of being delivered might very well might want to continue that out. but there are others that would suspect that would say i don't expect you to build a new hospital near me. you have looked at asking for the ability to have flexibility to make that choice. what happened if we took it as an alternative and once again we are talking about dollars and cents. what if we let them decide for themselves whether they want to have cured through a va facility or utilizing the choice program more fully and skip all of the extra stuff that you have talked about or whether or not they have already had care and now they have to go back in after 60 days. it is still the va making the decision. i'm sure that this is not a new

thought. so explain your logic in terms of not allowing them to make that choice than elves. >> we have spent a great deal of time talking about this. one of the things for us to keep in mind is that 81% of the veterans we provide care for have medicare medicaid or some form of private health insurance. oftentimes what you see today, you mention this fact earlier that the veterans have given the option for toys and somewhat elect to stay in and that is precisely what happens today. roughly half of 40 to 50% depending on who's the survey you are listening to. i would tell you my perspective part of those are deciding to stay because they are getting great care and they enjoy the camaraderie with other veterans, they have continuity of care because they have been receiving care for a long time and others

come there because they have an economic and others come there. so they have 20% co-pay for a procedure and you look at that colonoscopy or whatever it happens to be where the knee replacement which is an example that we use oftentimes in the veterans can go get it with medicare but he is going to wind up with a 7500-dollar bill that he has to foot. part of the answer comes and it's one of the options that we have talked about is that we step back and we look at some of the economic distortion. so what other providers become the primary payer and the va then defines a veteran against a 20% co-pay. then you really are providing the veteran with choice. and they don't wind up paying twice for the same care. so this isn't about protecting

their turf, all we are about doing is being good stewards of taxpayer resources. where ever that leaves us that's where we are. >> thank you sir. >> thank you very much. take you all for being here today and let me just say that the va has had a lot of problems as you have all talked about. some of you have been there longer than others and some of you have had private sector. i have problems like every other state and nobody has problems like colorado has with what is happening there. but let me just say that i need to get this on record and i have a situation, i don't know if it's been brought to your attention and it's gone far up the ladder. last month the office of special counsel talked about switching antipsychotic drugs based solely

on cost. the providers say this is what the veterans need and they made an executive decision. and i was told there is a new policy in place dispensing these drugs and we have not been able to obtain a copy of that. at the time i'm also told that there is a wallop investigation into the matter and we haven't heard much about that. at the same clinic which operates it has been close three times because of quality and i have a horrendous time because we are trying to get our veterans the care that they need. if you could give you an me an answer back as quickly as you can. >> i believe that once referred to here is oftentimes routinely when the office of special counsel has a finding that substantiate the whistleblower allegation we have positions

that really bored out and determine exactly what happened and where the accountability was an oftentimes that is part of it. >> it has been there and i have been trying to get an answer back. >> we will do that, sir. >> really believe that everything that we have talked about here my generation having tremendous need. that being said do you believe this you come from the private sector. >> okay, already. those that have more public and

more private would understand. you believe that we give better care to our veterans and i mean that in the case of quality of care in the time and the cost. and i'm not saying that we are going to shut the va down. don't think we are going to build everything else. >> i would tell you that we do not believe that that is the case. if you look at the typical veteran that we provide care for they are older and sicker and poorer, we have a highly fragmented health care in america and that is precisely the person that i don't think there is the best one turned into that system. if you go talk to veterans to a large number of veterans consistently what you are going to hear is are there instances where they had to wait too long for care or are we have made a mistake. yes, there are 55 million outpatient appointments.

>> we used alaska and how they were given so much better quality of care and quicker. and they don't even have a va hospital. >> if i might, i know alaska a fair bit. and i would offer the following. i think that the real question at the end of the day is which things are fundamentally done best by the va directly in which things have enough demand where it justifies building it and which things should be supplemented by the private sector because it's either not enough demand for where it makes sense to spread this applies simply because of the amount of resource and that is needed to deliver services and i think the band has always been true and i think that that is true in the dod system and that is why you

see tri-care constructed the way that it is. alaska has destroyed facility most of the footprint tends to be public in the dod through the indian health service or private. it's those two pieces working together that are ultimately going to deliver what needs to be done. >> the drug dispensary to our veterans is almost criminal. without proper guidance, you look at the high unemployment rates in our veterans and you look towards drug addiction. we have to do something. because drug abuse is one of the biggest killers that we have. our military and our veterans is absolutely off the charts. we are putting a drug, prescription drug abuse caucus together democrats and republicans working together.

>> we agree with you and we recognize it as a national problem and it is a problem inside the va. >> it's a problem it in the general society. thank you, senator. >> thank you mr. chair, thank you all for being here. just a couple of things and one is based on a comment earlier about some in the senate that are thinking that we should privatize this. i have not had a serious single discussion with anyone that has seen that in that way and if anyone here dead, all they need to do is spend some time to understand the unique nature of what they have to offer. there is no other more welcoming place in the va. not that there aren't opportunities for private care there really are already.

the non-va care is already a big part of what you do long before choices implemented and so you know i realize in these committee meetings sometimes our words carry more weight than they should but i don't think anyone should leave this committee meeting thinking that anyone has any serious goal or objective to privatize the entire va. going back to the point that the senator mentioned and i also have concerns about the denver hospital and i completely understand your predicament is you have to have a way to build it up. can you give me an idea about what the thought process was. and so what would that cause in terms of delay or ramping down what we would be doing with choice over the time that that money would not be available?

