Delivering Quality and Modern Healthcare to Michigan's Veterans and Servicemembers

All right, good morning everyone and um thank you for joining us and thank you um everybody who's here. This is an exciting opportunity to bring Congress back home to my district here, in the seventh congressional district, in a place that I have an a a special point of pride in, a a an area and a community and a a uh unit that I trained in in the army for about half of my career. So over the twenty-two years that I served, I spent about half of the time in in in uniform serving in this facility and tell it's a beautiful uh a a beautiful facility where we have some of the most technologically advanced helicopters in the entire world right behind us. And it's something that I'm certainly proud to represent and uh proud to to show off to to many of you today. I wanna give a special thanks to my friend, the ranking member, Nikki Baszynski. up here from her district in Illinois. I wanna thank you and welcome you to Michigan, Yeah. welcome you to my district, and uh look forward to our our hearing today. I really enjoyed coming to your district last year, Yeah. and we were talking uh before this about the similarities Yeah. of kinda communities that we represent and a lot of the overlap of of the types of people the types of communities the small towns and areas Mm-hmm. that we represent so it's uh it's great to have you here so thank you. Yeah. That was awesome. And uh Without objection, the chair may declare a recess at any point. And uh I also want to give a special thanks to the Michigan Army National Guard for hosting us here in Grand Ledge at the Army Aviation Support Facility and the staff from Michigan's Department of Military and Veteran Affairs that helped make this hearing possible. I want to thank General Rogers, our Adjutant General, for his uh willingness to open this facility for us today. Uh and of course I have the privilege of representing this community and it's especially meaningful return to return to the facility where I personally trained and served with so many others um that are here still serving today. I brought the House Committee on Veteran Affairs, subcommittee on technology modernization here, because oversight doesn't stop in Washington DC. We represent communities all across America. And I think a lot about how it's my job to be our district's representative in Washington, not Washington's representative back home here in Michigan. But bringing this committee here today allows both the ranking member and I and folks from Washington to hear about what's happening in communities like ours. It's important for Congress to hear from veterans, providers, and leaders in the community where they live, where they receive care, and where the rubber meets the road with VA systems that are felt every day by real patients. The mission of this subcommittee is to make sure that VA is leveraging the right technology to deliver the best care and benefits to veterans not only in Michigan but across the country. This means finally transitioning the VA into the twenty-first century. The modern health care landscape demands agility. We can no longer remain anchored to the expensive, inefficient, hospital-centric care models of the past. But technology alone will ma- will not make new health care providers appear. VA must continue to strengthen its community care program to ensure the doctors and providers living in our communities can continue to meet veterans where they live and work. Every decision VA makes should focus on putting veterans first, not bureaucracy. As many of you know, veterans here in Greater Lance, in the Greater Lansing area are about an hour away from both the Battle Creek and An- Ann Arbor VA medical centers, and further than that from Saginaw. So that means that in this community here in Grand Ledge, you would have to travel more than an hour to go to a large VA medical center. We have community, or we have a um community um outpatient clinic in Lansing that does great work, but if you need to go to one of the uh hospitals, you are more than an hour away from any of them. And that's not unique to this community. If you live in northern Michigan, you're you're two or even more hours away from a VA hospital in many instances. For some veterans, this distance makes getting care a burden, especially for the long wait times that can come from a VA hospital in certain instances. This topic is personal to me. When veterans are referred to community care, the scheduling process should be simple, fast, and focused on their health care. But for too long that has not been the case. What happens now is a scheduler ends up calling the veteran to book an appointment, gets some of their availability, a process that can stretch quite a long time, and then they call a whole bunch of providers in their catalog of community care partners that they work with, and that ends up delaying care for men and women who've earned it. And I've experienced this myself. I was referred for a very routine audiology appointment last year. I got called by a scheduler. They asked me what my availability was. I told them over the following few weeks, here's when I'm available, here's when I'm not. I didn't disclose to the scheduler that I was a member of Congress and would be traveling to Washington DC three or four days a week. But I did tell her I wasn't going to be in Michigan. And then a couple of days went by and I got a text alerting me to my scheduled appointment the middle of the week when I was going to be in Washington DC. And I called back, and they told me that because they couldn't accommodate my scheduling requests, they just booked me for the next available appointment. And I said, " Well, the next available appointment, I'm gonna be six hundred miles away." So that doesn't really help any of us, and then that takes more time out of their schedule for me to call and reschedule it, for them to go back out and look for the appointment, and to finally make something that is very routine finally happen. I'm pleased to see the VA finally taking steps to address these issues and update the technology and systems our veterans rely on. VA has been piloting the technology known as the External Provider Scheduling System or EPS for short. This scheduling system eliminates a large portion of the time and labor intensive aspects of community care scheduling by giving VA schedulers direct access to community providers' appointment availability. They can see in real time the audiology clinic down the street what their availability is and how they can sync a veteran's availability for an appointment that can be done very easily. Prior to this pilot, VA staff had to pick up the phone again and again, often calling the veteran and the provider multiple times to schedule a simple appointment getting in between that relationship. The telephone is an invention of the nineteenth century. The EPS program is an invention of the twenty-first century, and it's exactly the type of modern tool that VA should be using to advance access to care in mid-Michigan and nationwide. When service members sign up and when our sons and daughters go to war, they make a commitment to this country with the expectation that we will uphold our promise to them through high-quality VA health care access when they return home. When they walk through the doors at a VA hospital or call to receive care in their community that promise shouldn't fall through. The VA piloting of EPS is one of the many ways VA has begun to fix the problem and uphold that commitment. Through EPS, providers agree to share their scheduling grids the VA and allow VA schedulers to search and short up short appointments by distance, drive time and availability in a matter of minutes. With available community care appointments on one screen, a VA scheduler can book the appointment directly with the provider, which is one call to a veteran. This allows them to spend less time scheduling each appointment. It means schedulers can be more efficient and veterans, like the ones in this room, can get their appointments faster. EPS is now active nationwide in all VA medical centers, and I want to thank Secretary Collins for his work on delivering for our nation's veterans in this way. There are roughly twenty-four thousand community care providers currently active in EPS and that number will need to keep growing if the program is going to reach its full potential. While provider participation is critical, VA must also ensure that the technology is being utilized across the nation. Despite EPS's strong results, the prior administration repeatedly put roadblocks in front of the program. directly impacting veterans here in Michigan. In twenty twenty four, the Biden administration paused enrollment of community care providers, shut down active EPS sites and halted nationwide expansion plans, all while citing budget shortfalls that never materialized. The damage went beyond veterans. VA also undermined trust with the community care providers we're trying to recruit to participate in this program, who now are gonna think twice before partnering with the VA again. When I first heard about this, I knew we needed to take action. the program back on track for good. That's why, along with my fellow Midwesterner and ranking member Baszynski introduced the bipartisan HR thirty-four eighty-two, the Veteran Community Care Scheduling Improvement Act. This legislation will codify and expand VA's EPS program by authorizing a nationwide electronic scheduling process that allows VA staff to efficiently schedule appointments for veterans right away. This legislation would no ma- would insure that no matter who is in the White House, veterans are still able to access the quick appointments they've earned. My common sense bill passed the House last month unanimously, and I'm excited to see it included in the Take Care of America's Veterans Act. This package includes more than sixty other bipartisan bills to modernize, enhance, and reform the delivery of health care and benefits for veterans, and I look forward to President Trump signing this bill into law. This great effort will ensure EPS is not just a pilot or a four-year program, only available in certain communities, but rather a permanent capability for the betterment of veterans. VA has a real opportunity to improve veterans' lives with this technology, and I'm proud to lead the charge on it. At today's hearing, I expect VA to outline the progress made thus far, how integrated scheduling will be fully optimized, and its plans to integrate with new electronic health record system that we just rolled out here in Michigan and uh ensure that veterans receive appointments when they need them most. Before I turn it over to Ranking Member Buszynski, I want to remind everyone here today

Thank you very much, Thank you very much, Chairman Barrett, Chairman Barrett, and thank you again for welcoming me here to Grand Ledge and to your district. thank you again for welcoming me here to Grand Ledge and to your District. seventh district of Michigan. I appreciated you coming to my district. Gosh, I think it's been a little over a year now maybe,

Absolutely.

