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CD161: Veterans Choice Program

Nov 13, 2017

The Veterans Health Administration operates a taxpayer-funded health system to provide our nation’s veterans physical and mental health services. The Veterans Choice Program is a fundamental change to that system as it allows veterans to get taxpayer-funded health care in the private sector. In this episode, learn the history of the Veterans Choice Program, discover the changes that Congress and the Trump Administration have made to the program this year, and get some insights into the future of the program.

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Bills

H.R. 3230: Veterans Access, Choice, and Accountability Act of 2014

S. 544: A bill to amend the Veterans Access, Choice, and Accountability Act of 2014 to modify the termination date for the Veterans Choice Program, and for other purposes

S. 1094: Department of Veterans Affairs Accountability and Whistleblower Protection Act

Title I: Office of Accountability and Whistleblower Protection

Title II: Accountability of senior executives, supervisors, and other employees

S.114: VA Choice and Quality Employment Act of 2017

Title I: Appropriation for Veterans Choice Program

  • Deposits $2.1 billion in the Veterans Choice Fund, which will not expire.

Title II: Personnel matters

"Executive Management Fellowship Program"

  • A program to give VA employees 1 year of training in the private sector and to give private sector employees 1 year of training in the VA.
  • Between 18 & 30 people from the private sector and the same amount from the VA will be selected in August of each year to participate.
  • To accept the fellowship, the person must agree to work as a full-time employee of the VA for two years and is prohibited from working the corresponding private sector industry for two years after completing the program.

Performance Evaluations

  • Political appointees of the VA will have annual performance plans similar to the ones administered to career employees.

Promotions

  • Gives the Secretary of Veterans Affairs the ability to easily promote existing employees or people who voluntarily left within 2 years, one employment status at a time.

Employment Opportunity Database Creates a website that will list vacant positions at the Department of Veterans Affairs. Title III: Major medical facility leases

  • We're paying to replace VA facilities in 28 locations.
H.R. 3236: Surface transportation and veterans health care choice improvement act of 2015

Recommended Congressional Dish Episodes

Additional Reading

References

Sound Clip Sources

Hearing: Bills related to veterans choice; House Committee on Veterans Affairs; October 24, 2017.
  • 02:42 Rep. Phil Roe (TN): To that end, I believe it’s important to state yet again that this effort is in no way, shape, or form intended to create a pipeline to privatize the V.A. healthcare system. I want to be completely clear about that. Everyone who participated in the roundtable earlier this month and contributed to the development of this legislation should be completely clear on that. Everyone listening today should also be completely clear on that. Supplemental care sourced from within the community has been a part of the V.A. healthcare system since the 1940s and services to expand V.A.’s reach and strengthen and support the care that V.A. provides. Rhetoric aside, strengthening and support V.A. is what this consideration is about—this conversation is about. It should go without saying that V.A. cannot be everywhere providing everything to every veteran. Expecting V.A. to perform like that sets up the V.A. to fail. That’s why my draft bill preserves V.A.’s role as the central coordinator of care for enrolled veteran patients. In addition to consolidating V.A.’s menu of existing community-care programs into one cohesive program, my bill would create a seamless, integrated V.A. system of care that incorporates V.A. providers and V.A. medical facilities where and when they are available to provide care a veteran seeks and a network of V.A. providers in the community who can step up when needed. Under my draft bill, the V.A. generally retains the right of first refusal, meaning that if V.A. medical facilities can reasonably provide a needed service to a veteran, that care will be provided in that facility. But when the V.A. can’t do that, my bill would ensure that veterans aren’t left out to dry.
Press Conference: Trump signs veterans health care bill; C-Span; August 12, 2017.
  • 0:30 David Shulkin: The V.A. Choice and Quality Employment Act has three important components. The first is that this helps us expand our ability to hire medical-center directors and other senior executives to serve in the V.A. This is about leadership, and it’s really important that we get the right leaders helping us to do the job for veterans. The second is that this bill authorizes 28 new facility leases that will be in different parts of the country that provide our veterans with updated facilities, something that, again, we are committed to providing our veterans with world-class care. And third, and most important, this bill allows us to continue to be able to provide care in the community for our veterans to make sure that they’re getting high-quality care and not waiting for care. Already this year, in the first six months of this year, we have authorized over 15 million appointments for veterans in the community. That’s 4 million appointments more than what was experienced at this time last year. So we’re making a lot of progress in expanding Choice.
Hearing: Fiscal year 2018 Veterans Affairs budget; Senate Veterans Affairs Committee; June 14, 2017.
  • 12:29 David Shulkin: Two years ago—I’m sure you’re going to remember in July of 2015 we had too little money in our community-care accounts within the V.A., which we solved with your help by accessing unused funds in the Choice account. So we transferred money from Choice into community care. We now have too little money in the Choice account, which we’re working to solve, again working with you, with legislative authority, to replenish funds into the Choice account. So this is the situation that we’ve described before where for a single purpose of providing care in the community we have two checking accounts, and I will tell you, I wish it were easier than it is. We have to figure out how to balance these two checking accounts at all times. And obviously it’s not a science, it’s an art; and we’re having difficulty with that once again, and that’s why we need to work with you to solve it. The Veterans CARE program that we outlined for you last week will solve this recurring problem permanently by modernizing and consolidating all of the community-care accounts, including Choice.
Hearing: Examining the Veterans Choice program and the future of care in the community; Committee on Veterans Affairs; June 7, 2017.

