▶ 0:07:04Oh, there he is.
▶ 0:07:05Redmond. Jason Redmond,
▶ 0:07:08come here.
▶ 0:07:08Jason Redmond, report to the uh dis
▶ 0:10:50hearing will come to order.
▶ 0:10:53Good morning. Um, without objection, the chair may declare a recess at any time. We are expecting votes about 10:30, so odds are we will have to do that. Before I proceeded, I'd like to be clarify the purpose of this hearing.
▶ 0:11:07Article one of the constitution grants Congress the authority over fi uh financial matters and the powers to create law governing the uh executive branch and the responsibilities to oversee the execution of those laws. The committee is neither a stakeholder in this contract, a bidder nor a regulator.
▶ 0:11:32We are the constitutional body responsible for authorizing, funding, and overseeing the Department of Veterans Affairs. Our duty does not dismiss, diminish simply because a contract is large, complex, or currently active. [snorts] I also want to raise the issue of and timeliness with the testimony for today's hearing.
▶ 0:12:00This is the second time this week that we have not received the testimony from VA in a timely manner. It is incredibly frustrating for staff and members to try to prepare for a hearing without having testimony to review prior to the hearing. If this were not such an incredibly important hearing, I would consider prevent uh preventing VA from testifying today.
▶ 0:12:28However, given the importance of this hearing and the need for this committee to conduct critical oversight over this contract, I plan to proceed for this for the for the hearing, but rest assured that I will not be forgiving in the future. Now, I want to thank uh Mr. Richard topping for being here today. Mr. Topping is a VA assistant secretary for management and chief financial officer.
▶ 0:12:56before VA has before he has was chief legal officer for uh Caresource which is a medic Medicaid management care organization. He was also president of cares source military and veterans which is a pilot piloting com competitive health plan for triricare. More importantly, Mr. Hopping is also a veteran, an Army veteran, but we'll have to excuse him for that.
▶ 0:13:26Um, this is a whole jarhead thing. I can't help it. Um, I believe the background makes him a good fit to lead the Trump administration's effort to manage VA's community care next generation contract. However, this contract is going to cost the American taxpayer an estimated $1 I want to make sure this money goes where it needs to go.
▶ 0:13:51Improving health care access for veterans nationwide, no matter who at the VA is in charge. This hearing is the beginning of the conversation between VA and Congress to ensure this contract will maximize health care access and choice for veterans. The community care next generation contract or CCN nextG is one of the largest government contracts in the nation's history.
▶ 0:14:21It is also a unique type of IDIQ contract being used to purchase health care. I'm sure that Mr. Tobin will explain that that in detail in his testimony, but long story short, this is a revolutionary idea.
▶ 0:14:41If done properly, this contract would allow unprecedented flexibility for VA to award contracts and task orders that would leverage competition for the benefit of our veterans. It is an it is an ambitious idea. If it works, it may be one of the most important innovations in governmentrun healthc care programs.
▶ 0:15:10Unlike the first generation CCN NextG would all would award multiple contracts at the outset rather than being stuck with just one contractor. This will allow different contractors to compete for new task orders. As I understand it, the idea that the VA would be able to leverage new ideas and innovation for the benefit of the veterans.
▶ 0:15:37[clears throat] This contract structure would also provide a way to off-ramp poor performing contractors. CCN NextGen will also feature valuebased care or VBC at a base requirement. VBC has long been an effective way for health systems to control cost while promoting quality care.
▶ 0:16:04It is a concept that is fully vetted and tested by Medicare and it is it is long overdue in healthc care access for veterans in the communities where they I'm glad that we'll be able to that we will be paying providers for the health care they deliver rather than services they bill. Another new feature of this contract is uh utilization management or M.
▶ 0:16:33This is an important cost control tool, but it is also sometimes seen as a burden placed on providers and patients. One example of M is is the dreaded prior auth uh authorization. Now, without it, payers would have no way to stop unnecessary spending. But with it, some doctors have to move heaven and earth to get the right treatment for their patient.
▶ 0:17:00Needless to say, we're in interest to know how VA plans to strike the proper balance that ensures veterans receive the care they need and deserve while also preserving and maintaining programs integrity. VBC and M are only two of the many new features of the CCN NextGen contract. I bring up these two because they are both rich in opportunity and in need of congressional oversight.
▶ 0:17:28Neither of these are new concepts in American healthc care, but they are new to the VA. Now, I want to know how well VA is preparing to implement these features in the community care program. Having Mr. Topping at the helm does give me confidence, but as a great man once said, trust but verify.
▶ 0:17:51I want assurance backed with details and explanations that VA will make every effort to ensure that the real world execution matches the vision. I need to know that VA will innovate where necessary and lean on existing resources and expertise.
▶ 0:18:12For instance, the Department of War is managing complex contracts and the Department of Health and Human Services has whole divisions dedicated to payment policies. There will be new ground that VA must break and let's not rein reinvent the wheel. Mr. Topping, we are all eager to hear how you will be bring the uh this together for the millions of veterans uh in VA services.
▶ 0:18:40We are eager to hear what your team has been working on from the CFO and all the way down to the contracting officer and also we are eager to hear in details how you implement how you will implement such a complex system and bring veterans care into the next generation. As I understand it, there are some topics that VA will choose not to get into. I understand the VA finds it uh unprecedented to hold a hearing on an active contract uh uh solicitation.
▶ 0:19:11I appreciate the sensitity of the contract, but it also unprecedented to avoid Congress's oversight of $1 trillion of spending. My staff and the ranking member staff have been told that some topics are offlimits because of the sensitive nature of the contract uh and and solicitations.
▶ 0:19:35We will have we've tried to create a venue in which VA would feel comfortable to speak candidly to our members but unfortunately VA failed to assure us of the of such cander. As such, we are not able to close uh portions of this hearing for more uh candid conversation. I would also like to thank the ranking member Takano and his staff for working with us uh to exercise this oversight. Mr.
▶ 0:20:02Tano, I assure you this hearing is only the beginning of congressional oversight. Community care is an extension of VA care. It should go without saying that VA must get this right. When veterans call my committee, they want to know how they can access their earned health benefits at VA.
▶ 0:20:24They don't ask contracts what VA is used to provide the care, but that's the core of the next generation contract and why we must have this hearing. We must deliver modern health care access and choice to our veterans without runaround running around or red Veterans have been enrolled in VA at rates in every part of this country.
▶ 0:20:53Community care is the only way that VA can keep up with this mission. It is the best way we have to get health care to the veterans with the right treatment at the right time at the right place. If we don't do our due diligence to maintain and improve community care, we dishonor the memory of the countless veterans who have lingered on secret weight list at the VA medical centers without receiving the care they earned. Let me say that again.
▶ 0:21:23We must get this right. Before turning to the ranking member, I would also like to take a moment to thank Representative Brownley uh for her years of service to this committee. Uh you've done amazing work on health committee uh health subcommittee uh relating to suicide prevention and also improving services for women veterans and I want to say how much thankful we are and so thank you.
▶ 0:21:47Uh, I know you have the rest of the session, but um I hope you enjoy retirement and and uh that life is better on the outside um for you in the future. Yeah. Yeah. So, and with that, ranking member, I'll now recognize you for your opening statement.
▶ 0:22:04Thank you. Uh Mr. Chairman, as you mentioned in your uh the very beginning of your opening comments, you uh you referred to the uh untimeliness of the testimony uh from VA that was due at 10:00 a.m. on Tuesday. Uh we did not receive the testimony until 6:00 p.m. last night. Uh I advise uh the VA uh witnesses to review on YouTube, and I'll have my staff look it up and send it to you.
▶ 0:22:35uh the reaction of Republican uh of of the Republican chairman of the Judiciary Committee from the state of Wisconsin, James Sensen Brener's reaction when testimony arrived uh late. He cancelled the hearing.
▶ 0:22:52We're reviewing uh a a contract of enormous proportions, historic proportions, and you gave our committee uh way less time than they were owed under the uh under under this uh uh under our committee rules. And uh I if I were chair, I would have postponed the hearing because we need to review uh your testimony and prepare the questions uh for this committee. It is inexcusable.
▶ 0:23:22This should never happen And I want to reiterate that. It will not happen again or I will lodge an even larger protest with the chairman. This is disrespect to Congress. And I, in my opinion, we're showing way too much difference to the administration in this case. We represent the American people and this is a near trillion dollar contract. Enormous disrespect. get your testimony here on time, especially when we're reviewing a trillion dollars.
▶ 0:23:55Thank you, Chairman Boss, for uh yielding. And as I said, nearly a trillion dollars. I must admit, I'm a bit taken aback uh hearing our Republican colleagues speak positively about the government spending uh such a large sum. Although I in the chairman's words uh he uh he he he showed some uh some some uh concern actually a great deal of concern about the amount of money that we're talking about spending here.
▶ 0:24:22To put it in perspective, the $700 billion ceiling on this contract for VA community care is equivalent to what President Trump offered Denmark to purchase Greenland. And just as I believe the president is nec unnecessarily agitating our most important allies, I fear VA's plans for community care network generation contract will put the agency on an unsustainable course barreling toward privatization, hollowing out direct care.
▶ 0:24:51And I believe as my colleagues will go through the questioning, uh, we're going to look at what appears to be an unsustainable trend, uh, in the increase in expending in the community care accounts. I'm willing to pay any price for veterans to receive every benefit they deserve, including access to highquality healthcare.
▶ 0:25:10When we passed the largest expansion of of veterans benefits in history, the Pact Act, we know we knew more veterans would use VA services, and that we would need to invest in VA to pay for the cost of war. VA is the best place for veterans to receive care. Throughout the chaos of the last year, my Democratic colleagues and I have loudly voiced our concerns about VA's future.
▶ 0:25:34VA's future is dependent on its people, and VA is VA is underst staffed. If we walked into any VA facility in the country right now, I guarantee that the director would tell us their number one concern is underst staffing.
▶ 0:25:52So, it is difficult for me to sit here and discuss this enormous contract for community care, which is one of the, if not the largest procurement in VA's history, uh, when we have not seen this administration make similar investments in VA direct care itself. Instead, every headline we read, every whistleblower email we receive, every veteran perspective shared at our town halls is about cuts and how those cuts are impacting veterans ability to receive the VA care they know, love, and rely on.
▶ 0:26:22Secretary Collins proudly carried out the performance the performative performative OM decree to illegally terminate probationary employees only to be ordered by the courts to reinstate them. He oversaw and encouraged the departure of nearly 40,000 employees last year, including thousands who vacated frontline veteran-facing uh positions. And now we are anticipating the impact of his directive to cut nearly 30,000 positions from VA's roles.
▶ 0:26:50There have been no hiring incentives, no investments in VA itself under Secretary Collins, only cuts. Yet today, VA comes before us with a grand vision uh to continue to grow community care. VA has tripled how much it spends near spends annually on community care since it sinceh 2018.
▶ 0:27:12This RFP valued at nearly a trillion dollars over 10 years will continue the exponential out of control unsustainable growth of community care. And you wonder why I'm ticked off that you come here uh and bring uh your testimony, give it to submit it by 6 p.m. last night. Now uh we have here behind me the poster.
▶ 0:27:36According to VA's own data, the number of individual veterans using community care increased by only 34% between 2021 and 2024. However, during that same period, expenditures for community care grew a whopping 67%. From 19.7 billion in 2021 to $32.9 billion in 2024.
▶ 0:28:00This far outpaces the growth of health care costs for civilians also receiving care in the private sector. And civilians also know that the cost of health care rises faster than regular So VA care is VA healthcare is growing faster than civilian healthcare. We should all be asking ourselves why. Why did the cost of community care so drastically outpace the number of veterans using it?
▶ 0:28:28And what controls is VA putting in place in the next generation of this contract to contain those costs? Sadly, I fear the answer to that question will disappoint us. If we divide the $700 billion ceiling for the contract over its 10-year span, that leaves us with VA averaging about $70 billion in annual spend on community care going forward, which is over double what VA is spending today.
▶ 0:28:55And again, what is the justification for this rapid VA's testimony today will claim that it is implementing cost containment, a cost containment framework it expects to reduce community care spending by 54 billion over the next decade. And even if that speculative cost savings pans out, this RFP still estimates VA will spend $30 billion more a year over the course of the new contract than it is spending now.
▶ 0:29:26I'm sorry, this is not cost containment. its cost explosion. While this RFP is lengthy and dense, it provides little detail as to how the new structure will address the issue I believe is most important when we evaluate community care, and that is the quality of care veterans receive outside of VA. The patient experience is tantamount, and I fear this RFP does not adequately address persistent issues veterans face when receiving care in the community.
▶ 0:29:57When asked how VA will oversee contracts of this magnitude, Mr. Topping indicated that VA may procure contractors to perform that oversight. Procure contractors to perform the So, we're going to get contractors to oversee a contract. This is a recipe for disaster.
▶ 0:30:19Oversight of contracts is an inherently governmental function and outsourcing that function to the private sector will leave this behemoth of an acquisition vulnerable to waste, fraud, and abuse. VA historic has historically struggled with contract oversight due to lack of staffing. In 2024, VA had only half the staff it said it needed to oversee community care contracts.
▶ 0:30:46We have no reason to believe that VA staffing levels have improved considering the mass departure of employees, experienced employees uh last year through the deferred resignation program, voluntary early retirement and natural attrition coupled with the consequences of governmentwide hiring. In addition to leaving the contractors to oversee themselves, this RFP leaves open the door for the insurance companies we expect to bid to enrich themselves beyond the cost of the contract.
▶ 0:31:17Insurance companies have been on acquis insurance companies have been on acquisition sprees vertically integrating and buying up hospitals, clinics, pharmacies and other parts of the health care supply chain across the This trend towards consolidation is increasing care costs and diminishing patient access. Now what does this mean for veterans? It means that when veterans need care in the community, they are going to have fewer choices.
▶ 0:31:46Perhaps an insurance company that wins a CCN nextG contract chooses to create a network of only of providers whose practices that insurance come that the insurance company owns. Nothing in this RF RFP prevents that. from happening. I fear this RFP does nothing to guard against the issues VA experienced with the current third party administrators who won the contract during Donald Trump's first term.
▶ 0:32:14The third party administrators failed to coordinate network adequacy with the 172 VA medical centers nationwide. And as a consequence, we have networks that are not reflective of demand and weight times for community care often exceed those of VA. Let me repeat that.
▶ 0:32:32Community care often ex the weight times for community care often exceeds those of VA because of the insufficient contract that was approved during the first Donald Trump We have heard complaints that there are providers who are currently considered in network for the CCN who are not actually accepting veteran patients. The current thirdparty administrators only grew the provider network by 7,000 providers between 2021 and 2024.
▶ 0:33:02That's a poulry 4% growth in the supposed quote unquote choice veterans are promised for care in the community. Additionally, nothing in this RFP requires the contractors to build a network of only of providers who have the same level of training as VA providers, including on veteran cultural competence.
▶ 0:33:21We had no way to ensure that veterans were going to see a culturally competent provider in the community because there was no way to ensure uh that those community providers would undergo that level of training or certification. This will invariably lead to worse patient outcomes and a negative experience for many of the veterans who have complex medical needs directly related to their military experience. Chairman Boss, I hope that we can work together to develop a robust oversight plan.
▶ 0:33:48And I'm glad to hear that this is a first of of hearings that we expect to have uh regarding oversight of community care. Uh we uh we have a we need to work together to develop a robust oversight plan with a regular cadence of required briefings and hearings with VA as this contract is executed and hopefully uh with testimony that arrives on time. We must chart a path forward that adequately balances investments of VA care and community care.