>> in identifying the nonrecurring maintenance and construction projects we had a capital planning process it actually builds a prioritized list of his years long based upon the pace of funding that we normally expect to give. so when we look at the $5 billion in funds we basically have reached into that list and pulled a segment out to put into that priority bucket. you know, what happens now is a substantial portion if we were permitted to do this, it would wind up in the 2017 budget because they've been that would fall back into the prioritized piece. >> that is why i was asking the question because you could infer from some of the discussion that there was a 700 million-dollar

hit the care nothing provided versus taking a look at how that was going to return out of the choice program and that is how i was asking. it sounds like there's leveling assumptions. >> that is exactly right, the movement has been that we would work it back to the funding stream as quickly as we could. >> i think that in order for what you have requested in a letter that you have and to to have any prayer of serious consideration, you need to map out hollywood have assurances that it doesn't materially affect it because of the way that you would plan to spend that money anyway. >> thank you for raising the issue is. >> otherwise i would tend to go back to the well articulated position of the ranking member. the other question that i have and the thing that i think is important is that we need to get a five-year or tenure or twenty-year picture of what

choice care and that it's critically important for you going back and re-looking at the capital improvement trying to figure out how to do it, the answer is going to be different depending on where you are. the senator will rightly say that they have a higher per capita veterans population i have one that exceeds the population of several states. this would be necessarily different and the non-va care and the choice would be necessarily different but we have to come up with that long-term visit and based on what it appears to be the interest of the senate to continue down that multi-pronged path so that you are taking pressure off of capital arm and

in some areas and maybe redoubling them in some areas and that the variant one thing this committee meets to see and then we need to be very specific about what we want beyond rick and mortar presence in the form of non-va care to get this right. >> if i could make two quick observations, your absolute spot on. first of all, we have is ourselves to make certain decisions on what can be made for the community. we have talked before my example of the chairman remembers optometry. why would we send a veteran to get his eyes checked and classes. why would we not be routinely referring to that unless a veteran really wanted to come to the va. the other issue that were trying to get at what we are learning what we are saying is that every

time demand changes in part of what we're trying to understand when you look in phoenix where we know that we are under penetrated and the veteran market and improve access to care and we get a disproportionate response and we have to understand that the penetration phenomenon will affect the capital planning and i will talk with the folks about getting beyond that, looking over the horizon. we can't keep incrementally doing this because we're just where to stay behind and we are going to get ahead of this. >> thank you, mr. terry. >> tank you, senator. >> there is a shorter personnel in the testimony and a noted that you're going to be creating his residency positions in this is a matter that i have discussed with the va person in

hawaii. and it's more likely that the folks will be able to practice in the state. so how will these residencies allocated by capacity are there any increasing for medical students of hawaii raiment. >> i don't have a list with me today specifically aware this is going. >> have you determined where this is a matter. >> that is a multitier type of plan to deploy the 1500. the first round of those started this fiscal year and we actually went out, i frankly i did not think that our office would be able to do it but they went out and they sought applications and there are very specific criteria and a lot about them going to under resourced communities, they went out and saw those and

we have awarded several hundred for this first round this year. not as many as we had had thought maybe but more than we anticipated they would be able to award and specifically where they are as well. >> hawaii has a lot of rural areas that are underserved with by the va. and we thank you for the information. looking at the request to pay for the facility and it's very difficult for us to accept that you want to take money from the choice program to do that. so i would like to ask you this. when a veteran goes to the va to get care for a nonservice can read matter in this veteran has private insurance, do you have the authority to get reimbursed from the private insurance company for the care that the va

provides? >> as it goes we will build them and collect to offset the cost of the care that we provided. under choice we are actually the secondary payers and under the choice program with the way the law was written to patient has commercial insurance, the commercial insurance is the primary payer. and then we will make the provider up to the medicare rate. >> my understanding is that in the first instance are the veterans goes to the va and gets the treatment, often there is no reimbursement from his or her private insurance company. are you telling me otherwise? >> we will build a private insurance company if the patient has insurance.

>> do they reimburse you? >> yes we get paid from them. a lot of the patients have insurance and have medigap insurance. oftentimes they will not pay for this because of this gap coverage. oftentimes he will not get paid by those insurers. >> your reassuring me that they go after every dime from the private insurance? >> i can assure you that we go after every dime we can collect which is about 3 billion per year. >> or western about the outreach and the program, there is confusion out there and whether you find the veterans that have all five. my question goes to order the outreach efforts and you think you are succeeding in explaining the choice program aand also to

have community providers to get training on how to explain the program. >> know who the people are that are eligible to get a choice card and we mailed a letter to everyone of those people in the program started in november. >> many found it confusing. >> hopefully it is a lot simpler to understand we have actually tested that with veterans for we put it in the envelope. we have made a lot of phone calls and there's no question that i think that we can do more to be able to reach the veterans through website and mobile technology and mailings and other forms of communication and we need to do a better job of educating. >> we do need to do of her job.