Witness:

  • David Shulkin - Veterans Affairs Secretary
  • 12:55 David Shulkin: Just in the first quarter of fiscal year 2017, we saw 35% more authorizations for Choice than we did in the first quarter of 2016. So far in fiscal year 2017, we have approximately 18,000 more Choice-authorized appointments per day than we did in fiscal year 2016. But we still have a lot more work to do. That’s why we’re seeking support for the Veterans Coordinated Access and Rewarding Experiences program, the Veterans CARE program. Let me just go over that again because you need a good acronym in Washington. The Veterans Coordinated Access—that’s the C and the A—Rewarding Experiences program—the CARE program. I’ve testified before and I’ll report again today that our overarching concern remains veterans’ access to high-quality care when and where they need it. That’s regardless of whether the care is in the V.A. or in the community. Our goal is to modernize and consolidate community care. We owe veterans a program that’s easy to understand, simple to administer, and that meets their needs. That’s the CARE program, and now it’s time to get this right for veterans. So we need your help.
  • 14:23 David Shulkin: Here’s how veterans could experience V.A. healthcare, with your help. The veteran talks with their V.A. provider. That’s a conversation over the phone, virtually, or in person. The outcome is a clinical assessment. The clinical assessment may indicate that the V.A. specialist is the best for the veteran, or it may indicate that community care is best to meet the veteran’s needs. If community care is the answer, then the veteran chooses a provider from a high-performing network. That’s the veteran choosing a provider from the high-performing network. Assessment tools help veterans evaluate community providers and make the best choices themselves. We may help veterans schedule appointments in the community, or in some circumstances, veterans can schedule the appointments themselves. We make sure community providers have all the information they need to treat the veteran. We get the veteran’s record back. We pay the veteran’s bill. This is all about individualized, convenient, well-coordinated, modern healthcare and a positive experience for the veteran. If the V.A. doesn’t offer the necessary service, then the veteran goes to the community. If the V.A. can’t provide timely services, the veteran goes to the community. If there are unusual burdens in receiving care, the veteran goes to the community. If a service at a V.A. clinic isn’t meeting quality metrics for specific services, veterans needing that service go to the community while we work to support that clinic to improve its performance. And veterans who need care right away will have access to a network of walk-in clinics.
  • 19:20 David Shulkin: We want to make sure that if the service is low performing, if it’s below what the veteran could get in the community, that they have the opportunity—they don’t have to leave the V.A. They’re given a choice so that they are able to get care in the community or stay at the V.A., because, you know, if a veteran has a good experience and they have trust in their provider, they’re going to want to stay where they are. But that is the purpose. The whole idea here is to improve the V.A., not to get more care in the community. And the very best way that I know how to improve health care is to give the patient, in this case the veteran, choice and to make those choices transparent to let everybody see, because then if you’re not performing as high-quality service, you’re going to want to provide a higher-quality service, because you want to be proud of what you’re working on. And I want the V.A. to be improving over time, and I think this will help us do that.
  • 24:42 Sen. Patty Murray (WA): Secretary Shulkin, in your draft of Veteran CARE plan, you outline a number of pilot projects that sound to me uncomfortably like a proposals that are made by the so-called straw-man document. It’s from the commission on CARE and by the extreme, and to me unacceptable, plan put forward by the Concerned Veterans of America. And those include creating a V.A. insurance plan and separating it from CARE delivery, dividing the governance of a V.A. insurance plan and the health system, and alternative CARE model that sends veterans directly to the private sector. The goal of those types of initiatives, as originally stated in the straw-man document, is “as V.A. facilities become obsolete and are underused, they would be closed when availability and accessibility of care in the community is assured.” Those policies serve not only to dismantle the V.A. and start the health system down to a road to privatization, I just want you to know I will not support them, and I will fight them with everything I have. So, I want to ask you, why are you agreeing to pursue those unacceptable policy options? David Shulkin: Well, first of all, I appreciate you sharing your thoughts and as clearly as you have. I share your goal. I am not in support of a program that would lead towards privatization or shutting down the V.A. programs. What I am in support of is using pilots to test various ideas about governance, about the way that the system should be, organized in the way that we should evolve, because I don’t know without testing different ideas whether they’re good ideas or not.
  • 35:28 Sen. Jerry Moran (KS): You said something that caught my attention: this will not be an unfettered Choice program— David Shulkin: Yep. Moran: —and I wanted to give you the opportunity to explain to me and to the committee what that means. Shulkin: Yeah. There are some that have suggested that the very best approach is just give veterans a card, a voucher, and let them go wherever they want to go. And I think that there are some significant concerns about that, and you’re going to see this proposal is not that. This proposal is to develop a system that is designed for veterans, that coordinates their care, and gives them the options when it’s best for in the V.A. and when it’s best in the community. Unfettered Choice is appealing to some, but it would lead to, essentially, I believe, the elimination of the V.A. system all together. It would put veterans with very difficult problems out into the community, with nobody to stand up for them and to coordinate their care. And the expense of that system is estimated to be at the minimum $20 billion more a year than we currently spend on V.A. health care. So for all those reasons, I am not recommending that we have unfettered access. At some point in the future, if you design a system right, giving veterans complete choice, I believe in principle, is the direction we should be headed in, but not in 2017.
  • 39:05 Sen. Jon Tester (MT): I want to go back to the Choice program, community care versus V.A. care, and tell you where we’re probably all on the same page around this rostrum, but as we’re all on the same page and the budget comes out and gives a 33% increase for private-sector care versus a 1.2% increase for care provided directly by the V.A., it doesn’t take very many budgets like that and pretty soon you’re not going to have any vets going to the V.A., because all the money’s going to community care, and they will follow the money. I promise you they will follow the money. I think that—I don’t want to put words in the VSO’s mouth. He’ll have a chance here in a bit—but I think most of the veterans I talk to say, build the V.A.’s capacity. In Montana we don’t have enough docs, we don’t have enough nurses, we don’t have enough of anything. And quite frankly, that takes away from the experience and the quality of care, and so by putting 1.2% increase for care provided directly by the V.A. and 33% for private-sector care, we’re privatizing the V.A. with that budget. David Shulkin: Yeah. I told you I wasn’t going to say that you were right again, but there’s a lot that you said that I think that we both agree with. And the goal is not to privatize the V.A. What we’re asking for in this is something we don’t have. We need additional flexibility between the money that goes into the community and the money that can be spent in the V.A. Right now we’re restricted to a 1% ability to transfer money between. We are seeking that you give us more latitude there for exactly the reason you’re talking about, Senator. We need our medical centers and our VISNs to be able to say that they need to build capacity in the V.A. where it’s not available. The reason why we’re letting people go in the community now is because the V.A. doesn’t have it. We have to get them that care. Tester: I got it, but if we don’t make the investments so they can get that health care, they’ll never get that health care there. Shulkin: I— Tester: Okay.
Hearing: Veterans affairs oversight; House Appropriations Subcommittee on Military Construction and Veterans Affairs; May 3, 2017.