▶ 0:34:17We were given little opportunity to prepare for this procurement as VA posted this RFP in December with absolutely no heads up to Congress. My staff repeatedly asked VA for briefings on plans for the CCNA NextGen contract through 2025, but those requests were never fulfilled. We were and I'm offended. But those requests were never fulfilled.
▶ 0:34:39We the members of of this committee who have a constitutional oversight responsibility of VA found out about a nearly trillion dollar contract competition at the same time as the general public. This is unacceptable. We did not receive testimony for today's hearing, as I said, until 6 p.m. last night, giving us little opportunity to review it prior to this hearing. VA has done nothing leading up to this hearing to inspire confidence or trust in this process.
▶ 0:35:04In closing, like signing a bad mortgage contract or opening a credit card without reading the fine print, rushing into this huge taxpayer investment is a recipe for financial disaster. The contract terms alone lock VA into a long-term commitment with very little certainty about whether this contract will improve veterans access or outcomes. When confronted with a deal that sounds too good to be true, it's important to take a step back and not jump head first into a rushed, untested, costly proposal.
▶ 0:35:33Until we see a plan that reinvests in VA, VA direct care, not just private contractors, and until oversight is restored, this process cannot earn the trust of this committee or the veterans we serve. With that, I'll yield back.
▶ 0:35:47I thank the ranking member for his opening statement. And yielding back, ladies and gentlemen, a vote has been called in the House. The committee will stand in recess subject to the call of chair. It is my intent that we expect to be back uh 10 minutes after the final vote. Um and that we are in recess.
▶ 1:19:12committee will come back to order. Sorry for the interruption. Kind of what we do around here. Um, as mentioned earlier, uh, joining us today is the Department of Veteran Affairs, Mr. uh, the Department of Veteran Affairs, Mr. Topping. Mr. Topping, [snorts] you are now recognized for five minutes to present your opening statement. Uh, Mr. Chairman, uh, thanks for having me. Thanks for having us on this very busy day in the Congress. Um, uh, and and certainly I hear you on the delay on the testimony getting to you all last night.
▶ 1:19:42My, in my short time at VA, I've found it's actually easier to fix CCN than it is to get testimony approved through the process. So, uh, so I own the delay and we'll do a better time next time. Sir,
▶ 1:19:51parliamentary inquiry, Mr. Chairman. Uh, is it customary that we swear in the witnesses? It is that if the witnesses will rise, raise your right hand, please. Do you say I don't have the script in front of me? You got it. I think I can do it off the cuff, but let's do it
▶ 1:20:14Do you [gasps] Are you Can you swear that the testimony you're about to give is the truth? Nothing but the truth? Yes sir. No, the witnesses have answered in the affirmative. Now you can open.
▶ 1:20:31Thank you, Mr. Chairman, ranking member, distinguished members of the committee. Thank you for the opportunity to discuss uh veterans community uh care program and the community care nextgen contract procurement. I'm accompanied today by Miss Alicia Skullroo, executive director of external integrated uh networks, office of integrated veteran care, uh VHA. VA has long been recognized for the world-class care we provide to veterans across our more than 1500 medical facilities.
▶ 1:20:56In addition to the direct care system, VA has also been a purchaser of health care since before the World War II era. As a healthcare payer, VA partners with local hospitals, doctors, and other healthcare providers to ensure that veterans have access to the care they need where and when they need it. Caring for veterans is about more than operating hospitals. It's about supporting veterans physical and mental health and wellness, their families, caregivers, and leveraging community services beyond the walls of our facilities.
▶ 1:21:24Recognizing the key role that purchase care plays in VA's ability to provide for veterans health and wellness, President Trump and Congress passed the bipartisan mission act, which expanded access and choice for veterans and reinforced veterans mission as both a healthcare provider and payer. Today, VA is the largest single healthcare provider through our hospitals and our clinics, our 1,700 u uh sites of care, and the fourth largest health care payer.
▶ 1:21:49In fiscal year 25, 41.8% of all VA healthcare appointments were in the community. NextGen is VA's first major procurement effort to support this program. It's our opportunity to increase competition, upgrade, and modernize the provider network, enhance services to ensure that veterans receive the very best health care possible. whether they are at a VA facility or in their community from a local healthcare provider. We did not design NextGen alone.
▶ 1:22:16We talked to our veterans who overwhelmingly want the flexibility to choose between direct care and community care based on medical interest, availability, and convenience. We talked to our government partners. The departments of health and human services and of war have decades of experience and data on improving healthcare quality, reducing costs, and aligning incentives for better health and wellness.
▶ 1:22:37And we talked to industry, which is constantly innovating with new delivery models, leveraging data analytics, striving to be consumer oriented while tackling costs that remain too high. Combining VA's history, the data, this external input, VA successfully issued the CCN NextG request for proposals on December 15th, 2025.
▶ 1:22:57We are leading the nation with an innovative 10-year multiple award indefinite uh delivery indefinite quantity contract vehicle which has several key advantages over traditional federal healthcare contracts. First, the Idiq del drives and delivers competition and flexibility by allowing both national and regional health plans to successfully bid and be awarded a spot on the Idiq. This is the best of both worlds.
▶ 1:23:21We will have vendors with national reach and efficiencies of scale, but also regional health plans with unique capabilities that are locally adaptable to serve our veterans. And second, through the use of multiple rounds of task orders. This allows VA to iteratively adapt nextgen to meet veterans changing needs over time, changing demographics and infrastructure, and to improve VA sophistication to manage the program over the 10-year performance period of the contract. The Idiq is the how of this procurement.
▶ 1:23:50But the most exciting part of CCN NextGen is the what. NextG is designed on five pillars. Quality, value, alternative payments, utilization management, and program integrity. VA will implement a comprehensive quality program for community care providers based on nationally recognized measures for the agency for healthcare research and quality and the healthcare effectiveness data and information set.
▶ 1:24:12Contractors will track patient safety events, identify veterans at risk of avoidable visits and readmissions through predictive analytics, and while respecting their choice, guide veterans towards high performing providers. NextGen will modernize how VA pays its contractors for the care furnished to veterans by implementing valuebased payment models. We will begin with episode based payments for lower extremity joint replacements.
▶ 1:24:35As we gain the data and the expertise to manage alternative payments, we will introduce at least three additional models over the performance period of the contract to continually improve care. These models will shift payment away from volume and toward outcomes and total cost of care, which aligns contractor incentives with veterans health and system sustainability. We will introduce utilization management. This includes active management of inpatient admissions, emergency department use, concurrent hospital reviews, high-cost drugs administered in clinical settings.
▶ 1:25:06This will reduce unnecessary hospitalizations and inappropriate care while protecting veterans access to medically necessary services. NextGen will include a program integrity function to ensure that VA resources are protected and maximized. We will identify providers at high risk of improper building uh improper billing. Uh formalize oversight processes, expand data and technology for improper payment detection, use independent audits, and ensure veterans receive what VA is paying for.
▶ 1:25:34NextG also changes how VA pays our contractors to incentivize performance and outcomes. NextG will incorporate incentives and disincentives based on the total cost of care, quality performance, value based adoption, and payment integrity. Ultimately, contractors who achieve VA's quality targets while reducing our costs will share the value of will share in the value that they create for VA and our veterans. And speaking of costs, along with our improved care for veterans, NextGen provides real savings for taxpayers.
▶ 1:26:05NextGen's actual estimates based on independently verifiable data show significant savings of 8 to 14% over the life of the contract. These savings range from a low-end estimate of $54 billion to a high end of hundred billion over the life of the contract. These are gained uh these savings are gained by fewer unnecessary hospitalizations, improved management of high-cost services and drugs, improved quality, and stronger fraud prevention and payment controls. Mr.
▶ 1:26:32Chairman, NextGen is leading the way and how federal healthcare programs can be designed, procured, and operated. I appreciate the opportunity to share this information with you and the committee and look forward to answering any questions you may have. Thank you, sir. We're going to now go to questions. I'll recognize myself for five minutes. Um, Mr. Tavin, uh, the community ambulance services have shared that there's no way to know when a patient is a veteran.
▶ 1:26:56And I would like to to see if the NextGen addresses this this for all providers with limited claim windows. How will VA help the community providers experience in a case where they do have a short claim window for filing? Is there a process by which that will be part of this?
▶ 1:27:18Uh thank you, Mr. Chairman. So, so first of all, the claim window is 6 months. Uh and as you know, we've got proposed legislation in the access act that would expand that to 12 months, which would match how Medicare does this. Um, so there is a window in which a provider who provides this service can bill VA after they determine veteran status after the fact. But part of how we intend to design and manage this network and the capability to to verify eligibility and enrollment, these will be addressed through this.
▶ 1:27:44So our ability for a provider, a network provider, an ambulance provider, an emergency service to then be able to bill VA for the cost of that covered care again on the agreed payment schedule. Absolutely. Those are the types of things we are tackling in this repcurement sir.
▶ 1:27:59So what account are will the fund uh will fund the CCN nextgen?
▶ 1:28:06CCN nextgen sir has a direct appropriation and one of the things that we are doing at VA is not just the purchase cost of care and accounting for that as a program cost but also the administrative cost. So there are three costs that go to our inputs on community care. One is the administrative cost for the agency to administer it. our internal program management costs. We are organizing those direct to this program. Secondly is the costs that we then pay to our health plan partners and our vendors to manage this network.
▶ 1:28:36And the third are the purchase cost of care that the providers are paid who directly provide the service to the veterans.
▶ 1:28:42Is is it the intent uh or any anticipation that you will be using the toxic exposure funds resources for the community care? Um sir, we're going to maximize the resources available to us to ensure that the veterans get the care that they've earned that they deserve that they're eligible for under this program. U and we intend to do so in a way that maximizes our efficiency that we get the highest quality, lowest cost care, but we will re use the resources that Congress has afforded to us to do Okay.
▶ 1:29:10The nextG uh contract would include many features that are found in Medicare and other programs. How deep is your ongoing engagement with other agencies to help implement the new community care system?
▶ 1:29:25So, number one, this year, um, we partnered a program where we are working with CMS on improper payments and overpayments. And so, for the first time, VA has partnered with CMS on payment because we've got veterans who move between our systems and their systems. We have begun that work on how our systems collaborate and work together. Secondly, as VA builds out its program management capability, what we're talking about today is the program design of CCN NextG.
▶ 1:29:53But what comes next for VA's program management, our ability to operate this program, we're going to use the models that we see in other places in government. For example, the center for Medicare, which provides a framework for how VA would manage and operate a program of this size. There are state models. will incorporate the best of both to bring in how VA is organized, how VA manages this, how we use, ingest and action data for the outcomes that we are seeking in this
▶ 1:30:19Yeah. My big fear would be that that um you wouldn't pay attention to mistakes that Medicare has made over the years and get on the right track right off the start and take advantage of someone that's already got a system in place.
▶ 1:30:33Absolutely. when we talk to CMS and same deal uh when we talk to department of war our colleagues at the defense health agency is what were their lessons learned what works what hasn't and the five pillars that we are introducing in this program are tried and true methods these are tools that have been used in other programs in some cases for decades we are importing what we know works we have looked at the lessons uh some have been good some have not and we have brought those in our program this is a program that takes what has worked elsewhere
▶ 1:31:03Again, we're the fourth largest payer program, but we are not the only. And HHS operates the top three. We have looked at their successes, their failures, gotten their input, and we've done the same with industry. So, we didn't just say, "What is government's view on this?" We went and talked to industry and said, "You tell us how this has worked. You tell us where you've been successful, where you've been not. What have your pain points been?" We've incorporated that and built that into this program design.
▶ 1:31:28Well, I'm I'm telling you be before I yield back, um I want to let you know that we don't this, as I said in my opening, this is just the first of many meetings. We need to keep you here on a regular basis talking to this committee. So, we can watch this process. Uh we've had other things that VA has done that they go off on their own and uh don't give we don't get the oversight that we need. And so, I want the commitment from you that you will we can do that.
▶ 1:31:56Mr. Chairman, anytime you will have me to come back and talk about NextGen, I will come.
▶ 1:32:00Okay. Thank you very much. I yield back and recognize ranking member for his five minutes.
▶ 1:32:05And I will expect prompt answers from my staff from you as well. I cannot have delays uh in in and I do not ever want to see a major program announced uh at the same time the public hears it. So uh do I have a commitment from you on that?
▶ 1:32:19Yes, sir, you do.
▶ 1:32:20Thank you. Uh community care spending is out of control across multiple administrations. I have raised concerns about how much spending is going into the community care account at the expense of direct VA provided care. Underscoring these concerns are VA uh underscoring these concerns are VA's transfers so far this fiscal year of over $2 billion into the community care account. Mr. Topping, from what account did you transfer the $2 billion?
▶ 1:32:48Uh ranking member, there have been no transfers this year into the community care account.
▶ 1:32:52There have been no transfers. That's what that's your answer.
▶ 1:32:54Correct. Yes, sir.
▶ 1:32:55Okay. You stand uh you stand by that. You're under oath.
▶ 1:32:59Yes, sir. There have been no transfers this year. In FY26, there have been no
▶ 1:33:04Uh in FY25 we're talking about.
▶ 1:33:06Yes, sir. In FY25, there were transfers.
▶ 1:33:09Uh what what accounts uh from what accounts were the $2 billion
▶ 1:33:14As I recall, sir, I think it became from medical support and compliance and there was a transfer of um one I forget the exact number, but I believe the transfer was 1.3 1.4 4 billion into the account.
▶ 1:33:24Uh, can you make sure that you get us the the accounts that that money was transferred in FY25, the $2 billion?
▶ 1:33:31Yes, sir.
▶ 1:33:32Thank you. Uh, VA requested $48 billion in mandatory and discretionary funding for community care for fiscal year 2026, and that is what you received. As of now, VA will VA need to transfer more money into the community care account before the end of fiscal year 2026?
▶ 1:33:52I'm sorry, sir. Or was that a question as to whether we'll need to transfer?
▶ 1:33:55As of right now, will VA need to transfer more money into the community care account before the end of this fiscal year of 2020 26 of 2026?
▶ 1:34:05Um sir, as of right now, um my financial cost estimates along with my spending to date again understanding that there is both a data and a claim claim lag, but as of right now, no.
▶ 1:34:17My time is short. Just answer the
▶ 1:34:19sir. As of right now, my data does not show that.
▶ 1:34:22Okay. So, the answer is no. You will not. You are telling me that you do not need to that you that you're saying you have sufficient funding from your $ 48 billion FY2026 appropriation and you don't plan to ask for any more money. Um, is that right, Representative? As of right now, my appropriation for FY26,
▶ 1:34:42it's a simple question. Yes or no,
▶ 1:34:43sir. My appropriation is 50.174 billion 206 million. That's the appropriation and sir that is the budget that I am managing to
▶ 1:34:52Well, I asked you about the $ 48 billion FY2026 appropriation
▶ 1:34:58uh to the community care account. You don't plan to ask for any more money than that,
▶ 1:35:02sir. The number is 50,174
▶ 1:35:07All right. Okay. Well, so you don't plan to ask for any more money uh for that
▶ 1:35:10No, sir. At this time, my data does not show that I will need to do that. And no, I do not, sir.
▶ 1:35:16Okay. Well, um, Miss Skullroo, contractors are required to self-report conflicts of interest even though many insurers own clinics and provider networks. How will VA independently detect and prevent contractors from steering veterans to affiliated providers for profit?