but uh very excited that uh to be here today and and couldn't agree with you more that being here reminds me of home, very similar districts and feels um from the Midwest. I I suspect that the issues also that face our veterans in both of our districts are very similar too. Uh for me the closest VA facilities um are outside of my district. and many veterans drive long distances to the closest one to receive care. It's a real struggle in particular for our rural veterans. It's for this this reason that I believe that community care is an important part of VA health care especially in rural America. However, getting a community care appointment from VA continues to be a major pain point. Uh veterans wait for a scheduler to call them, then they wait. while the scheduler calls around to different providers, looking for an available slot. The whole process takes far too many phone calls and, quite frankly, far too much time. It delays veterans' care and it needs to be fixed. The External Provider Scheduling Program, or EPS, is a promising new tool in that effort. The technology allows VA schedulers to book appointments directly into community care providers' scheduling grids, eliminating or at least um reducing a cumbersome phone-based processes. It's a great idea and a good tool. I absolutely support this effort and in fact as Chairman Barrett mentioned, he and I have wrote a bill to support and improve the EPS program. That being said, we must be clear-eyed about the reality of VA's efforts with EPS. While they may have successfully deployed the technology, the network of community care providers sharing their scheduling grids continues to be insufficient in the number and diversity of specialties to making to make it a meaningful tool. There are well over one million community providers, and VA has only signed up about twenty-five thousand. That's barely two percent. Additionally, we've recently learned that of the providers that have signed up, they have a greater than thirty percent turnover rate, meaning they're losing providers while almost as fast as they're signing them up. VA prioritized the deployment over recruiting efforts and now I suspect there are many facilities with a shiny new tool that is effectively useless. I wonder what it is costing the taxpayers to maintain a system that is under-resourced and under-utilized. Without a critical mass of providers and different specialties, VA's schedulers will only be able to use EPS for just some appointments, if they're lucky. For the rest of the appointments, the schedulers will continue to rely on multiple phone calls between the veteran and different providers to find an available appointment, book it, and then call to confirm. This is inefficient and leads to veterans waiting weeks just to schedule an appointment. In twenty twenty six, the technology exists. VA brought the te- bought the technology. I wanna understand why it's not being used to the full effect. and how VA intends to get it on track. Additionally, VA recently began to pilot uh capability to begin to pilot a capability in EPS that will allow schedulers to see VA's own appointments, as well as community care appointments. This capability that was already available during the earlier EPS pilots, but then was shut off uh was shut down inexplicably. This integrated scheduling tool could ensure veterans have the opportunity to make about when and where they receive care. We keep hearing that when we give the choice, veterans will choose VA with integrated scheduling, we're giving them that opportunity. I want to hear more about this pilot, including how they will determine how they will determine the requirements for the new tool, what measures of success they've established, and how they're defining success. Veterans deserve to have the ability to see VA's access alongside community care. I want them to have the capability, um, but we have to ensure that the tools are properly developed and also deployed. Um, as I said in the beginning, community care is an important part of VA health care, especially for our rural veterans. But I feel like we need to acknowledge that rural health care is struggling. Almost two hundred rural hospitals have closed in the last twenty years, and hundreds more are at risk right now. We must ensure access to quality health care for everyone, but especially for veterans that we committed to care for. As we look in to make as we look to make it easier for veterans to get care in the community we need to also ensure the longevity of the VA uh both VA and community care need to be fully funded so that no one um does not happen the so one does not happen at the expense of the other and the VA will continue to be there to care for our nation's veterans. It was a part of the contract and it is a part of the cost of war. Uh, thank you, Mister Chairman, and I'll yield back.

Thank you, ranking member Basinski. Uh, I also just wanna briefly point out that my mom and dad are here. Um, Pat and Mary Ann Baird, along with three of my four kids, so appreciate you guys. I guess they didn't actually believe I I was in Congress, so they had to come, they had to come see it for themselves. Um, but thank you. And I will now introduce our witnesses. From the Department of Veterans Affairs, we have Mr. Andrew uh Grat- Gratison. Gratison, Senior Advisor to the Undersecretary for Health at the Veteran Health Administration. Thank you. Accompanying Mr. Gratison is Dr. Mark H- uh, Houseman, Chief Medical Officer for Veterans Integrated Service Network ten, VISN ten, and Mr. Zachary Schwartz, Principal Deputy Assistant Secretary for Office of Information and Technology. And finally from the Government Accountability Office, we have Miss Carol Harris, the Director of IT and Cybersecurity at GAO. Welcome to my district. And thank you all for making the time to be here with us. At this time I'll ask the witnesses to please stand and raise your right hand. Do you solemnly swear under the penalty of perjury that the testimony you're about to provide is the truth the whole truth and nothing but the truth? Thank you and let the record reflect that all witnesses have answered in the affirmative. Mister Gratison, you are now recognized for five minutes to deliver your opening statement on behalf of VA.

Chairman Barrett, Ranking Member Basinsi, uh, thank you for the opportunity to testify on VA's efforts to modernize scheduling and improve community care access. Joining me today is Doctor Mark Hausman, Chief Medical Officer of Bizinten, and Mister Zachary Schwartz, Principal Deputy Assistant Secretary in our Office of Information and Technology. We will update the subcommittee on the External Provider Scheduling, or EPS, program, and our integrated scheduling pilots underway in Charleston, South Carolina and Atlanta, Georgia. Veterans, veteran service organizations and members of this committee have consistently emphasized that scheduling challenges have been one of their most significant pain points for veterans seeking care. Secretary Doug Collins listened to VA's customers and under his leadership, VA is making it easier and more convenient than ever for those who have worn the uniform to choose the care for which they're eligible that best fits their lifestyle. EPS is a technology platform that improves the process of scheduling veterans with community care providers, by supplying information, allowing VA staff to schedule veterans directly into available community care provider appointment slots through a single user interface. As you're aware, under the Biden administration, veterans faced unnecessary delays in accessing community care, due to the decision to pause the implementation plan on EPS. This slowdown limited veterans' ability to quickly and easily schedule appointments with community providers. The EPS program is now directly advancing VA's modernization goals by delivering a more consistent, transparent, and intuitive scheduling experience. The modernized EPS program now delivers the following benefits to veterans and their caregivers. Improved productivity that enables VA to schedule more than three times as many community care appointments per day. compared to what we were doing before. Clear, timely choices that allow appointments to be booked in minutes, not days or weeks. Real-time visibility into c- eligible community care provider appointment availability, and increased efficiency that will eliminate many calls, faxes, and emails. Taking together these improvements ensure greater consistency of services across VA medical centers nationwide. Since we last testified before this subcommittee in May twenty twenty five, VA has moved from int incremental deployment to nationwide availability of the EPS program platform. Since late twenty twenty five, the EPS program has been rolled out across every VA medical center. As of May twenty twenty six, there were over twenty nine thousand community providers, and more than forty one thousand provider services. available under EPS. More than a hundred and fifty thousand appointments have been booked through the platform. In January, twenty twenty-six, VA commenced two integrated scheduling pilots in Charleston, South Carolina and Atlanta, Georgia. This effort allows viewing both direct care and community care appointments on the same platform. Within three months of the commencement of this pi- of these integrated scheduling pilots, VA scheduled over a thousand appointments. Both sites are also testing new veteran self-scheduling capabilities through EPS that would allow eligible veterans to book their own appointments with VA providers or certain community care providers online through VA dot gov or using our mobile app without calling VA or a provider's office. While the EPS program has reached na- national availability, we recognize its long-term success and value to veterans depend heavily on community Not all community providers are familiar with our technology. To increase awareness, VA meets with community care providers and explains the benefits in their clinical operations and VA's ability to support the coordination of care efforts. VA leverages data to identify and engage community care providers who specialize in a category of care with a high annual referral volume in geographic areas with limited EPS program coverage. When VA engages with community clinicians and provider organizations to explain the program's benefits. We highlight that there are no fees, no change to their health records or scheduling platforms, and our community care providers retain full control over the appointment grids with secure schedule of sharing. Nebraska's statewide rural transformation initiative is a leading model, having expanded EPS program connectivity across dozens of rural hospitals and clinics. VA is similarly working with third-party administrators and providers who have entered into a Veterans Care Agreement to simplify participation and ensure broad understanding across the community care network. In conclusion, I'm pleased to inform this committee that under Secretary Collin's leadership, the EPS program is a nationally deployed scheduling capability that is reshaping how veterans access their care. VA is moving closer to our goal of having a single scheduling solution that allows veterans to book appointments that are best for them, whether at VA or in the community, through modern and convenient methods that meet their expectations. VA remains fully committed to ensuring that EPS supports timely, high quality care and enhances veteran expectations across the entire scheduling journey. Thank you, and I look forward to your questions.

Thank you, Mister Gratison, the written statement of Mister Gratison will be entered into the hearing record. Miss Harris, you're now recognized for five minutes to deliver your opening statement on behalf of GAO.