Witness:

  • Dr. David Shulkin - Veterans Affairs Secretary

 

  • 16:13 David Shulkin: More veterans are opting for Choice than ever before, five times more in fiscal year 2016 than fiscal year 2015, and Choice authorizations are still rising. We’ve issued 35% more authorizations in the first quarter of fiscal year 2017 than in the same quarter of 2016.
  • 18:00 David Shulkin: My five priorities as secretary are to provide greater Choice for veterans, to modernize our systems, to focus resources more efficiently, to improve the timeliness of our services, and suicide prevention among veterans. We are already taking bold steps towards achieving each of these priorities. Two weeks ago the president signed a reauthorization of the Veterans Choice Act, ensuring veterans can continue to get care from community providers. Just last week the president ordered the establishment of a V.A. accountability office, and we’re moving as quickly as we can within the limits of the law to remove bad employees. V.A. has removed medical center directors in San Juan; Shreveport, Louisiana; and recently we’ve relieved the medical center director right here in Washington, D.C. and removed three other senior executive service leaders due to misconduct or poor performance. We simply cannot tolerate employees who act counter to our values or put veterans at risk. Since January of this year, we’ve authorized an estimated 6.1 million community-care appointments, 1.8 million more than last year, a 42% increase. We now have same-day services for primary care and mental health at all of our medical centers across the country. Veterans can now access wait-time data for their local V.A. facilities by using an easy online tool where they can see those wait times. No other healthcare system in the country has this type of transparency. V.A. is setting new trends with public-private partnerships. Last month we announced a public-private partnership of an ambulatory care development center, with a donation of roughly $30 million in Omaha, Nebraska, thanks to Mr. Fortenberry’s help there. Veterans now have, or will have, a facility that’s being built with far fewer taxpayer dollars than in the past. Finally, V.A. is saving lives. My top clinical priority is suicide prevention. On average 20 veterans a day die by suicide. A few months ago the Veterans Crisis Line had a rollover rate to a backup center of more than 30%. Today that rate is less than 1%. In support of our efforts to reduce suicides, we’ve launched new predictive modeling tools that allow V.A. to provide proactive care and support for veterans who are at the highest risk of suicide. And I’ve recently announced the V.A. will be providing emergency mental health care to former service members with other-than-honorable discharges at all of our medical facilities. We know that these veterans are at greater risk for suicide, and we’re now caring for them as well as we can.
  • 23:19 David Shulkin: The VISTA system is something that, frankly, V.A. should be proud of. It invented it, it was the leader in electronic health records, but, frankly, that’s old history, and we have to look at keeping up and to modernize the system. I’ve said two things, Mr. Chairman, in the past. I’ve said, number one is, V.A. has to get out of the business of becoming a software developer. This is not our core competency. I don’t see why it serves veterans. I think we’re doing this in a way that, frankly, we can’t keep up with. So, I’ve said that we’re going to get out of that business. We’re either going to find a commercial company that will take over and support VISTA or we’re going to go to an off-the-shelf product. And that’s really what we’re evaluating now. We have an RFI out for, essentially, the commercialization of VISTA that we wouldn’t longer be doing internally.
  • 27:33 David Shulkin: We also, as we get more veterans out into the community, out into the private-sector hospitals, we have to be very concerned about interoperability with those partners as well.
  • 38:24 Rep. Debbie Wasserman Schultz (FL): Given that your goal is one program, are you analyzing which program ultimately would be phased out, because we have a tendency to instead of phasing out programs because they have people with a vested interest in them, simply— David Shulkin: Yes. Schultz: —going along to get along rather than rocking the boat, and so if we’re adding $3 1/2 billion to the Choice program and it had 950 million left, there have been challenges with the Choice program and confusion, and there are still challenges with the community care program, in what direction is the V.A. thinking of going when we—and what is the timeline for ultimately— Shulkin: Right. Schultz: — phasing out one program and only having one? Shulkin: Right. Well, with almost certainty I can tell you there will not be