▶ 1:35:33Thank you very much for that question. Our TPAs do not steer um our veterans to providers. Th those decisions are made by the veterans. It's
▶ 1:35:45well, how would you know that?
▶ 1:35:49You you just claim that RTPAs don't do that. But is there how how is a VA going to hold our TPA accountable?
▶ 1:35:56They don't have the opportunity to do that. That's not how a veteran gets to the community provider. The veteran gets to the community provider either by choice because they've selected them. Now the network is built by the TPAs that we control via our credentiing process, our accreditation process and our assessment of the providers um quality. Um
▶ 1:36:21so you're going to represent to me in this committee that every clinic, every provider uh you know is is not owned by the TPA.
▶ 1:36:32I'm not representing that at all, sir. Well, then how is it that you're able to answer my question in the way that you've answered it? You know, how will VA independently detect and prevent contractors from steering veterans into affiliated prov providers for profit? If you can't figure that out, you can't tell me that. So, ranking member, the way the system currently works, VA controls the clinical referral and VA controls the placement with the community provider. The the TPA, the vendor does not control the steerage. VA does. These are RPA.
▶ 1:37:02You're not really answering my question. You're you're evading the question. You're avoiding the the intent of my You're not able to answer how TPAs avoid this conflict of interest. You don't uh there's no I don't you're not answer. You're not talking about any enforcement mechanisms beyond simply trusting contractors to disclose conflicts.
▶ 1:37:22I I would suggest, sir, that's a huge flaw in the assumptions that you're bringing forward to us. I My time is up. I yield back.
▶ 1:37:31Representative Radwagon. [clears throat] recognized for five
▶ 1:37:39Uh, thank you, Chairman Boston and Ranking Member Takano for holding this hearing today and thank you to the witnesses for your testimony for your appearance. Mr. topic. What was the contract type for the first generation of contracts and what is the contract type for the next generation and what is the significance of the difference for Uh thank you for the question representative.
▶ 1:38:08The the first gen contracts were direct soul source contracts to the awardees and so there are two vendors under the current nextgen contracts that operate those exclusively. The difference with NextGen being an Idiq is that the government will have the ability to bring on multiple vendors and multiple contractors. Those contractors can then compete across the life of the contract for different task orders.
▶ 1:38:34That allows VA to change program design to learn from mistakes to increase our capabilities and capacities to innovate and evolve the program over time. So the difference will be we picked a program, we awarded contracts and that's what we've had for the past contract. What we're able to do under the Idiq and why this is so unique and so different, it allows us the flexibility to pick, innovate, and for vendors to compete and improve continually across the life of the contract.
▶ 1:39:01So Mr. Topping, does uh VA believe it needs any additional legislative or regulatory authority to act on the next generation contract? Ma'am, at this time we don't. We believe we have it. However, as we go through this process, engage with the oversight of this committee. Stay engaged making sure we're reporting. Um, as we may or may not need additional authorities, we intend to come to this committee and work with you and your staff to ensure that we have it.
▶ 1:39:29Thank you, Mr. Chairman. I yield back the balance of my time. Thank you.
▶ 1:39:33Representative Brownley, you're you're recognized for five I apologize. My staff was just telling me I have a vote in another committee, but um I will take my time. Um so, uh thank you uh to the both of you for being here today. And I have to say that uh you know everything um you have said in your opening comments with regards to your stated goals I agree with.
▶ 1:40:03you know, and if you succeed in uh raising and the and and having higher quality of care uh with less resources, um I will be the first to commend you honestly. Honestly, but when I review the $1 trillion contract that you have put forward, I'm just absolutely not convinced that that you can succeed in those goals.
▶ 1:40:30Better quality, less And over the last decade, community care continues to increase exponentially. I think we can agree on that. Turning VA, I think it more into a payer system rather than a a provider of health care.
▶ 1:40:48And it seems that the next gen contract is not it's clear to me, let me just say that you're not shutting down and the contract's not shutting down VA facilities uh whatsoever. But it does not require in in my opinion any kind of important oversight like requiring prior authorization to to receive care in the community.
▶ 1:41:13It seems to me based on what you're saying that competition is the oversight piece uh within the contract. If people can't compete, they're out. If they can compete, they're in and and they'll be doing a good job.
▶ 1:41:30So do you agree with that assessment in in the simplest terms that you believe that competition is the is the um main component uh for uh for oversight.
▶ 1:41:47Thank you representative. I believe the main component of this contract and why this is different is this gives VA the tools and again tried and true tools the five tools we're going to use. This gives us the tools to hold our contractors accountable and our ability under the Idiq to off-ramp non-performing contractors. That's what I believe is different about this. So, I don't believe that the competition is what's going to drive the outcomes. I believe VA's management is what's going to drive the outcomes.
▶ 1:42:15But the competition is a tool that allows us to ensure that only vendors that are achieving our expectations for them, are hitting those quality scores, are achieving the cost savings, and doing it in a way that VA oversight agrees with and is consistent with our values. That's what we're able to do in this, and that's what's different. We don't have that ability under the current.
▶ 1:42:36But the you know your your first point of um control if you will and using your words that would be a prior authorization whether uh you know it's appropriate for the veteran to go into the community or not. But I believe what you're proposing is that a veteran just can go into the community and these other tools that you have um can control that.
▶ 1:42:59Well, let's let's talk about the utilization management uh part of this program uh and and prior authorization which is one part of that and had been one part of M used differently over time but fundamentally what M is and M has been around for 30 or 40 years is says that for any given diagnosis there is a finite universe of treatments to treat that diagnosis and so for example when we send a veteran to the community for PTSD could you know could be could be therapy could be medication,
▶ 1:43:29could be psychiatric care. It's not a knee replacement. A knee replacement is not responsive to that veteran's need. What M allows us to do is package this up and know that we ensure that veterans are receiving the the care that is responsive to and therapeutic to the diagnosis. That's how we're going to use that tool in this contract.
▶ 1:43:51you said in your testimony that you have talked to many um with regards to this new proposal uh new system uh within the VA and you talked to you said you talked to industry. I I'm curious to know how much engagement you've had with veterans across the country. Uh, man, we've been very engaged with veterans both through our VSO groups, through our individual outreach, through through the RFI feedback that we've had.
▶ 1:44:20We've been engaged with veterans who are the users of the system. They are the endstate. The goal of this is ensuring that our veterans are best served. They're our customers. And so, that's why we're doing this.
▶ 1:44:31Can see my time's limited and it's almost over. So, can you just give me a list of the VSOs that are supporting this um this program? Can you name them now for me?
▶ 1:44:43Ma'am, I can take that and bring you the
▶ 1:44:46Thank you. I yield back.
▶ 1:44:49General Burman, you're recognized for five minutes.
▶ 1:44:53Thank you, Mr. Chairman. [snorts] Um, it's been interesting to sit here and listen. Um I've got a lot of prepared questions in front of me and I will get to some of them but is as I listen I'm kind recall the mission act of 2018 which started this ball in motion. Okay.
▶ 1:45:18And and the point is has there been any lessons learned that have been tabulated by the VA since that time, maybe by your, you know, predecessors or whatever that when we implement anything, the ability, you know, in in the military, No, no battle plan
▶ 1:45:49survives first contact because the plan is the plan until you put it into kinetics and then it is modified. so we could talk for hours and maybe the time is right now.
▶ 1:46:04As a follow on, I would suggest to have a closed meeting with our committee where there's no cameras, no just to to really get because you can't cover this and a dialogue that involves honesty. But uh any is there anything that has appeared to you that has become redundant uh that is necessary?
▶ 1:46:31The redundancy is necessary or the opposite is that it's unnecessary the redundancy that you put into place. Okay. Any anything pop out in your as you look at what you have seen and what you're trying to do? Do you try to evaluate? Do we need to continue to do this step? Does it add value?
▶ 1:46:57General, thank you for the question. I think so. Absolutely. As we look back on lessons learned and some of the and some of the issues that we had, the the prior contract was not designed to be a program of the size, scape, and scope and scale that it now is serving 9.1 million veterans uh literally wherever they live. And so our ability to make sure that this program is sustainable but also achieving the outcomes and access that we're looking for our veterans has been our guide stone in
▶ 1:47:26But has there been anything that is ju just that you could give us a data point and if the answer is none okay but is there anything that since trying to implement this and get everything up and running that you've said absolutely this is a waste of time and money.
▶ 1:47:42it's not adding value to the Has there been any list of things so that people could say, "Wow, didn't see that coming, but okay, makes sense." I think as a committee, we want to hear [snorts] confidence in your ability at the Veterans Administration to create this and to keep it going, to make the ch necessary change, to stop doing stuff and not let bureaucrats
▶ 1:48:13and contracts that, you know, a reason to not do something that you know deep down because that but that's that's a unit that's in the military. it's in within the unit to make changes that they see because they're right in the middle of the fight.
▶ 1:48:28Um, representative. So, three things. One, this program has been unmanaged since its inception. So, none of the tools, none of the controls that we are talking about introducing here have been available for. So, VA had no ability to manage this program to drive quality, to focus on the outcomes for veterans, to focus on cost. We've now got the ability to do that in this contract. So that's number one. Number two, the way we designed this unmanaged program made it very difficult for industry to partner with us.
▶ 1:48:59It made it very difficult for community providers to serve our veterans, made it difficult for our TPAs because it didn't operate like any other payer program which made it one-off anomalies that made it difficult to be part of this. And then thirdly, and I think most importantly, and this is the one that VA owns that we are working on together, is our program management for this was not built to run a payer program. We are focused the program design is
▶ 1:49:26I hate to cut you short, my time's running. So I would suggest to you that under Secretary Collins leadership, we've seen the reorganization of the visions and and how they're set up. Uh what I would like to see is in that the already existing and announced vis vision reorganization plan how that will affect or maybe no effect no effect on your ability to to do what you're tasked to do and with that I yield
▶ 1:49:56back.
▶ 1:49:58Mr. McGarvey.
▶ 1:50:00Thank you Mr. Chairman. Appreciate you all being here. I mean look my focus is the veterans. It's the focus of this committee. It's my focus. We have to do what's best for our veterans. They put on a uniform. They served. They sacrificed for us. And we promised we'd take care of them. So, when I think about this, I want our veterans to who who need it and want it to get their care through the VA. I know the VA can't necessarily provide every single service available. We got to have a VA that functions.
▶ 1:50:23And so when we're here talking about these community care networks right now, I want to talk about what it looks like in Kentucky because in Kentucky we have a lot of veterans and we have a lot of veterans in rural areas. So we can't look at this in a vacuum in this hearing and this year the Trump administration, last year the Trump administration passed a bill they refer to as the one big beautiful bill.
▶ 1:50:47Well, the Kentucky Hospital Association, which isn't exactly some flaming liberal organization, has predicted that 35 rural hospitals in Kentucky could close because of the funding cuts that are going to come through this. This means our veterans, our men and women who served, who are already in healthc care deserts [clears throat] and 41 counties in Kentucky don't have an OBG obse. So, the system can't continue like this.
▶ 1:51:15And my concern is that when we think about community care filling the gaps, we have to look in places like mine where community care is already struggling and it's expected to get worse. So again, I understand we can't rely on the VA for everything, but thinking that community care is a silver bullet, I don't think is the solution either to what we're looking at. So, what happens to veterans when these community care network contractors build networks that look adequate on paper but don't reflect real provider capacity?
▶ 1:51:46Let's get the Washington speak out of this. Looks good on paper. Our vets aren't going to be able to go to the doctor, right? That's what we're worried about here. And these are some of the questions we have to ask ourselves about this because of the promise, the legal and moral promise we've made to our veterans to take care of them. So, Mr. Top, I'm going to start with you. What safeguards are in place right now to prevent a lot of these large national insurers, you know, the big companies we're talking about from bypassing rural providers because they are less profitable to contract with.
▶ 1:52:15Thank you so much for that question. So, so number one, I think there's three things in there that I want to hit. So, number one, um, community care is one tool that VA has to serve our veterans. And we talk about this being a trillion dollar 10-year contract, and it is, but at the same time, we're going to spend $2 trillion in direct care during that same time frame. So, these are two tools. We have our facilities. We opened 25 new facilities last year. We've got five more coming on. That's 30. We've invested $800 million in infrastructure under Secretary Collins's leadership.
▶ 1:52:45So, we are engaged on that part of this as well. Um, so that's number one. Number two, network adequacy in rural areas. Rural veterans disproportionately rely on community care. It is more important for rural veterans in Kentucky and other states to ensure that we've got the providers and the adequacy. Our work here is complementaryary to what we are doing in rural health in America because we are one more payer and we're going to manage this like a payer.
▶ 1:53:10This creates predictability for those hospitals, those rural hospitals, those pro those providers to participate in this program and be with us. And back to if we've got a national company who's looking at this nationally, they have 50 states, 25 states. The one of the major the key change in this on using Idiq, again, VA is going first. One of the innovations on this is if we can't get the coverage we need in Kentucky, we can bring in a Kentucky provider to support VA in Kentucky.
▶ 1:53:40We can do that. We can offramp a national that's not meeting the needs and bring in a local company that knows Kentucky, that knows the rural areas, know the urban areas, and we can use their network to serve our veterans. The flexibility under this program is unique and meaning.
▶ 1:53:55Yeah. And I'm I'm just going to interrupt you there because like look, this is a perfect example of okay, that all sounds great. I trust this committee to have veterans interests first and foremost. I don't trust big insurance companies to take care of anybody. The sole thing that motivates them is profit. It's not people and it's certainly not our veterans. And you can talk about one trillion and two trillion dollars and those are really big numbers that you can paper over in front of this committee, but until we're looking at those contracts and we're looking at those numbers, those are just asurances.
▶ 1:54:25And we have the right to be skeptical when we are talking about private insurance companies taking care of people because right now they don't. Um, so I want to go to the next question. Uh, many of these CCN biders are vertically integrated insurers. That means again, let's take the fancy. They own doctor's practices. Their motive is profit. So what they want to do is make the most profit. And how is the VA going to prevent these companies from steering veterans into their own facilities to maximize profit. You talk about what's going on the ground.
▶ 1:54:54I want I look at what's going on in their books because I think that's what they care about.
▶ 1:54:59Representative, that's a fair question and I go back to what I said earlier. the vendors, our health plan partners on this a don't make the clinical referral from the direct care system to community care. VA does that. Um they don't make the referral to the provider. VA determines that. They don't determine eligibility. Um and so VA drives where and how our veterans receive care. And the whole, you know, going back to the pillars that we're using, including quality, we want to know what we're buying.
▶ 1:55:27We want to steer our veterans to the highest quality, lowest cost providers. Again, that's a goal. is not unique to VA. It's new to us, but we're bringing this into this program. We are going to make those determinations. Our vendors, our health plan partners on this don't drive that. VA does. We own our veterans, and we are accountable for their care.
▶ 1:55:45Yeah. Thank you. I'm out of time, Mr. Chairman. Thank you for letting that go on. And I just will I just will say again, our focus is not on VA versus primary or community care. Our focus is on the veterans and what's best for them. So, I really want to continue working with you on this. Thank you. Representative Van Orton, you're recognized for a minute.
▶ 1:56:01Mr. Topping, there are very few occasions where Mr. Takano and I agree. This is one of them. How big is your
▶ 1:56:13Uh, is it more than one?
▶ 1:56:17Sir, to support me on this, I have two.
▶ 1:56:19Okay. Well, I have one and and my he goes by Dutch. His real name is Clark. He puts together these awesome binders for me. It's got everybody's bios and stuff in there and everything. And then this morning he had to hand me this. You know what this is? This is your testimony. This should be in here, but it's not because you didn't provide it until last night. And you we're not putting up with that. It does not matter who is in the White House.
