who do a good job.
Mr. Collins. I agree.
Secretary McDonald. We are trying to do more of that. And
accountability is about having a culture where people self
report. I was pleased, as I told you earlier this morning, that
Dublin self reported that they had some problems at their
consults. I was pleased that Dayton self-reported. When we get
to the point where people are self reporting, that means they
are fixing the system that they are working on; that is a good
thing and that is a good culture.
Mr. Collins. Mr. Secretary, I agree. I think one of the
things I--from my perspective Ms. Wiggins and her staff--I see
them sitting in front--have been outstanding in that regard, to
at least get us answers. Frankly, what I like about them is
that they will tell me, ``I do not like it any more than you
do, Congressman.'' I am sure that you love to get those memos
in which there are some questions.
You brought up an interesting issue, because it was
popularly reported, and this was actually--it was not popularly
reported. It was in the newspaper in Atlanta. The gentleman----
Secretary McDonald. Do not believe what you read in the
papers.
Mr. Collins. No, I never have on myself. But, the gentleman
in that situation you brought up--yes, he is facing charges
now, but he was transferred from Augusta to Atlanta. His own
attorney said it was because he needed a change of scenery. He
did not need a change of scenery. He needed to be in jail.
Secretary McDonald. I am unfamiliar with that detail. All I
know is the investigation carried on. It was carried on
thoroughly. It went to the FBI, the Department of Justice, and
he is facing 50 charges.
Mr. Collins. We will look forward to those----
Secretary McDonald. I----
Mr. Collins. I appreciate it, Mr. Secretary. I am just
reflecting--I have been in front of four town halls this week,
and VA was part of every one of them. Senator Isakson knows
that as well. It was the first question this morning in
Hiawassee, GA, on Sunrise.
I want to turn a little bit, and from a positive
standpoint, ask how do we go from the Choice plan that we have
put into action, what are some of those obstacles, and how do
we fix it? One of those issues that I hear about a lot right
now is how do we get--and I would like for you to address the
challenges of finding and including outside VA providers,
because I know in Atlanta--and we talked about the mental
health issue--there is just simply no providers to be able to
step forward. What is the perspective helping to fill that gap
right now?
Secretary McDonald. The ultimate answer is to go to one
consolidated Choice Program. Right now, we have, as I said in
my remarks, seven different ways of veterans getting care
outside the VA. It is so complex that our employees do not get
it and veterans do not get it. And the complexity also deals
with the kind of service available in each one and the
reimbursement rates.
When I went to Montana with Senator John Tester, all the
providers were complaining to me about all of the other six
programs, except one, ARCH; it was because ARCH had the highest
reimbursement rates for people in Montana. What we have got to
do is get all of those seven different programs down into one,
and if we do that, I am convinced we are going to be able to
get--and get it at the right rate, the Medicare rate--we are
going to get more and more people in that program rather than
cherry picking their own program, which is what is happening
today.
Mr. Collins. I appreciate that. I think one of the things
we will hear in the second panel--and you have heard as well--
is, one, there seems--and this goes to the Health Net issue--
there seems to be by a lot of the folks who have to contact our
office that we are going to hear directly from one in just a
little bit--that Health Net seemed to add a layer of
bureaucracy that cuts off even the stilted communications. Many
times that was happening and unclear. I would like--and I am
not going to ask this specifically----
Secretary McDonald. Well, we have got to eliminate that
bureaucracy.
Mr. Collins. So, I think that is what I want to hear.
Again, I am not sure why adding a bureaucracy to help do this
actually was encouraged or started in this position of Health
Net and others. Address that issue, because there seems to be
communications where you call one--``Well, we never heard from
the VA.'' The VA says ``We never heard from Health Net.''
Health Net goes back and forth. We are going to hear about this
in a minute, so I would just like to hear your discussion on
it.
Dr. Tuchschmidt. I think that the Choice Act, as it was
written, is very complicated. We put it together in 90 days,
which was a challenge. I would suggest that it is not designed,
either legislatively or in its implementation, in a way that
really meets, I think, the customer service standards that we
want either for veterans, quite frankly, or for providers.
We have been working on the plan that you all charged us
with to submit by November 1 to really not only consolidate
these programs, but to say, ``How do we put this together in a
way that really makes sense, that improves the business
processes, and makes it easier for everybody to be able to
access care outside of the VA facilities?''
This month we are bringing together a roundtable of
industry experts to talk to them about how they do this, about
where the industry is going, both in terms of managing quality
and appropriateness of utilization. I am confident that the
proposal we bring you in November is going to address a lot of
these issues.
Mr. Collins. My last question--and, Mr. Chairman, I
appreciate the indulgence in the Senate and the House in
working together.
The Chairman. Absolutely.
Mr. Collins. There is an issue--one of the first things--I
was excited about your appointment because you brought the
business acumen from running a successful organization outside
that cut through what a lot of us have to deal with in the
Federal Government. And there are a lot of areas. It is not
just VA. It is everywhere. We have good people at our clinics,
we have good people at our hospitals, and I never want it to be
understood that the problems of a few reflect the problems of
all. That is something we do not need to have happen.
The issue, though, comes up in some things that I have
heard from our--and I have toured along with the senator the
facilities in Georgia, and there are some simple things that
seem to be, from a Congress perspective, in the contracting,
purchasing--simple things, where you have--I know in Atlanta
there was an issue of a simple fixing of a part that cost--I
want to say $17,000--and it took them 3 to 6 months to order
the part while at the same time we are serving veterans on
paper plates, costing more than the part.
It is my understanding that that could be fixed at your
desk. If that is not true--and some of these other areas of
contracting, where we just seem to be redundant--what can we do
in Congress to fix that? And if it can be fixed at your desk,
what is being done to fix what were perceived as common-sense
issues?
Secretary McDonald. That is actually part of our
transformation that we call MyVA, which is the overall
transformation we are trying to make of the VA. There are five
strategies. Number 1 is to put the veteran at the center of
everything we do, and start measuring veteran satisfaction for
the first time.
Number 2, improve the employee experience. If you check,
the best customer service companies in the world also are the
best companies to work for. That is not an accident. You know,
you have no hope of caring for the veteran unless your
employees are happy and have a good experience.
Number 3--and this speaks to your point--is to improve our
internal support services. Our acquisition, our logistics, our
human resources, our recruiting, our hiring--these are all
system that are broken. We have got teams of people now working
to change them, working with the private sector to learn how
best to do them; the changes are underway.
Number 4, quickly, is create a culture of continuous
improvement. We are teaching employees Lean Six Sigma, which is
a technology that engages employees and helps them change the
systems they work on.
Number 5 is creating strategic partnerships. There is a lot
of good will in this country for veterans, and we are engaging
partners to help us--as the chairman said, as force multipliers
to help us. We did not do that in the past.
We have put together a plan that is about 55 pages long. If
you do not have it, we will make sure you get it. We have been
through it with the Committee, and we have a couple of Members
of the Committee who are doing a deep dive with us who have
business experience. We are making good progress.
Mr. Collins. Well, Mr. Secretary, I appreciate the answers.
There is still a lot that we could talk about. We are
continuing to get this. It is not going to be something that
goes away, and I think that trust factor that you talked about
is both from a congressional perspective and from a department
level as well. There is a lot of distrust there.
So many times, for us, in either house--to ask for
flexibility, to ask for trust--we are going to have to earn it.
I think those are the things we are doing. I appreciate your
answers.
Mr. Chairman, I yield back. [Applause.]
The Chairman. Mr. Secretary, would you repeat for me how
many people you said you disciplined in your first year as
secretary?
Secretary McDonald. Well, we have terminated over 140,000.
The Chairman. When you say you terminated, does that mean
they took early retirement or were transferred?
Secretary McDonald. No, this is--they may have been in
probationary period, and we ended the probationary period, or
they left, or they were disciplined. I do not know how many
retired. I would have to check those numbers.
The Chairman. But is not it true that it is almost
impossible for you to fire somebody under the current law?
[Applause.]
There is a good ending to this question, by the way.
Secretary McDonald. The actual number fired is 1,800.
The Chairman. I beg your pardon?
Secretary McDonald. The actual number of fired is 1,800.
The Chairman. But it is very difficult to do.
Secretary McDonald. You know what? I have done it in the
private sector and I have done it in the public sector, and I
would tell you it is, in some ways, easier to do in the private
sector, because what happens in the private sector oftentimes
is you cut a deal with the employee, so you are able to buy
them out. You can not do that in the public sector.
The other thing that happens in the public sector is that
the due process is baked into the process, whereas due process
in the private sector only happens if the employee chooses it,
right, because they take you to court. So, it is a little bit
different in the public and private sectors, but I would not
argue that that is an excuse for not being able to deliver good
customer service.
The Chairman. The Rubio-Ayotte bill is pending in the
Senate. Is that not correct?
Secretary McDonald. It is, and we have said we are against
any bill that differentiates VA from any other department of
government. You know, I have got gaps I am trying to fill. I am
hiring 1,100 new doctors. I am hiring 4,000 new nurses. You
have given us a chance to hire people under the Choice Act.
We can not hire the people when Members of Congress are
going to somehow differentiate the VA versus other departments
of government. That does not cause people in government to want
to work for the VA. So, I am against that bill because it
differentiates us. I think I have the tools I need to hold me
accountable if I do not deliver. I think I have the tools I
need.
The Chairman. Well, I ran a lot smaller company than
Proctor & Gamble. I had 250 employees and 1,000 agents. You had
125,000, if I am not mistaken.
Secretary McDonald. That is correct.
The Chairman. But the ability to manage your workforce and
have positive incentives as well as accountability measures in
which you held people accountable is a wonderful way to run a
business versus where you do not have that. So, I would suggest
not wanting to be treated like any other government agency--
different from any other agency is a good statement to make. I
understand that. I think it is also critical to understand that
we have had some unique problems within the VA that we need to
try to deal with.
Secretary McDonald. Mr. Chairman, let me explain something.
When I came to the VA, and I got the relative rating of the SES
employees from the previous year, everyone was rated
outstanding and above average, right? That is not
accountability.
The Chairman. That is self reporting.
Secretary McDonald. That is not accountability. So, what
did I do, right? As I told you, nobody in VHA was rated
outstanding. Nobody in VHA is getting a bonus for the year that
their secretary resigned. That is accountability.