three programs, because the current Choice program will run out of money— Schultz: Right. Shulkin: —by the end of this calendar year. So, that program is going to go away and should be through December of this year. What we are hoping to do is to work with you so that we can introduce a community-care funding program—the chairman referred to it as Choice 2.0—which is a program that makes sense for veterans, which is a single program that operates under one set of rules for how veterans get care in the community. And that new legislation, which we believe needs to be introduced by late summer or early fall in order to make the timeline, would end up with a single program. Schultz: So, you eventually envision phasing out community care with the advent— Shulkin: Yes. Schultz: —of Choice 2.0.
  • 1:33:11 Rep. Charles Dent (PA): In the one-page FY ’18 skinny budget we received in March, there’s a V.A. request for $2.9 billion in new mandatory funding, presumably to complete the FY ’18 funding for the Choice program after the mandatory $10 billion of the program is completely exhausted in January, I guess. Does this indicate the administration’s intent to fund the successor Choice program out of mandatory funding? David Shulkin: Yes.
  • 1:45:37 Rep. Tom Rooney (FL): And many of the providers that are technically participating in the Choice program are refusing to accept Choice patients because they know that they’ll have to wait a long time to get paid themselves. So some providers that don’t accept the Choice patients will only do so if the veteran agrees to pay for the services up front. And that leaves the veterans in that same bind they were in before Choice, which was either face the excessive wait times at the V.A. facility with no option to obtain immediate care elsewhere without paying out of pocket first. And obviously that’s not the point, or that’s not what we’re looking to do. So, I mean, you as a doctor can probably appreciate, you know, with these people that want to take the Choice program to help veterans but they know that it’s going to take forever to get reimbursed be like, hey, will you pay me first, and then, you know, we’ll deal with getting reimbursed later. I don’t know if that’s the rationale, but it sounds like that. The OIG has criticized the V.A.’s monitoring oversight for these contracts and reported that these contracts still don’t have performance measures to ensure the contractors pay their providers in a timely manner, and the OIG made this recommendation January 30 of this year. So, as you work to expand the Choice program, how are you implementing the OIG’s recommendation specifically with regard to timely reimbursements? David Shulkin: Well, there is no doubt that this is an area of significant risk for us, that monitoring and making sure that the providers are paid is critical because of the issues that you’re saying: the veterans are being put in the middle. I would not recommend the veterans put out money for this. That is, as you said, is not the point of it. What we have done is we have done multiple contract modifications. We’ve actually advanced money to the third-party administrators. I’ve suspended the requirement that providers have to provide their medical records to us in order to get paid. We are improving our payment cycles through the Choice program, but it’s not perfect by any means. We have to get better at our auditing of these processes, and those were the IG recommendations, and we are working on doing that. So this is a significant area of risk for us. In the reauthorization, or the redesign, of the Choice program, what we’re calling Choice 2.0, we want to eliminate the complexity of this process. The private sector does not have to do the type of adjudication of claims that we do. They do auto adjudification. They do electronic claims payments. We just are not able to, under this legislation, do all the things that, frankly, we know are best practices. That’s what we want to get right in Choice 2.0.
  • 1:56:40 David Shulkin: Our care needs to be focused on those that are eligible for care, particularly when we have access issues. So, I’d be glad to talk to you more about that. I do want to just mention two things. First of all, our policy is for emergency mental health care for other-than-honorable, not dishonorably, discharged; dishonorably discharged who were not— Rep. Scott Taylor (VA): Sorry if I misspoke. David Shulkin: Yeah, yeah, okay. Rep. Scott Taylor (VA): But I do applaud you for those efforts. David Shulkin: I just wanted to clarify that. Rep. Scott Taylor (VA): I know that there are a lot of wounds that are mental, of course, and— David Shulkin: Absolutely. Rep. Scott Taylor (VA): —I get that. I applaud you for those efforts.
Hearing: Veterans affairs choice program; House Committee for Veterans Affairs; March 7, 2017.

