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“Roles and Responsibilities: Evaluating VA Community Care”

House Veterans Affairs Committee, Health Subcommittee Hearing

February 12, 2025 (recording here)

HEARING INFORMATION

Witnesses & Written Testimony (linked) (Panel One):

• Dr. Steven Braverman: Chief Operating Officer, U.S. Department of Veterans Affairs, Veterans Health Administration

• Dr. Sachin Yende: Chief Medical Officer for Integrated Veteran Care, U.S. Department of Veterans Affairs, Veterans Health Administration

• Ms. Sharon Silas: Director, Health Care Team, Government Accountability Office

• Dr. Julie Kroviak: Principal Deputy Assistant Inspector General, U.S. Department of Veterans Affairs, Office of the Inspector General

Witnesses & Written Testimony (linked) (Panel Two):

• Dr. Scott Kruger: Physician, Virginia Oncology Associates

• Mr. Dave McIntyre: President and CEO, TriWest Healthcare Alliance

• Mr. Ed Weinberg: President and CEO, OptumServe

• Mr. Chris Faraji: President, Wellhive

Keywords mentioned:

• Community care, referrals, wait times, care coordination, medical records, accountability, transparency

IN THEIR WORDS

OPENING STATEMENTS FROM THE SUBCOMMITTEE

• Subcommittee Chairwoman Mariannette Miller-Meeks spoke on the importance of ensuring veterans receive timely and effective healthcare through the VA's community care program. She stated that veterans should not have to navigate bureaucratic obstacles to receive care, nor should providers face unnecessary administrative burdens to serve them. She pointed to multiple reports of delayed referrals, canceled appointments, and long wait times as evidence of systemic failures. The Chairwoman underscored that the hearing aimed to hold the appropriate parties accountable and ensure the program serves veterans rather than Washington bureaucrats.

• Subcommittee Ranking Member Julia Brownley acknowledged the necessity of community care while stressing the need for a balance between VA-provided and outsourced healthcare services. She voiced concern over the rapid increase in spending on community care, which has reached $42 billion annually, without sufficient oversight from Congress. Ranking Member Brownley criticized the VA’s lack of contractual requirements and performance metrics, making it difficult to determine whether veterans are receiving timely and high-quality care. She urged her colleagues to conduct more rigorous oversight before advancing new legislation that could exacerbate existing issues.

SUMMARY OF KEY POINTS (PANEL ONE)

• Dr. Steven Braverman committed to improving VA healthcare and ensuring the community care program functions efficiently. He outlined his leadership philosophy, prioritizing communication, veteran care, customer service, and common sense. He highlighted the progress made under the VA MISSION Act, with over 5.4 million veterans referred to community care, but acknowledged challenges in coordination and administrative efficiency. Dr. Braverman reaffirmed the VA’s dedication to working with third-party administrators and stakeholders to address these issues and enhance the program for veterans.

• Ms. Sharon Silas outlined GAO’s findings on the VA’s administration of the community care program, pointing to ongoing challenges in scheduling, oversight of third-party administrators, and ensuring timely access to care. She noted that while the VA has established appointment scheduling timelines for VA providers, it has yet to implement similar standards for community providers. She also mentioned weaknesses in the VA’s oversight of its contracts with third-party administrators, calling for improved monitoring and accountability measures. Ms. Silas stressed that addressing these issues is critical as community care continues to expand.

• Dr. Julie Kroviak summarized the OIG’s oversight work, which has identified significant gaps in the VA’s management of community care. She reported that veterans frequently experience delays in referrals and poor coordination between VA and community providers, which affects the quality and timeliness of care. She raised concerns about inadequate oversight of community providers, lack of monitoring for opioid prescriptions, and failures in integrating medical records. Dr. Kroviak also said that staffing shortages and outdated IT systems further hinder the VA’s ability to manage payments and ensure proper oversight of the program.