Accountability is not only firing. Accountability is giving
people the rewards for their performance that they have earned.
And I think I can--I am doing that. I do not think I can do
that; I am doing that. Now, the SES Association did not like it
very much, but that is what we did.
The Chairman. Well, we are proud of what you are doing. One
last comment I will make for the benefit of the audience
because I heard them clap--that VA employee is under a criminal
indictment now?
Secretary McDonald. Yes, sir.
The Chairman. From Augusta. That took place because as
chairman of the Committee, we wrote the Department of Justice
and asked them to investigate. We brought DOJ into the agency,
and I think that got the attention of everybody around the
country that we are going to look that hard, because if you
manipulate consults or you manipulate medical information,
which was the case with this Augusta person, it could be a
criminal offense. In this case, it was a criminal offense, and
they are subject to imprisonment.
You do not want to send anybody to jail, and you do not
want to fire anybody. But if everybody does not think you have
a standard to live up to, they will always sink to the lowest
common denominator and never the highest. I learned that a long
time ago. [Applause.]
Secretary McDonald. Mr. Chairman, there are 180 other
people being investigated right now, and I am very certain that
the FBI will be involved in some of those 180. This story has
not been written yet. I mean, we still have many, many chapters
to go, and it will have an impact on the culture.
Mr. Collins. I have a clarification. When I made this
comment earlier when we were talking about firings, you used
the number 140,000, and then you were just handed a note of
1,800.
Secretary McDonald. No, no, no.
Mr. Collins. Is it 140,000 that were let go, or 1,800 that
were fired?
Secretary McDonald. I am sorry. I did not mean 140,000. I
meant 1,400. Over 1,400 have been terminated; yes, have been
terminated. That means not just fired, but that means
terminated. Let me get back to you with the exact number.
Mr. Collins. OK. There is a numbering issue there, and if
you will get back to me--because something right there is not
making sense.
Secretary McDonald. We will get back to you. But, yes, it
is 140,000 losses--terminations, 1,800 of which have actually
been fired.
Mr. Collins. Of the 140,000--OK. A termination and a firing
for a lawyer is very close.
Secretary McDonald. Well, a termination could be for poor
performance. A termination could be during your probationary
period; you have had poor performance, and----
Mr. Collins. But that is not retirement.
Secretary McDonald. No, that is not a retirement.
Mr. Collins. That is not a ``I am leaving my job.''
Secretary McDonald. These are not all retirements.
Mr. Collins. But, they are also not ``I am just coming in
and quitting.''
Secretary McDonald. That is correct.
Mr. Collins. Or would this number include folks who just
say, ``I got a better job somewhere else. I am leaving.''
Secretary McDonald. Probably.
Mr. Collins. So, that would include----
Secretary McDonald. I would think it would, yes, sure.
Mr. Collins. OK. We need to get better clarification
numbers on that.
Secretary McDonald. But I can tell you that our retention--
--
Mr. Collins. Oh, I understand completely. But we will get
better clarification.
Mr. Chairman, thank you for that clarification.
The Chairman. Because 140,000 is one-third of your total
employees, if you have 314,000 employees?
Secretary McDonald. Yes.
The Chairman. Check on those numbers.
Secretary McDonald. I am.
The Chairman. I am not good at numbers, so I am not going
to--but we will check on them and get the right information to
all of you.
Let me thank the secretary. Dr. Tuchschmidt, thank you too
for being here. I hope you are going to stay for the second
panel, because I think the second panel is going to be very
informative in both a positive and a constructive way, So, I
hope you will stay for that.
Secretary McDonald. I am sorry. Mr. Chairman, can I correct
the record now?
The Chairman. Yes, sir. The record is to be corrected.
Secretary McDonald. 1,755 employees have been terminated--
1,755 is the number that have been terminated.
The Chairman. 1,755. That makes more sense. Thank you, Mr.
Secretary. Thank you for cutting your vacation short to come to
Georgia. We appreciate it very much.
Secretary McDonald. Thank you very much.
The Chairman. I would like to ask our second panel to come
forward, if you will set up the table.
We are very fortunate to have a distinguished second panel
on our Veterans Choice hearing today, and I want to urge
everybody to listen closely. I have read the testimony of each
of these individuals. It is very informative, and it will
answer or illuminate or enlighten some of the questions you
have heard us ask the secretary.
First and foremost is Ms. Donna Hoffmeier, Vice President
of VA Services with Health Net Federal Services.
We are delighted that you are here today and thank you for
what you do.
Dr. Stephen Jarrard, Provider and Veteran, lives in Rabun
County, GA, which is a place I love very much.
We are glad to have you here today.
Dr. Wayman Duane Williams, Georgia State Leader of the Iraq
and Afghanistan Veterans of America, thank you for your service
to the country.
And Carlos with the best name in the world--Chacha.
Is that right? I would love to see you dance, Carlos. You
would be good, I know. We are delighted to have you here today.
Your story is compelling, and we appreciate it very much.
We will call on Ms. Hoffmeier first.
STATEMENT OF DONNA HOFFMEIER, VICE PRESIDENT, VA SERVICES AND
PCCC PROGRAM MANAGER, HEALTH NET FEDERAL SERVICES
Ms. Hoffmeier. Thank you, Mr. Chairman. Chairman Isakson,
Representative Collins----
The Chairman. Pull the microphone real close. Almost
swallow it. You have to almost get it that close.
Ms. Hoffmeier. I appreciate the opportunity to testify on
Health Net's administration of the Veterans Choice Program.
The Chairman. I am going to interrupt you once more--is
there a sound person in the room? If you can ratchet it up a
little bit, I would appreciate it. She is hard to hear.
Try it again. I am sorry.
Ms. Hoffmeier. I appreciate the opportunity to testify on
Health Net's administration of the Veterans Choice Program.
Health Net is proud to be one of the longest serving health
care administrators of government programs for the military and
veterans communities. We are dedicated to ensuring that our
Nation's veterans have prompt access to needed health care
services and continue to believe there is great potential for
the Choice Program to help VA deliver timely, coordinated, and
convenient care to veterans.
From the start of the Choice Program, Health Net has worked
collaboratively with VA to implement Choice and to identify and
address process and policy gaps or needed improvements. In
Georgia, we have made nearly 7,500 Choice appointments for
veterans and currently have over 400 in the process of being
appointed. Another 1,000 cases are either awaiting
documentation from VA or contact by the veteran to initiate
care.
Our provider network team works closely with the VA medical
centers to develop a provider network tailored to meet the
needs of Georgia's veterans. Our Choice provider registry
includes 5,700 providers and 21 hospitals, including a number
of large health care systems. Through these large health care
systems, we are able to provide access to an even greater
number of physicians who are affiliated with these
organizations.
Our network in Georgia also includes several dedicated
psychiatric hospitals and 14 federally qualified health
centers. We continue to conduct outreach to providers with
which VA has longstanding relationships, including VA
affiliates and preferred providers.
Implementation of any new program is always challenging,
particularly when the change is significant and the
implementation period is very condensed. The very limited
implementation period for Choice did not afford VA time to
develop necessary policy and process guides, nor did it allow
us the time to develop operational processes, make needed
system changes, and to effectively hire and train the staff
needed to support a program of this size and complexity.
We only had about 30 days of close collaboration and
planning with VA before going live, which is an extremely
aggressive implementation period by any standard. There clearly
have been bumps in the road with the accelerated rollout of
Choice--delays in eligibility information being made available,
confusion over program details and inconsistent expectations,
incorrect and sometimes conflicting information provided to
veterans. These bumps have understandably caused a level of
veteran frustration.
While issues are common with the startup of any new
program, many of the challenges with Choice to date are the
result of inadequate development and transition time. We are
working very closely with VA to address these challenges and,
more importantly, to develop solutions for these challenges.
For example, we are working with VA currently to streamline
the process for receiving eligibility information on veterans,
which has been one of the biggest sources of frustration for
veterans. VA is phasing in a new eligibility process for wait
list eligible veterans that will provide the Choice contractors
with much more timely access to eligibility information.
To address challenges with incorrect information being
provided, we have initiated additional training for all
customer service representatives. And we have also deployed
senior, very experienced operational and training experts to
directly oversee that training.
We continue to work with VA to set realistic timelines for
new initiatives and program changes. Since the start of Choice,
the number of changes have been fast and frequent. We fully
support VA making changes to increase the use of the Choice
Program, but it is essential that adequate time be allocated so
we can retrain our people and execute the change effectively.
When timeframes are pushed to unrealistic levels, mistakes
happen. It is just a reality.
We continue to advocate for the creation of process and
policy manuals that clearly articulate program procedures and
expectations. This will help ensure consistent application of
Choice across the board with both contractors and all VA
facilities.
To ensure veterans have ready access to community care,
providers must be willing to participate in the Choice Program.
Widespread adoption by community providers requires the
elimination of unnecessary impediments. We are currently
working with VA to identify those impediments and to,
hopefully, get those impediments removed.
In closing, I would like to thank you, Chairman Isakson,
for your leadership in ensuring our Nation's veterans have
prompt access to needed health care services. Working together
with VA and with the support and leadership of this Committee,
we are confident that Choice will deliver on our obligations to
this country's veterans.
Thank you.
[The prepared statement of Ms. Hoffmeier follows:]
Prepared Statement of Donna Hoffmeier, Program Officer, VA Services,
Health Net Federal Services, LLC
a history of partnership
I appreciate the opportunity to testify at today's field hearing on
Health Net's implementation and administration to date of the Veterans
Choice Program.
Health Net is proud to be one of the largest and longest serving
health care administrators of government and military health care
programs for VA and the Department of Defense (DOD). Health Net's
health plans and government contracts subsidiaries provide health
benefits to more than five million eligible individuals across the
country through group, individual, Medicare, Medicaid, TRICARE, and VA
programs.
For over 25 years, in partnership with DOD, Health Net has served
as a Managed Care Support Contractor in the TRICARE Program. Currently,
as the TRICARE North Region contractor, we provide health care and
administrative support services for three million active-duty family
members, military retirees, and their dependents in 23 states. We also
deliver a broad range of customized behavioral health and wellness
services to military servicemembers and their families, including
guardsmen and reservists. These services include the worldwide Military
and Family Life Counseling (MFLC) program, which provides non-medical,
short-term, problem solving counseling, rapid-response counseling to
deploying units, victim advocacy services, and reintegration
counseling.