one of the things that we have to remind ourselves of is that there is no parallel to this it's not like an insurance card where you walk into your doctors office and present your insurance card, there is no frame of reference for people to understand how it works. why have a benefit, do i not have a benefit it's hard for us to explain was why we have to keep trying. >> we would love that. thank you. >> thank you mr. chairman. briefly i would like to ask a question. i understand that the third-party administrators raised the issue of how much clinical documentation is being sent by the va many due to

having a wait time of 30 days which presumably is overwhelming and you now have a pilot program to only send the clinical information and i guess the question is is it proving successful and also if you would like to comment from your standpoint as what is going on. >> when we first set up the program we gave every patient in the system an appointment and put them on the choice list so that they could decide at any point in time which direction they wanted to go. we have learned to experience over the last months this but it doesn't always work. it doesn't help the veteran rs quite frankly it's not cost effective. so we have the pilots and we

have just learned this to see how it goes and how it can improve the business processes. a quite agree we are moving in the direction that the point of service finding out what we can provide or offering them the opportunity to go outside to the choice of ram if they choose to go up and our staff much like they do outside of choice for all of our other appointments, we worked directly to get that part of the choice program. at that time we hope we have learned how to do this smarter and better so that we will greatly reduce the volume of people that we are referring to and are only providing medical record documentation's for the patients who choose to go outside of the system. >> that sounds excellent.

>> is a very good idea and eating at the table in the initial design and we are getting ready to launch we had two days to make a decision. the question was heavy make sure that all the right information's and place to be able to serve people on the front and. >> the back and consequences are obvious and making the change makes a lot of sense and we're looking forward to supporting it. >> this has been going exceptionally well in our area and we just approved is a dual to move forward with this across all of the regions and we are getting this in less than 24 hours and it's very effective. >> it is kind of a rocky road as you're working through these things but it sounds like this is encouraging. >> thank you, mr. chairman. >> senator, just because you have a very good committee

meeting here. we thank you. and thank you for your work. and quite frankly i don't know where to start, you guys do a good job in the private sector does a good job don't think that the pirates sector doesn't have their fallibility is just like you guys are. and in the bookkeeping nightmare that could come with this, i lived 50 miles and my nearest hospital is 12 miles away. and it's staffed by a nurse practitioner. so the question becomes is that somewhere you want to go to heaven of them in and if i don't, guess where the nearest hospital is. and the bookkeeping here is just amazing and i just i know that

we are trying to do the right thing and that you are trying to do the right thing, people are mad because they think it is the wrong thing. but you talked about the 40 mouthing as far as not offering service. you talked about how it doesn't make any sense of the guy has no glasses, why should them halfway across the country. when you did your analysis did you include the savings that would occur to the va by not shipping them a long way away rematch because i think that's really important. if i was a veteran i probably would've signed up for just this benefit. but the truth is that if you're talking about what it costs, it's also a savings just in mileage alone. did you include that in the overall net dollar figure? >> we actually do not we have worked through several options

with what it might look like. we have not taken into account a great many savings. in the short run we were modeling this. in the short run our structure is 90% of costs are fixed. mostly the rest of the of the structure and the building don't go away. >> the mileage is also not a fixed cost. if you have to put them up in a room that is not a fixed cost. >> there are two aspects of the travel under is the true cost savings and there is the cost avoided and that is not a real savings, that is a cost that you did not realize.

>> correct. >> come on, that sounds like that out there. truthfully. i mean the fact is that if you are doing the actual cost analysis and you would've spent the money, you have to include that in the savings. by no means do i think this, but truthfully if we are going to deal with honest figures this has to be included. >> clearly it does have to be included. >> even if the level of analysis is better than what we had initially lay down to the individual patient and we haven't picked up some of those incidents. ..

it changes the nature of it. >> it's wrapped up in that and it needs to be a near-term exercise. >> with steel with that because i think it's confusing right now. i think there is a little manipulation going on. >> and if i might one of the issues i was attempting to address is the fact that we built a network in our area that has 100,000 providers. the requirements are more extensive than those under choice. if you are participating providers. those things need to be blended together so that we don't have

disincentive to participate in one program versus another. >> fair enough. >> and the reimbursement rates need to be the same. 700 million transferred 400 million. i don't have a problem with that by the way. the questions i have is this is a miracle drug. when you anticipate those costs to flatten out so you aren't going to need those kinds of dollars? >> i think the conversation that needs to be held at this house committee and the appropriators has to do with the requirement that we managed great i would tell you our thought, the va's thought is we should be talking about a requirement where veterans that are hep c positively manage that number two functional zero by the end of 2018. that is what i think the requirement should the. so what we need to do with step back from that and lay out a

plan that says this is what would be required in order to manage that requirement so we are not back-and-forth. the first time we deny a veteran access to treatment to his hep c positive because he doesn't have advanced liver disease everybody thinks we are depriving a veteran of care. we need to reach agreement on what the requirement is. >> one last question. you talked about residency slots and i think that is great and i would support it but i believe residencies or three years. >> it depends on what the specialty is. >> what about for internists? >> three years. >> and that is what we are short on right? the question i have is this place changes every two years and to have three years in a residency you have to have the money for that residency. talk to me about how this works because you have forward funding

but you don't have forward funding for three years. so what do you do if congress does something irresponsible. >> that has been known to happen a time or two. >> i think this is one of our concerns. when we started new residency slot all of those slots have to be funded for the duration. >> that is not the case today. >> that's important to know as we move forward. and when he are going to start the residency program? and will it start this fiscal year? >> we actually don't own the residency slots. they are owned by the academic centers. we pay for trainees to offset their salary. additional slots that we added started this academic. >> so this fiscal year. >> the academic year that will

start this coming july. >> so this budget we are dealing with this. if your budget comes in short this may be a program that goes -- >> i doubt it because we have made commitments at this point. >> thank you guys for your work. appreciate your flexibility mr. chairman pang. >> thank you to all the members and thanks for -- i appreciate every time and effort very much. we will take a two-minute break. >> we appreciate the collaborative working relationship mr. chairman. >> it's the only way to do it. [inaudible conversations]