Chairman Barrett and Ranking Member Budzinski, I want to thank you for inviting us to testify today on VA's efforts to ensure that veterans have timely access to health care. through its scheduling systems. As requested, I'll briefly summarize our prior work on VA's scheduling environment and the related challenges for VA providers, schedulers and veterans. In FY twenty twenty-three, VHA provided roughly seventy-one million appointments to veterans. VHA also provided roughly forty-seven million appointments with non-VHA providers through the veterans community care program, during that same time period. In doing so, the department uses a patchwork of systems that have been developed in ways that make scheduling with both VHA and non-VHA providers difficult for veterans and staff. Additionally, VA has experienced IT challenges related to the outdated inefficient nature of systems and its efforts to modernize its health information system. VA has dozens of systems and tools that support scheduling appointments, managing referrals, and monitoring wait times. VISTA facilities primarily use VISTA scheduling but it may also access at least nine additional systems in the process of scheduling appointments with VA providers. VA operates another five systems used by staff for managing referrals, and another eight systems to engage with veterans about medical appointments. So that brings a tally to twenty-two systems. Oracle Health facilities have another set of scheduling systems, fourteen in total. And they use some of the same systems that Vista facilities use as well, to schedule appointments and manage referrals. So adding to that tally, that's a total of thirty-six systems right there. Additionally, VA employs tools for monitoring scheduling timeliness, providing estimates of wait times on its public web site, and determining a veteran's el eligibility based on wait time for community care. Given this environment, schedulers and veterans are experiencing challenges when making appointments. Facility staff must open multiple to schedule a single appointment, and as you said, then they gotta get on the phone and make those phone calls. They must also run reports in different systems to identify veteran self-scheduled and self-cancelled appointments, and appointment requests. Navigating this complexity makes schedulers inefficient or require work arounds that may vary across sites. MVA has told us they are working to standardize veteran appointment scheduling at Vista and Oracle health sites. But they have not yet determined how the modernized and updated products used for scheduling will interface and be pulled to com and combine with the data into a comprehensive report. So consequently, the result is a labor and resource intensive process for VA staff that has continued to evolve over time. Our work has shown that less than forty percent of facilities scheduled more than half of their community care appointments within VHA's seven day standard. Further, fewer than ten percent of facilities scheduled more than seventy-five percent of appointments within the standard. In twenty twenty we recommended that leadership assess community care staffing and resource needs and develop a plan to address any identified risk to their ability to schedule timely appointments VA concurred but the department has yet to fully implement it six years later veterans have also experienced challenges requesting an appointment on-line getting confirmation once an appointment is scheduled and and receiving duplicative appointment reminders. VA is working toward having one enterprise-wide solution to address these issues among other things. VA's OIT and VHA have also been collaborating to address its scheduling system challenges. They initiate a project to modernize these systems at Vista facilities, which includes several concurrent efforts. For example, one is intended to allow provider-based scheduling, which is the ability to see a provider's schedule across multiple modalities, so it's like in-person and telehealth in a single application. VA is also d- deploying EPS for VA schedulers to schedule veteran appointments directly online with community care providers, and deployments have been in progress since twenty twenty four. In May of last year we reported that while OIT and VHA had employed some key planning practices for the overall modernization effort, there were still gaps, such as accounting for the full Thank you. Thank you.

Miss Harris, the written statement of Miss Harris will be entered into the record, and uh thank you to all of our witness witnesses. We're gonna proceed with questioning and I now uh recognize myself for five minutes for questions um Miss Harris I know you mentioned thirty-six I think you said, different systems that all touch on scheduling, whether that's internal VA or outside in the community.

That's correct.

Uh you also mentioned the um breakdown of the total number of appointments. for veterans, I think that ratio is roughly forty percent is done out in the community currently. Is that relatively accurate?

Yes, that's correct. Yes.

Um, I know we've seen a rise in that since the allowances for veterans to be able to do that more easily. Um, many of them take advantage of that and I think that speaks to their interest in going in all likelihood closer to home for a lot of the more, you know, routine appointments that they may have or something that may not be a um a veteran-specific type of condition that would necessitate their specialized care at the VA, for example. Um, with the new introduction of the the intentionally more rapid um deployment of the HRM, will that cut down on this thirty-six systems, or are we just gonna multiply that by layering more systems on top of old ones in the meantime?

I mean the, I think I can't fully answer that question because VA has yet to provide a comprehensive view of what that final um scheduling process should be.

Mm-hmm.

Um and and again it's like it's I think it's like a Lewis Carroll saying like, if you don't know where you're going, any road will take you there. And so VA has not yet defined what that final destination looks like. So again, you know, you have um

Mm-hmm.

a lack of a fully defined business process for what that standardized scheduling appoint um scheduling workflow looks like and then what are the underpinning

Yeah.

IT solutions that that are supposed to support that EPS could be one of those systems, but it's not the silver bullet. And the sites that we have told that we've talked to have said, you know, there's promise there, but again, you need to have more community care participation to make it more effective. Right. Um, and we haven't seen how that is going to be integrated with the Oracle health uh revenue cycle scheduling suite of of applications there those fourteen that I mentioned so until we see that comprehensive strategic plan of what that final two B state looks like it's it's not it's it's not possible

Yeah.

for me to answer your question.

Yeah I don't want to uh speak on behalf of the ranking member but I think uh we share an interest in the end goal of having veterans be able to pick up the phone or go online, communicate through the VA, and then be given the full portfolio of options available to them, whether that's inside the VA or outside of the VA. Could say you can get a VA provider here that's further from home, you know, uh next week, or maybe if you want a community care provider it'll be in ten days or two weeks, but it'll be closer to home for you and might fit your schedule more adequately, or something like that. That's the end state that we're trying to get to. Um, and I know that we have simultaneously EPS coming in while we're doing health care modernization I think the focus of VA has been in some ways necessitate necessitated by the urgency of the electronic health record rollout to to put a lot of emphasis around that, but we've gotta be able to walk and chew gum at the same time, and and certainly having thirty-six systems does not make that very

Yeah.

very ideal. Um, Mister Grattison for or or from VA, any any of those with you on on your side, uh can you speak to what we're doing to bring about more participation by community care partners? Because one of the biggest challenges I see is we can build the the best system possible, but if we don't have participation, it's not gonna benefit anyone. It's not gonna benefit the providers and it's not gonna benefit the veterans. We've got thousands of community care providers in in in this area, but very very very few of them are actually signed up through the EPS system in in the network of VA facilities in in this area.

Mm. Thank you for the question, Mister Chairman, and we agree the long-term success of EPS is contingent on being able to bring more community care providers into EPS. And how are we going about that? We're going about it at all levels, from our Under-Secretary of Health, uh engaging large um community care providers uh at the executive level, and being able to bring that business case, and also clearing up misconceptions that some of our providers have, whether there are costs associated with it, whether they retain full control over their scheduling grids, or have to make system upgrades themselves. Once we clear up those misconceptions that there's no cost, no uh uh d- electronic health record updates need to be made, and they retain full control, we've seen broader adoption. We're also leveraging the relationships that our medical center directors have with their communities. And at all levels, we're having this engagement to bring more providers on board.

Great, thank you. Uh, Ranking Member Basinski, recognized for five minutes.

Yeah, thank you, actually I'll probably pick up where you've left off. I think that's exactly kind of my concern as well, which is this is a great tool, but if we don't have enough, um, you know, we're estimating, I think, about two percent community providers that are participating. Um it's just not enough adoption and we wanna see more adoption, so I appreciate what you've said about prioritizing that. Um I just I'm curious um y- if I could drill down a little bit more, how do you think the VA is defining what a sufficient network would be of community providers for any one given facility?

Thank you for the question. Um Ultimately, we wanna make sure that our our veterans are able to select the care that's right for them so uh uh I I can get back to you with a specific number of uh or percentage Mm-hmm. of community care providers that would be sufficient but it'll be reflected Mm-hmm. in a veteran being able to soluce the uh select the care that's right for them. And we've seen enormous growth in the number of community care providers Mm-hmm. that are participating in our pilots that are uh underway in Charleston and Atlanta, where we've really s spent Mm-hmm. dedicated effort to grow our network of community care providers deliberately. Um and and those percentages continue to grow, Mm-hmm. and it's reflected in the number of appointments that we've uh successfully booked over the last three months over those pilots we've booked more than a thousand appointments which is um more than nationally we're Mm-hmm. booked in January of twenty twenty five before this administration Mm-hmm. took office so we're seeing enormous growth um but ultimately Mm-hmm. we we wanna get as many providers as possible signed up.

Could you give a little bit more specificity on what that growth looks like? I think you mentioned North Carolina, is that what North Carolina was the the state that you focused in on? So given that state, cuz that's been a priority, like what is the percentage of participation in that state now that you've been there, that will have community provider participation?