As an established partner of VA, Health Net has collaborated in
supporting Veterans' physical and behavioral health care needs through
Community Based Outpatient Clinics (CBOCs), the Rural Mental Health
Program, PC3 Program, and the Choice Program. We also have supported VA
by applying sound business practices to achieve greater efficiency
through claims auditing and recovery and claims re-pricing. It is from
this long-standing commitment to supporting the military and Veterans
communities that we offer our thoughts on the role of Choice in
augmenting VA's ability to provide eligible Veterans with timely access
to needed health care services.
the evolution of choice
In August 2014, with the leadership of this Committee, Congress
passed and the President signed into law the Veterans Access, Choice,
and Accountability Act of 2014 (VACAA, Public Law 113-146, ``Choice
Act''), which directed the establishment of a new program to better
meet the health care needs of Veterans. The law directs the
establishment of a Veterans Choice Card benefit that allows eligible
Veterans who are unable to get a VA appointment within 30 days of their
preferred date or the date medically determined by their physician;
reside more than 40 miles from the closest VA health care facility
(there are different mileage rules for some states, such as New
Hampshire and Hawaii); or face other specific geographic burdens in
traveling to a VA facility to obtain approved care in their community
instead.
Health Net's Contracted Choice Regions 1, 2, and 4
(includes 13 of 21 VISNs with 90 VA medical centers in all or part of
37 states; Washington, DC; Puerto Rico; and the Virgin Islands)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
As background on VA's approaches to delivering non-VA care, VA
developed the PC3 Program to provide eligible Veterans access to health
care through a comprehensive network of community-based, non-VA medical
professionals. In September 2013, Health Net was awarded a contract for
three of the six PC3 regions. These regions include 13 of 21 Veterans
Integrated Service Networks (VISNs) and 90 VA medical centers in all or
part of 37 states; Washington, DC; Puerto Rico; and the Virgin Islands.
In October 2014, VA amended our PC3 contract to include several
components in support of the Choice Act. These components included
production and distribution of Choice Cards; establishment of a Choice
call center to answer Veterans' questions about the Choice Program and
to verify eligibility; appointing services for eligible Veterans with
Choice-eligible community providers; and claims processing. Since VACAA
required implementation by November 5, 2014, we worked collaboratively
with VA and TriWest (the contractor for the other three PC3/Choice
regions) to develop an implementation strategy with extremely
aggressive timelines. This ambitious schedule allowed minimal time to
hire and train staff and to reconfigure our systems for the new
program, which contains many requirements that differ from PC3 and
therefore have to be tracked and recorded separately. Despite the fast-
paced implementation schedule, on November 5th, Veterans started to
receive their Choice Cards and were able to call in to the toll-free
Choice telephone number and speak directly with a customer service
representative about the Choice Program.
On April 24, 2015, VA published a second interim final rule that
changed the way VA measures distance for purposes of determining
eligibility. VA now considers the distance a Veteran must drive to the
nearest VA medical facility, rather than the straight-line of geodesic
distance to such a facility. This change resulted in an expansion in
the number of Veterans eligible for the Choice Program.
Most recently, on August 4, 2015, Congress passed a number of
improvements to the Choice Program through H.R. 3236--Surface
Transportation and Veterans Health Care Choice Improvement Act, which
became Public Law 114-21. These program improvements include expansion
of eligibility for Veterans, expansion of the pool of providers
eligible to participate, clarification of wait times, removing the time
limit on an episode of care, and modification of the distance
requirement. The new law also requires VA to develop a plan to
consolidate all non-VA care programs by establishing a new, single
program to be known as the ``Veterans Choice Program.'' We commend the
Committee for working to address some of the unintended limitations
contained in the original legislation.
engaging collaboratively
From the start of discussions on implementation of VACAA, the VA
Chief Business Office, Contracting Office, and senior VHA officials
have worked closely with both contractors to establish priorities,
provide policy guidance, and develop process flows. As the Choice
implementation progresses, more policy and process items continue to be
identified. We are working closely with VA and TriWest to ensure that
key policy or process items are addressed quickly; doing so is
essential to program performance and effectiveness.
building the choice provider network
A key component to the success of Choice is acceptance by community
providers. To provide Veterans with timely access to care in their
communities, Health Net proactively recruits providers to Choice. Since
the implementation of Choice, we have collaborated with VA medical
centers and actively reached out to providers and professional
associations to build a network. Highlights of our efforts to build a
robust provider network are summarized below.
highlights of health net's choice provider network development
Sent outreach letters to 22,264 TRICARE contracting
entities to encourage providers to register for participation in the VA
Choice Program; these entities represent anywhere from 156,000 to
200,000 community providers
Sent outreach letters to the 7,650 vendors on the VA
Nomination Report that have not yet joined the VA Choice Program
Participated in joint VA Medical Center and Provider
Meetings to encourage key VA Medical Center vendors to register for the
VA Choice Program; as needed, Health Net staff are assisting large
organizations register their multiple locations
Conducted outreach to all 280 VA Affiliates to encourage
participation in the VA Choice Program
Participated in a presentation to the AAMC on the VA
Choice Program; scheduled to participate in calls with AHA and AMA to
present similar information regarding VA Choice Program to their
membership
Contacted all VA Medical Center Hepatitis C preferred
vendors to encourage participation in the VA Choice Program; Health Net
is making outreach calls to all PC3 contracted, VA Choice Participating
and Registered Gastroenterology and Infectious Disease providers to
determine if they treat Hepatitis C patients
Used the American Liver Foundation directory to identify
community providers who treat Hepatitis C patients; all providers not
already eligible for the VA Choice Program will receive telephonic
contact asking them to join the VA Choice Program
In Georgia, our provider network team works closely with the VA
medical centers in VISNs 7 and 8. We have developed an extensive
provider network to meet the needs of Veterans receiving care at the
three VA medical centers in Georgia: Charlie Norwood VA Medical Center
(Augusta); Atlanta VA Health Care System (Decatur); and Carl Vinson VA
Medical Center (Dublin). From January 31, 2015, through July 31, 2015,
our Choice provider network in Georgia grew from 3,084 providers to
5,677 providers--an increase of 84 percent in six months.
Our Choice network in Georgia currently includes 21 hospital
providers, including large health care systems such as Saint Joseph's
Candler Health System (Savannah), Southeast Georgia Health System
(Brunswick), Southern Regional Medical Center (Riverdale), Doctors
Hospital (Augusta), and Coliseum Medical Center (Macon). Through these
large health care systems, we are able to provide access to an even
greater number of physician specialists who are affiliated with these
organizations. Recognizing the high demand for mental health services,
our Choice network also includes dedicated psychiatric hospitals, such
as Southern Crescent Behavioral Health System, Saint Simons by the Sea,
and Summit Ridge Hospital. Provider counts for the top 10 specialties
in our Choice network are shown in the table below.
------------------------------------------------------------------------
Choice Provider Count in
Top 10 Provider Specialties Georgia As of July 31, 2015
------------------------------------------------------------------------
Chiropractic............................. 358
Physical Therapy......................... 344
OB/Gyn................................... 260
Optometry................................ 257
Surgery--Orthopedic...................... 201
Surgery--General......................... 191
Podiatry................................. 181
Cardiovascular Disease................... 173
Ophthalmology............................ 171
Dermatology.............................. 116
------------------------------------------------------------------------
In building the Choice network, we recognize the importance of
collaborating with providers where VA medical centers have established
relationships. For example, we initiated a strong effort to integrate
federally Qualified Health Centers (FQHCs) in our network. We are
working very closely with VHA's Office of Rural Health on this effort,
and participated with VA at the National Rural Health Association
annual conference and National Association of Community Health Centers
webinar. To date, we have been very successful and have contracted 14
FQHCs as Choice providers in Georgia, as shown in the table below.
Federally Qualified Health Centers in Georgia
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Christ Community Health Services J.C. Lewis Primary Health Care Center
Coastal Community Health Services Oakhurst Medical Centers
Community Health Care Systems Palmetto Health Council
Curtis V. Cooper Primary Health care St. Joseph's Mercy Care Services
Diversity Health Center Southside Medical Center
East Georgia Health care Center Southwest Georgia Health care
Four Corners Primary Care centers Valley Health care System
----------------------------------------------------------------------------------------------------------------
increase in choice program utilization--results to date
Since the inception of the Choice Program in November 2014,
workload volume has dramatically increased. In the 37 states that
Health Net supports in Regions 1, 2, and 4, monthly call volume has
grown from an average of 27,000 calls in November 2014 to over 202,000
calls in July 2015. Correspondingly, the monthly volume for appointment
authorizations has grown significantly, from 1,800 authorizations in
November 2014 to almost 29,000 authorizations in July 2015. VISNs 7 and
8 account for about 7 percent of the authorizations.
program challenges and recommendations
Implementation of any new program is challenging, particularly when
the change is significant and the implementation period is condensed
into a very short timeframe. The very limited implementation period for
Choice did not afford VA time to develop necessary policy and process
guides, nor did it allow for us to make needed system changes, develop
business processes and work flows, and effectively hire and train the
number of staff to support a program of this size and complexity. There
clearly have been bumps in the road with the accelerated rollout of
Choice--delays in eligibility information being available, confusion
over program details, and incorrect or sometimes conflicting
information provided to Veterans. These bumps have understandably
caused a level of Veteran frustration. While issues and challenges are
common with the startup of any new program, many of the challenges with
Choice to date are the result of inadequate development (e.g., in terms
of program policies and procedures) and transition time.
While the collaboration with VA since the start of the Choice
Program has been solid, there is still considerable work that needs to
be done with regard to the development of policy and process guides or
manuals. Having clear policies and procedures in place is essential to
ensuring that everyone understands the program requirements--VA staff,
contractor staff, and Veterans. Well-designed program policies and
procedures also ensure consistency across the country. In addition,
more work remains to be done to adequately train staff, conduct
provider outreach, and enhance Veteran education.
There currently are multiple options for non-VA care including
Choice, PC3, local agreements/direct contracts, individual
authorizations (``Fee''), other national contracts (e.g., dialysis),
and Project ARCH. Each option has different reimbursement levels,
different requirements for community providers (e.g., requirements for
return of medical documentation, credentialing, etc.), and different
``administrators'' (VA Medical Center non-VA care staff, VA contracting
staff, PC3/Choice contractors). These various options create enormous
confusion with non-VA (community) providers, Veterans, VA Medical
Center staff, and contractor staff.