[inaudible conversations] sydney it was a good first panel. i apologize to our second panel is that it took so long but the participation you were illustrating by the looks on your face i'm sure you enjoyed it too so thank you very much. the welcome back to the senate veterans affairs committee. darren selnick advisor for concern veterans for america. joseph violante director of disabled american veterans mr. bill rausch who is missing in action right now for awol. political director for iraq and afghanistan veterans of america.

carlos field taste of the veterans of foreign wars and we welcome all of you and we will start with you mr. butler. >> chairman nye six and ranking member blumenthal and distinguished members of the committee on behalf of our national commander michael hamm in the 2.3 million members of the american legion we thank you for this opportunity to testify regarding the american legion steel of the progress of the veterans choice program. the american legion supported the access to choice and accountability act of 2014 as a means of addressing emerging problems than the department of veterans affairs. v-8 waits for medical care have reached an unacceptable level as veteran struggled to reset access to timely health care within the va health care system. it was clear this with changes were needed to ensure that veterans have access to health

canada timely matter. as a result the american legion to charge by setting up veterans benefits centers in big and small cities across the country to assist veterans in need and their families as a result of the systemic scheduling crisis facing the va. the american legion dbc charges work first-hand with veterans experiencing difficulty in obtaining health care are having difficulty in receiving their benefits. on november the fifth, 2014 va world of the veterans choice card program and after six months is clear the program fell short of initial projections from cbo. according to the va metrics dated november 31, 2015 there were approximately 51,000 authorizations issued for non-va care since implementation of the program with about 49,000 appointment schedule. when you compare these numbers to the opera 8 million cards

issued one would ask why to be a issue so many choice cards? nevertheless the american legion is optimistic that the recent rule change by eliminating the straight-line rule and using the actual driving distance will allow more veterans access to health care under the chase -- choice program. the american legion believes if va were to move forward with the rule change to include the va medical facility that can provide the needed medical care or services everyone would see increases in minimization and access to non-va health care. the american legion applauds the senate for unanimously -- reminding the department of veterans affairs they have the obligation to provide non-va care where they cannot offer the same treatment as one of its own facilities within the 40-mile driving distance from the veterans homes. we now call upon the house to take up h.r. 572 the veterans

access to community care act and ensured its swift passage. let's get these bills to the president's desk and make sure we have taking care of our veterans. during a recent visit last month to examine the health care system in puerto rico the american legion learned that the va staff had mistakenly telling veterans that no one on the island was eligible for health care and to the chase card program because there is no medical facility further than 40 miles from anywhere anyone lived. the american legion is concerned that as a result of inadequate training there could the staff in many health care facilities in vail to receive proper training of the result of bad indications and providing incorrect information to veterans. recently the american legion learned to be a contract required these third-party administrators to report daily

choice metrics however these contracts have now expired in the tba are no longer required to report these daily metrics. the last report b.a. provided was dated march 31, to 2015. the american legion is concerned that since the tba is no longer required to provide these metrics va can lose track of the numbers. the american legion calls on congress to require va to report these daily metrics throughout the duration of the contract or explain how they will continue to track this information. in fiscal year 2014 va spent over $7 billion on non-va health care. many of the non-va purchased care programs managed by different program officers and va central office in some of these services are handled outside of processing systems. v-8 current purchase models incorporate all of va's non-va care programs into a single

integrated purchased care model. congress should look into streamlining non-va care statutory authority. one gets a better sense of how the choice program of play out over the next couple of years. v-8 90 care statutory -- should be consolidated and rationalize incorporated lessons learned from the va choice program. thank you and again mr. chairman ranking member blumenthal i appreciate the opportunity to present the american legion's views and look forward to the answers to questions you may have. >> we appreciate your willingness to follow up and come to all the hearings. thank you roscoe. darren selnick with concern veterans of america. >> members of the committee i appreciate the opportunity to testify at today's hearing on implementation future of the present choice program and thank you for your leadership in

ensuring veterans get the quality health care they deserve. free choice health care remains remains -- like a moraitis in the desert move closer. the choice program is unsuccessful and long-term solutions. current rules pertaining to choice not present real choice. they require veterans to obtain obtain -- prefer there will to make a choice. instead they require veterans to to -- va. veteran should not access permission to select health care provider. be implementation against a choice program is that a failure. for example the associate press reported gao says veterans health care costs are high-risk for taxpayers the number of medical claimants to take longer than 90 days to complete his nearly doubled 37 medical claimants have been major at 11.