Uh, today in our pilot sites in Charleston,

Yeah, South Carolina.

South Carolina, and and Atlanta, Georgia, uh, we're, uh, approaching seven percent of our community care providers that are currently uh participating, Mm-hmm. Mm-hmm. and that number continues to grow. Um, Mm-hmm. when this administration took office there were fewer than there was about three thousand providers nationally that were uh signed on to EPS and and were over thirty-four thousand so we've seen a ten x increase in the number of providers that are currently uh enrolled in EPS but Mm-hmm. But we we want to continue to accelerate that growth.

And and just because we're in Michigan and then I represent Illinois, do you know any of the statistics on the uh percentage of adoption of community care providers in our state?

Um I I do uh there's a lot of room for growth here um Doctor Hausman can help with some of the specific numbers here in Michigan um but um but this is an area where we wanna

Mm-hmm.

be able to bring the benefits that our veterans are experiencing at our pilot sites in Atlanta and Charleston. We wanna be able to bring those benefits here to uh veterans in Michigan. We wanna bring them uh to your veterans in Illinois.

Yeah, in Michigan uh participation is low at the moment, um but I do wanna comment on that. So Michigan is one of the states that when the program was kind of paused,

Mm-hmm.

and reset and rescaled,

Mm-hmm.

Michigan was kind of put put on pause for a period of time there. Um but what's important is there was actually some groundwork that was laid here in the state of Michigan up to that point. Um, and conversations have taken place since then that I think will allow us to get um, some key providers um, you know, ready and preparing to participate sooner than later. Mm-hmm. Um, specifically we have been engaging with Trinity Health and University of Michigan, as well as Henry Ford and Ohio Health. So right there are four larger health systems um, that would make a huge impact uh, in terms of um, um, you know, volume of care that they provide and of course improving the efficiency and the experience for veterans. Uh, last thing I would note is we we do enjoy a very, um, productive relationship with the Michigan Health and Hospital Association.

Mm-hmm.

Um, and they are an active partner with us in engaging some, uh, serve as an inter intermediary, almost a,

Mm-hmm.

can help us with making introductions, uh, and highlighting the benefits of this program. So that's a really important, uh, relationship that we have that we're gonna leverage moving forward.

And when you say it it's very low, just to put a finer point, like where where are we numbers-wise,

So for the four facilities in the Lower Peninsula of Michigan, we have between five and eight hundred providers, uh EPS providers enrolled. Now the majority of them are telehealth, mental health providers that are part of a national practice.

Mm-hmm.

So when you look at providers that are actually kind of able to see veterans in person,

Mm-hmm.

in our region it's gonna be much smaller.

Okay. Um I will um yield back to you. I just ran out of time.

Sure, that's fine, we'll do another uh we'll do a second round,

Great.

so um,

Great.

Doctor Haussmann then, um, what about, I know you mentioned um, some of the larger hospital networks that you've made inroads with, but what about the small community providers, physical therapy for example, that might be an independent um, practice, you know, close to home, something like that you gotta do twice a week on your way to work, um, it makes a lot of sense to do that close to home. what work have we done to do outreach to those smaller you know, um providers that may not have the robust technology of a major major hospital system?

Yeah, I would say that's where we've made the most concrete gains so far. So for example, we have uh in Ann Arbor podiatry, Battle Creek in Detroit, dermatology, audiology, uh optometry and dermatology in Saginaw, plus mental health. So we um uh you know, as we kind of look at strategically how to grow this program, Um the large health systems we know take some more time. They have their own processes and bureaucracy and um and a lot of, you know, a lot of the key to that is is kind of the relationships that kind of help open the doors and get the conversha conversation started. Um but we find that with the smaller clinics, the podiatry clinics, the chiropractors, acupuncture, et cetera, optometry, it could be a much faster and direct process. And we particularly um engage those that are doing a good volume of veteran care already. Um, and then of course doing a good job taking care of batteries.

Okay. Um, and then what about our um smaller, you know, independent hospitals, for example? We're gonna hear from some on the next panel um that aren't part of a big, you know, conglomerate hospital network that goes from coast to coast in Michigan. I have a couple of those in my own district. Uh, what are we doing to not overlook the services they can provide?

Yeah, I mean that's a real opportunity as well. Um, so as we, you know, i- as we approach this challenge of en enrolling providers. Um, we do take a look at data. So we typically, you know, we we look at providers, number one, that are doing a good amount of veteran care and that we know do a good job of taking care of veterans. So you have to start somewhere, and that's where we tend to to start. Um

But not not to cut you off, but if they're not currently being looked at for community care, how do we know that they're serving veterans? I mean, a proportion of the population is veterans that they would naturally serve already, but I guess, how is that a threshold if they're not in the system? We know they're providing quality care, cuz they're licensed, they're they're doing it,

Right.

they're you know, we can look up their records and compliance, their customer reviews, all of those things. Um but how do we know how many veterans they're serving already?

But so, yeah, g great question. So we um so for VA paid care, we know exactly how many referrals we send to exactly which providers in the community so that's something we track actively and as we engage with the

Right.

uh, enterprise EPS team. That's kinda how the conversation has started. Um, who are the providers that you rely on most, who, which providers do a good job? You know, we know they provide good quality and that's where we start to build out the strategy for engagement.

Okay. So if a a a hospital was not currently being referred patients from the VA, it would be much harder for them to initiate that community care relationship.

Uh, yeah. I would say if they're not doing VA care, um, they're probably not gonna be towards the top of our list. that said, if there is an interest, especially in an area that is not well served, um we would be very, very happy to engage early.

Okay. Thank you. Uh, Mister Schwartz, uh, what do you see as, uh, I know you're on the the the tech side of this,

Mm-hmm.

um, is I know that in general this is a broad statement, but um a lot of physicians have complained to me, not in the VA system, just out in general, their frustration with health record referrals with different health record systems with you know, having to manage all of that when they should be spending their time on patient care, if this is viewed as one additional tech thing they gotta figure out,

Yeah.

they might be a resistance to that. How are we able to break down that that barrier for for those that might be a little more old school in their practice, for example?

Their their way of thinking. I appreciate the question. What our complete focus is is ease of use. We have to develop the technology that brings the grids in from our external providers, to make it as easy as possible. So what our team has developed is a way to grab only the information that we need, cuz I also hear complaints or concerns about privacy and security as well,

Mm-hmm.

taking other patient information that are not veterans. So we wanna make it as easy as possible. We allow the providers to put the information that they need, and only the information that they need, in a very easy place for us to use technology to grab that. as opposed to building connections or building out new systems. We work with what they have so that there isn't any new set-up they have to do, or any new set-up or configurations they need to buy, cuz that's another concern we have.

Great. Thank you. Uh, Ranking Member Zitzke, you're recognized for five minutes.

Thank you, Chairman. Um, could I ask Miss Harris just to further elaborate on your testimony? Um, because we know the number um, the history of GAOs, you've had a number of audits of the VHA scheduling. uh process, could you just flag concerns that you have in the way EPS has been deployed um over these several years and then currently and then maybe what you'd recommend or what observations you'd be looking for to say hey we're making real progress here.

Mm-hmm.

Sure. So um what we do know is that I think VA has a very good handle on the reasons for why

Yeah.

um but their medical centers can't efficiently and effectively schedule these appointments for community care. They've been systematically identifying these reasons over years at this point.

Mm-hmm.

Um but it all points to this is a very labor and resource intensive process. And I wanna make sure we don't have blinders here because EPS is focused on the actual process of scheduling the appointment, but there's also managing the referrals and monitoring the wait times too. So you that's how we need to holistically be looking at scheduling appointments. And that's also um one of the reasons why providers are reluctant to join EPS because there's also, okay, once they have the referral, they're required to submit medical documentation after the initial visit and the final visit. And getting that documentation to back to the VA medical facility is is a very difficult process.

Mm-hmm.

Um, so that's sort of the the bigger picture here. And anecdotally what we have heard is while EPS does, yes, it shows promise, but getting community care providers to sign up has been difficult and at this time, the onus has been on the facilities. They've received very little help from VHA, at least the sites that we have talked to, um in in getting that support to to get the the community care providers to sign up. There's also issues with, okay, once a community care provider has been signed up, the coding of their specialties is also sp- in many time in many cases inaccurate. So they go to they there's it still requires a phone call by the scheduler to ensure, okay, a particular aspect of cardiology is in fact, you know, accurately, you know, i is accurate on the web s or on i within EPS, um, as as an example. And then also getting as, um, as Andrew had said, you know, specialty care like, you know, pulmonology, cardiology, oncology, getting these specialties and and the and the providers that that support those specialties into EPS has also been a challenge as well. So I I just wanna make sure it that we focus not just on the act of scheduling

Mm-hmm.

appointments but it's this holistic process and that's part of the reason why providers are reluctant to to participate.