Witness:

  • David Shulkin - Veterans Affairs Secretary
  • Michael Missal - Veterans Affairs Inspector General
  • Randall Williamson - GAO Health Care Team Director
  • 20:35 David Shulkin: However, we do need your help. The Veterans Choice Program is going to expire in less than six months, but our veterans’ community-care needs will not expire. This looming expiration is a cause for concern among veterans, providers, and V.A. staff, and we need help in eliminating the expiration date of the Choice program on August 7, 2017 so that we can fully utilize the remaining Choice funds. Without congressional action, veterans will have to face longer wait times for care. Second, we need your help in modernizing and consolidating community care. Veterans deserve better, and now is the time to get this right. We believe that a modernized and revised community-care program must have seven key elements. First, maintain a high-performing integrated network that includes V.A., federal partners, academic affiliates, and community providers. Second, increase Choice for all veterans, starting with those with cer—(audio glitch). Third, ensure that enrolled veterans get the care they need closer to their homes, when appropriate. Fourth, optimize coordination of V.A. healthcare benefits with the health insurance that an enrolled veteran already has. Fifth, maintain affordability of healthcare options for the lowest-income enrolled veterans. Sixth, assist in coordination of care for veterans served by multiple providers. And last, apply industry standards for performance quality, patient satisfaction, payment models, and healthcare outcomes.
  • 23:24 Michael Missal: In October 2015, V.A. provided Congress with a plan to consolidate all V.A.’s purchased care programs into V.A.’s community-care program. Under consolidation, V.A. continues to have problems determining eligibility for care, authorizing care, making accurate payments, providing timely payments to providers, and ensuring the necessary coordination of care provided to veterans outside the V.A. healthcare system.
  • 30:30 Randall Williamson: Finally, substantial resources will likely be needed to carry out Choice 2.0. Resources needed to fund IT upgrades and new applications for Choice are largely unknown but could be costly. Proposed changes in Choice eligibility requirements, such as eliminating the 30-day, 40-mile requirement for eligibility, could potentially greatly increase the number of veterans seeking care through community providers and drive costs up considerably. Also, if medical-center staff begin scheduling all appointments under Choice 2.0, as V.A. currently envisions, hiring more V.A. staff will likely be costly and tediously slow. Already, since Choice was established, V.A. medical-center staff devoted to helping veterans access non-V.A. care have increased threefold or more at many locations.
  • 1:04:00 David Shulkin: We are looking primarily at technological solutions, and we are looking at the use of telehealth, which we are doing across V.A. on a scale that no other health system in America is even approaching—2.1 million visits; over 700,000 veterans getting access through telehealth services—and so we are looking at this very seriously about dramatically expanding its use to be able to support where we don’t have health professionals.
  • 1:06:20 David Shulkin: Remember, we have four missions. The clinical care is what we always talk about, but we also have an education mission. We train more American healthcare professionals than any other organization in the country, we have research that’s dedicated solely to the improvement of the wellbeing of veterans, and we also serve a national emergency-preparedness role. So, all four of these missions are very important to us. I would just say two things. One thing is we know from the Choice program that only 5,000 of the several—of more now than a million veterans who’ve used the program chose only to use the Choice program. So they’re saying exactly what your constituent told you, which is the V.A. is essential and important to them. But we are not going to allow the V.A. programs to be diluted, and one of the reasons why that’s so important is that we need to modernize the V.A. system. Our lack of capitalizing the V.A. system in terms of the buildings, the equipment, the IT systems, could make it a noncompetitive system. But we’re going to make sure that the facilities that are open are the best for veterans, and veterans are going to want to continue to get their care there. The community-care program is a way to make sure that we supplement the V.A. in an integrated fashion.
  • 1:10:00 Rep. Mike Bost (IL): The department itself has estimated that it can treat and cure most of the remaining 124,000 diagnosed cases of hepatitis C within the next three years. Is it the V.A.’s commitment that that timeline will be held to and that these will be treated regardless of the level of their liver disease or where they might be at? David Shulkin: Yes. Thanks to the support from Congress, we were provided the resources to meet that timeline. I actually think we’re going to beat it, but with one caveat. What we’ve learned is that our initial outreaches, we were getting thousands and thousands of veterans to come in and to get treatment. We have a treatment, of course, as you know, that now cures more than 95% of hepatitis C. So it’s tremendous medical advance. The doctor to my right is one of those doctors. He’s an I.D. doctor who does this in his clinical work at the V.A. Unknown Speaker: Thank you. Shulkin: What we’re finding now is, and if Dr. Yehia wants to comment on this, we’re finding that we’re now seeing less and less veterans coming in to get cured. There is a substantial number of veterans for a number of reasons, either psychological reasons or social reasons, who are not taking advantage of this care. And so this is now becoming a research question for us. How do we have to begin to approach people that are saying, I have a disease that may end up killing me, but I’m not interested in the treatment. And so I think we’re going to beat your three-year timeline, but there's still going to be a subset of veterans that don’t want to come in and get care.
  • 1:12:50 Rep. Mike Bost (IL): What would happen if we didn’t make that extension go past the August 7, and what would be the final cutoff if we don’t get it past? David Shulkin: Well, first of all, if we don’t do this extension, this is going to be a disaster for American veterans. We’re going to see the same situation that we saw in April 2014, that Senator Kaine started out tonight with, that we saw in Phoenix. And so here’s the timeline. We do need to do this now. As I think Chairman Roe referred to, already today veterans are not able to use the Choice program, because the law states that we have to obligate the funds now for when the care is going to be delivered. So a pregnant veteran who comes to us and says, I want to get care using the Choice program, they no longer can, because nine months from now is past August 7. But this is now beginning to happen with care that is multiple months in length, like oncology care and chemotherapy and other types of therapies. We have a chart that shows that when you start getting towards the end of April to May, this is where you’re going to start seeing a large number of veterans not being able to get access to care, because episodes of care that we’re used to, like hip replacements and other things, are generally three to four months. So we think the time is now that we need to act. Bost: Okay, so, but what we’re doing is not any intention to privatize or anything like that. This is just making sure that those people who are on the Choice program, that we are moving forward to make sure that those services are provided. Shulkin: Not only that, but this is not going to cost any additional money. We are just seeking the authority to spend the money that you’ve already given us past August 7 of this year.
  • 1:17:15 David Shulkin: We are going to go and we are going to start providing mental health care for those that are other-than-honorably discharged for urgent mental health. And we want to work with Representative Coffman on his bill on this, and we want to do as much as we can. But I don’t think it can wait, and so we’re going to start doing that now. I believe that’s in the secretary’s authority to be able to do that.

 

Hearing: A call for system-wide change; House Committee for Veterans Affairs; October 7, 2015.

Witnesses:

