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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- Allows veterans to get medical care
outside the Veteran's Administration system; they can go to any
health facility that serves Medicare patients, health centers, the
Defense Department, and the Indian Health Service.
How it works: Veteran notifies VA, VA puts Veteran on an
electronic waiting list or authorizes their request, VA works out a
payment agreement with the health care provider, VA reimburses
health care provider but no more than they would for Medicare
- If the veteran gets treated for
a problem that was not related to their military service, their
health insurance plan will be responsible for payment and the
health care provider will be responsible for going after the
insurance company for the money.
can not be charged higher co-payments for care at private
facilities than they would have been charged at the Veteran's
This program will end in three years.
- Orders a
private-sector review, establishes a
fifteen person commission, and creates a
technology task force to review VA practices.
Wait times for care can not be considered when determining
performance bonuses for top officials at the Veteran's
administration and performance goals that disincentivize using
private health providers for veteran care
will be eliminated.
Wait times for health care at the VA, VA facility
quality measures, and
VA doctor credentials will be published online.
- The VA will
add 1,500 graduate medical education residency positions for
five years to address staffing shortages.
Extends the program that reimburses medical students for education
increases the amounts they'll receive for working for the
- Expands coverage for
mental health care related to sexual assaults, which will
veterans on inactive duty. This will be
effective August 7, 2015.
- Extends a pilot program for assisted living care for veterans
with traumatic brain injuries
until October 2017.
Disqualifies public colleges that charge veterans more than
State residents from being qualified schools for veteran education
- Makes it
easier to fire or transfer senior executives at the Department
of Veteran's Affairs.
Appropriates $15 billion to implement these changes.
Title I: Office of Accountability and Whistleblower
Title II: Accountability of senior executives, supervisors, and
- Gives the Secretary of Veterans Affairs the power to
suspend, demote, or fire senior executives
as long as the executive receives 15 days advance notice and
all evidence against him or her, legal representation, and the
ability to argue their case in an official process created by the
Secretary that takes no more than 21 days.
- Gives the Secretary of Veterans Affairs the power to
remove, demote, or suspend Veterans Administration employees
for performance or misconduct.
- The Secretary
can not remove, demote, or suspend a whistleblower without
approval of a Special Counsel or unless the Assistant Secretary
refuses to act on the whistleblower account or unless a final
decision has been made regarding the whistleblower's
- Gives the Secretary of Veterans Affairs the power to
order the repayment of bonuses or
relocation expenses paid to VA employees if the Secretary
determines that the employee engaged in misconduct or poor
performance before the bonus was awarded. There is an
appeal process via the Office of Personnel Management.
Title I: Appropriation for Veterans Choice Program
- Deposits $2.1 billion in the Veterans Choice Fund, which will
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.
18 & 30 people from the private sector and the same amount
from the VA will be selected in August of each year to
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.
- Political appointees of the VA will have annual performance
plans similar to the ones administered to career employees.
- 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.
Recommended Congressional Dish Episodes
- Article: VA secretary David Shulkin: I don't
consider this Texas church gunman as a veteran by Melissa
Quinn, Washington Examiner, November 6, 2017.
- Article: Funding for a new veterans choice
program remains the big, unresolved question for VA by Nicole
Ogrysko, Federal News Radio, October 24, 2017.
- Article: AFGE ramping up anti-privatization
campaign, as VA readies new Choice draft by Nicole Ogrysko,
Federal News Radio, October 17, 2017.
- Article: Focus on VA hiring, not Veterans
Choice, AFGE says by Nicole Ogrysko, Federal News Radio,
October 6, 2017.
- Article: Trump signs bill to speed up VA
disability appeals process by Richard Sisk, Military.com,
August 23, 2017.
- Article: Last-minute Veterans Choice funding
bill filled with key VA hiring flexibilities by Nicole Ogrysko,
Federal News Radio, July 28, 2017.
- Article: Fix for Veterans Choice shortfalls
fails in the House with little funds left by Nicole Ogrysko,
Federal News Radio, July 24, 2017.
- Radio Transcript: VA pane report to suggest more
private care choices for veterans, Morning Edition with David
Greene, NPR, July 6, 2017.
- Article: Shulkin offers first glimpse at a
new VA Choice plan by Nicole Ogrysko, Federal News Radio, June
- Article: Trump extends program allowing some
veterans to use local doctors, hospitals by Lisa Lambert,
Reuters, April 19, 2017.
- News Report: Barry
Coates dead; veteran was at heart of VA scandal by Scott
bronstein, Nelli Black, Drew Griffin and Curt Devine, CNN
Investigations, January 27, 2016.
- Article: How the VA developed its culture of
coverups by David Farenthold, The Washington Post, May 30,
- Article: Obama accepts resignation of VA
secretary Shinseki by Greg Jaffe and Ed O'Keefe, The Washington
Post, May 30, 2014.
Sound Clip Sources
Hearing: Bills related to veterans
choice; House Committee on Veterans Affairs; October 24,
- 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.
- 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
- 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.
- 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
- 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.
- 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
- 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
- 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
Hearing: Veterans affairs choice program;
House Committee for Veterans Affairs; March 7, 2017.
- 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
- 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.
- 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.
- Robert McDonald: then Secretary of U.S. Department of Veterans
- David Shulkin: Under Secretary for Health, U.S. Department of
- Brett Giroir: Senior Fellow at the Texas medical Center Health
- 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
- 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
- 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.
- 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.
- 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
- 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
- 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
- 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
- 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
- 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?
- 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.
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