• Full Committee Chairman Mike Bost restated the importance of VA community care and defended the Committee’s past oversight efforts. He referenced testimonies from veterans and family members who had experienced failures within the VA system and spoke in support of his bill, the ACCESS Act. He asked Dr. Braverman what the Trump administration was doing to ensure veterans were at the center of every VA decision. Dr. Braverman responded that Secretary Doug Collins had already set clear guidance prioritizing veterans in every decision. He assured the Committee that this principle was being followed throughout the VA and that his team remained committed to that mission.

• Ranking Member Brownley asked Dr. Braverman about Secretary Collins’ statement that the VA might take two to three more years to award the next generation of Community Care Network (CCN) contracts. She requested clarification on the key programmatic decisions delayed by the previous administration. Dr. Braverman explained that the VA was ensuring that future contracts adhered to acquisition standards and that the process was being expedited as much as possible.

• The Ranking Member also asked whether new contracts should include stronger oversight regarding wait times and quality of care. Dr. Braverman agreed that improvements were needed and stated that the VA was incorporating lessons learned into future contracts. Dr. Sachin Yende added that the VA was focusing on enhancing medical document returns and other oversight mechanisms for the next contract.

• Rep. Greg Murphy criticized the VA for repeatedly appearing before the Committee on this topic without displaying any improvements in the delivery of community care. He asked Dr. Kroviak what concrete changes the VA should implement to prevent delays, especially for veterans with serious conditions. Dr. Kroviak called for clear policies prioritizing high-risk specialties and internal oversight to ensure compliance.

• Rep. Murphy expressed frustration with the lack of urgency in addressing delays and questioned why there was no accountability when VA leadership ignored concerns raised by staff. Dr. Kroviak responded that defining clear roles and responsibilities was essential for holding leadership accountable. Rep. Murphy insisted that delays in care directly impacted patient outcomes, especially for conditions like cancer, and urged the VA to implement a stronger accountability system.

• Rep. Sheila Cherfilus-McCormick expressed concerns about VA staffing shortages affecting the administration of community care and questioned whether President Trump’s federal hiring freeze would worsen these issues. Dr. Braverman assured her that the VA had secured exemptions for critical positions, including medical support assistants and nurses, to prevent staffing shortages from affecting care coordination.

• Rep. Cherfilus-McCormick also pointed out that community care spending had increased from $14.3 billion before the MISSION Act to an estimated $42 billion in FY 2025. She asked Dr. Yende if this increase threatened the VA’s ability to fulfill its core missions, particularly its role in responding to emergencies like hurricanes. Dr. Yende stated that he was not aware of any direct impact on emergency response efforts but promised to provide more details. He clarified that while community care was expanding, VA facilities were also increasing direct care capacity, particularly in residential treatment programs.

• Rep. Derrick Van Orden shared his strong frustration with the VA’s lack of accountability, citing numerous GAO and OIG recommendations that had not been implemented. He compared the volume of unaddressed recommendations to those made, illustrating the problem visually. He questioned the witnesses on how many recommendations remained unimplemented, stating that it seemed like the VA was caught in a cycle of ignoring oversight findings. Dr. Kroviak acknowledged that hundreds of recommendations had been made but could not provide an exact number of those unimplemented. Rep. Van Orden argued that the VA operated with little to no accountability and claimed that real change would only come when leaders were held responsible for failing to act on oversight findings.

• Rep. Herb Conaway focused on the disconnect between VA policies for referral timeliness and actual wait times in the community. He asked Dr. Yende whether the VA’s current contracts with third-party administrators were contributing to this issue. Dr. Yende admitted that VA standards for access were not mirrored in community care contracts. He confirmed that the lack of contractual requirements for third-party administrators made it difficult to ensure that veterans received timely care. Rep. Conaway suggested that the Committee should review current contracts to determine whether there were opportunities to enforce stricter requirements and ensure that future contracts aligned with VA expectations.

• Rep. Abe Hamadeh echoed his colleagues’ frustration over systemic delays in veterans' access to care through the VA community care program. He accused the VA of using misleading wait-time metrics, canceling appointments excessively, and creating unnecessary barriers to referrals. He asked Ms. Silas about the main factors contributing to these barriers. Ms. Silas explained that delays stemmed from the VA’s complex eligibility process, difficulties in finding available community providers, and scheduling challenges. She said that veterans often compete with non-VA patients for appointments, making access more difficult.