last fall cpa commissioned poll veterans. the results showed 90% favored efforts to reform veterans health care 88% said eligible veteran should be given a choice to receive medical care from any source they choose 77% said they want more choices involved in higher out of park it -- pocket costs. we choose a health care insurance provider primary care physician. health care organizations provide quality can be any care because if they don't they will lose their patience to summon up in order to fix the va health care system both choice and competition must be injected into the system. va recognizes the value it options for potential organization that put the veteran and control how when and where they observe. and enforcement veteran should not have the control and will not under the current va health care system. va needs to have a 2015 health care system but we believe the veterans roadmap and solution can do just that. this roadmap was developed by the veterans health care task force chaired by dr. bill frist

jim marshall from a congressman from georgia the manhattan institute and dr. mike -- bha's undersecretary could we develop 10 veterans or patrols a service for guiding foundation. these principles included the veteran must come first and not the va. veteran should be it would choose where to get their health care focus on prior to tis service connected disabilities and specialized needs. va should be improved and preserved. current enrollees in bha needs of the company. implement these principles we laid out three categories a reform in nine policy recommendations. first an independent government chartered nonprofit corporation. the power to make decisions on personnel i.t. facilities partnerships and priorities. second give veterans the option to see private health care coverage with va funds. third, refocus veterans health care of those with service connected injuries.

key policy recommendations including provider function to separate institutions established the health insurance program is a program office in bha. establish accountable care organization the nonprofit government corporation separate from b.a. preserve the traditional va health benefits for raleigh's preferred and see coverage from private sector to three plan choices. full access to the m. at grated grated -- integrated health care system health care choice elected a private health care insurance plan legally available in the state finance premium support payments and medicare veterans can you use their va funds to defray the cost of premiums and supplemental coverage. lastly create an implementation commission to implement the independence that. between the services the hsi to properly design policy recommendations likely to be deficit-neutral. in order to fix the veterans

health care we must i keep in mind general omar bradley said. we are dealing with veterans not procedures. with their problems not ours. this is why we are sure to use the veterans in the panasonic roadmap to fix and be the future veterans health care. veterans must be sure they will be able to get the access choice and quality health care they deserve in this mission failure is not an option. we are committed to overcoming all obstacles to stand in the way of achieving this mission and the court to work and the chairman or ranking member and members of this committee to achieve this shared mission. thank you. >> thank you mr. selnick. let me just interject at this point. i have read and i'm sure richard s. too the fixing veterans health care report that the organization did which is not standing report you think it is called ultimate choice if i'm not mistaken. with that mistaken. without they could import? >> that would be a good name.

>> in a representation of the changes are far more broadband some on the panel might look for us to do in terms of preserving what va does but i want to commend you on that and let you know we are watching what you have recommended and we are taking a look at it. richard and i have one underlying principle. we are going to make veterans choice work and is not an option that my work and if it doesn't work and we will think of something else. how are works will take the best ideas and input and you are report is one that will help. this is going to be a process and evolution as we go through but one thing is for sure we are not just hoping it's going to be over one day. we are going to make it happen one way or another. >> iq. >> mr. sim six. >> chairman isakson ranking member blumenthal members the committee on behalf of the va and the 1.2 million members all of them are wounded injured or made ill from their wartime service thank you for the opportunity to testify on

temporary choice program. while it is too early to reach a conclusion about this program we are beginning to see lessons. as of last week almost 64,000 choice authorizations have been made and 43,000 appointments have been scheduled. by comparison about 6 million appointments are completed monthly inside the egg and another 1.3 million appointments completed outside va using non-va care programs other than choice. a number of reasons like to contribute to lower than expected utilization of the choice program. since let's bring va has used every available resource to increase its capacity to provide timely care that may have shifted some of the demand away from choice. ea was low in rolling out choice cards and in educating its staff. we also hear troubling reports of a significant lag time between when the va clinician determines the veteran is eligible for choice and a

third-party administrator can see this authorization in their system. finally some veterans refer to go to va. the bottom line is we do not have adequate information today and need to take steps to gather sufficient data before making any permanent changes greatly must study private sector wait times and access standards coordination of care, patient satisfaction and health outcomes to those who use the choice program. mr. chairman recently dav vfw the legion road to congressional leaders to extend the mandate of the commission on care to allow at least 12 months for its interim report and at least additional six months for the final report. he called on congress to refrain from taking any permanent systemic changes until after the commission submitted its recommendations and then allowed sufficient opportunity for stakeholders and congress to engage in a debate worthy of the men and women who serve.

for more than 150 years going back to president lincoln's solemn vow to care for him who shall have war and the battle the va health care system has been an embodiment of our national promise yet today some are proposing to make it just another choice among health care providers while others are calling for the va to be downsized or eliminated. but for millions of veterans wounded injured or ill from their service there is only one choice for receiving a specialized care they need and that is a healthy and robust va. although the va provides comprehensive medical care to more than 6 million veterans the va's primary mission is to meet the unique specialized health care needs of the nation's 3.8 million service connected disabled veterans. the va was downsized or eliminated it would the private

health care system would be unable to provide timely access to the specialized care they require even if all disabled veterans were dispersed into private care there would only be 1.5% of the total adult population. does anyone truly believe that a market-based civilian health care system would provide the focus and resources necessary for the small minority and the way va does. mr. chairman while far too soon to settle on how to reform the va health care system and integrate non-va care we can at least outline a framework to rebuild, restructure realign and reforming the va health care system. first rebuild and sustain the its capacity by recruiting hiring and retaining sufficient clinical staff and by funding a long-term strategy to repair and maintain va facilities. second restructure the many