  • Robert McDonald: then Secretary of U.S. Department of Veterans Affairs
  • David Shulkin: Under Secretary for Health, U.S. Department of Veterans Affairs
  • Brett Giroir: Senior Fellow at the Texas medical Center Health Policy Institute
  • 13:37 Robert McDonald: As you know, we have five strategies: first is improving the veteran experience, second is improving the employee experience, third is achieving support-service excellence, fourth is establishing a culture of continuous improvement, and fifth is enhancing strategic partnerships, and we would be happy to drill down on those during the question period.
  • 14:17 Robert McDonald: In the past year, we’ve moved out aggressively in response to the access crisis, meeting increasing demand and expanding capacity on four fronts: more staffing, more space, more productivity, and more V.A. care in the community. During that period of time, we’ve completed 7 million more appointments for veterans of completed care: 4 1/2 million in the community, 2 1/2 million within V.A. We’ve added more space, we’ve added more providers, we’ve added more extra hours, all in effect to get more veterans in. But because of that, and because we’ve done a better job of caring for veterans, we have more veterans desiring care. So even those 97% of appointments are now completed within 30 days of the needed or preferred date, the number not completed in 30 days has grown from 300,000 to nearly 500,000.
  • 16:15 Robert McDonald: We simply can’t make many necessary changes because of statutory limitations. We need to consolidate our various care in the community programs. We need a freer hand to hire, assign, and reward the executives we task to act as change agents. We need a freer hand in disposing of outdated, unused, or little-used facilities. We need a freer hand in the management of existing facilities so facilities’ managers can adjust their use of resources to the changing needs of veterans.
  • 25:47 Brett Giroir: As background, in 2014 9.1 million of 21.6 million U.S. veterans were enrolled in the VHA. Of these, 5.8 million were actual patients, and on average these patients relied on the VHA for much less than 50% of their healthcare services. These demographic data combined with access challenges suggest reconsideration of whether the VHA should aim to be the comprehensive provider for all veterans’ health needs or whether the VHA should evolve into more focus centers providing specialized care while utilizing non-VHA providers for the majority of veterans’ healthcare needs. Either paradigm could be highly beneficial to veterans as long as the demand and resources are prospectively aligned and there is a consolidation of current programs to simplify access to non-VHA providers.
  • 30:05 David Shulkin: The V.A. approach is to find the very best care that serves the veterans, and I think that we’ve shown that in response to our access crisis that we have encouraged the use of community care to address our access issues. I think the difference here between—maybe what I would expand on what Dr. Giroir said is that the care that V.A. provides is very, very different than the care that the private sector provides. The V.A. provides a much more comprehensive approach than just dealing with physical-illness issues. It provides psychological and social aspects of care that actually meet the needs of what veterans require. And that's why I think that we really do need to do what Dr. Giroir said, which is to see what VHA provides best for our veterans and what care can be provided by the private sector, and it’s that hybrid-type system that's going to meet our veteran's needs.
  • 34:39 Former Rep. Corrine Brown (FL): I think the elephant in the room is that there are people out there that would actually want to just completely close the V.A. and privatize the entire V.A. system, which is totally unacceptable and it is absolutely not what the veterans want. And as you begin, I want you to discuss flexibility, but I want you to let people know how many people we actually serve every day throughout this country. Robert McDonald: Thank you, Ranking Member Brown. As I was going through my confirmation process, I often got the question from senators why—you know, from some senators, small group—why don't we get rid of the V.A. and just give out vouchers? So I studied that—as a business person, I wanted to know—and what I discovered was V.A.'s not only essential for veterans, it's essential for American medicine and it's essential for the American people. Three-legged stool: research. We spent $1.8 billion a year on research. We invented the nicotine patch. We were the ones who discovered the aspirin was important for heart disease—take an aspirin every day. First liver transplant. First implantable pacemaker. Last year two V.A. doctors invented the shingles vaccine. I could go on. That research is important for the American people, and I didn't even mention posttraumatic stress or traumatic brain injury or prosthetics, things that we're known for. Second, training. We trained 70% of the doctors in this country. Who's going to train those doctors without the V.A.? We have also the largest employer of nurses and the largest trainer of nurses. Third leg is clinical work. Our veterans get the best clinical care because our doctors are doctors that not only do the clinical care but also do research and teach in the best medical schools of our country. So I think the American people benefit from the V.A., and it would be a big mistake to even think about privatizing it.
  • 1:06:06 Rep. Phil Roe (TN): Let me go right to what I wanted to talk about which is my own veteran’s officer at home—person that does my work at home—and basically what she’s saying is, how do you get an appointment through the Veterans Choice Program? She said she had been trying to put together a summary, and what's happening is there’re two ways you get in there: a veteran can either be eligible by a 30-day wait list or more than 40 miles. And the most of problems she saw were the 30-day list. And this is what happens. Below is the information’s been given to me by the roll out of the program. In my experience, there appears to be a breakdown somewhere in this process but have been unable to get clear answers on how to fix it. The V.A. blames TriWest; TriWest blames the V.A. Eligibility is determined by the V.A. primary-care doctor if the appointment’s passed 30 days. The non-V.A. care staff then uploads this list of eligible veterans to the V.A. central office here in Washington nightly, and the veteran’s told to wait five to seven days and then call TriWest. The central office then sends the information to TriWest, can take three to seven days. If the consults don't get added, medical documentation didn't get uploaded, authorizations gets canceled, then the veteran’s on a merry-go-round. Look, when they came to my office to get an appointment, I said, you need an appointment with Dr. Smith. They went out front and made the appointment. That's what should happen. It ain’t that complicated. And all of this in between—and I could go on and on—TriWest has a different view of it, and I want to submit this to the record because it really gets to the bottom of what’s actually going— Unknown Chairman: Not objection. Roe: Thank you, Mr. Chairman. The non-V.A. care staff were given no training on this, and they basically were left just to wing it, how to make these appointments. That was one of the things was brought up in the report. Our local V.A. care—non-V.A. care staff—increased from 5 to 15 but still are struggling to make all these appointments, and there's talk of—now, listen to this right here—there is talk of calling each patient for every appointment to make sure they keep it. If the patient says, I don't want to go, they still are told to call them two times a month until the past the appointment