We commend this Committee for directing VA to develop a plan for
consolidating all non-VA care programs. Of note, consolidating options
into one approach that minimizes VA-unique requirements for community
providers should have a very positive impact on the willingness of
community providers to participate in Choice and ultimately, enhance
Veterans' access to care. As VA moves forward with the plan, we offer
the following considerations:
1. The consolidated plan and implementation strategy must clearly
define the program and VA policies and procedures.
Adequate Transition Time: Transition timelines must
allow for adequate implementation, staffing, and training.
Clear Program Policies and Manuals: Development of
policy and operations guides or manuals that provide clear
instruction to all parties--VA medical centers, contractors,
Veterans, and Congress--on how the program is to operate, is
essential. For example, such policies and manuals might
address: what services are/are not covered by VA; rules for
eligibility, authorizations, and return of medical
documentation to ensure consistency for Veterans and providers;
reimbursement requirements for proper payment of provider
claims; and systems rules outlining integration between VA and
contractors, security requirements, and details for reporting
requirements.
2. Unnecessary impediments to community provider participation must
be eliminated.
The most common complaint from providers is the administrative
burden of complying with requirements that exceed those of commercial
or even other government programs such as Medicare. Removing these
requirements will remove impediments to provider participation and
offer Veterans greater choice.
Streamline Medical Documentation Requirements:
Medical documentation requirements are not consistent with
commercial/community standards. VA requirements for medical
documentation are often more detailed than the accepted
standard of practice in commercial health care. For example,
PC3 and Choice require specific elements, short timelines, and
provider signatures. VA asks for more documentation and more
specific detail than is typically provided in private sector
health care, such as provider social security numbers. In
addition, many of these requirements are not required for the
other non-VA care programs.
Timely Medical Claims Payment: Delays in payment of
medical claims are often due to issues with the return of
medical documentation. Providers are not paid until medical
documentation is returned and accepted by VA. This delays
payments to providers who have already legitimately provided
the services and complied with the requirements to return
medical documentation. Continued delays in payment will result
in dwindling community provider participation and access
problems could return.
Consistency in Reimbursement: There is a need for a
consistent methodology for the reimbursement rate
determination. The amounts paid to providers should be equal to
the amount paid under the Medicare program. When there is not a
Medicare rate, the payment should follow the state's prevailing
rates instead of VISN- or VA Medical Center-specific rates.
Modifications to Scheduling Process to Reduce No-
Shows: There is a high level of appointment no-shows in the
community. Currently, we are required to schedule appointments
for Veterans we are unable to reach by phone, and then notify
these Veterans of their appointment by mail. This process
increases Veteran no-show rates and causes frustration with
community providers. Community providers have no ability to
bill VA for these no-shows, nor can providers bill the Veteran
a fee. This process also creates frustration for VA Medical
Center staff because Veterans show up for VA appointments that
may have been canceled due to a community appointment being
scheduled through Choice. More importantly, Veterans may not
receive needed care in a timely manner. Modifying this process
would reduce community provider reluctance to participate. We
currently are working with VA on such a modification.
Improve the Process for Follow-Up for Authorizations:
Timely follow-up on requests by community providers for
additional clinically appropriate care is essential. Choice
services are authorized for an ``episode of care.'' Once an
episode of care is complete, additional authorizations are
necessary, even for follow-on care that is normally considered
standard of practice. VA is addressing this issue and progress
has been made already to ensure timely approval of requests for
additional services. We appreciate VA working collaboratively
with us to address this challenge.
committed to veterans' choice
In closing, I would like to thank the Committee for its leadership
in ensuring our Nation's Veterans have prompt access to needed health
care services. We believe there is great potential for the Choice
Program to help VA deliver appropriate, coordinated, and convenient
care to Veterans. We are committed to continuing our collaboration with
VA and TriWest to ensure Choice succeeds in providing Veterans with
timely access to care when VA is unable to provide it. Working
together, and with the support and leadership of this Committee, we are
confident that the Choice Program will deliver on our obligation to
this country's Veterans.
The Chairman. Thank you, Ms. Hoffmeier.
Dr. Jarrard?
STATEMENT OF STEPHEN JARRARD, MD, FACS, GENERAL SURGERY/GENERAL
MEDICINE, LAKEMONT, GEORGIA AND A VETERAN
Dr. Jarrard. Mr. Chairman, Congressman, Mr. Secretary, Mr.
Deputy Under Secretary, Committee staff, and fellow panelists,
thank you for the opportunity to appear before you here today
on behalf of Georgia veterans, one of this great State's most
valuable natural resources.
I feel qualified to provide some input within my scope, as
I am both a health care provider and a veteran. I served in the
Army on active duty as both an infantry officer and then a
surgeon. During my medical school and training, I was always
honored to work in VA medical facilities to include Mountain
Home, TN, and Augusta, GA.
It is an honor to be a veteran, but more of a personal
honor to me to earn their trust, establish a bond with them as
a physician, and help take care of them. As a provider, it is
never a bother to attend to their needs, and I only hope our
Nation never loses that perspective about her sons and
daughters who have sacrificed and served both now and in the
past.
On that note, I would commend the Veterans Administration
for recognizing a problem in the care of our veterans and
coming up with a good program to help solve that problem.
Especially in rural areas, like Rabun County, GA, where I
practice medicine, Veterans Choice gives our veterans good
options to get safe and quality care in a timely manner. Health
Net seems to have good oversight and management and does a good
job coordinating this care and seeing it through to completion,
which is no small task.
Also, tying reimbursement to Medicare rates is not unfair,
and I believe that most providers would want to be a part of
this system and help the VA to care for these veterans. I did
personally find that it was easy to register and become part of
the database and, therefore, to become an option in the
Veterans Choice Program.
I have not yet personally carried an encounter through to
completion, so I cannot speak to those parts. But I look
forward to that and trust that it will be organized and smooth.
I would also commend Health Net, Ms. Hoffmeier, as your
provider information materials have been both useful and
informative.
Many providers and veterans remember a former cumbersome
system in both appointments for veterans and management and
reimbursement for providers. That memory will need to fade and
be proven past.
We would all like it to be better, and I again appreciate
the chance to provide two specific recommendations to that end.
I believe the program could benefit from wider publicity and
efforts to register more providers. This information also needs
to be kept very current for the veterans on the Web site.
When I put my own zip code into the provider search area, I
saw a list of many of my colleagues who really do not know
about the program or their contact information is out of date
or not correct. More effort should be made to publicize through
provider channels, such as State medical associations,
specialty organizations, and even county medical societies. And
I will pledge to do this through our own local Stephens and
Rabun County Medical Society. I consider it a patriotic duty to
help with this program, and I know that many of my Georgia
medical colleagues would regard it the same way if they knew
more about it.
Another thing I think would help is to recognize those
providers who have stepped up and accepted the Veterans Choice
responsibility and are actively participating and caring for
veterans under this program. Perhaps some kind of recognition
symbol or logo that they could publicize in their own marketing
materials or on their social media outlets.
This should be something that veterans could easily
identify with and look for to know that this provider is
approved by the VA and could be an option in their spectrum of
care should they need it or if they just feel more comfortable
staying closer to home and having a more local provider.
Again, sir, it is an honor to have the opportunity to
participate in this valuable discussion regarding the care of
our veterans. As they in their past and current service
represent the strength of our national fiber, none of us deny
the priority they deserve, and it is a privilege to still serve
by assisting on their health care team.
Thank you very much. [Applause.]
[The prepared statement of Dr. Jarrard follows:]
Prepared Statement of Stephen Jarrard, MD FACS, General Surgery/General
Medicine, Lakemont, Georgia
Mr. Chairman, Congressman, Mr. Secretary, Mr. Deputy Under
Secretary, Committee Staff, and Fellow Panelists, Thank you for the
opportunity to appear before you here today on behalf of Georgia
Veterans--one of this Great State's most valuable natural resources. I
feel qualified to provide some input, within my scope, as I am both a
Healthcare Provider and a Veteran. I served in the Army on Active Duty
as both an Infantry Officer and then a Surgeon. During my Medical
Schooling and Training, I was always honored to work in VA Medical
Facilities, to include Mountain Home, TN and Augusta, GA. It is an
honor to be a Veteran, but more of a personal honor to earn their
trust, establish a bond with them as a Physician, and take care of
them. I consider them my brothers and sisters, and therefore they are
family. It is never a bother to attend to their needs--and I only hope
our Nation never loses that perspective about her Sons and Daughters
who have sacrificed and served both now and in the past.
On that note, I would commend the Veteran's Administration for
recognizing a problem in the care of our Veterans and coming up with a
good program to help solve that problem. Especially in rural areas,
like Rabun County, GA where I practice medicine--Veteran's Choice gives
our Veterans good options to get safe and quality care in a timely
manner. Health Net seems to have good oversight and management, and
does a good job coordinating this care and seeing it through to
completion--no small task. Also, tying reimbursement to Medicare rates
is not unfair, and I believe most providers would want to be a part of
this system and help the VA to care for these Veterans. I did
personally find that it was easy to register and become part of the
database and therefore to become an option in the Veteran's Choice
program. I have not yet personally carried an encounter through to
completion, so I cannot speak as much about ease of use, but I look
forward to that and trust it will be organized and smooth. I would also
commend Health Net, Ms. Hoffmeier, as your Provider information
materials have been very useful and informative.
However, we would all like it to be better, and I again appreciate
the chance to provide two specific recommendations to that end.
I believe that the program could benefit from wider publicity and
efforts to register more providers. This information also needs to be
kept current. When I put my own zip code into the provider search
area--I saw a list of many of my colleagues who don't really know about
the program, or their contact information was out of date or not
correct. More efforts to should be made to publicize through provider
channels such as State Medical Associations, Specialty Organizations,
and even County Medical Societies (and I will do so through our local
Stephens-Rabun County Medical Society). I consider it a patriotic duty
to help with this program, and I know many of my Georgia medical
colleagues would regard it the same way if they knew more about it.
Another thing that I think would help is to recognize those
providers who have accepted the Veteran's Choice responsibility and are
actively participating and caring for Veterans under this program.
Perhaps some kind of recognition symbol or ``logo'' they could
publicize in their own marketing materials or social media outlets.