non-va care programs into a single integrated extended care network which incorporates the best features of fee-based pc3 and other purchase care programs and provide this program with a separate and guaranteed funding source. third realign and expand the e-health there are to meet the diverse needs of future generations of veterans including women veterans. this should include networking care nationwide with extended operating hours. fourth a foreign va management by redesigning its performance and accountability report in restructuring its budget process by implementing a system which stands for planning programming budget and execution. mr. chairman this framework is not intended to be a final or detailed plan nor could it be part of one at this point but it offers a new pathway to a future that truly fulfills lincoln's

promise and that concludes my testimony. i'd be happy to answer the questions. >> thank you very much mr. rausch. chairman nye singson ranking member blumenthal -- ranking member blumenthal thank you for the opportunity to share these views with you at today's hearing. as has been drafted and it has final language being debated. it's a highly complex lob but the department is working hard to implement to ensure veterans are not left waiting for an acceptable length of time to receive health care services. my remarks will focus on the experiences of utilizing the va trace program. members have reported to us by way of survey research. ishmael provide recommendations to congress and the secretary must consider not to get the program operating at the height of its potential. these recommendations include legislative clarification of the

eligibility criteria for access in the choice program, strengthening trading guidelines for va schedules charged with explaining criteria to veterans and continued active engagement with veterans organizations to broadly identified the conference of strategy and plan for delivering non-va care in the community moving forward. in examining the current criteria for determining which veterans are eligible to use the choice program those who must wait longer than 30 days for employment and those who have more than 40 miles to the va medical cysts -- facility more clarity is required to veterans are all to bring the reporting they are unsure of their eligible for choice and va has been inconsistent in communicating whether veteran can access in individual cases. based on her most recent survey data over one third of our members have reported they don't know how to access the choice program. this is compounded by reports by in some cases be a schedules are not explaining eligibility for

choice. the secretary and lucia must continue to engage scheduling personnel of ongoing evolving trading standards so an i'm veterans call the va they receive consistent and clear understanding of their eligibility for the choice program. the va has improved in this area but with so many veterans confused about eligibility training criteria must be strengthened and maintain. congress should aid in the apartment implementation by clarifying bob at the 40-mile criteria must relate specifically to the va facility in which the needed medical care will be provided. this frustrating example that continues to surface is specialized care to va facility outside the 40 miles but through strict interpretation of their current -- is ineligible because of facilities may be geographically and they veterans address. one of our members illustrated this recently by saying quote

because there is a city block in my area i was tonight. the clinic doesn't provide the treatment need for my primary service connected disability. the nearest medical center in my network is 153 miles away and quote. congress must provide needed clarity and work with va and it sounds like you are too limine cases like those described. there've been encouraging developments relating to implementation of the choice program specifically va's actions to step up and fix the effectiveness of the 40-mile rule calculations related to the driving distance. that revelatory correction was much needed and as a result there are hundreds of thousands of new veterans eligible for the choice program. we applaud secretary of mcdonald and deputy secretary sloan gibson for their leadership in listening to their customers to make that change happen. the statistics on choice utilization among among veteran populations as of this month's date there've been 59,000 authorizations and nearly 47,000 appointees. this data verifies veterans are

using the program and va has been making progress to implement a complex and important program. we are committed to remaining actively engaged with the veterans making use of the choice program so we can keep current on the veteran experience. we are mindful that thousands of appointments being conducted there will be thousands of unique experiences and we want to engage those levels of satisfaction with our members through this program. the satisfaction the cost of care purchased outside of va facilities in understanding issues come up will allow us to better realize that veterans book focused strategy and plan for non-va care in the can into forward. appreciate the hard work of this congress the va and the veteran community and recognize its stay focused on improving veteran health care delivery in the short and long-term. robust discussion on the scope and cost of maintaining health care networks is contemplated which is wireless recommendation is simple and something we have touched on before. we must continue to work

together to keep communication active between all relevant stakeholders. mr. chairman we sincerely appreciate your committee's hard work in this area and we wanted to know know we stand ready to assist this congress and their secretary to achieve the best results for the choice program now and future and we look forward to taking your questions. >> thank you very much. mr. violante. is that close enough? >> chairman nye six and ranking member blumenthal the vfw and the artillery thank you for opportunity prisoner views on the choice program. before they can i want to say the vfw opposes the va's change the way veterans choose to use the veterans choice program. the veterans must have the opportunity to explore their private sector options before rejecting the va appointments. this changes the bureaucratic convenience that will negatively affect -- identify new issues

this choice program faces and recommending reasonable solutions. yesterday we gave her a second report evaluating this program was made 13 recommendations on how to ensure the intended goal of expanding access to health care for americans veterans. our initial report identified a gap between a the number of veterans who are eligible for the program and those who were given the opportunity to participate. our second report has found that the va has made progress in addressing this gap. 35% of second survey participants who believe they are eligible were given the opportunity to participate. that's a 16% increase for her initial survey. for 30-day years participation hinges on va schedulers eligibility. the lack of systemwide training for front-line staff has resulted in veterans receiving