• Rep. Hamadeh then asked if codifying access standards into law would help ensure timely care. Ms. Silas responded that establishing a standard for when a veteran actually receives care—rather than just when an appointment is scheduled—would improve oversight and ensure better tracking of access issues.

• Rep. Hamadeh questioned why the VA did not use the date requested versus the patient-indicated date to track wait times more accurately. Dr. Yende responded that VA wait times were calculated from the date a primary care physician requested a specialty appointment, ensuring a consistent and objective metric. Rep. Hamadeh countered that this approach still seemed to favor VA convenience rather than reflect actual veteran experiences.

• Rep. Kelly Morrison talked about ensuring quality healthcare for women veterans. She cited a 2016 GAO report that recommended including performance metrics for women’s health services in community care contracts and asked Ms. Silas whether the VA had implemented those recommendations. Ms. Silas confirmed that the VA had not included performance metrics in contracts but had instead developed a monitoring dashboard. She stated that while a dashboard was helpful, contract-based performance metrics would have created a higher level of accountability.

• Rep. Morrison then asked Dr. Braverman why the VA had not modified its contracts to implement GAO’s recommendations. Dr. Braverman admitted that he could not speak to past decisions but assured the Committee that the VA was open to incorporating such recommendations in future contracts.

• Rep. Morrison then asked Dr. Kroviak about the biggest challenges in obtaining medical records from community providers. Dr. Kroviak mentioned delays in receiving, uploading, and correctly filing medical records, which hindered care coordination. She urged for better oversight and training to ensure that community care providers returned medical documentation in a timely and accessible manner.

• Rep. Kimberlyn King-Hinds described the severe lack of healthcare resources for veterans in U.S. territories. She explained that veterans in her district often had to fly to other islands or even Honolulu to access care, incurring significant out-of-pocket costs. She asked Dr. Braverman what the VA could do to improve care access in remote areas. Dr. Braverman admitted that he was not familiar with the specific challenges faced in the Northern Marianas but committed to looking into them.

• Rep. King-Hinds then asked if the VA could expedite filling a vacant administrative specialist position in her district, which was critical for coordinating care. Dr. Yende acknowledged the unique challenges in territories and committed to following up on the issue, adding that the VA worked closely with third-party administrators in remote regions.

• Chairwoman Miller-Meeks defended VA community care, countering claims that it was inferior to VA-provided care. She noted that community providers, like VA doctors, were required to follow prescription drug monitoring programs. She asked Dr. Kroviak whether the OIG had verified community providers complying with state-level prescription monitoring requirements before making recommendations on opioid oversight. Dr. Kroviak admitted that the OIG had not directly checked state prescription monitoring databases but had instead relied on VA records.

• Chairwoman Miller-Meeks then discussed wait-time calculations, noting that veterans should be able to choose between the VA and community care based on actual availability. She asked Dr. Yende whether veterans were being given that choice. Dr. Yende confirmed that veterans should be presented with both options and be allowed to choose based on appointment availability.

• The Chairwoman then challenged claims that community care was more expensive than VA-provided care. Citing GAO reports, she pointed out that while community care accounted for 40% of VA healthcare in 2023, it only used about 25% of the VA’s healthcare budget. She asked Ms. Silas if this suggested that community care was more cost-effective than VA care. Ms. Silas stated that while those numbers were accurate, she would need to review the budget details to determine if community care was definitively more cost-effective.

• Chairwoman Miller-Meeks then asked Dr. Braverman how much it would cost if all community care services were instead provided directly by the VA. Dr. Braverman responded that it was difficult to determine since VA healthcare included fixed costs unrelated to per-patient expenditures. However, he acknowledged that the VA was facing increasing strain due to the expansion of eligibility under the PACT Act.