This should be something that Veterans could identify with and look for
to know that this provider is ``approved by the VA'' and could be an
option in their spectrum of care should they need it or if they just
feel more comfortable staying closer to home and having a local
provider.
Again, Sir, it is an honor to have the opportunity to participate
in this valuable discussion regarding the care of our Veterans. As they
and their past and current service represent the strength of our
National fiber--none of us deny the priority they deserve and it is a
privilege to still serve by assisting in their health care. Thank you
very much.
The Chairman. Thank you.
Dr. Williams?
STATEMENT OF WAYMAN DUANE WILLIAMS, GEORGIA LEADERSHIP FELLOW,
IRAQ AND AFGHANISTAN VETERANS OF AMERICA
Dr. Williams. Chairman Isakson, Congressman Collins, on
behalf of Iraq and Afghanistan Veterans of America and our
nearly 400,000 members and supporters, over 11,000 of whom
reside in Georgia, I want to thank you for this opportunity to
share our views with you today. IAVA was one of the leading
veterans organizations involved in the early negotiations on
the VACAA, and we took an active role in advocating for its
passage.
My remarks will focus on where we have been, where we are,
and where we are going with the Choice Program based on the
experiences of those using the Choice Program in Georgia. The
general information and personal experiences I would like to
present were gathered through a combination of: (a) recent data
reported by the Atlanta VA medical center; (b) preliminary
analysis of member responses to the IAVA national member
survey; and (c) my own personal interactions with local IAVA
members.
The population of veterans enrolling for VA care is growing
quickly, as you know, and Georgia is no different. This growth
comes with a huge increase in demand, and I would rather go
with numbers rather than percentages. In 2014, the Atlanta VA
ended the year having seen 96,000 patients. But by the time we
got to 15 July, the Atlanta VA had seen 100,000 patients.
By comparison, most other VA medical centers service 50,000
to 60,000 veterans a year. Most VA health providers serve 1,200
patients annually. But here in north Georgia at the Atlanta VA,
our physicians and nurse practitioners and PAs are seeing 1,300
to 1,400 patients annually. Thus, our concern in Georgia is
that we must have both specialty and primary care providers to
match this population growth, especially our female veterans.
The Choice Program can be a great boost to providing this
support with proper foundation and education. The Atlanta VA
medical center is referring correctly to Choice, and right now
there are over 35,000 veterans who can not be seen inside of 30
days, but they have been referred to the Choice Program.
Even before the Choice Program came to fruition, the VA
experienced challenges with meeting the demand for health care.
The three VA medical centers in Georgia have made significant
improvements over the past 3 years in improving customer
service, thanks in large part to changes in local leadership. I
would like to commend Ms. Leslie Wiggins, our Atlanta VA
medical center director, who has been particularly responsive
in holding employees accountable.
But we understand work needs to be done. We are at a point
where access to care and customer service really do have to be
differentiated.
Preliminary analysis of IAVA's most recent member surveys
show that on a national level, 54 percent of the respondents
still do not know what Choice is; 95 percent of those
respondents have never used a Choice card; 43 percent indicated
that one of the reasons for not using the Choice card was
because they do not know how to use it; and of the 5 percent of
the respondents who did use the Choice card, 40 percent of them
had a very negative experience.
In my personal interaction with local IAVA members, I have
found that those who were able to use the Choice card were very
happy. However, the program has been challenging for some
veterans to successfully use. I would like to highlight the
experience of one recently demobilized Army Reserve veteran and
her frustration with trying to use the Choice Program for an
orthopedic problem that required an orthopedic consultation.
The consultation was ordered by her primary care provider
in April, and the Atlanta VA did not have any available
appointments until August, thus making her eligible for use of
the Choice Program. But then over 2 months and six calls to the
Choice appointment line and one call to the local VA OEF
coordinator and finally the call to the Choice Program manager,
they said they just could not get authorization for her to be
seen.
The end result was that she saw an orthopedic surgeon at
the Atlanta VA on Monday. Her response to me at the end was,
``I give up on Choice.''
Based on the observations, I would like to make a few
recommendations that the Congress and the VA should consider in
order to get the program operating at its fullest potential.
Those recommendations include strengthening the training for
the Choice Program for all parties involved. For VA employees,
such as the non-VA care coordinators who are primarily
interacting with the veterans seeking care and the contract
care provider, provide the referral technology training so that
they have hassle free scheduling.
Finally, I recommend that there be some sort of reviewing
and streamlining of the operational process by which the Choice
Program is implemented. We understand that this is a new
program, and the change in VA culture to a more veteran-
centered care is highly welcome. Contracted care for our
veterans must also keep the veteran at this center-of-service
philosophy.
IAVA is committed to remaining actively engaged with
veterans making use of the Choice Program and advocating for
the best access to care for our veterans. This includes but is
not limited to IAVA's role in consolidation of the numerous
care in the community programs into one simple and easy to
understand program, as mandated by the law.
We appreciate the hard work of Congress. We appreciate the
hard work of our VA and our partners in the veterans community,
and we understand that we will continue to work together for
the success of this program.
Mr. Chairman, I sincerely appreciate the Veterans' Affairs
Committee's work on this issue and your invitation to us to
participate in this, and we stand ready to assist the Congress
and the department to achieve the best results for health care
for our veterans.
Thank you for your time and attention, and I will be happy
to answer questions.
[The prepared statement of Dr. Williams follows:]
Prepared Statement of Wayman Duane Williams, Georgia Leadership Fellow,
Iraq and Afghanistan Veterans of America
Chairman Isakson, Ranking Member Blumenthal, and Distinguished
Members of the Committee: On behalf of Iraq and Afghanistan Veterans of
America (IAVA) and our nearly 400,000 members and supporters, over
11,000 of whom reside in Georgia, thank you for the opportunity to
share our views with you at today's hearing The Veterans Choice
Program: Are Problems in Georgia Indicative of a National Problem.
IAVA was one of the leading veterans organizations involved in the
early negotiations on the Veterans Access to Choice and Accountability
Act (VACAA) and took an active role in advocating for its passage. This
is a highly complex law that the Department of Veterans Affairs (VA) is
continuing to effectively implement in order to ensure veterans are not
left waiting unacceptable lengths of time to receive health care
services.
My remarks will focus on where we've been, where we are currently,
and where we're going with the Choice Program based on several
experiences of those utilizing the VA Choice Program in Georgia. The
general information and personal experiences I would like to present
were gathered through a combination of recent data reported by the
Atlanta VA Medical Center to the medical center veteran advisory board
on July 15, 2015, preliminary analysis of member responses to the IAVA
national member survey, and my own personal interactions with local
IAVA members.
The population of veterans enrolling in VA medical centers is
quickly growing, and in Georgia this is no different. With this growth
comes increased demand and this is challenging capacity. The Atlanta VA
Medical Center is particularly fast growing: FY 2014 ended with a total
enrollment of 96,000 unique veterans with chronic care problems, and by
July 15, 2015 this same type of enrollment was at 100,000. Most VA
medical centers provide service to 50,000 to 60,000 veterans with
chronic care problems and most VA health providers serve 1200 patients
annually, but the North Georgia VA providers see 1,300 to 1,400
patients. Thus our concern in Georgia is that we must have both
specialty and primary care providers to match this population growth.
The Choice Program can be a great boost to providing this support with
the proper foundation and education to properly. However, according to
the August 18, 2015 report provided to the Medical Center Veterans
Advisory Board by the Atlanta VA Medical Center's quality management
team, there are 35,000 veterans waiting for longer than 30 days for
either a Choice provider or their VA appointment.
Even before the Choice Program came to fruition, the VA experienced
challenges with meeting capacity and providing customer service at the
same time. The three VA medical centers in Georgia have made
significant improvements over the past three years in improving
customer service thanks in large part to changes in local leadership.
Leslie Wiggins, the Medical Center Director of the Atlanta VA Medical
Center, has been particularly responsive in holding employees
accountable, but work remains to be done. We are at a point where
access to care and customer service cannot be confused.
Preliminary analysis of IAVA's most recent member survey shows that
on a national level, fifty-four percent of the respondents still do not
know about the Choice program, ninety-five percent of respondents have
never used a Choice card, and nearly half (forty-three percent)
indicated that one of the reasons for not using a Choice card was
because they did not know how to use it. Of the 5 percent of
respondents who did use the Choice program, 40 percent had a negative
or very negative experience.
In my personal interactions with local IAVA members, I found that
those who were able to use the Choice Program were happy with the
service. However, the program has been challenging for some veterans to
successfully utilize. I would like to highlight one particular
experience of a recently demobilized Army Reserve veteran and her
frustrations utilizing the Atlanta VA Medical Center and Choice Program
for a joint concern that required orthopedic consultation. The
consultation was ordered by her primary care provider in April, but the
Atlanta VA Medical Center did not have any available appointments until
August, thus making her eligible to use the Choice Program. Over the
course of two months and six calls to the Choice Program appointment
line and one call to the local VA OEF Coordinator, no record of the
consultation could be found in the system. The end result of her calls
was a recommendation from a Choice Program manager to maintain her mid-
August appointment at the Atlanta VA Medical Center. Her response to me
at the end of describing this process was, ``I give up on Choice.''
Based on the experiences I've witnessed in Georgia, I would like to
make a few recommendations that Congress and the VA should consider in
order to get the program operating at its fullest potential. These
recommendations include: strengthening the training for the Choice
Program for all parties involved, to include providing clear and
concise information to each veteran eligible for the Choice Program on
how to utilize the Choice services, to VA employees such as the Non-VA
Care Coordinators who are primarily interacting the veterans seeking
care and the contracted-care provider and their network to ensure
hassle-free scheduling. Additionally, I recommend reviewing the
operational process by which the Choice Program is implemented for each
veteran to ensure a streamlined and timely delivery of care with a
defined point of contact and customer service support system that
veterans can use to resolve issues with scheduling appointments.
This is a new program, and the change in VA culture to more
veteran-centered care is a new, and welcome, focus. Contracted care of
our veterans must also keep the veteran at the center of their service
philosophy. IAVA is committed to remaining actively engaged with
veterans making use of the Choice Program and advocating for the best
access to care for those veterans. This includes, but is not limited
to, IAVAs role in the consolidation of the numerous Care in the
Community programs into one simple and easy to understand program
mandated by law.