dated or misleading information to va continues -- must contain to improve this process and training to ensure that all veterans who are eligible for the program are given the opportunity to participate. our second report found a decrease in satisfaction among veterans to receive non-va care. this is a direct result of veterans not being able to find viable options in the private sector. the 40-mile standard used established geographic raised eligibility for the veterans choice program was based on eligibility for tri-care prime however there is a distinct difference between the veterans population in the military population. 36% of veterans enrolled in va health care lipid rural areas. thus measuring the distance servicemembers traveled to military treatment facilities and using that same standard to measure distance traveled by veterans to va medical facilities does not properly

account for the diversity of its population. our second report found a commute time standard based on population density would more appropriately reflect the travel burden veterans face in accessing va health care. regardless and the va must commission a study to determine the most appropriate geographic a standard for health care furnished by the va. is the future of va health care system are evaluating it is important to recognize that the quality of care veterans receive from the va significantly better than what is available in the private sector. moreover many of va's -- could not be duplicated or properly supplemented by private sector health care especially for combat related mental health blast injuries or service related toxic exposures to name a few. with this in mind the must continue to serve as the initial touch point and guarantor of

care for all enrolled veterans. although enrollment in the va health care system is not mandatory and despite more than 75% of veterans having other forms of health care coverage more than 6.5 million of them choose to rely on their earned va benefits and are by and large satisfied with the care they receive. moving forward the lessons learned in the veterans choice program should be incorporated into a single systemwide non-va care program with veteran centric and clinically driven standards which afford veterans the opportunity to receive private sector health care if va is unable to meet the standards. more portly rva care must supplement the care that veterans receive from va medical facilities and not replace it. ideally va would have the capacity to provide access to direct care for all the veterans it serves. we know however that va medical facilities continue to cooperate at 115% capacity and may never

be able to build enough capacity to provide direct care to all the veterans it serves. va must continue to expand capacity based on staffing models for each health care specialty and patient density threshold however the va cannot rely on building new facilities alone. when thresholds are exceeded they must use agreements with other health care systems and affiliated hospitals when possible and purchase care when it must. mr. chairman this concludes my testimony. i am prepared to answer any questions you may have. >> mr. fontes at the beginning of your testimony is that va must immediately address and i couldn't find it in the printed testimony. writing your first two or three sentences? >> my first statement was the

change that was announced on how veterans elect to use the choice program. right now they are scheduled with the va does that appointment is beyond 30 days they keep that appointment and they call triwest or healthnet and explore what their options are in the private sector. that means they are making an informed decision when they decide to essentially reject the va -- if you change that to having a veteran make the election before exploring their private sector options is not an informed decision and actually leads to veterans if they go to the private sector having to go to the back of the line and restart their rescheduling process all over again. >> i want to make sure i understand this. i'm a veteran that was more than 40 miles from the clinic so i'm eligible for veterans choice. you are saying i should make a

private appointment through the midwest, what's the name? and make the va appointment and i can choose which one i want and not automatically go to the private provider? >> for 40 miles i believe they should continue to contact triwest however 30-day or sit va can't find an appointment within 30 days right now the va schedules that appointment. let's say it's 60 days from now but in talking to triwest for example for dermatology the average appointment is 60 to 90 days so now i am choosing for waiting six days in va to waiting 90 days in the private sector. i should know that the wait time in the private sector is 90 days before making that choice. sloan if you will answer this question. if i'm a veteran in over 40 miles from the clinic i can

automatically call triwest to make an appointment, right? >> over 40 miles yes sir you can. example he is citing is 30 days wait time and the proposed process we were talking before senator boozman mentioned about all of the administrative material for clinical information is being sent over. what we are trying to do is to streamline that part of the process. when this case said that veterans are not pleased with the appointments that process happens within a couple of days and they should build a come back to va to say i wasn't able to get a timely appointment for the tpa refers the authorization back. but it is a consequence of making a change rather than booking the appointment with va and referring to veteran over to the third-party administrator. >> mr. chairman just to be clear there are two distinct processes processes, one for 30 days and one for 40-mile or so.

i think one of the issues that the proposed changes is looking to address is now shows and cancellations. so when they veteran alex, when the veteran accepts an appointment in the private sector triwest or healthnet until the local facility this veteran has chosen choice cancel that appointment. however currently have va schedule or if va staff member has to go and manually cancel the appointments. this will prevent that however this will come at the cost of the veterans experience. >> that is what i was getting at because i was hearing their words a potential problem. >> there are better ways to address that issue. i feel a process could work but just a more seamless way of triwest and healthnet notifying va that the veteran

has accepted a private sector appointment. >> i want to open a hornet's nest but i'm going to go ahead and do it anyway. i had to pay $30 penalty for not keeping an appointment at glanna for health care was getting and i think you can't put everything on the shoulder of triwest or the va. if somebody doesn't do their job by letting va or tri-care to know which one they are going to keep i would be the first person to say there ought to be a penalty for not keeping that appointment that way the communication is complete. i know there will be some that don't like that idea but it gets everybody's attention. if we are going to be more efficient i think everyone has to be part of the efficiency including the veteran getting the benefits. i just wanted to put that in there. not to start a hornet's nest but thank you for raising the question. it's very help pull. senator blumenthal.