▶ 1:56:48Uh Secretary Collins, I think, is awesome. He's doing great. I love Donald Trump. But we're not going to put up with that. Period. just never do that again. It's unacceptable. And I agree with Mr. Tano on this. I also agree with Mr. McGarvey went out skateboarding or something right now about this vertical integration of insurance companies. Um, okay. So, here's the issue. I think I'm the only member of this committee that's actually used community care. I get all my healthcare through the VA system and community care is part of the VA system. It it it is.
▶ 1:57:19And I've had, you know, tremendous experiences with community care for like dental stuff and orthopedics cuz I'm old and whatnot. But here's what I hear from my veterans. The bureaucracy at the VA tries to slow roll community care. And one of the things that they've come up with is very innovative. You know, it's within like 45 minutes you're supposed to go to the VA.
▶ 1:57:42If you're ex outside of the 45 minutes, they've created all these seps everywhere so that more and more people are within this 45minute radius. So then then they don't have to be referred to community care. And we're talking about it's 1, two, three, six. It's a one with 12 zeros after it is what we're talking about.
▶ 1:58:03I I really am interested to know how much of this, you know, one with 12 zeros behind it, uh, the VA is going to be spending to create these capac, in my opinion, intentionally exclude the veterans ability to seek community care. And I know you don't have that answer. I'm not trying to I'm not going to punk you here. I know you don't have that answer, but we need to have that answer. And as my colleague, Mr. McGarvey said, you know, this ain't about the VA, dude.
▶ 1:58:33It's not about the bureaucracy. It's about the veteran. And if our veterans are not getting timely, highquality health care, there's a problem when we're talking about spending a trillion dollars on this. So, I want to implore you, I will implore you to make sure that you're focusing a trillion dollars to make sure that our veterans healthcare is a trillion times better. Not that we create a trillion more bureaucratic positions.
▶ 1:59:03Um what what is the average time from the request for health care that is unavailable at the VA to the point where the veteran is referred to and treated in the community care system? Uh representative, there's a range of times depending on location and those range all the way from 4 days up to 54 days depending on where it is and what the service is.
▶ 1:59:26Okay. Um, do you think that a veteran waiting 54 days to get healthcare is
▶ 1:59:31I do not.
▶ 1:59:32Okay. Then how are we fixing that, sir?
▶ 1:59:35Through the proposal around NextGen and how we intend to bid and run this program. And sir, I want to go back to I want to go back to one of the points I think you made that's that's critical about Seabox and referrals into community care. I think that's that's incredibly important. Number one, Secretary Collins has made clear. We are investing in infrastructure. We are opening facilities and that is so that there is more direct care capacity for veterans. Absolutely we are doing that.
▶ 1:59:59But the other thing that Secretary Collins said is we are very aware well aware that in the last administration bureaucratic impediments were thrown up to prevent veterans from going to the community if they wanted to even if it was a continuity of
▶ 2:00:11I experienced that firsthand.
▶ 2:00:13And so what Secretary Collins introduced uh last spring is the best medical interest. Best medical interest allows the veteran with the provider, not the bureaucrat, not the referral, but the provider and the veteran to make the determine whether the veteran should go to the community.
▶ 2:00:30Medical interest allows that. Sir,
▶ 2:00:31what what percentage of veterans that should be eligible for community care are turned down or pushed into the more than 50 day window.
▶ 2:00:41Sir, I'll have to take that and bring you back that data.
▶ 2:00:43I would really appreciate that answer. So listen, man. I got a tremendous amount of confidence in Doug. I He's a personal friend of mine. He's a chaplain. He's a good man. He's a veteran. I know that you served in the army. Sorry about that. Mike is right. But um we we expect we we don't expect good things from you. We expect great things from you and we will hold you accountable regardless of who is in the White House. Is that clear?
▶ 2:01:06Yes, sir.
▶ 2:01:07Very well. You I yield back.
▶ 2:01:09Congressman Ramirez, you're recognized. you came in after.
▶ 2:01:16Thank you, uh, chairman. Well, it's been a year. It's been a very long year. Um, and I've been really thinking about the work that we do here, and I want to talk a little bit about our recap. Since the secretary stepped into leadership, the VA has eliminated diversity, equity, and inclusion initiatives. It's allowed Doge access to VA's data. It's made it its mission to help reduce the VA workforce by 30,000 employees by the end of 2025.
▶ 2:01:48And it's also doubled down removing 35,000 healthc care positions this month according to an internal memo according to VA staffers and congressional aids. So I got to say folks, it's hard to believe that Secretary Collins gives a damn about veterans when he's actively undermining the vision the mission of the VA. You can't say you serve veterans when their doctor appointments are being delayed and cancelled due to staffing shortages.
▶ 2:02:13You can't say you serve veterans when you repeatedly attack the VA workforce who actually serves our veterans. And today we're going to talk about the community care network next generation contracts. Well, Collins tears down the VA with one hand. He then doze up the pieces to corporate interests with the other, enriching them while veterans are going to go unserved and uncared for. In his actions, we see exactly who Secretary Collins really serves.
▶ 2:02:39Driving the VA towards privatization, we know only serves corporate interest, and it puts profits over veterans. So, I want to get into some of these questions. Despite the VA's severe staffing shortage, the NextGen contract structure introduces significant oversight complexity. The VA is planning to establish a bench of contractors through this 10-year indefinite delivery indefinite quantity multi-awward contract model.
▶ 2:03:08Contractors on the base Idiq will compete on task orders. So the VA will have many layers of contractor activity to oversee. So Mr. top. And given that the VA is down to down 30,000 employees with the plan to get rid of 35,000 more positions, it's really hard for me not to wonder who exactly you plan on having oversee this contractor activity because according to a GAO report released in August 2024, the VHS Office of Integrated External Networks,
▶ 2:03:38which is involved in oversight of the contracts, was staffed at 57% of its authorized level as of February of 2024. At the same time, the contracts management and performance team within that office was staffed at about 50% of the authorized level. Committee staff asked for updated staffing me uh numbers during our recent briefing with you on the CNN NextGen procurement, but the VA has yet to provide those to committee. So, Mr. Topping, here's my question.
▶ 2:04:08How do you anticipate meeting its contract oversight and execution obligations, particularly given the president's ongoing limitations on hiring?
▶ 2:04:21Representative, thanks for the question and the chance to set the record straight on on this. So, let's talk about staffing. VA is appropriated for 455,000 employees. Our operational strength is 447,000 employees. That's a delta of 8 thou 8,67 actually. That's the delta. 5,000 of those are clinicians in the clinical setting in VHA. We are working to fill those to ensure that we are fully staffed. There's an 8,000 employee difference, not 35,000.
▶ 2:04:51This garbage story from the Washington Post about 35,000 positions being cut, it's not true. the post reached out to us to
▶ 2:04:58I want to really specifically come back to CCN contract oversight and I want to just do a follow-up question because I know we have limited time here. How many positions, so let's go go specifically here, are currently authorized for CCN contract oversight and execution? And number two, do you intend to increase the number of authorized positions for the nextG?
▶ 2:05:19We will build the program management capabilities necessary to manage a
▶ 2:05:24Do you have a number of how many you're going to authorize?
▶ 2:05:26I do not have a number yet because we haven't built it yet. We are in the process of doing that. What we what we are bringing to you today for your oversight is the design of CCN nextgen program management is the next and again I say what I said earlier this is not unique to VA we have the center for Medicare CMS does this we are not the only ones to manage a program like this we will look at best practice best structure we will bring those to VA and it's not just
▶ 2:05:51you're looking at this best practice let me ask you a follow-up question as you're doing the planning tell me a little bit about how you're considering what percentage of the currently authorized contract oversight positions you already have available to be filled.
▶ 2:06:07The way we manage the current contract, which is an unmanaged contract and very different from what nextgen is, is is not the same as we're going to program management and design the new one. We will design program management inside VA to match the new
▶ 2:06:22Mr. stopping. My time is up, but I definitely want to make sure that we have a follow-up on these staffing numbers that it seems like you have a number and we have another based on the members that we have seen. So, we'll follow up. Thank you.
▶ 2:06:33Representative South, you're recognized for five minutes.
▶ 2:06:36Uh, thank you, Mr. Ch. Uh, chairman. Uh, I've got questions on kind of going forward on this because, um, Idiq in some government contracts are the race to the bottom. Let's just be honest. Um when you add when and and I understand we've been told that you're going to have a vendor that might have the capability might submit the capability but you won't use the services currently but you might get to them later.
▶ 2:07:05Is that not going to make first of all their submission more expensive because you're going to have them in a contract that you may or may not be paying them for and uh then you might limit the numbers of vendors too because that requires a vendor to have a wider range of services.
▶ 2:07:25Can you address that because it looks to me like you might be limiting to the larger vendors uh who are going to be able to meet that uh representative, we are very much intentionally not limiting the large vendors.
▶ 2:07:40The in the intention and the ability to use the Idiq is to open this up to competition to non-large vendors, but to those who might bring regional capabilities, regional capacity that would not be able to operate on a national or semi-national scale. We want those vendors on the vehicle. they will incur a cost to bid and and uh and and um and be awarded a spot on the vehicle.
▶ 2:08:04But once they do that, the vendors who are on the vehicle with us, large and small, have a seat at the table with VA with our program management team to design those ne next task orders. There are two initial task orders in the initial award. Those look a lot like what we have now, large regional. But we are going to immediately partner with the vendors on the vehicle to to begin to build the next more regional, more adaptable, more local models in our task orders.
▶ 2:08:31Okay, you've already heard our concern about $1 trillion and these are inputs and this committee and uh particularly me are always concerned about the VA. I want to give you the [clears throat] the and you've got it the the the range to run on, but these are inputs outputs. How are you going to identify to off-ramp vendors who are not participating? Because this is where the rubber meets the road.
▶ 2:08:58How are you going to make sure you have an efficient process to do this? Sort of the vendor oversight process, the contract requirements will be spelled out. Those will be very specific. And unlike in the current program where really all we can do is bicker about that. All we can do is litigate that all and the only remedy is the ultimate remedy which is termination or replacement. Our ability for vendors who don't who do not meet our technical requirements or even our value requirements and how they're serving our vendors.
▶ 2:09:26We have the the government has the ability to offramp that vendor.
▶ 2:09:30Who is that person? Who has that decision makingaking authority to make the decision? You are now offramped. That is the department of veterans affairs and the program management team.
▶ 2:09:41What level is that?
▶ 2:09:42That would be inside the agency for the and the lead program for this office.
▶ 2:09:47Okay, that's a that's a little nebulous. Uh look, 40% of care is now under community care, right? So this is a rhetorical question. Once we get over You're going to hear the privatization argument ramp up. So then right now we know we know that uh veterans get the private coverage more of them say they're in good health than the the veterans who get care in the big VA.
▶ 2:10:18So is I'm concerned about the future here because once we get over 50% you start hear this argument about privatization you have privatized care. um how then are we going is the VA then going to be expensive specialized care only?
▶ 2:10:37So give me your vision for the future and basically in 10 years what does the success of this program look if we go over 50% of care is given by community care is provided by community care providers.
▶ 2:10:51Representative Secretary Collins has been very clear. We are not privatizing the VA. We are investing in the direct care system and we are investing in the community care program. We want veterans to have the choice where he or she receives the care and if they prefer direct care, we want them to have the access to that and the world-class care they get there. If they choose the community, we want them to have access to that as well too.
▶ 2:11:13what this program looks like 10 years from now and where we are moving to and we are starting with where we are and we will progress through this task orders again with the vendors on the vehicle is we ultimately want to be focused on paying for the highest quality cost the highest quality care that we can receive and that's based on agreed upon measurements and metrics our data and our ability to action that for the lowest possible cost of care that's what success looks like and ultimately that the veteran can choose where he or she receive wants to receive his or her
▶ 2:11:43care.
▶ 2:11:45I have more questions, but my time is up. I yield back, Mr. Chairman.
▶ 2:11:49Dr. Dctor, you're recognized. Dr. Dctor,
▶ 2:11:54thank you, Mr. Chair. Um, and I I love and thank you, uh, Mr. Topping. I love hearing that you want to pay for the highest quality care veterans can receive. I think we all want that. Um I would like to ask first which healthcare organizations in the US either government nonprofit or for-profit have utilized this indef indefinite delivery indefinite quantity Idiq contract structure you are proposing
▶ 2:12:22representative VA uses Idiq's uh and uses them in multiple areas and multiple spaces. This is the first time for a healthcare contract that VA is using this. Um this is used outside of our agency and other parts of government as well too. The Idiq is a vehicle which allows the government to buy services if it doesn't know upfront exactly what it needs and when, but can pick a stable of vendors that we know are capable of delivering that. That's the that's the use of the Idiq.
▶ 2:12:50The model of an Idiq is not new, not new to VA, not new to government. It is new.
▶ 2:12:55I do want to get through a lot of questions. So, I app I appreciate that. But I I think I understand it's not new, but I think that we all have concerns um with some of those well-vetted vendors that there have been misuse of federal dollars that should have been taking care of veterans and and may have been misbuilt, let's say.
▶ 2:13:17Um, so for our committee to do effective oversight, I would like to see a list after this hearing of those entities and any market research VA has conducted on those organizations that we are considering using this contract. Um, and based on your testimony, it seems contractors alone will propose and pilot alternative payment models to test on the veteran population. How does the VA plan to evaluate these care models especially related to quality outcomes when they are being offered outside the direct care system?
▶ 2:13:47VA will make the determination on which models we use. So VA will drive this VA will make the ultimate decision. What we do want to do and again this goes back to the Idiq vehicle is we want different vendors with different capabilities and they'll be regional. We understand that we want these vendor partners to come in and make proposals based on what they have used and what has been successful in their network in their areas. Those will be different in different parts of the country.
▶ 2:14:12What we're going to be able to do in terms of value based care in the upper Midwest largely rural uh where you've got potentially you know limited providers versus what we could do in metro DC very different. That's why we want them to bring the proposals, but we will make the decision.
▶ 2:14:26And I appreciate that. And I think it all sounds fantastic, but really putting it into practice has been extraordinarily difficult. I come from a healthcare organization. I know this very well. And I just want to use as an example, um, my team sent a letter to Secretary Collins on September 22nd asking for what was, um, required by Congress in December 2022 for the VA to develop a plan to ensure veterans are informed of expected weight times at VAS and in the community.
▶ 2:14:56That was over three years ago. We asked for that information and our team has been reminding folks weekly since September that we are waiting for that information and still have not gotten an answer to that.
▶ 2:15:08I find it hard to believe that we are still waiting for just how long does it take for a veteran to get an appointment in the community over three years from when Congress said it should be so that we actually have the capacity to have appropriate oversight and um transparency for outcomes for our veterans if we can't even tell when they are getting appointments. I would love your response to that.
▶ 2:15:30Representative, let me take that. I haven't seen the letter. I'm not aware of the ask. Let me take that and come back to you.
▶ 2:15:36Um Mr. Chair, if I may ask to submit into the record the um letter dated September 22nd, 2025, it'll be available for all. Um I also want to just
▶ 2:15:45without objection.
▶ 2:15:46Thank you, sir. I appreciate that. Um you noted in your testimony also that the VA will implement comprehensive quality programs for community pro providers based on nationally recognized measures that will quote ensure veterans are not simply referred to any available provider, but to those demonstrating strong outcomes and safe high quality care. Again, I share this goal.