SUMMARY OF KEY POINTS (PANEL TWO)

• Before the second panel began their opening statements, Full Committee Ranking Member Mark Takano raised a parliamentary inquiry regarding the Truth in Testimony forms that non-government witnesses were required to submit. He pointed out that two of the witnesses had stated on their forms that they were not fiduciaries of their respective organizations. Given that both individuals were CEOs of companies that held over $70 billion in VA contracts, the Ranking Member questioned whether their responses were accurate. Chairwoman Miller-Meeks responded that it was important to hear from third-party administrators since contracting was a central topic of the hearing. She then affirmed that the witnesses had completed the required forms and disclosed their information as instructed. She stated that they had accurately filled out the documentation and that their responses were accepted by the Committee.

• Dr. Scott Kruger acknowledged significant challenges to community care, including long delays in authorizations and poor coordination between VA and community providers. He recommended streamlining the referral process to reduce delays and improving communication between the VA and community providers through better medical record-sharing platforms. He advocated for clearer performance benchmarks for third-party administrators to enhance efficiency and accountability and underscored the importance of timely reimbursements to encourage more providers to participate.

• Mr. Dave McIntyre highlighted TriWest’s role in facilitating over 65 million community care appointments for veterans. He stated that TriWest ensures rapid provider reimbursements, paying most claims within three days with 99% accuracy. Mr. McIntyre stressed that ongoing efforts aimed to refine appointment scheduling processes and strengthen partnerships between TriWest and VA facilities. He also urged Congress to fix the six-month claims deadline for provider reimbursements, arguing that TRICARE, Medicare, and commercial insurance all allow 12 months.

• Mr. Ed Weinberg described OptumServe’s role as a third-party administrator for the VA’s CCN in regions 1, 2, and 3, covering 36 states, Washington D.C., Puerto Rico, and the U.S. Virgin Islands. He reported that OptumServe had facilitated over 159 million veteran care visits and maintained a network of 2.4 million care sites. He pointed to provider retention as a major challenge, noting that timely reimbursements were crucial to keeping providers in the network. He also mentioned strong relationships with VA leadership, meeting regularly with VA medical centers, regional offices, and veteran service organizations to ensure ongoing improvements.

• Mr. Chris Faraji discussed Wellhive’s mission to modernize VA community care scheduling using advanced healthcare software. Wellhive’s External Provider Scheduling (EPS) system enables real-time access to appointment availability, reducing phone calls and back-and-forth coordination. However, despite its success, EPS remains optional, meaning many VA facilities still rely on outdated manual scheduling. He urged Congress and the VA to fully integrate EPS into the VA system to cut through bureaucracy and accelerate veteran care. He also noted that EPS had recently expanded to include mammogram and imaging appointments, improving access to women’s healthcare within VA community care.

• Ranking Member Takano questioned Mr. McIntyre and Mr. Weinberg about the capitated payment system, where third-party administrators receive payments based on the number of veterans referred to them. Both confirmed that their compensation increased with the number of referrals. When asked whether they assess the quality of care delivered by providers, both responded that they conduct assessments and share the results with the VA but do not make the information available directly to veterans.

• Ranking Member Takano challenged their claims, arguing that because third-party administrators do not require providers to return medical records, they lack the necessary data to evaluate quality effectively. He criticized the lack of conditions requiring payment upon the return of medical records and questioned whether audits were conducted to prevent opportunistic billing. Both Mr. McIntyre and Mr. Weinberg stated that their companies perform regular audits and are also externally audited on a quarterly basis.

• The Full Committee Ranking Member raised concerns about potential double billing, questioning whether UnitedHealthcare’s Medicare Advantage program and VA community care were both being billed for the same veteran’s care. Mr. Weinberg did not have an immediate answer but promised to provide the Committee with the data. Ranking Member Takano accused the companies of exploiting a loophole, arguing that billing both Medicare Advantage and the VA constitutes a taxpayer-funded windfall at the expense of veterans. Both third-party administrators denied any wrongdoing but agreed to provide revenue figures for their community care contracts.