time. That's a complete waste of time. And the outpatient clinics also ought to be able to add patients to the electronic wait list instead of sending them over because appointment may come up; veterans get left out like that. And the TriWest portal is not very friendly. Private doctors did not like jumping through all the hoops of the Choice programmers saying they must give a percent of their fee to TriWest in order for TriWest to file the claim. So, we have a clinic that’s closing in our office, in our V.A., on a chiropractic and pulmonary clinic, because the doctors are just fed up with the way the system is. It’s so bureaucratic. So, anyway, I could go on and on. This is a very extensive—this is on-the-ground stuff that’s going on today at our medical center, and I bet you it's going on around the country. And I think these are things I will submit to you so you can get to work on this, and, again, appreciate the effort that you put into it. Mr. Chairman, there’s some valuable information here for the V.A. to use. And I yield back. Unknown Chairman: Thank you. Ms. Brown, you had a question. Corrine Brown: I do, because I want the secretary to answer that, because I think—I'm meeting with TriWest today—but the important thing is, you can't send a veteran to an agency or anywhere until they get prior approval from the V.A. because the most important thing is that that doctor get that reimbursement. So can you clear this up? I mean, no person in my office can send someone to a doctor; it must go through the system so that you get prior approval. And once that's done, how long—why does it take so long for that physician to get reimbursed, and can he answer that question? Robert McDonald: We have flowcharted that process, and let me let David talk about the improvements that we’ve made to that process. He'll answer questions one and three, and I'll take two on the facilities. David Shulkin: Okay. Dr. Roe, I think your old adage on the three A's is exactly right. And you have to remember we brought this Choice system up in 90 days. This is a national, very complex system, and what we've heard after bringing it up in 90 days is exactly the type of feedback that you've been hearing from your constituents. The secretary and I are both out in the field, we understand that these problems are happening, and so what we've begun to do is to redesign the system and to process-map it out. Both the secretary and I spoke to the CEO of TriWest last evening, and we are beginning now to make outbound calls to the veterans before they had to call in. We are beginning to actually embed TriWest staff in the V.A. so that they're working in teams, and we're beginning to start eliminating some of those steps. It is going to take a while. It is painful to watch this when you hear stories like what you're hearing, but we understand the problems there, we are working very hard, we think TriWest and Health Net are working to help us make the system better, and we're committed to doing this with urgency.
  • 1:58:08 David Shulkin: We do have a crisis in leadership. We have too many open, vacant positions. We have too many people in acting positions and interim positions. You can't expect that you're going to have a transformation in a health system unless you have stable leadership in place. We need your help on this. We need your help to help create the V.A. to be an environment people want to come and serve and to be excited about, and we are asking for your help in Title 38 for the—Hybrid Title 38—to be able to help get the right type of compensation for leadership positions in V.A. That will help us a lot.
Hearing: HR 1994 VA accountability act and HR 3236 surface transportation and veterans health care choice improvement act; House Rules Committee; July 28, 2015.
  • 1:28:40 Bradley Byrne (AL): We don’t need to have a government-run healthcare system for our veterans. We need to transition out of it and give all of our veterans a card, just like an insurance card.
Hearing: Veterans Affairs health care and budget; House Veterans Affairs Committee; July 22, 2015.
  • 19:20 Robert McDonald Clinical output has increased 8% while budget has increased 2%, 35% more people (1.5 million beneficiaries)
  • 20:22 Robert McDonald Increased Choice authorizations by 44% (900,000), 4% more appointments, percentages of wait times, wait times for types of care
  • 21:50 Robert McDonald Care crisis of 2014 was caused by an imbalance in supply and demand, VA has been governing to fit a budget, not making budget fit the care, stats on new enrollees, 147% increase. enrolled veterans use VA for 34% of their care
  • 56:00 Robert McDonald Here is a packet explaining the transformation of the VA, we have an advisory board full of CEOs, VA is going through the largest transformation in it’s history
  • 1:09:40 Tim Heulskamp (KS) Concerned that money will be redirect away from Choice and he thinks “many employees” are not supportive of Choice, throws out bullshit numbers James Tuchschmidt corrects him and said they took money out to pay for the Hepatitis C drug
  • 1:11:50 Tim Heulskamp wants to know why only two people have been fired for the wait time scandal. Robert McDonald many have retired, one indictment, 1,300 have been fired, new leadership, 7 million more appointments this year
  • 1:27:30 Rep.Jackie Walorski (IN) Veterans died because of the Veteran’s Administration, I wanted to see people go to prison, list of things she’s pissed about, "Nothing is working” Robert McDonald 300,000 on wait list a year ago, low wait times,
  • 1:35:00 McDonald we need a better system for anticipating what demand will be. 34% of eligible people are using VA system right now
  • 1:35:20 Robert McDonald the crisis in 2014 was due to Vietnam vets, not Iraq & Afghanistan and we need to prepare as they age
  • 1:36:00 Rep. Beto O’Rourke (D-TX) Why don’t we “refer out" the care that’s not directly related to military service? Robert McDonald people like to have all their doctors in one place, private sector doctors have to treat veterans differently - different questions to ask
  • 1:41:00 Phil Roe (TN) Getting veterans outside care should be be through 1 program because it "aught to be easy"
  • 1:43:50 Robert McDonald Moral is low because people don't want to be called out for not caring. They work hard every day
  • 1:46:00 Kathleen Rice (D-NY) Why is there a budget shortfall? Robert McDonald 7 million more veterans needed care. "That's the reason"
  • 1:56:00 Mark Takano (D-CA) New way of operating with non-VA providers - "Care in the Community" - not a conspiracy to "disappear the VA" - That's why we changed the name
  • 2:05:00 Brad Wenstrup (R-OH) We should "outsource" collections” of payment from veterans with other insurance James Tuchschmidt We are looking at doing that. Wenstrup we should take bids.
  • 2:18:00 Robert McDonald We are in favor of Choice program & we need to know about any employees who aren't because "that would be wrong" - Don't care where they get care as long as it's great care
  • 2:20:00 Jerry McNerney (D-CA) Do you favor public private partnerships? Robert McDonald Yes, it's part of our transformation strategy. we have an “office of strategic parterships”
  • 2:22:55 James Tuchschmidt We thought more people would use Choice, the goal was to not have vets waiting more than 30 days for care, we're asking to use that money to pay for care we purchased, we want a bill before you leave in August
  • 2:28:00 James Tuchschmidt We’ve treated over 20,000 veterans with hepatitis C and veterans can use the Choice Program to get their treatment Rep.Ralph Abraham (LA) $500 million would be designated for Hepatitis C treatment Robert McDonald yes
Hearing: Non-VA care: An integrated solution for veteran access; House Veterans Affairs Committee; June 18, 2014.