We appreciate the hard work of Congress, the VA, and our partners
in the veteran community. We must continue to work together and keep
all communication active between all stakeholders.
Mr. Chairman, I sincerely appreciate the Veterans' Affairs
Committee's hard work in this area, your invitation to all us to
participate in this important hearing, and we stand ready to assist
both Congress and VA Secretary Bob McDonald to achieve the best results
for the Choice Program now, and in the future.
Thank you for your time and attention, I am happy to answer any
questions you may have.
The Chairman. Thank you, Dr. Williams.
Mr. Chacha?
STATEMENT OF CARLOS F. CHACHA, SFC USA (RET), VETERAN
Mr. Chacha. Thank you, Mr. Chairman. Mr. Chairman,
Honorable Doug Collins, thank you for allowing me to speak.
I like Choice. I want to tell you when I got the little
card that said Choice, I said, ``Wow, I can go to my doctor
next door, down the street in 10 to 15 minutes and I will be
good.'' Came to find out that is not a fact.
Choice is a good program. What I found out, based on my
experience with Choice and dealing with Choice, is that,
basically, the right hand does not talk to the left hand.
Somebody got a dog and pony show, and we are better off. Simple
as that.
I understand--I think they have got three different
databases. You got the people who you call--and they had a
number--and ask for an appointment. They are located in one
part of the United States. Then you have somebody who will make
an appointment, in my case, for a rheumatologist, someplace in
Kansas City, another place, another State. Then, if I want a
colonoscopy, that will be in another State.
Their system, their database, does not talk with each
other. If I called Choice right now and I say, ``I need to know
when is my appointment for a rheumatologist,'' they might be
able to tell me. But if I say, ``I need to know when my
colonoscopy is going to happen,'' they need to go to another
database or I need to talk to somebody else.
It is frustrating. It frustrates me as a person that I had
to call, and the person at the other end either is not properly
trained, or they do not care about us. I had to ask to talk to
a supervisor. I talked to a supervisor who told me I am not
authorized to have a colonoscopy, even though my primary care
doctor sent a request to Choice, and they receive it in Choice
in April 2015.
It seems to me that some of the papers get lost because 1
minute, they have everything they need. They have got the
authorization from the VA. They have got the doctor's name, and
everything is good. The next minute, they can not find
authorization, and we have to start all over again. We are
reinventing the wheel.
We do not need to do that. We need to have one system, and
everybody needs to be properly trained. We need to have
managers and supervisors that care. I have found three people
that I was able to talk to, and they cared for us. The rest of
the people, in the seven or eight times I talked to them--they
really did not care about me--as simple as that. I was just a
number.
It took me almost 4\1/2\ months to finally get my
rheumatologist appointment. It was this week. I am going to see
a doctor for a colonoscopy the 31st of this month. The paper
was submitted on April 30, and now we are in August. So, I am
just now getting those appointments.
You might not believe it, but the only reason I am getting
those appointments is because I stir up congressional. Why do I
need to stir up congressional for something that is supposed to
be there for us? [Applause.]
We put ourselves out there for everybody here to be a free
person. I did my time. Now it is time for me to get it back.
Please just get one database, one--and better training.
Thank you, Mr. Chairman. I appreciate your help.
[The prepared statement of Mr. Chacha follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Well, thank you for your personal story. I
would ask, were all of your attempts to make those appointments
through Health Net?
Mr. Chacha. Yes, sir, the 1-800 number.
The Chairman. I would like to ask Ms. Hoffmeier: Can you
address what he just said?
Ms. Hoffmeier. Mr. Chairman, as I said, we know that there
have been challenges from the beginning, and I have gone
through and seen some of the input on his record, only when we
discovered the case just this week. Some of it is based on the
eligibility process that we discussed, so we can only authorize
care for cases where we actually have the eligibility
information and a consult, and then a contact by the veteran.
But then there are also--I mean, I will not make excuses
for mistakes. There have been a number of mistakes made. There
is no question. I completely agree with the recommendation for
adequate training, which was one of the comments I made in my
testimony.
The challenge that we have had is there have been so many
changes made so quickly that we are retraining our staff every
week. You can not expect there not to be mistakes when rules
are changed almost on a weekly basis and we have to retrain and
ensure we have everything in our scripts within the system.
Staff are supposed to follow the scripts. But when the process
is modified frequently, the reality is it is hard to keep the
training up to date.
We are addressing a number of the specific concerns. I
would like to mention some of the improvements we are making to
address a couple of the things that Mr. Chacha mentioned, which
is the regional nature of our appointing process.
We are in the process--we had used for the patients in our
community care program an approach we referred to as regional
pods. We had a team that was dedicated to each VISN so they got
to know that area, and they made all the appointments for that
area. Choice has grown so fast that we have not had the time to
put the pods in place. We are moving to that model; it will
take time with the volume that we are seeing with Choice.
We also are opening operational centers throughout our
regions. We do have a number of locations throughout our
regions already, but earlier this week, I visited one in VISN 8
we are building and looking to staff; it will include a
significant staff in VISN 8. We will end up with staff that are
dedicated to each VISN that will get to know the specific
geography, the providers in that VISN, and that should help
facilitate the process considerably.
We also are putting more nurses up front so that we have
nurses looking at the authorizations right off the bat. One of
the things that is a challenge is that not every consult looks
the same. Sometimes, with the consults that we receive, it
takes a lot of work to go through the consult and figure out
what exactly is required--what service is required.
For the more complex consults, we are having nurses review
them to try to make sure that we can clearly identify what is
needed up front, and that will get the process started more
quickly. For the rheumatology issue, I can tell you I know part
of the problem was provider acceptance. I think I talked about
this at the May hearing in Washington. It is a new program,
which we have had a lot of hesitation by community providers,
particularly the harder to find specialties.
It is a new program. As the secretary testified, there are
so many options right now with VA that providers can
participate in. There are direct authorizations, local
agreements, there is Choice, there is PC3, there is ARCH, and
providers are very confused. They are picking and choosing
which program they participate in, and certain specialists have
said, ``We are going to wait and see how Choice works before we
sign up.'' So, we did have some problems getting
rheumatologists on board.
All of those are items that we categorize; and we meet
every day to work through each of these issues. As a veteran
myself, I do not like hearing these problems any more than
anybody else in this room does. But, it is an unfortunate
reality of an extremely aggressive timeline that has not
provided ample time for training.
The Chairman. You know, listening to Mr. Chacha, I was
reminded of my youth. My father believed in corporal
punishment, and I can always remember right before I got a
spanking, he said, ``Now let this be a learning experience to
you.'' I did not get nearly as many spankings after that, I can
tell you.
Your story should be a learning experience, both for
Secretary McDonald as well as Health Net as well as Congressman
Collins and myself. Really, that amount of time, that amount of
misdirection, that amount of disconnect really should not
happen.
Now, you are correct in some of the reasons why it
happened. We are fixing the Choice Program on the run. But,
really, there ought to be a way to learn from your experience
to fix those problems that exist within the system so the
veterans do not go through this frustration.
By example, you said one of your difficulties is
establishing eligibility. Right?
Ms. Hoffmeier. We do not establish eligibility.
The Chairman. No, no--finding out if they are eligible or
not.
Ms. Hoffmeier. Right.
The Chairman. How do you find that out right now?
Ms. Hoffmeier. Currently the process is that VA transmits a
file to us. It is a very large file, and we get the file at
different timings. So, we receive mileage eligible veteran
files on a weekly basis and wait list eligible veterans on a
daily basis----
The Chairman. Let me interrupt. So, everybody in the
audience--the mileage is 40 miles or more out?
Ms. Hoffmeier. Correct.
The Chairman. You got a verification on that, number 1,
right?
Ms. Hoffmeier. Yes, sir.
The Chairman. The timing is 30 days or more delay for the
appointment. Is that correct?
Ms. Hoffmeier. The wait list, yes.
The Chairman. Now beyond that, what other eligibility
requirements do you have to have?
Ms. Hoffmeier. Those are the eligibility requirements for
Choice. What we have to get is the eligibility information from
VA that is passed to us in these files.
The process involves first the VA medical center uploading
this information somewhere internally at VA. Then there is a
different office at VA that takes that information and then
transmits it to us.
The Chairman. But why would it--excuse me for interrupting.
But why would it take a file this thick--that was your
reference--to determine whether somebody lived 40 miles or more
away from a clinic or could not get an appointment within 30
days?
Ms. Hoffmeier. The eligibility file just comes to us from
VA. The reason that file is so significant--it is records from
across all of our regions. So, it is not for one individual.
That is all of the veterans in our region. VA provides us with
updates in these files. It is all transmitted electronically to
us.
That is one of the improvements that VA is working on right
now, which we are very excited about, to be honest, because one
of the things that has been a real challenge for even the VA
medical centers to understand. The VA medical centers have a
very, very good source of information--they call it the VA
Viewer--that provides simple, easy to follow information on
what the veteran is eligible for, what care they need.
We do not have access to that. So, instead, it goes through
this complicated process. This new process that is being put in
place by VA will include not giving us access to the Viewer,
but sharing that information with us directly from the VA
medical center level, so we get it almost in real time.
It is being rolled out in phases, so VA is starting first
with a subset of veterans that are eligible, because they need
to do some system reconfiguration in order to make it work, and
we need to also be able to test it. We have started that,
actually. I think that will make a huge difference in what I
call the runaround.
I mean, it has been a runaround in many cases for veterans,
because they will call us, and we do not have the eligibility
information. By contract, we cannot do anything without that
information.
The Chairman. Well, this story is one of the reasons we
have hearings exactly like this so we can find out the real
story about what is going on out there. Now I have got to ask
you this. If I heard Mr. Chacha correctly, the referral he got
from Health Net for rheumatology was a rheumatologist in Kansas
City. Is that right?
Mr. Chacha. No. The person who was handling my
rheumatology----
The Chairman. They lived in Kansas City.
Mr. Chacha. They were in Kansas City.
The Chairman. But the rheumatologist was in Georgia.
Mr. Chacha. Yes.
The Chairman. Well, that is good. I was really worried you
were getting referred to Kansas City.
Mr. Chacha. No, no.
The Chairman. Dr. Jarrard, let me ask you a question. You
said you have not completed your first consult. Is that right?
Dr. Jarrard. That is correct.
The Chairman. So, you have not been reimbursed by VA for
any services you offered under Choice. Right?