Mm-hmm. Could I just ask, Mister Gratisson, like in those conversations with the providers, helping to demystify the process for them and getting them on board, you know, uh just responding to what Miss Harris has kind of outlined, How have you been kind of working with these community providers to get some of these specialists more on board? What could you share some more specificity around that recruitment process and how it's improved?

Absolutely. Thank you for the question. And and this is an area where we've been fortunate to be able to partner with GAO to better understand the nature of this issue and to engage our community providers. So part of this uh and I'm pleased to report we now have seventy-five total active specialties uh that we're able to offer through EPS. Um but we wanna continue to grow that footprint uh because ultimately our measure of success will be our veterans being able to access the exact service that they need in the mo- in the way that's most convenient to them. When it comes to um making sure that that we're able to offer our suite of services, um uh i- it's it's it's no different uh than engaging a- anyone else and being able to spell any misconceptions here. We wanna make EPS as robust as possible, uh a unified platform where a veteran can compare direct care appointments and community care appointments. Um and we think that ultimately uh uh they'll continue to select our care more often than not, uh uh b- uh because we'll put up our wait times against anyone in the community.

Okay, I was just gonna ask you one question though just to interrupt a little bit on the community care piece and to drill down on the scheduling. When you're recruiting them are they are once a community provider is in the system do they when we're talking about scheduling have that opportunity to approve or accept um the appointment or what is do they retroactively get to do that

well i i i would um engage my partner from office of information and technology when

mmm ok

it comes to approval or disapproval but uh when when a community care provider makes

right

an appointment available It's our expectation that we'll be able to fill that slot.

So they can't reject it.

Um, the the

Just to confirm, you're asking the rejection by VA saying

By community care, the community care provider. Can they reject the appointment?

No, once once it's made available it's it's accepted.

Okay.

They can always cancel an appointment if a doctor is sick or something, but no, we expect we expect that the veteran can book that appointment then.

Okay. Um

We're gonna try and do a uh third round, but we might go

Yeah.

but I it is two minutes ago for the third round?

Sure, yes, yes.

Okay, why don't we do that, um just to um uh accommodate for the for the next panel. Um uh appreciate the uh conversation though. I wanted to get a sense um, Miss Harris, if you have any thoughts on this. There's been allegations that there's been a resistance within VA to embrace community care as a um as a um option for veterans by maybe slowing down the implementation or things of that sort. Do you feel that there is a resistance within VA to make community care scheduling as easy as possible or is there a reluctance within the VA to to maybe skew more veterans toward the internal VA care?

Yeah, well we made a recommendation to VA and to VHA to take a look at the seven day calendar standard for scheduling um an appointment for community care. Um and s- and we And they, which they did imp- which they did take a look at. They looked at the standard and they ultimately decided to keep the seven day standard. And like I said earlier, less than forty percent of facilities are able to meet that standard um for for at least half of those appointments. And so, again, I think these facilities are overwhelmed because the process is very labor and resource intensive. I don't I I mean through the course of our work, I don't we haven't seen any evidence that this is done on purpose, but because it is such an a labor and resource intensive thing,

Yeah.

these these facilities are very overwhelmed, and if VA isn't going to adjust the standard, then they need to find a way to help these facilities to meet it.

Yeah, and with thirty-six now layered systems on there, it begins to question, okay, what like at what point are we having too many systems interfaced with one another,

Yeah.

causing too much error tendency either between systems on the IT side or whether through the human error of inputting into those systems just uh cross filling and everything else. So um thank you, appreciate it. Ranking member Basinski.

Yeah, I just have one final question and actually if you wouldn't mind, Carol, is it just further elaborating on a question I'd asked earlier around uh what would the GAO need to see to kind of better um I guess a signal that would be sent from the VA that they're actually working to fix some of these issues. And I'm glad to see that you're working together, but what would be those steps that you would say they're making progress?

I mean the foundational step is for us to see a strategic plan. We need to see how VA intends to streamline and standardize their appointment scheduling process, from managing the referrals to setting up the appointments to following up and and mainta monitoring those wait times, that holistic process, and then we need to see the IT architecture that's gonna support that that end state. Um so we need to see, okay, if it's EPS, you know, as one of the major tools that they intend to use, okay, um how that and any other new applications coming online, how that is going to support that end state. And then also of the existing thirty-six plus systems that we have, what are they gonna do to turn them off or if they're gonna keep them on, how that's gonna be integrated with all of the other applications that they have. So we need to see uh a holistic strategic plan from them, because otherwise all of these initiatives, EPS you know included, if we don't have that end state, then the current things they're doing are well-intentioned but they are aimless.

Can I just ask, Mister Gratison, is that something the VA would be open to doing, is putting together kind of a master plan, it will say having getting the opportunity to serve on this committee, we know there are very large implementation plans, EHRM, EPA, these are all critically important, but it does seem like one bigger vision, um, a bigger s- master strategy might be helpful to bringing these systems in.

Well, I appreciate the opportunity to address this, because we're we're aware of a number of the open

Yeah.

recommendations from GAO's May twenty twenty five report and um look forward to delivering a comprehensive timeline and plan to the GAO. We expect to be able to deliver that so that we can close that recommendation um later this summer.

Great. Thank you. You're back.

Thank you. Um thank you so much for our uh first panel. Uh appreciate you all coming uh to Grand Ledge, Michigan to the seventh congressional district of Michigan to provide testimony today we appreciate your uh partnership in that so thank you for being here. Um and uh you're now excused and we will wait for just a moment as the second panel comes to the witness table. So if you're on the second panel, if you can come up, um they will put your name tag out for you as well.

All right.

We're gonna do a quick shift change. Yeah, thank you. Mm.

Oh, it's there.

It's gotten cold by now. Yeah, thank you.

Oh, it is down.

Oh, okay, yeah.

I just got a text message.

Oh yeah, yeah. Um, on our second panel we have Mister Jed Hansen, co-chair and founder of the Rural Veterans Health Special Interest Group at the National Rural Health Association. Next we have Major Michael Reeve, Director of Veteran Affairs for Shiawassee County. Finally we have Mister Ben Frederick, Associate Vice President of Advocacy in Government Relations for Memorial Healthcare. and a former colleague of mine in the Michigan legislature. So thank you all three of you for being here today. Uh, I'll ask the witnesses to please stand and raise your right hand. Do you solemnly swear under penalty of perjury that the testimony you're about to provide is the truth the whole truth and nothing but the truth? Thank you and let the record reflect that all witnesses have answered in the affirmative. Thank you all once again for attending today. Mister Hanson, you're now recognized for five minutes over your opening statement on behalf