  • 50:40 Rep. Beto O’Rourke (TX): Why have the V.A. at all? Why not privatize that care? The private sector could do it better. What’s missing in the V.A. is competition. Our veterans deserve the very best. Let’s not keep them in this institution that’s not working. From veterans, almost to a person, I hear, if I get in the V.A., I love the care. I’m treated very, very well. The outcomes are great. Don’t touch the V.A. So, what do you do best, and what does the V.A. do best? And five years down the road, after we get out of this current crisis, what will this look like? Unknown Speaker: That’s a great question. And it’s an honor to serve El Paso, where I spent part of my childhood when my dad was in the army as a doc. I will tell you that I hope it does not take five years. And I think everybody else would echo that statement. My belief is that the first phase is to make sure that the program that the V.A. has invested taxpayer money in—VAPC3—is put in place, is mature, that the processes on the V.A. side are mature, that our processes are mature, and that together we’re identifying where those pockets of veterans are that might not otherwise be able to get what they need in a complete capacity through the direct V.A. system because they lack the capacity to deliver on all the needs, and that the V.A. syst— Yes, sir. O’Rourke: Let me—I’m sorry to interrupt you, but I do want to understand what you think beyond taking care of capacity issues when the V.A.’s not able to see someone in a reasonable period of time. Are there specific kinds of care that you all would be better equipped to take care of? For example, I often think the V.A. is or should be better at handling PTSD or the aftereffects of traumatic brain injury because they see so many people like that as opposed to your typical health system or hospital. Maybe that’s a V.A. center of excellence. Is there something on the outside that we should just move all appointments or consults or procedures in a given area over to the private sector or let the private sector compete for? Unknown Speaker: Great question. My personal view is that it’s too early to ask that question—or to answer it, probably a better way to put it. It’s early to ask it, it’s right to ask it, you’re looking over the horizon line, but that we first need to get the pieces plugged together. And then there needs to be a make-by decision, category by category, and facility by facility, to look at what’s best done with taxpayer funds. Is it best to have the direct system provide care for four veterans in a particular category? Is that really necessary? Or should we buy that on the outside because it’s more efficient and more effective?
  • 54:30 O’Rourke: You know, I’ve been on this committee for a year and a half now—it’s my first year in Congress—but I’d never been approached by a lobbyist on my way in to a meeting. Today I was, who represents providers in the private sector in El Paso and said, we have a hard time getting paid. It takes us a year sometimes. We want to see these veterans who are not able to be seen by the V.A., but it’s going to be really hard to do this if we don’t get paid.
  • 1:34:00 Jolly: We need to do even more in providing a veteran choice. This, bottom line. The question, though, is how do we do that in a way that’s fiscally responsible? And so my question for you generally—and again, if you don’t have enough information, that’s certainly fine—in your role of supporting non-V.A. care, can you give either an assessment, if you have the technical information, or if it’s just in a working opinion on the cost effectiveness compared to traditional care, realizing that we have hard infrastructure costs within our V.A. system that aren’t reflective when you go to non-V.A. We can look at all sorts of data. I’m somebody who thinks typically data’s manipulated to get whatever outcome or position we want to finally be able to support. But can you give an opinion or assessment on the cost effectiveness of non-V.A. care versus within the V.A.? Ms. Doody: I can tell you from our experience with Project ARCH—and I wish I could give you specific numbers, sir—the company Altarum, who was contracted to collect this information—my understanding is they’re going to report back to you folks in 2015—are looking at the cost of care per veteran. From my understanding, it is less than if they would have gone to a V.A. facility for certain procedures. So, again, it’s anecdotal. It may be geographic; I can’t comment on the other regions or other states in our nation. But also just limiting the amount of mileage, the travelling that the veteran would have to do travelling to a V.A. hospital to receive care as a savings to the system also.
  • 1:45:00 Titus: You confirm that you can’t talk about the cost effectiveness; there’s just not enough data there, yet you think it’s working pretty well, but we don’t have any hard figures, and we also know that CVO’s been kind of unable to assess the cost going forward, and nobody’s talking about how to pay for it. Yet, we are moving pell mell towards more veterans using this kind of non-V.A. care. And it’s not that I’m opposed to that, but I want us to do it right or else we’ll be having hearings five years from now, talking about all the problems with non-V.A. care. Now, to hear y’all talk about it, you’re not having any problems; things are working great under your networks. But we know that’s not true, either. I mean, there are problems out there, and we need to be serious about how to address them from the beginning. Now, as I understand it, y’all are just kind of like the middleman, like Sallie Mae and Medicare Advantage, where you have a contract to provide a service. That’s fine, but as you push more people out into the private sector, do you see your kind of business growing, or is your network going to cover more areas, or are more new networks and competition going to come on to be part of this new system that we’re going to be creating?
Hearing: A continued assessment of delays in VA medical care and preventable veteran deaths; House Veterans Affairs Committee; April 9, 2014.
  • 2:35 Rep. Jeff Miller (FL): On Monday, shortly before this public hearing, V.A. provided evidence that a total of 23 veterans have died due to delays and care at V.A. medical centers. Even with this latest disclosure as to where the deaths occurred, our committee still doesn’t know when they may have happened beyond the statement from V.A. that they most likely occurred between 2010 and 2012. These particular deaths resulted primarily from delays in gastrointestinal care. Information on other preventable deaths due to consult delays remains unavailable. Outside of the V.A.’s consult review, this committee has reviewed at least 18 preventable deaths that occurred because of mismanagement, improper infection-control practices, and a whole host—a whole host—of maladies that plagued the V.A. healthcare system all across this great nation.
  • 8:53 Rep. Jeff Miller (FL): Mr. Coates waited for almost a year and would have waited even longer had he not personally persistently insisted on receiving the colonoscopy that he and his doctors knew that they needed. That same colonoscopy revealed that Mr. Coates had Stage IV colon cancer that had metastasized to his lungs and to his liver.
  • 13:55 Barry Coates: My name is Barry Lynne Coates, and due to the inadequate and lack of followup care I received through the V.A. system, I stand here before you terminally ill today.
  • 16:10 Barry Coates: I’ve talked to numerous veterans since all this occurred, and a lot of them, I hear the same story like my story, you know, why didn’t we receive help, why didn’t I get care earlier, why didn’t it get outsourced? And outsourced is probably a good thing that needs to be put into policy if it’s backed up to a part they can’t control.
CNN Report: Veterans dying because of health care delays, January 30, 2014.

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