• Rep. Hamadeh criticized Democratic colleagues for blaming community care providers for VA mismanagement. He argued that bureaucracy was the real issue, not private partners working to expand care access. He then asked Mr. McIntyre whether centralized appointment scheduling had improved veterans’ access during COVID. Mr. McIntyre confirmed that scheduling improved when TriWest handled it instead of the VA, and he believed that resuming centralized scheduling could further improve access.

• Rep. Hamadeh asked what obstacles third-party administrators faced in maintaining provider networks. Mr. McIntyre noted that network development had been successful, but retaining providers remained a challenge due to administrative burdens. When asked how the VA could improve referrals, Mr. Weinberg emphasized the need for standardized processes, better tracking, and more accountability.

• Ranking Member Brownley expressed concern over Dr. Kruger’s earlier testimony that reimbursements were sometimes lower than Medicare rates. She asked Mr. Weinberg if OptumServe was paying below Medicare rates. Mr. Weinberg assured her that OptumServe adhered to VA payment structures, which were aligned with Medicare rates. However, Dr. Kruger clarified that historically, the VA took years to process claims, and payments were issued at current rates rather than rates from the time of service.

• Ranking Member Brownley questioned the disparity between Mr. McIntyre’s claim of a three-day reimbursement process and Dr. Kruger’s experience of waiting five years for payments. Dr. Kruger acknowledged that reimbursement had improved significantly in the last six months but noted that navigating the VA’s approval process for treatment remained difficult. Ranking Member Brownley then asked whether third-party administrators would be willing to improve transparency around community care wait times, to which both Mr. McIntyre and Mr. Weinberg agreed.

• The Subcommittee Ranking Member praised the EPS system, arguing that it should be universal across the VA. She questioned whether the VA had deliberately chosen to keep EPS optional. Mr. Weinberg confirmed that the VA made the decision and that he supported universal adoption of EPS.

• Rep. King-Hinds asked Mr. McIntyre whether TriWest had enough providers in the region to meet demand. Mr. McIntyre acknowledged the challenges, explaining that while TriWest had providers under contract, some areas lacked healthcare infrastructure, making in-person care difficult. He underlined the need for circuit-rider providers—medical professionals who travel periodically to underserved areas—to ensure veterans receive care without excessive travel burdens. He agreed to follow up with her office to develop solutions.

• Rep. Morrison asked Mr. Weinberg and Mr. McIntyre whether they supported including performance metrics in future contracts to ensure accountability for women’s healthcare services. Both witnesses agreed, stating that transparency and standardized tracking metrics would enhance oversight and improve care quality for women veterans.

• Rep. Morrison inquired whether network providers had adequate training in military cultural competency, suicide prevention, and opioid safety, which are mandatory for VA providers but optional for community care providers. Mr. Weinberg acknowledged that he did not have exact figures on how many providers had completed these trainings but stated that OptumServe had partnered with organizations to offer specialized training. Mr. McIntyre confirmed that TriWest had similar training programs, stating that many state medical licenses already required opioid safety training.

• Chairwoman Miller-Meeks also supported the EPS system and asked Mr. Ferraj whether it should be adopted across all VA facilities. Mr. Faraji strongly supported universal adoption, arguing that unequal access to EPS created inconsistencies in scheduling. Chairwoman Miller-Meeks also asked whether EPS could be used within VA facilities for internal appointment scheduling. Mr. Faraji confirmed that a 2023 pilot demonstrated that it was effective for both community care and VA scheduling.

• Chairwoman Miller-Meeks asked Dr. Kruger about challenges in sending and receiving medical records. Dr. Kruger stated that his clinic faxed records to the VA but had no confirmation of receipt, adding that his VA facility deprioritized processing outside medical records. He described significant obstacles in accessing test results from VA-approved scans, often waiting for VA notification rather than receiving records directly. He also noted that even when he ordered scans, the VA technically issued the orders, preventing him from retrieving results directly due to HIPAA restrictions.

• The Subcommittee Chairwoman then asked Mr. Weinberg how delays in VA referrals impacted care. Mr. Weinberg claimed that referral delays directly harmed veterans, making it harder to provide timely care. He stated that OptumServe prioritized collaboration with VA medical centers to address these issues, but systemic inefficiencies persisted.

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