Here we go. Chairman Barrett, ranking member Buszynski. Thank you uh for the invitation to Michigan's seventh district and for the opportunity to testify today. I appreciate your leadership in this committee's continued commitment to improving access to care and services for our nation our nation's veterans and service members. For those of you on this committee that have served, thank you. My name is Jed Hansen. I'm a co-chair of the National Rural Health Association's Rural Veteran Special Interest Group and I also serve as Executive Director of the Nebraska Rural Health Association. Congress expanded veterans' ability to receive care through the Mission Act in two thousand and eighteen. From my perspective, EPS represents a promise kept. This committee and Secretary Collins and the current VA administration should be commended prioritizing modernization of the veteran experience. Across rural America, this effort is seen as both a commitment to our veterans and as an investment in our rural communities, hospitals, and clinics. While veterans may be eligible for community care, eligibility alone does not create appointments, as we've heard uh from some of our other testifiers today. EPS helps translate eligibility into access by connecting veterans, community providers, and VA schedulers through a more coordinated process to uh ultimately reduce administrative burden, improve scheduling efficiency and expand access. The National Rural Health Association's special interest group recently identified expansion of EPS as one of its two pro- policy priorities for twenty-six. Through discussions with rural providers, hospital leaders, veterans, and policy makers across the country, one question continued to emerge. How do we move from early adoption to broad statewide utilization? In my home state, we're tempted to answer that question. Nebraska's goal is simple. Achieve the level of provider participation necessary to make EPS a reliable statewide scheduling tool for veterans, providers, and VA schedulers. To support that goal, the Nebraska World Health Association developed a statewide EPS expansion strategy in partnership with the Nebraska Hospital Association. Nebraska DHHS and ultimately our governor's team incorporated that approach into Nebraska's Rural Health Transformation Program application, creating a strong statewide partnership around this implementation strategy. The strategy seeks to engage Nebraska's broader rural health care network, including hospitals, clinics, FQHC's, behavioral health providers, dental practices, and more to create that critical mass that you've been talking about needed for network adoption. Importantly, uh, this effort, uh, thi- this will, uh, this will demonstrate how existing federal investment can accelerate implementation. The Veteran EPS project represents the very best of what RHTP funding can be, funding that supports technology, that improves access to essential services for veterans, and supports rural workforce. The VA's effort to expand scheduling f- of compensation and and pension examinations through EPS also represents an equally important opportunity. Efforts that are particularly important for transitioning service members who may be unaware of available resources and as they transition into civilian life. Just as EPS can improve access to health care services, it can also help connect veterans to disability evaluations needed to establish service-connected conditions and access their earned benefits. Supporting provider training, onboarding, and outreach is going to be essential. Expanding local capacity alone is not sufficient if veterans remain unaware that these services or examinations are available within their own communities. Nebraska plans to support regional veteran benefits and resources events that connect veterans their families and caregivers and local health care permit professionals to services disability benefits resources into the community support programs that they need this first of a kind statewide program is designed to raise awareness for all those supporting veterans in rural areas. Taking together Nebraska's plan reflects a broader lesson improving access requires more than technology alone. It requires technology, provider capacity, and outreach working together to ensure veterans can successfully access both health care services and benefits. Our experience with EPS and other statewide health care modernization initiatives suggests that technology adoption is most successful when innovative tools are paired with trusted implementation partners trusted state and regional organizations, such as the Center for R- uh for Rural Health Care here in Michigan or ICANN in Illinois, are great examples of who those partners could be in your own states. Based on our national discussions and Nebraska's implementation plan, I respectfully offer these three recommendations to the committee. First, continue supporting statewide implementation strategies that achieve broad participation among uh community providers. Second, pair technology deployment with provider onboarding, training, and technical assistance, and outreach to es- to ensure a successful adoption and utilization of EPS. And third, continue advancing interoperability and care coordination between the VA and community care providers. Scheduling is a vital first step, but future success will increasingly depend on stronger integration of referrals, clinical records, benefits, processes, and care coordination workflows. EPS is undoubtedly a transforming eligible uh technology to access care for veterans, but ulti- but the ultimate measure of success will be whether veterans actually are able to utilize these services. Chairman Barrett, Ranking Member Basinski, thank you again for the opportunity to testify and for your commitment to our nation's veterans and service members. I look forward to your to your answering your questions.

Thank you. Thank you. And uh, Mister Hanson, your written statement will be entered into the hearing record. Uh, Major Reeve, you're now recognized for five minutes to deliver your s- opening statement on behalf of Shilohson County. Thank you for being here.

Chairman, Ranking Member, and distinguished members of the committee, thank you for the opportunity to provide testimony regarding the challenges veterans in Shiawassee County, Michigan face when accessing VA health care. I serve as the Director of Veterans Affairs for Shiawassee County, and I'm also a veteran with twenty-seven years of active duty service. Through both my professional role and professional or personal experiences, I have gained firsthand insight into the barriers veterans encounter when seeking care through the Department of Veterans Affairs. As a rural Michigan county, Shiawassee has a veteran population of approximately five thousand individuals. Many of the veterans we serve are older adults, as our demographics suggest the average age is seventy-five years old. Many of these individuals have disabilities and limited transportation options. As of two thousand eighteen, we have transported four thousand seven hundred and twenty-nine veterans to VA appointments at VA facilities or to referred health care providers. Assessing care often requires travel to these VA facilities, mostly in Saginaw and Ann Arbor, which are urban, making reliable appointment scheduling, communication, especially important. Of note, it takes our drivers one hour, twenty-two minutes to travel seventy-four point five miles to An- Ann Arbor, or fifty-two minutes traveling forty-one point four six miles to Saginaw. We have also transported veterans to Battle Creek, which is one hour, thirty-seven minutes at a hundred and two miles, and also Detroit, which is one hour, thirty-three minutes and eighty-seven miles. Veterans frequently experience long wait times for appointments, and specialized services. In some cases they are told the next available appointment is more than a month away, leading some to seek care through the emergency department for more immediate attention. We've also encountered situations in which appointments at the Saginaw or Ann Arbor VA Medical Center are canceled or rescheduled without timely notif notification This can create unnecessary travel and strain limited transportation resources. I've experienced this personally as having driven to Ann Arbor for a medical appointment, only to arrive and learn upon arrival that it had been canceled without prior notice. Excuse me. Additionally, we have observed situation which veterans establish successful relationships with their local community care provider, only to have their care redirected back to the VA facility when that service or specialty becomes available through the VA system. These transitions uh often disrupt com- uh continuity of care and create frustration for the veterans. who then must adjust to new either new providers or treatment plans. From both my professional and personal perf- perspective, improving communication, reducing appointment delays, and supporting continuity of care would significantly enhance veterans' access to the health care services. The challenges we see in Shiawassee County reflect broader trends affecting veterans throughout Michigan and across the nation. More than thirty percent of Michigan's veterans live in rural communities, where transportation barriers and travel distances com uh complicate access to care. Federal oversight agencies and independent researchers have also identified ongoing concerns regarding appointment scheduling's wait times and coordination within both the VA and community care systems these findings reinforce what we experience every day at the county level that timely communication again, efficient scheduling and reliable care coordination are essential to ensuring the veterans receive the health care they have earned through their service. I appreciate Congressman Tom Barrett's leadership and collaboration on the Veterans Community Care Scheduling Improvement Act, as well as the continued utilization uh and a s- few tweaks for the external provider scheduling system. These efforts represent meaningful steps toward improving care, coordination, and helping veterans access the health care services they have earned through their time in service to our nation. Thank you for your attention to this important issue and for your continued commitment in improving the access to America's veterans. I look forward to answering any questions.

Thank you, sir. Thank you again for being here. And the written statement of Major Reeve will be entered into the hearing record. And uh, Mister Frederick, you're now recognized for five minutes of your opening statement on behalf of Memorial Health Care.

Thank you, Chairman Barrett, Ranking Member Buzinski. Very much appreciate the invitation to participate in this hearing and offer comments on providing world-class health care services to our veterans and rural mid-Michigan. I have the pleasure of serving as Associate Vice President of Advocacy, Government Relations and Business Development for Memorial Healthcare, which is a mid-sized independent rural hospital located in Owasso, Michigan. We serve patients at our main hospital in Owasso and more than forty outpatient sites across six counties a very wide swath of service delivery rank from the standard inpatient to numerous specialty offerings, including neurology, orthopedics, rheumatology, pulmonology, oncology, freestanding, uh cancer center, GI, home health. I'd do that list to speak to the continuum there. The other thing, and, Mister Chairman, I appreciate you mentioning, is that it's not just a hospital building, it's a continuum of care. And in rural areas there is a predominance of employed providers that are in that primary care space. So the front door to the health care access system, ninety plus percent chance that that primary care family medicine provider is gonna be a Memorial Health Care employed uh provider. So it's a true continuum of care. We very much align with the mission of this committee, as the origins of our hospital were directly inspired by the Wasp community's desire to serve the veterans of Mid-Michigan, following World War One. Our original nineteen twenty-one edifice still stands as an ongoing memorial honoring those veterans and the many who have followed. In fact, our legal name remains the Memorial Hospital. And our campus is home to Wasp's war memorial honoring those who perished in World War One. Our system CEO st- sends his best regards to this committee and regrets being unable to address you personally. He himself is a veteran of the United States Marine Corps, and many members of our m- leadership team and eight hundred members strong workforce are proud veterans of the United States military. The culture of Memorial has long included recognition of our team members who served and a commitment to providing health care to the veterans who live, within the communities wh- we serve. One of our most solemn traditions at Memorial is a code honor, staff recognition, which marks the passing of any inpatient or long-term care resident who served, who's at our facility. We flag a patient's veteran status during our intake process to ensure a ready connection as we can with available services. And we also strive to ensure veterans are aware of their benefits and are enrolled as a participating provider in the community care program, and through partnership with our county VA. Thank you, Chairman Barrett, as well, for your efforts to ensure that the VA proactively notifies veterans of their options to receive community care through other work that you've done. Previously veterans had to know and proactively urge uh the the utilization of those local services. This simple change in how a conversation is even initiated at the VA will drive convenience and cost savings timely care and better outcomes to the VA system, but it's also a bit of a warning as to how much work needs to be done in addressing that basic communication or culture so that the veteran's not constantly placed on that self-advocate position of knowing what to ask when and so on. But thank you for that effort. In twenty twenty five, we served over four hundred individual veterans in our inpatient setting and over four hundred in outpatient care. Hundreds more veterans were served with primary insurance that was outside of uh VA insurance. We are not satisfied with those totals, and I'm sure if you talk to other rural hospitals, they'll have similar responses. However, they they they represent a small portion of the estimated bi- veteran population who call Shiawassee and rural, and Michigan home, as noted by uh Major Reeve. But it does speak to the fact that we have, I think, a a additional utilization capacity that uh but for the option, uh we would absolutely embrace. As a community hospital in a rural region, our patients already face significant challenges that limit access to essential health care services such transportation, average age. Our veterans carry the additional burden of wounds both seen and unseen, which can affect their willingness to seek care and their ability to stay connected to care when facing frustrations or barriers. Independent hospitals offer a true partnership that is community focused. Our competitive advantage is personalized patient care and that direct connection we establish with each individual in addressing specific needs. The overarching concern I would wish to bring to this committee, uh on behalf of our team, is simply the degree of self-advocacy we see from veterans who are trying to remain with us as their medical home. There's a big travel distance for us, as mentioned by the chairman. But the burden often does follow on uh fall on the veteran themselves to initiate, follow up, and navigate that system that does not communicate across its own components. So the aspirations of these efforts are quite exciting to us. We're doing as much listening and learning today as anything, um but it's not something that we've presently looped in on. And we wanna make sure that any type of implementation is is in accord with our own personalized standard of care and that patient experience as well. And we thank this committee very much for the attention and the time. Thank you.