Dr. Jarrard. Not yet, sir.
The Chairman. Are you aware that under Choice, it is the
secondary payor if there is any other insurance coverage, and
your veteran would have to pay a copayment when you saw him?
Dr. Jarrard. Yes, sir. As I said, the Health Net
information is very adequate and thorough. I was aware that if
the other insurance is primary, there may be a copay according
to whatever that insurance company requires for that visit.
The Chairman. As a physician and as a veteran, would you
think it was a disincentive to use Choice if you knew you could
go to the Clairmont Hospital and get it paid for through
regular VA payment without a copayment, but if you got referred
within Choice, you would have to make a copayment and you would
be secondary?
Dr. Jarrard. Yes, sir. But I think you would have to figure
out the amount of time it may take you to get seen at that VA
facility, and some veterans may feel that way. But, in general,
I would say the answer to your question is yes.
The Chairman. Well, that is a great way that you answered
the question. I commend you on that answer, because the
circumstances do dictate. I mean, if you are in emergency care
or you are ill, you are going to go wherever you can get the
service, and that is going to dictate the situation. If you
have some flexibility, it might be different.
But one of the reasons I brought it up--we have been
talking with Secretary McDonald and his staff--when we passed
the Choice Act we created some unintended consequences.
Right, Secretary McDonald?
Secretary McDonald. Yes, sir.
The Chairman. One of them is the one I just illuminated,
where there are different sets of circumstances for the
physician to be reimbursed, depending on which avenue they
attract in terms of services, which is a problem the veteran
should not have to worry about, quite frankly, in my judgment.
So, I wanted to bring that out.
The last thing I want to ask you as a practitioner--and I
do have a place in Rabun County, yet I hope I do not ever need
to see you, but if I do, I am glad that we met under good
circumstances.
Dr. Jarrard. Yes, sir.
The Chairman. But if I needed to see you, and I made an
appointment for next Monday, and I did not show, would you bill
me for not showing? Or do you have a 24 hour notice, or do you
have a fine for not showing? Tell me what your practice is.
Dr. Jarrard. Well, sir, my personal philosophy on that as a
practitioner in Rabun County is I would never do that to my
people, regardless. But under the Health Net rules----
The Chairman. I am going to come see you. [Laughter.]
Dr. Jarrard [continuing]. Under the Health Net rules, that
is disallowed, meaning no veteran can be charged for a missed
appointment, nor can the VA or Health Net be charged for a
missed appointment.
The Chairman. Well, the reason I bring it up--we are
looking at an omnibus approach to solving some of the technical
problems with Choice and VA health care. Some of the ones we
have already talked about--some tweaks that need to be done one
way or another. But, you know, in the private sector--one of
the problems in getting doctors to participate in Choice is
that if you can not be reimbursed when somebody does not show,
or you can not have a penalty for somebody not showing, then it
costs them money to have an appointment unfilled that they made
24 hours out.
Would it be unreasonable if somebody used Choice to make
sure the veteran understood that if they made the appointment
and did not show, there would be a $35 fee for not showing?
Does that bring about more accountability on the veterans, from
the veterans' standpoint? I am asking you tough questions, I
know.
Dr. Jarrard. It possibly could, as long as they were
informed ahead of time and knew that. Where you will see most
of those policies about charging for no-show appointments is in
urban areas. Doctors are very busy. They have a full schedule.
If someone no-shows without prior notice, that slot could have
been filled by someone else that is waiting longer to get an
appointment.
In your rural areas where these veterans are most likely to
live, out away from the VA medical center or the VA clinic, you
do not find those policies as much. But, I would only say that
that was fair if veterans knew ahead of time that that was the
policy, and that they would be willing to take that risk. Now,
I believe--and I want this to become a really good thing.
And, sir, I am sorry for the experience that you had.
Mr. Chacha. I understand.
Dr. Jarrard. I am glad we are here today to talk about it,
to get it fixed.
I want this to be such that that veteran is so happy to get
that appointment and to get some care under the system that
they would not want to be a no-show. I believe that most of
them would be grateful. That was my experience working in VA
medical centers in various places in the country while in
training, that it was very pleasant that the veterans that you
took care of were always grateful.
That is something you do not always see. It is like money
in your pocket when that happens. It is like extra pay.
The Chairman. Absolutely. It is very rewarding.
Dr. Jarrard. I hope that happens.
The Chairman. After all they have sacrificed for us, the
least we can do is provide the best quality service to them.
Dr. Williams, thank you for mentioning women veterans. You
know, it is ironic--I was sitting here thinking when you did
that--people are forgetting that pretty soon, women veterans
are going to be 10.2 percent of those eligible for VA health
care, and it is growing dramatically because of Afghanistan and
Iraq. Today, two female Rangers are being inducted in the U.S.
Army at Fort Benning, which is indicative of what is happening
to our military.
I appreciate your standing--and one of the things I have
said as chairman of the Committee is I want to make sure that
we look forward in the future, understanding that our clientele
in terms of veterans health services is going to change. There
needs to be a focus on all services and on services that are
particular to women and particular to men. Your advocacy is
very much appreciated.
You said 54 percent of your members do not know about
Veterans Choice. Right?
Dr. Williams. Yes, sir. According to the survey, that is
what we got back. It was a little surprising to us, but it is
what it is.
The Chairman. Well, everybody that has testified has
referred to a lack of clear understanding on who is eligible
and who is not, and there are an awful lot of veterans who have
told us one way or another that when they try to find out, it
is very cumbersome and very difficult.
Your organization has done a great job of sending us a lot
of things we ought to do that are very well thought up and we
have done some of them. I would hope your organization would
think outside of the box and be a voluntary resource for me and
the Committee to make recommendations to us about how we could
better communicate from the VA to the veterans on what Choice
is, whether or not they are eligible, and make it in a seamless
way that would make it easier for them, because 54 percent is
inexcusable.
We have implemented a very large and very comprehensive
program in a very short period of time. But we did it to make
it easier for the veteran. If 54 percent do not even know about
it, then we are not doing our job. There ought to be some
better way that we can reach the veteran. The VSOs can be an
important help in doing exactly that. So, I appreciate your
testimony very much. Work on that as a project for me if you
would.
Dr. Williams. Yes, sir.
The Chairman. Mr. Chacha, you have got a colonoscopy coming
up?
Mr. Chacha. Yes, sir.
The Chairman. It is worth waiting for, I will tell you.
[Laughter.]
That is one thing you can delay as long as you want to.
Mr. Chacha. That is right.
The Chairman. I am just teasing.
Mr. Chacha. Mr. Chairman, if I may, can I touch on one
point?
The Chairman. Please.
Mr. Chacha. I know some people are going to be upset about
this, but----
The Chairman. Speak closely into the microphone.
Mr. Chacha. Some people might get upset about what I am
going to say, but the facts are the facts. I talked to a couple
of doctors, trying to find one to be my doctor, like a
rheumatologist or a GI, so I can go get my colonoscopy.
They explained to me the reason why they would not accept
somebody from Choice or the VA, although this is hearsay, what
I was told from these physicians and from these offices was
because the VA is taking 6 months to 1 year to pay the doctors
for seeing a veteran. Now they are turning--anybody that has
anything to do with the VA, they turn away because they are
afraid they are not going to get paid and they cannot stay in
business.
The Chairman. Well, I am glad that you mentioned that,
because we all--I see some nodding heads from some of the
professionals in the room. Prompt payment is a problem, and if
there is any--I know the secretary is here and some other folks
from the VA. The more reliable the reimbursement system for the
veterans is, the more doctors are going to want to participate
in it. I think that is a good point to make.
I do not know that we have a longitudinal--enough time yet
in the program to know if that is endemic to the program or if
it is just an anomaly. But that is something that is going to
expand our--I guess Ms. Hoffmeier might agree with that. Am I
correct?
Ms. Hoffmeier. That is one of the top reasons we hear from
providers for not participating in Choice--that they have had
experiences in the past that have been less than positive with
being reimbursed. We are paying the Choice providers for the
care, but it does take time to rebuild that confidence that
they will be paid in a timely manner.
VA is doing a great job of working collaboratively, though,
with us to address that. So, when we hear that from providers,
we work it through our VA contacts, who are working to try to--
you know, if there are still outstanding bills, to get those
bills resolved and to improve that perception of payment. That
really is a very important point.
I would like to comment on the no-show issue. That is
another significant issue we hear, and it may be the urban
providers, as Dr. Jarrard mentioned, but it is an issue with a
number of them, because right now, unfortunately, the way it is
structured, we are not allowed to call veterans. Veterans must
call us to initiate the appointment.
Once we schedule the appointment, we follow up with the
veteran to let the veteran know they have an appointment. If we
cannot reach the veteran, we are required by our contract to
send them a letter telling them when their appointment is
scheduled to occur.
What we are finding is that there is a high volume of no-
shows because we are not actually reaching the veteran live. We
are sending a letter. VA is working to change that as well, and
I think once we get that process changed, that will reduce the
number of no-shows and it may become less of a problem. But
today, it is a problem for provider participation.
The Chairman. Thank you very much.
Congressman Collins?
Mr. Collins. Mr. Chacha, you wanted to follow up very
quickly?
Mr. Chacha. Yes. When they are talking about the
appointments, appointments are made by Choice, and I have been
told by Choice that they cannot call my house and leave me a
message in my voice mail because of HIPAA or something like
that. They cannot tell me----
The Chairman. Because of HIPAA?
Mr. Chacha. Yes, sir. They use that for everything.
The Chairman. You can blame Congress on that.
Mr. Chacha. I mean, I just answer the questions, OK. But
that is what I have been told. I missed two appointments with
my rheumatologist because the appointments were made and I was
never contacted about it.
The Chairman. That seems like a solvable problem, having
recently gone to a physician and signing a HIPAA release on
whether they could call and leave a message on my voice mail.
Could there be some procedure when you sign up to become
eligible for VA health care that there would be a sign-off
where they could give the authorization to leave a message on a
voice mail or with another party? I am kind of directing this
to some of the VA staff. We ought to look at that.
Secretary McDonald. There is, Mr. Chairman. But the
question is about how pervasive can that be. In other words,
would you do it once and have a particular--the way HIPAA is
written--and we can work together on this--is that it has to be
very, very specific to an instance. But, you know, again, it is
law so we would have to change the law.