▶ 2:16:07However, given that vertically integrated healthc care entities often restrict patient visits to their own providers, how can you clarify any guard rails that will be in place to ensure that veterans in the community care programs will be referred to providers with highest quality outcomes rather than just those preferred by any contractor.
▶ 2:16:28Representative number one, we're using uh healthcare research and quality data. You've seen and you've worked with those. Hedis, you've seen, you've worked with those. These are well known, well understood by both payers and providers. We are using the metrics that the industry understands. We're going to measure to those where we set the goals and the outcomes and the requirements. VA will determine that. But all that is to say, too, and I I think probably this is the fourth time I've said it here today too, the the plans will not determine where the veteran goes. We will make the referral.
▶ 2:16:56We will determine where the veteran receives the care. and we want our veterans to go to those providers that can provide the highest quality at the lowest cost. The intent of this program and the tools that we have built into it enable us to do that.
▶ 2:17:11So, I'll follow up on that because I I worry that in the actual delivery systems, the VA is not going to have the level of engagement to actually be able to direct those visits. um we know that those vertically integrated systems are already shunting lower paid paying patients to different outcomes. So I I am concerned that you actually can deliver on that and would love to understand some details on that and follow up. Thank you, Mr. Chair. I apologize and we yield back.
▶ 2:17:41Representative Barry, you're recognized for five minutes.
▶ 2:17:43Thank you, Mr. Chairman. Appreciate it. Thank you for being here today and uh thank you for your testimony. Obviously, it's of high interest to this committee the amount of uh investment and commitment that we have for a contract of of this nature. But I do want to start by just kind of reminding folks of before we had community care options available to veterans what that looked like.
▶ 2:18:01And uh I was uh early in my tenure in the state legislature in Michigan, I heard testimony from a veteran in Michigan who had a uh hip replacement done at a VA hospital several hours from his home, probably 3 hours away. And they prescribed him physical therapy as is expected and normal after that.
▶ 2:18:20but he could not get physical therapy at the clinic 2 milesi from his house because he was technically in an area that had a VA facility within a commutable range, but they did not offer physical therapy at that place. They wanted him to go back to the hospital. He had the the the hip replacement 2 or 3 hours from his home. Entirely impractical. Obviously, changes needed to be made.
▶ 2:18:43And I think one of the lessons learned post 911 is that the VA was not really set up for the wave of veterans that came home off the battlefields in Iraq and Afghanistan and the unique circumstances that they were facing. And I think reminding us of why we're here and why community care can work for veterans is important for things that they need. Obviously, we need the VA for very um very important things as well. And this isn't an eitheror thing. It is a both thing.
▶ 2:19:12And I think we can acknowledge that as well. And it doesn't need to be one at the expense of the other. They can work in concert with one another. Uh I have the privilege of chairing the technology modernization subcommittee on this committee. And uh one of the things we are really investing heavily in is this electronic health record modernization that is coming.
▶ 2:19:33And I guess what I what I'd like to hear from you is as we roll that out, are we going to see a better integration with community care for veterans as they move portability, their electronic health records? Veterans like me who go to a VA hospital for part of my care, but also take care in my community for things that I feel I can realistically get there. But there's not a way of sharing those records.
▶ 2:19:57I had the same back x-ray no less than three times because one was within the VA, then to my primary care at the VA, then to the place they referred me to. They can't even share an X-ray scan between one another. So, are we going to see a benefit of that coming? Is that contemplated under this contract? And how do you see that performing?
▶ 2:20:19Representative, let me answer both those questions. So, one about the the constituent that you had that had surgery in one place, referred to the
▶ 2:20:27This was long ago, so it's not current.
▶ 2:20:29Could have been long ago, but I'm but I'm sure there may be other stories out there like that, too. And this was when Secretary Collins introduced best medical interest, this is exactly the type of thing he wanted to tackle. And so, where you've got for a veteran where the quality of care, but also continuity and convenience makes sense, the veteran should be able to drive that, not the bureaucracy. That is the intent of that change.
▶ 2:20:49So absolutely the impacts both direct care and community care that is part of it in terms of portability um and the ability for our electronic medical system to to speak to to work with compatibility. One of the things that under the current contract um that has really been unfunctional is we do not have an easy way for providers to transmit records. We have the same challenges with claims which really shouldn't even be there. But we have the same very much a problem with provider record transmission.
▶ 2:21:19And yet there are easy and commercially available exchanges that every other provider does this. Different providers from different systems move move claims, move records all day, every day. The new contract requires the use of commercially available and compatible systems. And the new system that VA is implementing, again, Vista's homegrown 30 years. the new system does have the ability to do that can ingest those records and then populate it through the new system.
▶ 2:21:48Very good. I don't want to cut you off but I do want to move to uh the second part of that which is I've seen through the electronic health record program just how these contracts can balloon into a cost that is way beyond what is initially advertised. and you know, we get into one of these contracts and we're too far into it to really claw back or pivot or change or make uh uh adjustments to that.
▶ 2:22:12What accountability measures can you assure us of so that as we go through this process knowing that contractors are going to try and charge us and nickel and dime us every change order along the way and everything else. How are we going to extract the best value for the taxpayers and for the outcomes for veterans to know that we're not going to have a contract swallowed up into something that is unmanageable and five or 10 years from now we're in a position where this thing is ballooned completely out of control.
▶ 2:22:40Uh so representative one thing again the Idiq gives us the flex the flexibility to bring in choose and swap between different vendors in the program to change the program as we go. That is what's novel about that. That's what's exciting about this. That's what gives us those tools and our and our ability to do that. We don't get swallowed up on this because we have time as we go across. And then ultimately, the cost of care and community care is not the administrative cost of the program. It's not what it costs VA to operate it. It's not even what we pay our health plan partners.
▶ 2:23:10It's the cost of purchased care. We want those health plan providers to have skin in the game in lowering our cost of care. And ultimately, where this contract does go is we are paying for quality. If they hit our targets, they hit our scores and they save money for us, they will share in those savings, that's how we drive and pull down the cost of care in this.
▶ 2:23:31Representative Kendy.
▶ 2:23:32Thank you, Mr. Chairman. Uh, today's hearing on community care network generation requires clarity about what the program is and what it is not. Community care was meant to supplement VA healthcare when timely care isn't available. was never meant or intended to replace the VA or be a vehicle for privatization.
▶ 2:23:52Veterans are a unique patient population with complex service connected needs from combat injuries to toxic exposures that the VA was specifically built to treat through coordinated holistic and specialized care. Shifting more care into fragmented private system risks, quality continuity and outcomes. This model is also unworkable. CCN NextGen demands strong oversight.
▶ 2:24:19Yet, this administration has cut tens of thousands of VA staff and failed to fill vacancies, including staff responsible for overseeing these You can't hollow out the workforce and expect the system to function effectively. We all know that billions will flow to contractors with limited accountability. And when care fails or becomes fractured, veterans will pay the price. Veterans kept their promise to our country. We should be strengthening the VA and not hollowing it out.
▶ 2:24:47I'm a healthcare practitioner myself, an occupational therapist. I was trained to look at the whole patient function, recovery, long-term outcomes, and continuity across providers. The CCN NextGen RFP provides extensive detail on contract structure and payment but very little on requirements for clinical quality, continuity of care or experience treating high-risisk So my question, Mr.
▶ 2:25:14Topping, is where in the RFP have you set specific quality of care metrics for community providers to
▶ 2:25:23Representative, thanks and good to see you again. And and so number one, community care nextgen is a supplement to the direct care system and the things that VA does well and VA does uniquely. And again, this is a trillion dollar over 10 program, but our direct care is two trillion over 10. This is one-third, that's 2/3. We are investing in those. We're opening new facilities. We've invested $800 million last year alone. We are investing in our direct care capabilities.
▶ 2:25:50And so for veterans who either need to go to VA for direct care because it's a unique capability that VA has or who choose to go that they have that ability and they have that choice. We are investing in that. And secondly, how quality will be measured. Again, we are using standard industry metrics for this. These are not unique to VA. These are not unique to providers. We're focusing on heat. We're focusing on the types of scores and measures that make a difference that we know providers are used to working to measure.
▶ 2:26:18we are going to use that as we then determine who and how and under these contracts whether we are meeting the requirements that we're setting out for them. So the so that is contemplated and included in this
▶ 2:26:30So I I understand the goal and the goal should be the the golden standard of care, the top quality care for our veterans. I believe we all should aspire to hit that goal. But if the quality care standards are not put into the contracts, they're not clearly defined. Isn't it fair to say that the quality and the continuity of care aren't being prioritized in the contract?
▶ 2:26:57Representative, they will be included in the contract and we have identified what our mandatory quality requirements are and what our scores are. There are mandatory and optional, but we have already identified those and those will be in the contract and they will be
▶ 2:27:12Well, it it seems to me the oversight of these contracts though are going to be left onto the contractors themselves that the quality of care is going to be left to a standard like they're policing themselves when it comes to quality of care like the fox watching the hen house.
▶ 2:27:29what you know, how do we assure our veterans and and this committee and Congress and the people that veterans are going to be provided that golden standard of care if we don't provide for the proper oversight of those contracts.
▶ 2:27:47Representative, we will manage our vendors. We are accountable to our veterans for the care they receive. We are accountable to you as Congress. Um, we will manage the vendors. This is our program. Our vendors will operate this as our partners on agreed agreed upon terms and requirements. And again, we have the ability to offramp vendors who do not meet our requirements, don't match our values.
▶ 2:28:09Will will they be self uh policing their own contracts?
▶ 2:28:16For quality of care, there will be
▶ 2:28:18Yes, sir.
▶ 2:28:19And and how is that oversight provided in the contract? How is that outlined?
▶ 2:28:22We will manage that. So, the requirements will be in the contract. We will manage that through our program office. And again the Idiq gives us the a ability to offramp vendors who do not meet those requirements. Those will be required. We will manage that and we will be accountable for their
▶ 2:28:39Well, just short on time here. Uh Mr. Chairman, I will yield back. Thank you.
▶ 2:28:46Representative Shiffless McCormack, you are recognized for five minutes.
▶ 2:28:50Thank you so much, Mr. Chairman, and thank you for being here and answering these questions. Um, you know, the possibility that our veterans could have access to care wherever they live is actually, I think, our shared goal. However, the VA doesn't have a good history of implementing any kind of technology modernization and I love what you're saying, but I think the scrutiny is coming because of VA's history. And so looking at that, I wanted to dive into what mechanisms were used in determining to go with nextgen as far as acquisition
▶ 2:29:23representative. So in terms of the contract vehicle or in terms of the technology that we are going to use to administer the
▶ 2:29:30the decision-m process
▶ 2:29:33um the decision-m process uh around CCN and to use the Idiq vehicle was to in introduce flexibility and competition and then the choice to use the five pillars were based on we know that those are controls that exist in every other healthcare program that have been successful. We know that we can leverage those to get to the outcomes that we're looking for. We made those choices based on that. And then our next step on this
▶ 2:29:59I want to interrupt you real quick because what I'm looking at is the price point and what the decision making behind the acquisition. For example, um as a missionritical, highly complex and high dollar value acquisition, NextGen clearly qualifies as a major acquisition's program under VA's acquisition lifestyle framework. So could we go into the framework that you used in choosing NextGen?
▶ 2:30:24Represent I'm not I'm not sure I clearly understand the question. The the the framework that we chose were based on what are the outcomes we are trying to achieve for our veterans and ultimately what we want is veterans to have choice. We want veterans to receive high quality care and we want taxpayers to get the best value for that care. That was the framework that we that we choose. So would Miss um Skull be able to answer that question? I know you do the financial question.
▶ 2:30:49Thank you. We did follow the acquisition lifestyle framework. Um that was that uh I have been um I've learned a lot about that in the last year and a half since I have been with the federal government and the VA and we followed and worked closely with SAC the strategic acquisition office and um have you know followed that process um as it is laid out. And have you already had the acquisition decision events A and B?
▶ 2:31:18I'm not familiar enough with it to speak to those details, but but I know that we can provide you that information.
▶ 2:31:24That would be excellent. And we want to know also who was provided or who was actually a part of those decision-making. And like I said, the extra scrutiny is because the VA has not been successful in implementation. So, we want to make sure that a lot of the failures we had in the past aren't being repeated. In addition to that, um I've heard you say several times that we're looking at best practices even with CMS. There's a unique culture within the VA that has caused the VA transition to different types of technology unsuccessful.
▶ 2:31:53And so one of the things that you know the last five years we've been doing this, I've learned is the presumptions that we make in private industry or in other government sentences um other government settings don't necessarily apply here in the VA. So as we're going forward, we do want to get more data and more information as implementation goes on. Um this process of flying, building the plane while flying it has not led to success. So do you know offhand any safeguards of reporting that are going to be present?
▶ 2:32:22So as we see the implementation, we're knowing wait times for for example. Do you have any of that lined up? We do. We have an extensive implementation team that has already began um meeting. Um we have over well over 200 um team members um throughout the VA that are participating in that.
▶ 2:32:46Um right now the the primary focus of that uh team once we've we've created the infrastructure and the work streams that will oversee the implementation. The predominant um um thing of importance right now is care coordination. Yes.
▶ 2:33:01If we were to select um a provider, a V a TPA, uh when we select a TPA, it will be very important that uh veterans who are getting care currently uh in in the field in the community that those referrals that all of that is hand hand by h one by one transferred over to community to the other provider.
▶ 2:33:23Um as I'm running out of time, I just want to make sure that when we have another opportunity to convene that we can actually have all that information in front of us.
▶ 2:33:30Absolutely. So as we're doing the oversight process that we can work together to make sure that this is actually successful because as I mentioned too many projects that we've spent a smaller amount of money on have failed and that ends up hurting our veterans. It ends up hurting our finances as we're funding it and it hurts everybody all across the board and we're like 10 years in trying to get it right. So the goal is to get it right as much as we can and spend the least amount.
▶ 2:33:55But flying the plane while building it has historically caused failure and we want to make sure we prevent that. Thank you so much. I yield
▶ 2:34:02Dr. Morrison, you're recognized for five
▶ 2:34:05Thank you, Mr. Chair. Healthcare workers are increasingly facing burnout and I hear about the administrative burden my physician colleagues are facing with an alarming frequency. A major part of what compelled me to serve in Congress was my firsthand experience as a doctor, seeing how difficult navigating our health care system can be. It's one of the reasons I fought so fiercely in my home state of Minnesota to pass legislation that reduces this burden. And it's why I have serious concerns with the significant changes that have been proposed to VA's community care network.
▶ 2:34:35The focus should be on delivering the best care for our veterans, prioritizing their needs and access to care. I'm sure you agree. Mr. Topping, the CCN NextGen contract will include incentives and disincentives to be implemented over the life of the contract. The incentive and disincentive plan for the east region task force only identified two performance objectives both of which seem concerningly easily attainable.
▶ 2:35:00The first incentive VA list is adverse credit reporting that is ensuring veterans are correctly build for co-pays and not improperly build for services to avoid having unpaid bills being sent to collections. It's my understanding that among the pressing concerns with vulnerabilities in the CCN, this has not been an issue in the community care program under the current structure. My colleagues that have served on this committee for longer than I have shared that they can't remember the last time a veteran reached out sharing that their community care claim was sent to collections.
▶ 2:35:30So, I'm having a difficult time understanding the logic between tying incentive payments to metric contractors that will e that'll easily be able to achieve. So, so Mr. topping briefly. How do small, easily achieved incentives protect the quality of care veterans receive and safeguard taxpayer dollars?