Thank you, Mister Frederick, and uh thank you to all of our uh panelists. Um um the statement the written statement of Mister Frederick will be entered into the hearing record, and uh I will yield myself five minutes uh for questions. Um Major Reeve, you uh very um succinctly pointed out the commutable distance for veterans seeking care in a traditional VA facility uh for whether you're providing that transportation service or whether they're on their own traveling there. Um, you know, I think about I I think you referenced those are probably from Awaso to these facilities I would imagine. Is that correct?

That is correct.

Yeah. So if you live in Perry or Langsburg, you're even further away from say Saginaw or Detroit or any of these other facilities that may be you know a further drive for you in that instance, making it definitely well over an hour for for a whole number of veterans depending on where they are geographically, even. within the county or in other parts of my district, in Clinton County for example, and other areas as well. Um, these are things that I think stack up on people. Um, but then you also pointed out that there is an issue of that, um, continuity of referral. If you start seeing a provider for a, uh, maybe a chronic condition that you have and you get referred out to community care, and then six months goes by and that referral lapses, and then they can get you into a VA facility, within the limits of what the community care program allows for the VA to retain, and it switches that provider. And I think for a lot of patients, having that continuity is very important. Having that same provider that you can build a relationship with is very important. And I think for veterans, maybe it's even more important depending on the types of challenges they're facing, particularly when you look at mental health, for example, that you need to build a relationship with a provider over such a sustained period of time. If you observe that in the veterans you've spoken to and the ones that you serve through your work?

Uh, thank you for the question. Uh, I have. Uh, a lot of times we'll see, as you just said, that veteran having that care at, uh, their, uh, home of, uh, record, if you will, and then having to transfer to a new doctor, new care. A lot of times the treatment plan will go back to something that has already taken place. uh potentially a referral out to some more tests that those tests are already in their records. Um there are other times that uh specifically in my line of work, so I'm gonna kind of n- narrow it down e- a little bit even further, but as a veteran service officer we also process claims and a lot of those claims as you're fully aware go towards CMP exams. Uh, those CMP exams, uh, in in I'll just use my case in particular, uh, I s- had one scheduled clear up in Midland. That's a two-hour drive from Owasso. And for this particular treatment plan, uh, I looked at how many other providers were in between my house and Midland. There were fifty-one other providers. Now, whether or not they were part of the community care n- network, I can't answer that. But, uh, the propensity to use those providers was there.

Sure, and if it's not a, you know, hyper-specialized type of treatment that's only done by a few providers, it begs the question of why they're not using the full complement of availability that that's that's out there. I mean, certainly they're licensed through the state or or otherwise to prove their adequacy of of doing that kind of treatment. So it really does beg the question of why they're not being utilized by the VA for that. Um, Mr. uh, Frederick, wanted to ask you through Memorial, um, i i what, I guess, what uh options do you see or what uh partnership availability do you see with the VA? And where are the shortcomings coming from your side of the perspective to open up the pathways for more veterans if they choose to seek services closer to home through the types of services that you provide through Memorial?

I think there's a few uh areas that have been mentioned by my team. I think we've heard a little bit about the connect the connectivity issue and just the communication issue with with other uh insurance coverage, we're able to be more of an advocate alongside the patient, just keep them connected with their care. But so often we see in between visits, they're charged with that next connection point. And we're kind of waiting to see what the determination's gonna be. To your point about the relationship, are they gonna be able to maintain that specialist relationship? Um oftentimes we have concurrent ticking clocks on number of visits and duration of authorization, which which uh compounds which compounds the issue.

I've seen that, yeah.

That's actually the the chief reason where we slip into denial situations is actually just that we we miss a a a deadline like that.

Yeah.

But there's a lot of pressure on that on that um uh on that veteran. The the other is uh things that would be rather routine like diagnostic transfer from the VA uh visit back to that uh community care primary relationship.

Mm-hmm.

Or are we stuck with a redundant testing situation? Or is that veteran now the courier for that information? So in the technology side, a secure electronic file transfer type of a model comes to mind pretty readily there. Is there a way for us to have some of that bilateral conversation? I think some of this is in very good faith, but it is still a kind of a one-way communication, and if we could really have that bilateral communication in a number of veins, our care team is eager to serve more and also show what we can do. Uh, you've been to our facility and know our capabilities. If it's the veterans' choice, we certainly wanna serve our own.

Very good. Thank you. Thank you, Member Buszynski, for five minutes.

Thank you, Chairman. Um, I wanna really applaud what's happening in Nebraska and the work that you're doing, Doctor Hanson. Um, I'd like to spend a little bit of time on that and and learn from your work. Um, in your testimony you indicate that the Nebraska Rural Health Association developed a statewide EPS expansion strategy. So I was wondering if you could spend some time talking about what was included in that strategy, how it went, lessons learned. Would love for you to talk about that.

Yeah. I absolutely love that question, so thank you for asking it.

Sure.

Uh, so through uh RHTP we developed a a plan where we could provide funding to each of our rural hospitals, uh their associated clinics, our FQHC centers in in rural Nebraska, and then roughly one hundred independent clinics and and offices that, thinking dental offices, therapy, et cetera. Um, it's we're uh providing approximately seventy-five thousand per hospital, and then twenty thousand per independent clinic site, uh to um to help um accelerate that adoption. Uh, with those dollars, uh those facilities can use that to offset any type of technical expertise that they're needing to be able to make that connection with EPS. Uh one of the early challenges that we found with uh some of our larger uh tertiary centers was just the the data mapping or the schedule mapping and those decision trees that were needed with with scheduling uh we also um are encouraging or will be encouraging uh local providers to to sign up to get training so that they can provide CMP exams understanding that um that um is a future strategy of the VA and then to just uh we know that there's a backlog of that as well, so to to encourage that. Then the final piece, uh I briefly been able to mention, uh was the idea of these regional benefits uh exams.

Mm.

Um I've had the the the fortune of attending um a a NASVEDA, which is the National Association of State Directors of Veterans Affairs, a few of their events. And couple of years ago I was um walking the Vendor Hall

Mm.

and I was amazed at at how many different benefits and and um different services are avail available for our veterans. I was also equally amazed at how little information is out there, and how few know about all those services. So we're really looking to uh in Nebraska to connect our hospital teams, our community health professional teams, and then in these regional events, making sure that our veterans know uh about the access that they have, the benefits they have, their caregivers, and then our community team so that we're really taking that comprehensive look at it. Um, the other thing that really can't be dismissed here is that, um, making sure that our local VAs are are synched up.

Mm-hmm.

Um, those schedulers have historically taken on a lot of work and it has, um, I I was amazed at hearing how many different, um, systems are are actually involved on the VA side.

Mm-hmm.

So we've been working very closely with, um, the, uh, the VA center, uh, for Nebraska Western Iowa and that leadership team uh to uh to work on communication strategies. Um it's netted even very recently just what that relationship looks like. We had a veteran presented to a critical access hospital, they ended up being moved over into a swing bed um uh um uh care plan and the local facility was receiving denials. Because of those deeper deeper relationships that we've developed in Nebraska so that we can serve as that liaison, we were able to connect in the VA team so that they could work on that strategy, so that it didn't have to rely on the veteran to be his, um in this case his own advocate, uh for um for for service coverage there, so.