>> thanks mr. chairman. you know we have been talking a little bit about how to pay for the denver crossover. >> we just figured it out. >> the chairman has told me that we just figured it out. so this has been a more productive afternoon then you could have ever hoped. >> i apologize. >> i want to thank all of you for your thinking through these issues in such a construct of them positive way. i was taught as a trial lawyer never ask a question if you don't know what the answer is going to be but i want to ask an open-ended question. given that the choice program and the choice and accountability act creates this fund of $15 billion my view is

that the potential rate on this money and the effort to use it as a kind of slush fund to pay for cost overruns in aurora and orlando and new orleans and las vegas where in fact in total there in 2.50 yen dollars in cost overruns is a real threat to veterans health care. we can debate how much private care should be provided and how much it should be through va facilities but there is no question in my mind at least at va facilities are an essential part of the health care mix of opportunities that we provide to our veteran.

therefore to say we are going to defer projects and delay construction on those facilities all around the country to pay for cost overruns and those medical facilities under new construction is a very dangerous threat. so let me make that statement and throw it open to you for comment. >> we have gone on record to state his position that he opposes taking money from the choice program and using that funding to support other means i've heard a lot of interesting conversations today about exploring of options thinking outside the box. so i think members of congress, the va need to do just that. they need to put their hats on

and to think about what is best. how can we come to a resolution that was served veterans the best without taking money from a program that is early in its stage and utilizing that funding for other means and purposes. if that's an option that should be the last option after you have explored all of the other options. >> let me just chime in. i would agree with him in what you are saying is we do not want that money rated grade i worked at the va from 2001 to 2000 worked in dha for two years and every time there was a management failure there was no accountability. it was just give me more money, give me more money.

having been at the va i used to do an audit on the books. i would love to see an audit to see what is really there and what is not. >> veterans should not suffer because b.a. is unable to get -- the va must atone for its gross mismanagement. they should find cost savings in this program and other programs in any way can. ultimately congress does have an obligation to ensure va has the means to complete this project and additionally further delay and uncertainty will only lead to higher cost overruns. >> there is no easy answer and i believe the facilities are necessary and must be completed. where that money comes from is another question that i think it was said it's about veterans and veterans need to be cared for. congress needs to find the money

somewhere to continue these. it should never happen again. i think the va should get out of the business of building hospitals. >> we would agree with regard to the construction and more broadly and in all cost overruns of va provide a high-risk of not providing the highest quality care for veterans. that's the bottom line. i va supports the secretary's budget request. we also support his request for greater flexibility and assisted in the previous hearing in theory without greater flexibility it would allow him to move more money back into choice so we support his request for that. more broadly we believe choices an opportunity to better understand how veterans and where veterans want to receive health care that they deserve. that frankly ties into what everyone is talking about which is a strategic plan for coordinated care and mr. chairman i think i was the

phrase he used in a previous hearing and we have started to use that. ultimately we believe whether joy stays in its current form or fashion we think it's an opportunity to better understand the customer or members of the va can move forward with a strategic plan to provide the best service possible. >> i appreciate all of your answers which confirm my views and the chairman and i have stated those views and the chairman has dated and i have as well but we have alternative different options that we think absolutely have to be explored and we look forward to working with you on those options and also on the concept of a con ability which all of you have mentioned. you have heard me talk about it earlier which includes looking backward, holding people accountable who in fact are responsible for this nightmarish

debacle and also looking forward and i might mention mr. violante in your written testimony discuss the va's need to redesign its performance and in the accountability report you make reference to the department of homeland security's similar regiment known as planning programming budgeting and execution as a possible model. i am sure there are other models as well but to your point mr. rausch i have said that the va ought to be out of the business of construction. the corps of engineers or some other agency should take over this function. no disrespect to the va. it is not within their job description to manage these mammoth multi-million dollar impact billion-dollar projects

on which the future of va health care depends and when you and i go to build a house we don't ordinarily we are not our own contractors. maybe some of you are but we tried to get a little professional help and that may be in an exact analogy but for all the government agencies, not just the va there should be some professional center of management that maximizes resources, reduces costs, makes it energy-efficient decide what material should be incorporated so i think we have a lot to discuss going forward. i welcome your participation in i thank chairman for this hearing. thank you all. >> thank you senator blumenthal and let me echo everything that richards and point out a couple of things.

originally in our first hearing the va testified told us on the 40-mile world in terms of distance driven versus growth line that was going to expand the number of people out of bowl bull for va choice. it would cost more money. now that we have talked about the care you need and that definition which we are working on one of the estimates is that it will cost more money than we planned. we understand that to go from point a which was the disaster in phoenix that lead to other problems to where we want to go it's going to take time and it's going to take money and it's going to take ordination. which is where the coordination word comes from. there are savings and coordination want to accept a few principles. principle one is that it views the private sector well and veterans like it and some alternative to make the system markets not a substitute. in certain cases it's an alternative venue or saving the va money and getting the private sector investment in getting

better health care to the veteran. i'm willing to look at this in a macrosense. we just did a budget in the congress. a tenure balance budget in 10 years. b.a. has problems that will take 10 years to financially solve the deal have to begin at some point in time. hopefully as we work through this problem in denver and get resolution on who builds what and when they built the we can also look at them macrosense of how we find savings to pay for the changes we need to make it eventually will have a delivery system that's less costly but it will take us a while to get there. but that said i want to thank you all for being here and thank you for your service to american appreciate the time you have given us today. [inaudible