▶ 2:35:50Representative, thanks for that question. And so again, the purpose and the intent of this contract is to be iterative and for us to be able to scale and evolve over time. Adverse crediting report credit reporting is a proxy for whether or not these TPAs are doing their job, which is processing and paying for claims. That is the number one thing that they were supposed to do is to ensure that our veterans do not receive bills for the services they have provided.
▶ 2:36:14This has been a management issue inside VA and this is an easy clear metric that they can manage to and that we can manage and report on to ensure that they are doing their number one task which is paying and managing claims. That's number one. The second thing we chose is the inclusion of value based u value based contract provisions in their network. And you can see that starts with a zero and ratchets up over time.
▶ 2:36:38The reason why we have done that is valuebased is a key component, a key control in this contract to ensure that we can pay differently for the quality that we want and with the integrity that we're looking for. This ratchets up over time the ability to ensure that they are that we have these in the provider network. And then what we intend to do is then drive the requirements on what we want out of VBR. It's ensuring that the infrastructure is in place. And lastly, the lower externity joint replacement.
▶ 2:37:06This is already a procedure or a process that VA has. We use this in the community. This is a well-known bundled payment. Um, and so we are starting with where we know we can manage. We can be effective. We can provide the oversight and we know industry can deliver. These are our starting points.
▶ 2:37:24I'm sorry to interrupt, sir. Would would you be willing to commit to working with us to implement meaningful guard rails that can prevent these incentives from becoming mechanisms that will actually be used to just drive excessive money to health insurance companies and payers that will be awarded these contracts?
▶ 2:37:42Absolutely. Yes, representative. We share we share that with you.
▶ 2:37:45Fantastic. It's my understanding that VA anticipates it will take until FY28 for full healthcare delivery under the CCN NextG contracts. What is VA's plan to bridge the current CCN contracts and services until the nextG contractors are in place and able to provide the full spectrum of care needed in FY 2028?
▶ 2:38:04Representative, we'd love to have no bridge. We'd love to implement the new contracts as soon as we can on time. Um, to the extent a bridge is needed when that comes and that goes through the acquisition and contract office process. To the extent a bridge is needed, we will implement that at the time. But our goal is to get this done, get this bid, get this right, and get these awarded and to begin to manage and operate this program as soon as possible.
▶ 2:38:29So, how will you ensure proper continuity of care for veterans during this transition?
▶ 2:38:36Thank you for the question. And that goes to what we were talking about a few minutes ago. Our implementation team right now, our primary focus and the the priority for the workstream is care
▶ 2:38:48Um these these things occur in industry um not infrequently where a TPA changes. There's a process in place to make sure that that care coordination is is done very well. We're pulling again from industry expertise to make sure we are thinking of every single avenue that we need to to make sure that no veteran falls through the crack during during that transition.
▶ 2:39:10Thank you very much, Mr. Chair. I see my time has expired. I yield back.
▶ 2:39:13Thank you. Representative Vinski, you're recognized for five minutes. Thank you, Mr. Chairman, and uh ranking member Takano uh for holding this hearing. Um, one of the major limitations of the current community care program is that there are about five different ways for providers to return medical records, ranging from faxing copies to participating in electronic health information exchange.
▶ 2:39:38Many of the existing mechanisms rely on manual retrieval of records and importation into VA's electronic health record which is both time consuming and lacking in true interoperability. Um most records never make it back to the VA which limits our ability to monitor the quality of care veterans are receiving in the community. So my question Mr.
▶ 2:40:02topping is to what extent does the CCN nextgen request for proposals address the technology needed to facilitate the return of medical documentation to the VA from network providers? Um and then as a second question, what challenges do you anticipate in in getting that information to the VA?
▶ 2:40:26So, the first challenge on medical records, which is well known at this point and documented, is driven in part by the fact that VA still uses an EHRM that's homegrown and about 30 30 plus years old. Uh, we are transitioning on a very aggressive schedule. Secretary Collins has been clear that his expectation is this will be done. This is being led by the deputy secretary. We are transitioning to a new EHRM that has these capabilities.
▶ 2:40:50Currently, for a provider to share records with VA and for those to then get into the Vista system, it is a manual process and that is unacceptable. Under the HRM system and in this contract, we are requiring the use of commercial exchanges. We are going to transfer medical records, share medical records in the same way the rest of industry does so that providers can use the systems they already have. There'll be an exchange and then we can bring those records into our system going forward as part of our EHRM implementation.
▶ 2:41:19So, and and I serve as the ranking member on the tech modernization subcommittee. So, definitely very much tracking this EHRM um implementation as it's been going. But this is going to be a big process. So, what you're saying is that through the manual process, that's how manually we'll be able to have to until EHRM is fully implemented, it'll be a manual process in ensuring that community care records get back to the VA.
▶ 2:41:48We will likely during this transition between now and when EHRM will be completed. So it is a completely electronic process straight data exchange from the provider through the exchange to our new system. That's fairly straightforward in the way that the rest of industry operates. We will still while we have Vista likely have to take from the exchange and there will likely be a process by which we will then have to pull those records in. That will continue. But that is part of the goal on EHRM is ensuring that we do not have to do that going forward.
▶ 2:42:19There will be a bridge.
▶ 2:42:20So that there there's a commitment that those records will get to the VA. Um is there you know returning of these medical records would there be a condition of payment? Um you know maybe if they don't return those payments to or they don't return those records to the VA would there be some kind of um you know condition on payment to the vendor if they don't receive it? Thank you for that question.
▶ 2:42:45We are not linking um payment to the vendor directly to um the return of medical records. However, we have put into the NextG contracts more of responsibility on the TPA to ensure that their providers are compliant with the the rules. So the contracts that the TPAs have with the providers must include the return of medical records. We we have also streamlined the way in which we will receive those medical records.
▶ 2:43:10So the facts or the the phone in all of that we have uh streamlined um what the expectction expectation is for return of
▶ 2:43:19Okay. And if there I mean if you're if you're taking kind of payment off the table is there will there be a process in place to just ensure when you see there's that gap that records aren't being I mean it's just important that the VA be the place where all that's
▶ 2:43:33Absolutely. We also are utilizing that as a as a data point for our preferred provider program. So if we have a provider who's not um who's not doing that, then they can lose designation as preferred provider.
▶ 2:43:45Okay. And this might go to my next question. Um is it the VA's expectation that contractors will provide a system that will be truly interoperable with VA's electronic health records, both Vista and Oracle? I think you've answered that question, but just anything further to elaborate on that
▶ 2:44:04Yes. Okay. Um, one other thing I just want to ask really quickly about the RFP. It includes optional line items related to the development of software processes. Could you just quickly say um, to what extent do you think the VA sees development of IT systems and software as a part of this effort?
▶ 2:44:24Thank you for that question. The the intent of the Idiq is to be broad so that should again so that we're nimble. Should we come to a point in time where that makes sense and we need that then we can utilize the multi-awward Idiq and issue a toer for that particular need whatever it may be
▶ 2:44:42and would that be an additional cost in addition to the trillion if you do decide that you need it
▶ 2:44:48the so the cost the cost for the technology requirements for the management of this program so let me first go back to the program management part of this which VA is now focused on our ability to manage these contracts we are building that and that includes includes a technology build. Um, we're getting ready to focus on a $300 million acquisition around that to ensure we have the capability to do that. So, that's number one, making sure that we have the resources, make sure we've got the team, the capabilities, and the resources to do that. How that then fits in with the network and our providers.
▶ 2:45:19We want to be as plugandplay as possible. We are the fourth largest payer, but we are one of the payers. And so, these providers also work with Medicare, they work with Medicaid, they work with Triricare. We want our system to be complimentary to work they are doing with the most interoperability as possible. So those have been our focus and that is a commitment to it both a financial commitment and a management focus on the build.
▶ 2:45:41Thank you for the extra time. Mr. Chair, I'm going to yield back.
▶ 2:45:44I'm going to explain to the audience and the pan and the u members what the intent of the chair is at the request of the ranking member. He does want to ask one more five minute. We're going to grant him that opportunity and then one on our side for Keith or for himself instead of him doing a second round because we got another panel we're trying to get to. Are you all right with
▶ 2:46:11Well, what I'm trying to do is get to the second panel as fast as possible. That's why I said we
▶ 2:46:16we'll just gohead do everybody that's
▶ 2:46:19Okay. So, You're recognized.
▶ 2:46:24Uh thank you, Mr. Chairman. Um Mr. Topping, you have uh you have given us the mantra several times. I'm trying to get to the details. Um I I don't think you answered Mr. Barrett's question about do you have a plan?
▶ 2:46:42Can you assure Congress that the 1.049 049 trillion dollars is the final cost for this program because in the VA we find they come back for more money almost every time. So I think that's what Mr.
▶ 2:47:00Barrett was asking and I would ask you directly how will you manage that in this managed program so that when you reach that that end dollar What are you going to do to make sure you don't come back for open-ended funding from Congress?
▶ 2:47:21So, Representative, there are three things that drive ultimately, you know, revas on cost. Number one are the original cost estimates which tend to be inaccurate and there are the reasons why they're inaccurate are there are things that are not in the model. For example, congressional changes, congressional intent, larger demographic shifts. There are things that we cannot quantify in a 10-year model in our enrolly healthcare cost model that make the model sometimes inaccurate. That's number one. Number two, by design, the VA system cost shifts.
▶ 2:47:51Veterans and their care, they can go from direct care to community and back again. Our system in terms of letting the veteran choose where he or she receives care is designed to shift that cost and that care. That's number two. And then number three, both of those programs, both the direct care system and the community care program up until now have been completely unmanaged. We have had no tools, no levers, no capabilities to manage those costs, to make adjustments. What CCN NextGen does on community care is it gives us program integrity.
▶ 2:48:21It gives us quality, gives us valuebased care, gives us utilization management, and it gives us alternative payments. It allows us to use those tools and levers to begin to be accountable for those costs and to pull those levers. And so for the first time and in the cost estimates I provided this committee where we show savings of 8 to 14% over 10 years, 54 to 100 billion. Those cost estimates are not based on VA data. Those cost estimates are based on CMS data on these tools used in other programs over the past 10 years.
▶ 2:48:51It's verified data. I believe those numbers and those projections are accurate and as accurate as they can be and I believe we can come back to you on time and on budget.
▶ 2:49:01Okay. So, Idiq uh contracts have a habit of not being solid and veterans uh the population between 04 and 24 I think decreased by 30%. The enroles have been stable the way I understand it, but the population has gone down by 30% over those last 10 years. So, as the population goes down, we're losing obviously our World War II vets and our Korean vets in great numbers.
▶ 2:49:31Uh and and frankly, we're not we're not uh in any active conflicts now. So, I think that will change. uh your transition plan. I believe that you do have a transition plan over two years uh because you've got like $425 million over two years for implementation. So I I assume you are having a soft opening which people would call a soft opening. You roll it out over time.
▶ 2:50:01Um question uh do you have community Karen? This may be something I just don't know. uh vizen boundaries have been sacrosanked here to four. Uh is this is this under this contract going to be different uh because El Paso, Texas for instance is at a vision boundary. So can you speak to that under this contract?
▶ 2:50:24Uh representative yes and no. Uh and yes we are going to have vision boundaries and this is part of the VHA restructure in which we are moving from 18 visions to five plus with health service areas as well. So our regions match those. However, under the Idiq and bringing in regional vendors, our intent is that those regions can then be broken up further, redesigned, we could have partnerships in those regions. What we want to be able to do is match the care we can deliver.
▶ 2:50:53What we're paying for and what we're achieving and what we need. We want to be able to match to the region in which we need to deliver it. So there is flexibility for us to do that. We will use the same regions. We will have the same boundaries, but we do have the ability to be flexible based on the needs of the veteran.
▶ 2:51:08So, cross vision boundaries. So, you have that flexibility.
▶ 2:51:11Yes, sir, we do.
▶ 2:51:12Okay, Mr. Chairman, I yield back. Thank
▶ 2:51:15Ranging member, you're recognized for
▶ 2:51:22go ahead.
▶ 2:51:23Trouble hearing you today, Mr. Chairman. So, um, thank you for the opportunity. So, um, just a couple last questions here. So earlier you told the ranking member that VA will not require any transfers to the community care account for fiscal year 2026. So I just want to make sure that that's absolutely correct
▶ 2:51:48representative. I want to be a little hedgy on that. And what and what I said and which is what I have right now is my data right now, my utilization data, my cost data, understanding that there is a data lag and there's a claims lag. Providers can bill me 6 months after the fact. And so the data that I have right now shows that our appropriation for FY26 is accurate and that is the number that we need. That is what we are managing to.
▶ 2:52:14Okay. And I also want to just confirm that you haven't had any discussions with our appropriations uh committee counterparts about possible transfers. I just want to make sure we're absolutely clear on this. I if you could answer that please.
▶ 2:52:31Representative I always have conversations with our appropriators. Uh they are they are my best friends as the CFO making sure they know what I'm managing managing to where I see risk where I see opportunity. um and making sure they know and I've got maximum flexibility to meet the aids of needs of the agency. Um and so coordinate with them and and uh just let me re ask let me uh re ask the question in a different way.
▶ 2:52:57What you just told us about transfers in 2026 is the same thing that you have said to the appropriations folks in your ongoing conversations. In my ongoing conversation, it was this is the data I have. This is the number we have. This is what we're managing to, but I want but I want all of my appropriators to know that as we manage this, we want to ensure that we have the resources we need to meet the mission and care for the veterans. Those are the conversations I've had with my
▶ 2:53:28Okay. Thank you. And one last question. So, um I I I I think the um when your plan, this new plan will be fully operational will be in 2028. Is that correct?
▶ 2:53:44Yes, ma'am.
▶ 2:53:46Okay. So, in 2028, we're going to have a new administration. What that administration looks like, we don't know, right? Um but so my concern is um while we're working really hard on this new delivery system, if you will for community care, um how are we how what are you doing to ensure that we under the current system is delivering high
▶ 2:54:16quality care, high quality care and timely care to our veterans? That's my concern because I I don't want to be talking about something that may or may not happen and meanwhile our veterans are getting less care. Every veteran that I speak to, almost every veteran I speak to prefers to get their health care within the VA. Um, and I am a, you know, I have always advocated for community care.
▶ 2:54:46It's it's a it's necessary to provide care to all of our veterans across our country and in terms of everything that they need uh for their health care and mental health care. So I I'm not against community care. I want to be clear on that. But I just want to make sure that we are providing the highquality care and that we have the ability today.
▶ 2:55:09And I worry about o all of the the cuts and vacancies that are in the VA that we don't have the ability to provide the care the highquality care that we need. I need some insurance asurances from you how you're handling that.
▶ 2:55:24Uh representative. So as a as a veteran who uses both direct and community care and also prefers direct care um when I when I can get it and community care when I can't um I share your interest in that too. Um the system that we have in place today both with direct and community is a system that we have and that we will operate until this contract is live.
▶ 2:55:43Um the tools that we have the limitations that we have those exist today but today the team that has focused on serving veterans through this program continues to focus on ensuring they get what they need when they need So, as we go through, you know, 2026, 2027, and 2028, um, so when there are vacancies that occur, you're going to fill those vacancies. You're not going to say, "Oh, I can now take those resources and make some kind of investment in the new system versus the existing system."
▶ 2:56:14VA has a huge investment in NextGen, getting this right, and being accountable for it. As we build the program management team and the design of that team, we will resource that to ensure that it is staffed appropriately, that it's got the right technology, that it's got the right tools, that they can manage this contract and we can be accountable for these outcomes to you and to our veterans.