That's really that's really impressive.

Thank you.

Can I just um drill down a little bit more? H can you tell me how many providers ended up then in Nebraska um actively sharing their grids with the VA through EPS?

Yeah, so uh currently we have Uh, we have a a handful of our critical access hospitals, and then we do have both major um our tertiary centers or our medical centers in the state sharing. Uh, those efforts to date have been focused more on targeted specialty, um, understanding that cardiology was a significant uh challenge in our state. We've also been rapidly expanding uh mental health and physical therapy i in our state as well. Um, through uh through RHTP that that Um there are certainly some challenges uh with the with the rollout and the procurement processes with that. Uh but the plan is to to effectively connect the entire rural healthcare grid in the state over the next couple of years.

And and I'm just curious, have you gotten any pushback from providers then that have been utilizing EPS since they've gone live?

Y- yeah the the uh the biggest challenge or or the biggest pushback and challenges, one was that scheduling uh mapping that was needed and looking at some of those decision trees, especially for some of the specialty services. Uh and then the other one is is just related to that critical mass that's that's ultimately needed. Um when our VA schedulers aren't used to being able to go out to a system and netting a positive um appointment, uh they're less likely to continue that adoption and so we um we're understanding that we need that any type of technology network needs critical mass. And this is one of them and and we were fortunate enough to be able to to work um to develop a plan and then uh one that our state ultimately adopted.

Great, thank you. I will yield back.

Thank you. We are gonna do a second round of questions but we'll um go to two minutes uh for the second round if that's okay. Um very good. Um, Mister Frederick, just picking up where we left off when uh time expired, you you mentioned a couple of things that I think are important. One is the testing redundancy or diagnostic redundancy that is done when moving health care back and forth between VA and then outside of the VA. One of the efforts we've undertaken for modernizing the electronic health record is to more easily share that information both within the VA itself, believe it or not, different VA facilities are not able to share that information today, but then also outside of the VA so that a uh a VA clinician can share information within a clinician outside of the VA network. So that's an effort that we're undertaking and we'd certainly appreciate your feedback along the way as this is implemented uh both locally here in Michigan but also nationwide as well um but the other thing you pointed out is when VA refers out for community care often there is both a timeline that that stands for as well as a number of visits that are allotted so you could hit your limit on one or the other before you know you might go for three visits for a referral before the ninety days that that referral stands for for example and then you're forced to kind of renew that referral or ask for additional which can be, you know, bureaucratic and troublesome and can kind of um affect the patient care outcome. Can you talk about how that is different generally than a traditional health care model or health insurance reimbursement or another way that a a patient may be referred for care?

Yeah, it the the biggest difference is this combination of visits to time limitation. Uh, typically when you're going through that authorization and you've determined that it's a covered benefit, you're able to proceed. Uh, or you have a care plan that speaks to a certain number of engagements in a, like a physical therapy setting over a period of time, and that's just a known schedule. So it, it is a bit disruptive for our team that does the, the uh, you know, running the traps on this to try to manage both of those timelines and again, whether they, th- they've taken it on themselves or not, mentally there's that recognition from the veteran themselves, or they have to manage that too. The other challenge that we're seeing, and I know uh Major Reeve actually may be able to speak this as well, is that the frequency visits trends, they're they're worsening. So the amount of recurrent visits that are allowed for certain purposes have declined in some of these areas. So we're seeing some challenges with just being able to get a person through rehab or or effectively in a p- s place where we're hopefully minimizing readmission, frankly.

Sure. Thank you. Major Reeve, I can give you a moment and then I gotta yield to the ranking member.

Uh, thank you. Uh, from what Ben was saying, um, in particular we we have got a veteran that was receiving, uh, um, some care. And the number of visits, uh, I believe was twenty-six, uh, for this particular service. Uh, the VA came back and said, " No, um, we're cutting that down to twelve ", and then if you take in account the travel time on top of that, uh, it's no longer feasible for this individual. then to t- uh take time off of work uh in order to to go to that. In addition, there's another veteran who is on dialysis three times a week, has to travel down to Ann Arbor, has to have somebody with him, so now there's two people essentially taken out of the fight, if you will, instead of going to memorial care just down the road ten minutes to receive that care back at home uh that afternoon instead of making it a whole day. as w- we all might be aware, dialysis is one of those things that just take a lot out of both the individual and the family.

Thank you. Appreciate it. Thank you both. Ranking member Buszynski.

Yeah, thank you, and maybe I could just pick up with um Major Reeve and just say, you know, again thank you for being here but thank you for your continued service. What you're saying is something that I hear from veterans in my rural district, um pretty consistently, how do we get the VA to do better at communicating? travel times, you know, we need to shorten wait periods, um. And so I'm guess I'm I I belie- I think the VA needs to do better. Um, but I'm curious if you have any recommendations on ways that we can im- make those improvements in those areas.

Thank you for the question. Uh, coming from a rural county in Michigan, uh, one of the big things I would say is the availability of a veteran's record to a uh third party if you will, Momor I'll just use Momorant Healthcare as the uh example. Um not only would if that individual selects through the community care network to receive their treatment closer to home, uh when that individual files a claim and needs to go to a CMP exam, we can then utilize those same services for that. Another big thing and issue in a lot of the different uh organizations and I hope I am uh, okay for them are nexus letters. It's one of the key requirements that the VA requires when filing a claim in order to make that service connection. And without that, you're gonna get denied most days of the week. A lot of times VA doctors are, uh, I don't wanna say unwilling, but they're hesitant in doing so. I don't know if it's because, uh Well, I'll just leave it at that. I'm I'm not quite sure why. And then that leaves the veteran themselves to find an endob provider to then write that nexus letter when if that Memorial Health Care was within that community care network, it would be a one and done service, not only for the continuity of care, treatment, but then the further service in developing that claim.

Thank you, I'll yield back.

Thank you and uh thank you to all of you on the uh second panel, thank you for being here today, we deeply appreciate your testimony, so thank you. Uh we are now gonna move on to uh closing statements, uh Ranking Member Buszynski.

Sure, I'll I'll just be very brief and say thank you to all the panelists, both the first panel and the second panel for being here. Uh thank you for your hospitality in Michigan's seventh district. Um it's it's an honor to serve on this committee, there's so much work that we have ahead of us on all of these different implementation programs, whether it's EPS, EHRM, these are big undertakings that the VA needs to be continuing to take on and I want to see them be successful, so I appreciate the opportunity to continue to do this work with you, Chairman. So thank you.

Thank you and uh thank you member ranking member Basinski for coming to my district today, I really appreciate that. Uh and I also want to thank our friends at the uh Michigan Army National Guard for allowing us to use this facility, uh Steve please thank uh the tag on my behalf. I think he did say we can take the Lakota out for a quick trip afterward, is that is that true? Okay, it's already out there? Great, yeah well Just, I won't put a scratch on it, I promise. Um, but uh, please uh, give him our appreciation as well and to everybody here at the uh, support facility, thank you for accommodating us today and thank you to our witnesses for being here, and sharing your real world experience of what's going on both within the VA, from the GAO, and from our local partners, and from our rural um uh, leaders in this way to tell us how we can make this work, cuz ultimately we share the goal of making this the best we can. for the veterans that we serve and, and this facility that you're in today really serves as an example, I think, of the men and women that we are trying to assist with this. You know, this is deeply rooted in this community. We've seen people leave here on a deployment. Over the twenty year long War on Terror there was only a, a handful of months that we didn't have some unit from this facility deployed in the fight somewhere or another around the world. And we've seen people leave, we've seen, we've welcomed them back home. Uh, you have soldiers that serve here and then maybe they leave after a number of years that their enlistment lasts for. Or maybe somebody, you know, one of my friends who I caught up with today is uh approaching his thirty-eighth year in service in the military. So it runs the full spectrum and and communities like this support all the different types of men and women who serve, but often we are a little bit further removed from your larger active duty facilities that might have a more robust VA component accompanying them. So when people come back to a unit like this, they're dispersed across this community, generally where they're commuting in from, which makes them further away from certain VA facilities, which I think then really brings about an urgency around how we are going to accommodate the community care network to best serve them in the area that we need to. So we have a lot of work ahead of us to the ranking members' point. Uh, we owe it to our men and women to do that work. I'm committed to that and uh, really appreciate everybody being here today and the work that we're doing here is gonna be brought back to Washington DC to implement the best that we can. So uh, I will uh, how about we have, hey Lewis, can you come up here a minute? Do you wanna swing the gavel, buddy? All right. So, with that I'll ask unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous material. And without objection, so we're to this hearing is adjourned. Go ahead. All right. Thank you.

Oh, you guys did a great job.