The Chairman. I told you it was a congressional problem.
Maybe we will make it an opt-in versus an opt-out type of
situation. Excuse me for interrupting. Go ahead.
Secretary McDonald. Something to make it easier for the
veteran.
The Chairman. Right.
Mr. Collins. I appreciate the chairman talking about that,
because I just left a doctor and I had to sign a who could be
notified form, which stays in my file. I mean, it is for my
doctor, my general practitioner. So, I am not sure that there
is that much limitation in it. You can actually do that. It is
something we can work on.
Secretary McDonald. We are talking about different
providers here.
Mr. Collins. Yes, different providers. We could get a
signature for different things. I mean, it is a signature.
I want to start positive. My mom always told me to start
positive. I have been sitting here, frankly, a little
frustrated.
Dr. Jarrard is one who serves in the 9th District. But
also, for those who may not know, he takes not only his medical
practice seriously, but his commitment to his education. He
serves on my Academy Board and helps put young men and young
women into our academies, which over and above any time that he
gives in service, not only to the medical community, but to the
Academy Board. I wanted to say thank you for what you do. We
have got a lot of good folks going in, and you are a big part
of that.
Dr. Williams, as well, from my service, in that what you
are doing is providing the missing link that is discussed a
lot, but I think it is almost like that storm, Mr. Chairman,
coming. We know the storm is coming with Iraq and Afghanistan
veterans and others that may in the near future; we are talking
about it. It is a good conversation, but we have got a lot of
instructional internal problems that are going to have to be
fixed in this regard.
Mr. Chacha, of course, is from my area, and we have been
working on your case, which, unfortunately, you have made my
classic case--why did you have to call me to get this solved?
Mainly because of the many, many days that you had to wait,
which leads me to a question that the chairman brought up.
I do not mean to be--I am just asking a question. Ms.
Hoffmeier, I do not believe you answered the chairman's
question. He said there were two eligibility issues, to which
you talked about files being sent over, and that they are this
thick, or they--that is a whole different line--but there are
two basic eligibilities for Choice. Why is that so difficult?
I apologize, but if you are going to tell me about file
transfer again, just say, ``You know, I really do not have a
good answer.''
Ms. Hoffmeier. No, the simple answer--and I apologize if I
did not express it clearly--is we must have confirmation from
VA of the eligibility. We do not determine the eligibility. I
understand what the rules are very clearly, the two types of
eligibility. But if we do not have something from VA that shows
us that veteran is authorized under one of those two
eligibility categories, we are not allowed to act on that.
Mr. Collins. So, I may have asked the question--and the
chairman or whoever may say this is--when VA reaches out to
you, they are asking for you to give an appointment. They
should have already researched eligibility requirements and
never called you unless they have determined eligibility.
[Applause.]
I am wondering--are we getting stuck semantically here? I
am beginning to wonder. I appreciate what you are trying to do,
but I am not sure why VA would even send you a file if they
were not eligible for Choice.
Ms. Hoffmeier. Well, I think part of it is you have to go
back to--first off, I think the chairman, or maybe it was even
you--mentioned early on at the very beginning that almost 9
million cards were sent out. The vast majority of the veterans
were not eligible for the program.
Mr. Collins. I apologize for interrupting, but please hear
me because I am really trying to understand this. Can VA just
send Health Net--and the secretary or somebody else maybe might
have to help, and I apologize--can they just send you any
veteran's file? Yes or no? Because if I went into the system,
if I took my DD214 and I went into the system, can they just
send----
Ms. Hoffmeier. The whole file?
Mr. Collins. Send the file for any reason, for whatever?
Can they just say, ``You know, we are going to send Doug's file
to Health Net?''
Ms. Hoffmeier. No.
Mr. Collins. So, the reason they would send a file to
Health Net, if I am tracking here, is because you are eligible
for the Choice Program. I am not sure why there is the
disconnect at are you eligible or not. If you get the file from
the VA, they are eligible. [Applause.]
I am not sure why we are even--I mean, this is----
Ms. Hoffmeier. No. I absolutely agree with you, and I feel
your frustration.
Mr. Collins. Then why is that a stopping----
Ms. Hoffmeier. I am telling you what----
Mr. Collins. Why do we stop there? Why do we stop at
eligibility?
Ms. Hoffmeier. Because the contract requires us to wait for
that eligibility file. We are not allowed, by contract, to act
based on a VA medical center telling us the veteran is
eligible----
Mr. Collins. I understand that.
Ms. Hoffmeier [continuing]. Or even them sending us the
consult.
Mr. Collins. This is frustrating for me, because, frankly,
I do not want to seem completely disagreeable here, but you
just added to my frustration. I do not expect you to take a
call from the VA and they say, ``Oh, by the way, they are
eligible.'' When you get the file, they are eligible. I think
that is where the disconnect is coming in; where Mr. Chacha and
many others are saying, ``Why do we start at eligibility?''
because then we get into the other issues of--and let me share
some quotes here.
I have asked my staff on many occasions, ``What are some of
the things that you hear?'' They tell me, ``The VA has not sent
your records.'' ``You are not in the system.'' ``You are
approved, but we are still waiting on other paperwork.'' We go
to other issues of folks who come to us, and if we are getting
stuck on eligibility, it is no wonder we are waiting 100 days,
talking to three different people--``I have your file'' or ``I
do not have your file.''
Ms. Hoffmeier, frankly, I am just going to leave it alone
at this second, except to say this. I can not get to these
other issues of why they can not get appointments if we have an
answer for eligibility that, frankly, I would have to say,
would possibly make sense to no one in this room. If we can not
get the eligibility part down, that you get a file and they are
eligible--not a call, not a ``Hey, why do not you ask them?''
But when you get the file, they are eligible. That should never
be an excuse anymore.
I know the chairman and I have discussed making this
bureaucratically as easy as possible. But as the secretary said
earlier, we are working to cut out the bureaucracy here. If we
get stuck there, I am not sure which way we go.
So, Mr. Chairman, there is a ton more that we could ask.
But this is part of the reason you are having this hearing.
This is part of what we are seeing, frustration-wise.
But from Health Net's perspective, there are a lot of other
issues about your training, your weekly training and your
turnover. I understand that. But there is a statement you made
earlier, that mistakes are just a reality; OK, and it happens
in a system. But mistakes that are not learned from are costing
our veterans. We have got to stop this. And having a discussion
on who is eligible or not is not really going to be a helpful
discussion.
I appreciate you, Mr. Chacha. You worked with my office. I
will let you continue to work with my office, that I think
there are some good things to come.
Mr. Chacha. We are here for you, sir.
Mr. Collins. Thank you for what you are doing.
Mr. Chairman, with that, before we close, I want to yield
back to you for follow up.
The Chairman. Well, you know, these hearings are important
for the reason that you learn what is going on in reality. Doug
and I work in Washington, DC, which is the devil's workshop,
and sometimes it is not the real world.
If we have gained nothing from this hearing today except
this one factoid that we can work on--because, really, as I was
listening to Doug--and I had asked the question and then
listened to Ms. Hoffmeier--why would a veteran seek a Choice
appointment? Because he could not get one within 30 days at
Clairmont, or because he lived more than 40 miles away? Those
are the two prerequisites, other than his being a veteran, or
her being a veteran.
Why does it take a file for somebody who is not a veteran
to try to determine that? Why does it take some--if we could
just simplify that process, so when a veteran made the call, in
a seamless time period, they could say, ``He is eligible'' or
``She is eligible'' or ``She is not''. We could solve what--you
could have solved your problem, Mr. Chacha.
Mr. Chacha. Yes.
The Chairman. We could have solved most of the other
problems that are mentioned.
Mr. Chacha. Four months ago.
The Chairman. I know the devil is in the details, and
Members of Congress tried to solve a lot of problems in August,
yet we created a lot of problems with the Choice program. But
we created a lot of opportunities as well. For all the horror
stories that we talk about in here, there are veterans who have
gotten services who would not have gotten them had they been
under the laws of 2014 or 2013 or 2012 or 2011. We are moving
in the right direction.
Secretary McDonald is trying to steer the ship of VA in
very difficult waters, and he is doing a good job of that. We
are not where he wants to be yet. We are not where I want to be
yet. But we are moving in the right direction.
Leslie Wiggins at the Clairmont Hospital has done a
remarkable job of turning that facility around, attitudinally
as well as service-wise, and I am grateful for that. A lot of
the things that have improved at that hospital are things we
learned from the last field hearing we had in Atlanta in 2013.
These are very worthwhile, and all of you coming today and
being a part of this--I am very appreciative. To each of our
panelists, thank you.
Secretary McDonald, who cut his vacation short--I know his
wife is waiting on him in Orlando right now--thank you. Thank
you to all your staff that came.
But, the people who really deserve a large amount of
credit--Doug's staff and my staff, who do the hard work, the
people that you call when you can not get the VA to respond,
though we try to be responsive--they are all here today. I want
to thank them for taking their time and all they do to provide
services.
To our host today in Hall County, Gainesville, GA, near the
lake that is full, I want to turn it over for closing remarks
to Congressman Collins.
Mr. Collins. Well, thank you, Senator, again. It is great
to have a partnership. And for those who have watched the
media, there is a picture that goes around almost every time--
Senator, you are in the paper a lot more than I am. But there
is always this picture of the senator speaking, and there is
this tall guy behind him. I am pleased to be that tall guy when
we are in Augusta together, because it has been a good time
and----
The Chairman. That was at a VA hospital.
Mr. Collins. It was at a VA hospital. It shows the
commitment that the senator has as chairman and also we have in
our congressional office to ask the questions that,
unfortunately, sometimes are not easy. But there are questions
that we get all the time.
I do want to say thanks again to our staffs and also to
North Georgia. This is my alma mater--the University of North
Georgia. I know Kate Maine. I see her up in the top--and Dr.
Jacobs.
Also we do have a fellow, one that works in public life,
and that is Senator Butch Miller who is here from--Senator
Miller from our great county up here in Hall. Thank you for
being here.
Thank you, panelists.
Mr. Secretary, although Gainesville is great, I know
Orlando is better because your wife is there. Thank you for
coming.
The Chairman. Would you please join me and rise as we
retire the colors? We will stand adjourned after the colors are
retired.
[Retiring of Colors.]
[Whereupon, at 3:48 p.m., the hearing was adjourned.]
[all]