▶ 2:56:36Okay. It sounds to me like you may indeed if there are folks that leave the VA there vacancies there that you may and use those resources for the new system versus the old system.
▶ 2:56:50We want to ensure that the program management capabilities of VA can manage this program, the program we have today, we want to manage that as best as we can, as effective as we can. And we are excited about these new tools, these new capabilities for better outcomes, better cost as we move forward. Thank you. I yield back. Thank you, Mr. Chairman.
▶ 2:57:08You're recognized for five minutes.
▶ 2:57:09Thank you. I I want to take this opportunity to clarify this issue over uh referrals from the VA and TPA's ability. So, this is a problem of the vertical the challenge of vertical integration of the healthcare industry. So, third party administrators uh build currently they build the network, right? They build the CCN network. Is that my understanding? That's what that's what part of their job is, right? Yes, ranking member.
▶ 2:57:36So, if they pick and choose which providers are part of those networks, we we're presented with an issue. If those networks are full of providers that the third party administrators own themselves because of the vert vertical integration, it doesn't matter that the VA is doing the referrals.
▶ 2:57:56They've set the situation that we've set up structurally is that they are in a sense going to be able to uh have veterans referred to uh providers in the networks that they already own. Do do you do you follow what I'm trying to say here?
▶ 2:58:13Yes, sir. um you haven't given us any assurance that you're preventing this scenario uh under the current contracts um or that you will prevent it under future contracts. Uh how will how will your proposed contract deal with the scenario I just presented to you?
▶ 2:58:32Um sir, so the goal is to ensure
▶ 2:58:35No, no, no. I don't want to know the goal. What mechanisms, what manner of enforcement, what ways, what what what tools will you have in the contract to prevent what I just what I just
▶ 2:58:47The mechanism is ensuring that VA has the authority to make the referral and determine where the veteran receives. Just I just showed you how the referral what good is VA's authority to refer when they have when they refer all they're going to be able to do is refer the the TPA refers them into providers that they already own.
▶ 2:59:08The referral and the placement VA owns that. VA is accountable for the veterans care. the TPA does the TPA does not have the authority to steer veterans um into a provider that the veteran andor the VA does not choose and the issue is not vertical providers owned by payers in some cases that might be the highest quality lowest cost care that's something that VA would benefit from and our veterans were what we want to do is regardless of who owns a provider ensuring
▶ 2:59:38that the veterans go to the highest quality lowest cost provider VA controls controls the steerage. VA places the patient. They belong to us. We make those decisions. VA will place the veteran.
▶ 2:59:51Well, does the VA does the do the VA schedulers have any visibility into which network providers are owned by the V by the TPA.
▶ 3:00:02Currently, to my knowledge, they do not. And I think that's something we can take back and and contemplate. uh we we have talked a little bit about preferred providers and that is something that we are building in a ro more robust way in
▶ 3:00:18Yeah. Well well so um this is a this is a a major flaw in the current system um and one which leads to some selfdeing by the third party administrators. they put the network together uh and say they've set up VA with a limit and if the VA has no visibility into where the veteran is referred to uh you can see the conflict right there
▶ 3:00:43again the the VA is the one who makes that decision and as we select preferred
▶ 3:00:48VA is making a very limited decision right it's you're making it sound like they have this choice but there's no the VA doesn't have a choice here the TPA has been able to set it up to their
▶ 3:00:59sir that so that's not True. Under NextGen, VA does have the choice because we have the quality.
▶ 3:01:05I'm interested in knowing more about that, but I need to get to another question. I I want to know more if you would get back to me about how under nextgen we prevent this situation. I have no assurance that this current flaw is going to be prevented in in NextGen. If community care is VA care, then the knowledge and skills of the provider should be equivalent. if that if that represent if that we're going to represent community care as VA care.
▶ 3:01:30Well, currently suicide prevention training to bring the knowledge of CCM providers to equivalent VA standards. Currently, that's voluntary, right? That's not something that VA can insist that uh CCM providers get or do in order to be able to treat uh our patients. Is that right? We want to ensure that all vet
▶ 3:01:54Well, just to answer the question, do you know if that's true or not? No, I can tell you it's not. It's voluntary. It is voluntary. VA cannot insist that they do uh that our providers uh the CCM providers uh must go through uh suicide prevention training equivalent to VA Do you know why?
▶ 3:02:20ranking member we want to ensure that all of our providers have the training skill set you don't know why the the answer is you don't know the answer that is is that um uh my understanding is that third party administrators have resisted in negotiations with VA uh the requirement that VA be able to insist that CCN providers receive trainings like suicide prevention
▶ 3:02:50because it would be too hard to recruit for their network. They have that power to push back on VA. VA should be able to insist that all CCN providers are trained to equivalent standards that are within a VA direct care.
▶ 3:03:06Uh don't you think that don't you think that's a reasonable uh level of So in nextgen we do have the requirement that um certain training that we require will be required of providers and the TPA's have responsibility to to ensure that that happens. I will say we can put into the contract that all physicians must wear purple shirts on That does limit our ability to build a robust network.
▶ 3:03:35I don't like the word
▶ 3:03:36you just you just pared what I just said, right? The reason why the reason why that this is not a requirement and is not enforcable is is exactly what you just said.
▶ 3:03:47It is
▶ 3:03:48it impairs the ability impairs the ability of the third party administrator to recruit and build out their network.
▶ 3:03:55That's basic. Yes.
▶ 3:03:56No. In in next gen in nextgen we do have the requirement. We have to we have to understand and and identify that that is a risk. That is absolutely a risk as we require more and more of providers in the network to do things specific to what the VA needs and and wants for our veterans. It it will impact potentially the network, but that's that's our problem. We and that's our TPA's problem. We then have to address it.
▶ 3:04:23We have to then build not an adequate network, but a robust network that meets the need. I can tell you it's a huge frustration of mine that the CCM providers we have now, we've not been able to get them to do suicide prevention training, which is one of the biggest biggest challenges we have at
▶ 3:04:41And you've not given me any clear answer that NextGen is really going to solve this problem. I yield back.
▶ 3:04:48Thank you. Uh on behalf of the committee, I want to thank you for your testimony uh for joining us here today. You are now excused because we do have another We'll wait a few seconds and uh get the second panel up. Thank you for being here.
▶ 3:06:08We want to welcome everyone uh on the and thank the next panel for being here. Uh on our second panel we have uh Mr. John Vic, executive director of concern veterans for America and Dr. Rachel Madley uh PhD director of uh policy and advocacy for at the center for health and democracy. Thank you once again for being here and attending today.
▶ 3:06:33Uh, I would like to, if each one of you would rise and raise your right hand, uh, do you solemnly swear that the testimony you're about to provide is the truth, the whole truth, and nothing but the truth? Let the record reflect that both witnesses uh, answered in the affirmative. Mr. Vic, you are now recognized for five minutes.
▶ 3:07:01Thank you, Chairman Boss, Ranking Member Takano, and members of the committee for the opportunity to testify today at today's oversight hearing on the future of the Veterans Community Care Program on behalf of concerned veterans for America. CVA is a grassroots network of thousands of vets, family members, and patriotic citizens that advocates for and defends policies to preserve freedom and prosperity for all Americans. Our organization builds engaged communities of vets, elevating their unique experiences and perspectives to help improve American lives.
▶ 3:07:31We believe that strong and healthy vets make for strong and healthy American communities. While CBA has focused on many issues since its establishment over 14 years ago, organization has consistently fought to empower vets to be at the center of their healthcare journey. Excuse me.
▶ 3:07:45[clears throat] As an enlisted marine and later as a Navy officer and now as executive director for CBA, I know a lot of and I have seen how the ability or inability to access quality and timely healthcare has profoundly impacted the lives of those that I've served with.
▶ 3:08:03That's why we advocate for choice and CVA helped elevate the voices of veteran VA whistleblowers who revealed that veterans had died while waiting for care on secret weight list during the Phoenix VA scandal of 2014. CVA helped shape and support the 2018 mission act, which passed with overwhelming bipartisan support and created the Veterans Community Care Program that we're talking about today.
▶ 3:08:29Community care now accounts for about 40% of overall VA healthcare and that's growing which is a testament to both veterans preferences and to this committee's willingness to tackle tough problems on their behalf. CVA's view of veterans healthcare is simple. At all times veterans should have the choice of seeking care either at a VA facility or a community care provider depending on which best meets their needs.
▶ 3:08:52It's the same choice that the congressional staffers get sitting behind you, and it's the same choice that the CBA staffers get sitting behind me somewhere back there. It's also the same model that our retired military and civilians are able to use. The Community Care Network's NextG contract offers an important investment in sustaining the hard one healthcare choices of the VA Mission Act and ensuring that veterans have quality choices to choose from.
▶ 3:09:15At the same time, members of Congress and policy makers at the VA will need to work together to ensure that the NextGen contract is carefully and efficiently managed to limit the potential for waste, fraud, and abuse. This contract should empower the thousands of incredible people at the Department of Veterans Affairs who truly want to be a partner in getting veterans the care that they need as soon as they can get it. Veterans need these community care options. Here in DC alone, the consequences of pushing veterans away from community care and towards sole reliance on the VA would be disastrous.
▶ 3:09:45As of January 20, 2026, new patient wait times for primary care uh at the Washington VA medical center or at over 35 days, according to the VA's own weight time tracking tool. This is well over the 20-day weight standard for non-spety treatment in the community. The same query found new patient weight times of 62 days for dental care, 66 days for OB/GYN treatment, 65 days for podiatry appointments, and 56 days for oncology appointments. That last one is for cancer.
▶ 3:10:14Mental health availability in DC is actually pretty decent at about 8 days, but up the road in Baltimore, it's 26 days. Phoenix is 39 days. Los Angeles is 55 days. And people that are finally ready to get mental health care treatment often just don't last that long. Rural veterans that volunteer for CVA often report the additional burden of ownorous travel requirements to VHA facilities sometimes hours away and across state lines for an appointment that took too long to get in the first place.
▶ 3:10:40That is why over 84% of veterans enroles at VHA rely on supplemental insurance outside the VA such as Medicare, Medicaid, Triricare or some other private insurance. Unsurprisingly, the veterans that have other insurance also report being healthier about 44%. So we should embrace what works. Protecting and expanding community care options is not about privatizing or otherwise eliminating the VA so that that so many veterans do rely upon. I myself utilize VA in addition to my other health insurance.
▶ 3:11:09This is about making VA a better partner to veterans and all the folks that treatment treat them. So Congress and the Department of Veterans Affairs should protect and expand our veterans treatment options and thereby prioritize dignity and agency and how each of us cares for our minds and our bodies. So, thank you again for having me today. I'll try my best to answer your questions.
▶ 3:11:30Dr. Medley, you are now recognized for five minutes.
▶ 3:11:34Chairman Bost, Ranking Member Tano, members [clears throat] of the committee, thank you for the opportunity to testify. The Veterans Community Care Program and the proposed community care network or CCN Next Generation Initiative represent a significant shift toward veterans receiving care in the private sector rather than through the VA. This expansion is based on the assumptions that private sector care is higher quality and more efficient and that private contractors will prioritize veterans over profits.
▶ 3:12:04The evidence does not support these assumptions. This pattern is familiar across federal healthcare programs. Privatization is often promised as a way to improve care and lower costs, but in practice, it frequently leads to higher spending, worse patient outcomes, and increased corporate profits. The community care program was created under the 2018 VA Mission Act and is currently administered through contracts with Tri West Healthcare Alliance and Optum Serve.
▶ 3:12:31These contractors build provider networks and process claims for veterans receiving private sector care. The VA is now seeking contractors for CCN Next Generation, an expanded program projected to cost up to $1 trillion over the next decade. This proposal dramatically expands a model that has already shown serious weaknesses. Experience with current contractors raises red flags.
▶ 3:12:54The VA Office of the Inspector General or OIG found that Optum Serve and Tri West build the VA nearly $1 billion more for dental services than they reimbured community care providers between 2020 and 2024. While permitted due to a gap in contracts, this practice highlights the risks of relying on private driven intermediaries to administer public health programs. These issues mirror well doumented failures in the private Medicare Advantage program.
▶ 3:13:24Insurers have marketed Medicare Advantage plans to veterans who primarily rely on VA care and use little or no Medicare services. Yet, the government still pays MA insurers the full amount. In 2020 alone, taxpayers paid more than $1.3 billion dollars to insurers for veterans enrolled in MA who used no Medicare services that year.
▶ 3:13:46United Health Group, the parent of both Optum Serve and United Healthcare and MA plan directly benefits from this duplication. These behaviors demonstrate that private company incentives are misaligned with the goals of the VA to care for those who served and used tax dollars efficiently. A substantial body of research shows that VA care frequently matches or outperforms private sector care.
▶ 3:14:12A comprehensive review published by the VA in 2024 found that most studies show VA care is equal to or better than community care and no studies found better patient experience in the private sector. Many private providers also lack military cultural competency, particularly in mental health care. Access problems further undermined community care.
▶ 3:14:34The OIG found that community care contractors failed to maintain adequate provider networks with VA staff repeatedly reporting that many listed providers were not actually accepting VA patients. The VA also delivers care more efficiently. Studies shower wait times for many specialties within the VA and VA clinicians are less likely to deliver low value highcost care. Administrative efficiency is another key advantage. the VA.
▶ 3:15:01Another key advantage, the VA employs far fewer administrative staff than private health systems, mirroring traditional Medicare's substantially lower overhead Proposed increases in community care funding are paired with reductions in funding for direct VA care, weakening the VHA's role as an emergency backs stop, training system, and research leader. Expanding community care without fixing existing problems risks scaling these issues.
▶ 3:15:29CCN Next Generation also imports Medicare Advantage style payment models, including capitation, risk adjustment, and shared savings incentives that allow contractors to retain up to 50% of savings from providing less medical care. In this context, these mechanisms have consistently led to care rationing and upcoding, raising costs while harming patients.
▶ 3:15:52In Medicare Advantage, insurers are overpaid by $84 billion each year due to their gaming of the very risk adjustment system proposed for these community care models. Instead of this community care expansion, the VA should reinvest the proposed increased CCN funding into expanding VA capacity by modernizing facilities and building additional facilities where needed, as well as hiring additional clinicians.
▶ 3:16:18When veterans do require specialized care unavailable within the VA, traditional Medicare should administer that care using its efficient claim system to reduce overhead costs and protect both veterans and taxpayers. Thank you for the opportunity to testify and I look forward to taking your
▶ 3:16:35Thank you. I now recognize myself for five minutes. Uh Mr. Vic, going forward, how can VA maximize veteran input in major contract actions such as this one? Thank you, Mr. Chairman. Notably, uh, according to the VA, a VA survey in 2022, which is the last year that the survey was conducted, 83% of veterans are satisfied with community care versus 69% for their VHA experiences.
▶ 3:17:03I do believe that, you know, whereas VA does play a critical role in any future administration of VA plays a critical role in contractor accountability in all VA accountability. I would love to see a time when VA accountability didn't mean all of the oversight things that you guys do that we do and also but rather meant like VA being accountable for patient outcomes no matter where those patients get their care but I do think a critical component of that too is surveying the people that are getting the care and following up on what their health care outcomes are not just how much we spend.
▶ 3:17:35What what are some of the opportunities you see for expanding and improving and delivery of health care with this next generation contract structure? Yeah. Well, I I think it's going to be critical to expand the pool of people that can treat veterans. Uh, you know, it's always seemed crazy to me and I've I've used the VA in my life and I've used I'm also a military reservist, so I also have access to Triricare.
