??nittd genius gamma WASHINGTON, DC 20510 February 5, 2019 The Honorable Robert Wilkie Secretary of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 Dear Secretary Wilkie: Last week, the Department of Veterans Affairs (VA) posted a press release outlining the Agency?s proposed access standards before engaging in meaningful consultation with Congress and Veterans Service Organizations. We are disappointed that, once again, VA has followed its now well-established pattern of lack of transparency with Congress with its failure to engage in dialogue about its plans with regard to the new Veterans Community Care Program, created under the VA MISSION Act of 201 8. Once briefed, we were disappointed that VA couldn?t provide basic information on how the proposed wait and drive-time standards would affect the Department, the veterans who rely on it for care, and the American taxpayer. Equally troubling is the apparent indifference of the Department with regard to the concerns that decisions made on access standards and designated access standards could cause too much care to shift to the private sector, crippling the largest integrated health care system in the country for those veterans who rely on its services, presenting a false promise of faster private sector care, and spending precious resources on private sector care that Dartmouth, RAND, and others have found to be of lower quality. In yet another statement released last week, the Department concluded that these new access standards represented a ?win? for veterans and any concern was wrong and predictable. Given the lack of fundamental information VA is currently able to provide on the proposed standards and what we know about the quality and access to care the Department is able to provide, we believe there is reason for alarm. It is not our intent to hamstring the Department with a litany of requests for information. However, our prior attempts to open lines of communication and seek information about how the Department developed its proposed access standards have been met with silence. So that we can better carryout our oversight responsibilities, ensure the VA is properly resourced, and ful?ll our obligation to America?s veterans, we ask that the Department provide written response to the following questions no later than February 22, 2019, so that we can have the information we may need to respond to the proposed rule in the Federal Register within the public comment period. We believe this basic information should be at-the-ready given the Department has already announced its decision on access standards. In developing the proposed wait-time and drive-time standards, which entities or private individuals did the Department formally consult? Informally consult? For purposes of this question, ?consult? has the meaning of ?seeking advice or information from? rather than merely ?providing information to.? How did VA incorporate feedback from these entities? Please provide examples. In formulating the proposal to ?designate? all types of care as eligible for community care, which entities or private individuals did the Department formally consult? Informally consult? For purposes of this question, ?consult? has the meaning of ?seeking advice or information from? rather than merely ?providing information to.? How did VA incorporate feedback from these entities? Please provide examples. How does VA intend to coordinate veterans? care as required under the VA MISSION Act? How did VA arrive at the proposed 20 and 28-day standards? Please provide data and other relevant information compiled in making this determination. What percent of current enrollees does VA expect will be eligible under the wait-time standard? What percent of currently eligible enrollees does VA expect will utilize private sector care under the wait?time standard? Please provide this information by VISN and medical facility. Does VA anticipate an increased reliance rate on VA health care as a result of the wait- time standard? What is that rate for each year over the next 5 years? Does VA anticipate more veterans will enroll in VA health care as a result of the wait- time standard? If yes, what percentage for each year over the next 5 years? Please provide the data compiled in making this assessment. Does VA intend to reduce the proposed 20-day standard to 14 days by 2020? Please explain. If yes, provide details on how the Agency intends to bolster internal capacity to provide care so that standard can be met. What is the anticipated cost of implementing the proposed 20 and 28?day standard in In Over 5 years? Over 10 years? Do these amounts mirror the projection developed through the Enrollee Health Care Projection Model, maintained by Milliman, Inc.? Please provide the Milliman projection. Do these costs include the amount required to pay Third Party Administrators or Community Care Networks to assist in facilitating access to care in the community? If yes, what percentage of those costs go strictly for Program overheard? Of the total projected cost over the 5?1 and 10tll years, how much of an increase does each amount represent relative to the total amount appropriated for Community Care Programs in FY19, including the Veterans Choice Program? 10. How does the Administration intend to fund the increased usage of private sector care? 11. How does the Administration intend to ensure that suf?cient resources are directed to internal capacity to ensure wait-times do not increase, leading more veterans to qualify under the wait?time standards? For example, how will the President?s FY20 budget request to Congress ensure that wait?times do not increase? 12. According to your own data, current trends indicate that 90 percent of veterans who qualify for private sector care choose to stay with VA, and of the 10 percent who utilize outside care, 90 percent return to VA after one appointment. If this trend holds and more veterans enroll in VA, how will VA ensure that capacity keeps up with demand and we do not repeat the problems of 5 years ago? 13. How did VA arrive at the proposed 30 and 60 minute drive-time standards? 14. What percent of current enrollees does VA expect will be eligible under the drive-time standards? Please break out the percentage for 30 and 60 minutes separately. How did VA calculate this percentage? Please provide the data utilized to make this determination. What percentage of eligible enrollees will utilize private sector care based on this drive-time standard? Please provide this information by VISN and medical facility. 15. Does VA anticipate an increased reliance rate on VA health care as a result of the drive- time standard? If yes, what is that rate? 16. Does VA anticipate more veterans will enroll in VA health care as a result of the drive- time standard? If yes, what is that percentage? 17. What is the anticipated cost of implementing the proposed drive-time standards in In Over 5 years? Over 10 years? Do these amounts mirror the projection developed through the Enrollee Health Care Projection Model, maintained by Milliman, Inc.? If not, what amount did the Model project? Do these costs include the amount required to pay Third Party Administrators or Community Care Networks to assist in facilitating access to care in the community? If yes, what percentage of those costs go strictly for Program overheard? Of the total projected cost over the 15?, 5t" and 101h years, how much of an increase does each amount represent relative to the total amount appropriated for Community Care Programs in FY19, including the Veterans Choice Program? How does VA expect community care funding to increase in relation to medical care VA funding in each of the next 5 years? 18. How will the President?s FY20 budget request to Congress re?ect a change in reliance on VA health care overall? 19. Does VA anticipate needing to hire additional staff to facilitate consult-approval and scheduling as a result of the increased usage for community care? If yes, how many additional staff nationwide? By By VA medical center? If not, please explain the ef?ciencies VA intends to employ to mitigate delay in care. 20. How will VA ensure staff have the information necessary to advise veterans on the quality of, and wait times for, care provided at private sector facilities when compared with those same metrics at VA facilities? 21. For the top ?ve types of specialty care for which veterans require VA services, what is the expected impact of the wait and drive-time standards? For example, how many veterans will be eligible for cardiology services based on the wait-time standard? The drive-time standard? 22. How many and what percentage of veterans in each of the next 5 years does VA project will utilize the Veterans Community Care Program but not care provided at facilities? 23. What is the projected effect of increased community care utilization on ability to provide in-house care? For example, will resources be shifted? Will rural VA hospitals and clinics see less usage if veterans turn to care only closer to home? 24. How does VA intend to comply with paragraph of section 1703B of title 38, United States Code, which requires VA to ensure that private sector providers are able to comply with the same access standards that VA will require of itself? Will VA make community wait-time information available to veterans, including at the time of making an appointment? We appreciate yoru? attention to this matter and await your prompt reply. Sincerely, . ?tr? ?2??er oi] Tester Brian Schatz ?an, mm 2229. i Patty @lrray 0 Patrick Leahy ?ax/W Bernard Sanders Mad 8W1 gherrod Brown Richard Blumenthal A4345 K/Zuiw Mazie KPHirono Ta yBal in Joe Manchin 111