▶ 3:17:56Uh, so I've had multiple different kinds of insurance and I've used them all over the country and it always seemed crazy to me that I was not able to necessarily go to the same doctor that the rest of my family used. I think that if you can expand the pool of people that can treat our veterans and you're layering that into the feedback that veterans give on on what works best for them, and by the way, some of them absolutely prefer going to a a VHA facility.
▶ 3:18:19Uh but if you can track accountability for the outcomes, expand this pool and then I think most importantly when somebody does underperform, whether it is something like electronic health records uh and not getting records back on care, not making it possible to have a solid continuum of care, being able to off-ramp those contractors efficiently without a bunch of red tape, that's So, um, also what are some important things VA, uh, to keep do you think VA should keep in mind, uh, when they're evaluating the proposals on these contracts to
▶ 3:18:49ensure the benefits are best for the veterans?
▶ 3:18:53I think past performance, uh, you know, one of the things that community care does is lean into the existing health care infrastructure. You know, unlike the VA system, which, you know, some of these facilities were built decades ago when populations existed in different places and where specialty care existed in different parts of the system, the the private healthc care industry, for instance, in Orlando, where I where I call home, uh it mirrors exactly what the local community needs, right? And so I think that being able to match that for veterans, right?
▶ 3:19:23And finding out exactly how to streamline service delivery directly to the vet, that's the most important thing to do. I have no more more questions. Ranking member
▶ 3:19:33Thank you. Uh thank you for the uh the patience of our witnesses for staying uh till this till their till this time. I'm I'm sorry that the VA witnesses have left and are not going to benefit from the answers that you're going to they could use your expertise. Frankly, um you've testified uh Dr. Dr. madly that CCNA NextGen leaves open the door to gaming and misuse of taxpayer funds.
▶ 3:19:59What specific flaws in the RFP create these risks and what changes are needed to protect veterans and and taxpayers?
▶ 3:20:06Thank you for that question, ranking member. One of the biggest flaws is the incorporation of what is called valuebased care models, but in this case is use of capitated payments and risk scoring of veterans where the contractors will be running these models that and they get to keep any 50% of any savings that they are able to get. And
▶ 3:20:34so it's a Medicare advantage model
▶ 3:20:37cap capitated payments and so they actually benefit by uh by withholding uh care.
▶ 3:20:45Exactly. And when the lower extremity joint replacement model that is being prescribed for contractors here was run in CMS, it was actually found that safety net hospitals were unable to achieve savings because they had more complex, more vulnerable patients who needed more care and so that savings is often coming from not providing needed
▶ 3:21:09Are these safety net hospitals are they located in rural areas? I mean I in rural areas I know these hospitals are under tremendous pressure because of the cuts in Medicaid.
▶ 3:21:18It was in both rural and urban areas and those safety net hospitals and this is mirrored in the CCN nextgen documents were then forced to repay CMS the money
▶ 3:21:31I'm just incredulous that capitated payments on the on the along the lines of Medicare advantage VA is going to do the same thing to our veterans.
▶ 3:21:39Yes. And it's also importing the risk adjustment system that bipartisan members of Congress have raised red flags about because it leads to upcoding of these patients and making them look sicker, meaning that they get higher payments from the government.
▶ 3:21:54Okay. So, profit incentives are often uh in conflict with care quality. How do those incentives manifest under the CCNG and how are VA safeguards sufficient to counteract them? We kind of already covered it, but maybe you can sum it up real quick.
▶ 3:22:07Definitely the way these contracts involve incentive payments means that contractors who do enact these valuebased care models and they're required to implement four get to keep 50% of the savings that they generate and that savings comes from lowering costs which comes from providing less care.
▶ 3:22:28We're going to incentivize pro private providers to to increase their profit margins for their shareholders and for their executives by potentially denying care to veterans. This is incredible. This is a beautiful kind. Well, whatever. Uh Dr. Madley and Dr. Vic, I'm going to ask you both this question. Who are your major donors uh to your organizations? Mr. Dr. M, let's start with you first.
▶ 3:22:50We are funded by grants from philanthropic organizations such as Arnold Ventures as well as small dollar donations from supporters who want more affordable healthcare.
▶ 3:23:00Mr. Vic,
▶ 3:23:01I do not work in donor development. Uh CVA has about 40 full-time staff. The the donors that I'm mostly concerned with are literally thousands of
▶ 3:23:09Oh, come on. Mr. Vic, CVA is a 501c4, not a C3, unlike the person sitting next to you. uh which is means it's political and it does not publicly disclose donors. Will you commit today to provide the committee a confidential list to CVA's top donors over the last five
▶ 3:23:28I I wouldn't be able to do that. Uh we
▶ 3:23:31and you're not.
▶ 3:23:32Um so you're here today asking Congress to allocate large amounts of veteran healthc care spending without telling veterans or taxpayers who is paying for your advocacy. Is that correct? I advocate for the thousands of grassroots
▶ 3:23:44Well, I'm correct. I'm correct. You're here. Grassroots my your your organization is paid for uh by a they're not it's not paid for by those folks. That's not the majority of whose funds you who funds you are are are donors that are very much interested in certain outcomes. Do any of CVA's donors, major partners or board affiliates have financial interests in healthcare delivery, insurance, managed care, or provider networks related to VA community care? I'm unable to answer that question. I don't know.
▶ 3:24:13Um well um is concern so you can't answer the question. Um but I'm sure that this will come out in due course. Is concerned Veterans of for America currently affiliated with Americans for Prosperity and Governance staffing shared services or funding streams?
▶ 3:24:30AFP is a sister organization of us. Yes.
▶ 3:24:33Uh say again
▶ 3:24:35a sister organization.
▶ 3:24:36It's a sister organization. And is your political arm branded CVA action registered as a service mark of Americans for for prosperity for action?
▶ 3:24:46I I have to get that answer back to you.
▶ 3:24:48Okay. So when CVA engages in advocacy and political activity, is it fair to say time has expired AFP organizational ecosystem? The answer is yes.
▶ 3:24:57Okay. Thank you.
▶ 3:24:58Thank you. And just for the record, uh the exec the uh center for health dem is a C3 but also a C4. They're both. They're both. So any rate, Miss Dr. Medley, is that true?
▶ 3:25:19We have a C4 arm as well as a C3 arm
▶ 3:25:22and and your C4 arm is involved in
▶ 3:25:27advocating for policies to lower health care costs and bring more transparency to insurance companies.
▶ 3:25:32Thank you. Thank you, Mr. Vic. Um, first let me just say thank you for your service. Um, I don't dispute any of the facts that you stated in your testimony. I just disagree with how we solve some of these issues. Um, I think do you consider yourself a VSO
▶ 3:25:55or or veterans for veterans of foreign wars? Um I mean we also are there's also CVA Foundation which is a C3 which is wholly involved in educational programming. Uh but cons the reason why it's called concerned veterans for America is because we advocate for things that benefit all Americans. Right. And so
▶ 3:26:11they advocate for all veterans.
▶ 3:26:14We advocate for things that matter to all Americans, but we al also get into veterans issues as well.
▶ 3:26:19Or all Americans. I see. So I, you know, it's just it's hard to kind of reconcile, you know, the political side of your organization that is supporting uh supporting candidates here in Congress, you know, uh making campaign contributions, supporting their campaigns and so forth, um who are advocating for X, Y, and Z, but that might not be what all Americans support.
▶ 3:26:45So, you know, I I I I have trouble sort of reconciling um how you can represent all Americans when all Americans may not have the same point of view as you do.
▶ 3:26:57For sure, we all Americans definitely don't have the same points of view. Uh for me, what the reason why I'm passionate about this uh especially talking about healthcare choice, I talk to veterans all over the country. Uh I get emotional about it, you know, when I talk about it sometimes, uh is because for me it's a matter of human dignity. And I do believe that any government sponsored, you know, healthc care subsidi subsidized program, there's problems with it. We face it with Medicare, with Medicaid, we face it with Triricare, uh, a lot of different things.
▶ 3:27:25I think that that's always going to be an accountability piece. and CVA will always be there to talk about the accountability piece too uh in as nonpartisan a way as we possibly can because I really do believe that if we make VA a a prime partner in this service delivery journey for veterans that we're going to have better healthcare outcomes we definitely have to have accountability in that.
▶ 3:27:47So have you been at at the table for all of the planning of this nextG proposal on the VA?
▶ 3:27:54Not all the planning. I don't I don't work for VA so
▶ 3:27:56no I understand but I'm just wondering if you or someone else uh in CVA has had a seat at the table.
▶ 3:28:03No, not not directly. I don't believe so. Uh I I take a lot of meetings with members of Congress. Uh we do talk to uh had a chance to sit down and chat with Secretary Collins one time. So that was pretty neat.
▶ 3:28:14You've never come to my office. I'll just say that.
▶ 3:28:17I can commit that we absolutely will come. [laughter]
▶ 3:28:20Okay. Well, I've been on the committee for 14 years and you've never knocked on my door. So um anyway uh Dr. Madley um you know you just talked about with uh the ranking member um some of the issues with regards to financial insistent in incentives conflicting with quality health care.
▶ 3:28:41So, I want to ask you, um, you know, based on everything that you've heard today and testimony and what the VA is is propose proposing, um, I don't know if you've had a chance to really study the the contract um, and so forth, but do you see other ways in which contractors will be more profitable based on this new contract? Thank you for the question, Congresswoman.
▶ 3:29:09And I do see aside from the alternative payment models, the ability for contractors who run integrated health care systems
▶ 3:29:20I'm sorry to in
▶ 3:29:20integrated healthcare systems. So that is the they have an insurance arm that they then have a provider arm, sometimes a PBM arm and so on. And in the design of the networks, contractors are responsible for choosing providers who will be in the networks. And this was talked about at length with the witnesses from the VA.
▶ 3:29:41But to my knowledge, reading the contract documents and hearing the testimony, there is no way for the VA to prevent a contractor from creating a network that is disproportionately made of providers that that contractor owns. And I will just say that there is evidence in the commercial market of insurers who own providers treating those affiliated providers very differently.
▶ 3:30:08For example, United Healthcare pays Optimum providers, which are providers that they own, up to 61% more than non-affiliated providers in the same network. And Optum Serve is currently a contractor for the community care program right now. So, we we have seen this evidence and there are no requirements as of now in the VA documents that would prevent it from
▶ 3:30:32Thank you. My time's up. I yield back.
▶ 3:30:34Dr. Dick,
▶ 3:30:37you're recognized by
▶ 3:30:38Thank you very much, Mr. Chair, and and thank you to our witnesses for coming. Um, one thing I I just wanted to respond to, Mr. Vic, is um you're you're talking about waiting times at the VA. I used to practice in the VA.
▶ 3:30:53I know many who still do and I've been told by several not at just at one VA that a lot of the administrative staff that were scheduling and screening um patients for appointments have actually been let go fired and so they're having a hard time filling their appointments. So I just would elevate the need for us to actually staff our vet VA vas so that we can actually deliver on the care even when doctors are sitting there with unfilled spots.
▶ 3:31:21Also, I having worked at a VA, I'll just push back on um the concerns about driving many hours to VA facilities, I had a lot of patients that would rather wait to go um to a VA or would drive long distances to go to a direct care um facility.
▶ 3:31:38So I I I do want us to have a balanced perspective on um the fact of the matter is the veterans should have a choice and they should have transparency so that they can decide um which we don't have right now and I brought that up earlier so I won't wax poetic about that but I I do have very significant concerns about the promises we're hearing from um community care providers versus what reality is. And the fact of the matter is as Dr.
▶ 3:32:04Madley has um raised that they can make a lot of money off of veteran contracts and not necessarily deliver um because we are not great at holding them accountable. Um as a member of this committee, Dr. Madley, I take really seriously as as I understand many of us do my role to steward our taxpayer dollars and as you cited in your testimony, there have been instances, for example, over $900 million in overp payments for dental services to Optimum and Tri West.
▶ 3:32:33um that appears to be a waste of taxpayer dollars in the community care program. Would you like to comment further on that at all?
▶ 3:32:43Thank you for that question and yes, the overpayments to the dental providers as it was explained from the third party administrators were due to the contracts not having language essentially that said they couldn't do that. And I think it really illustrates, as I said in my testimony, how oftentimes private contractors have incentives and fiduciary responsibility to their shareholders.
▶ 3:33:10And that is fundamentally misaligned with what the VA and what the community care program is trying to do, which is trying to provide care for our veterans and use our taxpayer dollars efficiently. So, I think it's a very good illustration and due to the fact that we haven't been able to conduct as much oversight on these contractors, there's probably a lot more examples of that happening and those misaligned incentives leading to wasting money.
▶ 3:33:34I will just follow up on that that I think it's a similar issue to the um training that provider network or providers in um networks are being asked to have the same level of training that our veteran providers do. I will just say as somebody who beheminently was against more mandates for my education as a physician who has a lot of um time being used for other administrative issues. I I absolutely as a professional agree with that.
▶ 3:34:03So you know that you are going to limit the networks if you are demanding that because doctors and nurse practitioners and others are already overstretched and so it is irrational for us to think that we are going to have robust networks and have all these requirements. It's simply not the case that we can get to the same level of quality for out of network community care providers as we do for people who take care of veterans every day.
▶ 3:34:28We were motivated to want to know about the impacts of exposures and toxins, which is another thing I wanted um to follow up with you about is is how do you see Dr. Madley um the ability uh for community care providers to have the level of understanding of veteran exposures and other um diseases are um airborne divisions who have many many joint um replacement issues and and
▶ 3:34:59skeletal issues. How can we provide um transparency and accountability for quality and service in these um contracts? what what can we do better?
▶ 3:35:09That's a great question and I would recommend first making sure that the contractors have to maintain accurate network data and in that listing of the providers within the community care network. I would recommend adding in which providers have fully completed the training such as suicide prevention training, um, opioid prescribing training and things like that that VA clinicians have gone through.
▶ 3:35:37Now, with the contractors that were used in the first generation of this, um, they were not able to keep their provider network data up to date. And so, again, going with similar contractors this time, they will likely not be able to provide that data. So, how can we find contractors who are motivated to be able to keep that accurate data? I would recommend
▶ 3:35:58And I'll just raise up, Mr. Chair, what you re stated at the beginning that we need to trust but verify. Um, someone great uh per your words said that. Um, I don't think that we have established the mechanisms here in government to do that. I certainly would argue that contractors overseeing contractors is probably not the right way. So I I know that this is a bipartisan issue and I very much hope that we will continue to
▶ 3:36:25and as I said at the very beginning we this is the beginning
▶ 3:36:29the beginning.
▶ 3:36:30No I very much appreciate that and I know my time has run out so I will
▶ 3:36:33well let let me tell you rest assured all of our all of everybody on this committee I know wants to help the veterans and make them make sure they realize that they get the best benefits they possibly can the best places they possibly can. So on behalf of the committee, I want to again say thank you to the witnesses and members who are being here for being here today and look forward to working with you to address the issues facing our veterans. Now the committee written statements uh the complete written statements of today's witnesses will be entered into the uh hearing record.
▶ 3:37:04Um that I ask unanimous consent. Do you need to No. Okay. Okay.
▶ 3:37:10You have my unanimous consent.
▶ 3:37:11All right. I have ask unanimous consent that all members have five legislative days to revise and extend their remarks including extenduous material into the record hearing. No objection. So ordered. This hearing is now adjourned.