Hearings to examine building a 21st century VA health care system

Good afternoon, everyone. Thank you for your presence. Welcome to our this week's hearing. Two weeks ago, we had the opportunity to discuss with Secretary Collins his vision for bringing the organizational and governance structure of the VA's direct care into the 21st century. Today, we're here to discuss how to achieve that same goal for the VA's community care system. Health care is local, and for many veterans in Kansas and across the country, the ability to see a doctor in their community is not a luxury, it's an essential part of their health care and well-being and the ability to use the VA health care benefits they earned through their service. Congress recognized the reality of this circumstance in 2018 with the enactment of the MISSION Act. The MISSION Act intended to make certain that no veteran, no veteran would be limited by geography, long wait times, bureaucratic barriers, the need for specific kind of care in seeking care from the VA, and that every veteran would have the opportunity for meaningful choice in where and how they receive their care they require. This afternoon, we're here to discuss where the VA has made strides in delivering on that promise and where it's fallen short. We will also discuss where improvements are needed to make the VA's community care program stronger, more sustainable, and more successful by putting the veteran first, expanding meaningful choice, and providing care when and where veterans need it and want it. To that end, I was encouraged to see the VA release a request for proposals in December for the next generation of community care network contract, followed yesterday by a separate request for proposals to establish a national dental community care contract. In many ways, these procurements reflect a welcome focus on innovation, competition, and accountability. They also signal a long overdue progress toward upholding industry standards, embracing value-based care, strengthening program integrity, and addressing persistent challenges such as timely return of medical documentation that have frustrated veterans, providers, and policymakers alike. Achieving these lofty goals can't be easy. The contracts must do more than look good on paper. The VA must deliver results for veterans, VA staff, and community care providers and taxpayers by leading to real measurable improvements in access, choice, outcomes, and costs. I look forward to hearing from the VA witnesses this afternoon about how the department can meet that mission and how this committee can support them. With that, I recognize the ranking member, Senator Blumenthal.

Thank you, Mr. Chairman. Thank you to our witnesses for being here today and for your service to our country and to all the men and women who work with you, veterans among them, and dedicated to the mission of providing gold standard health care to all of our veterans. We're here to discuss the VA's next generation of community care contracts, which will total about a trillion dollars to be live, as I understand it, in 2027, which gives us time to assess what the needs are for community care on contracts that will be indefinite delivery and indefinite quantity, which is kind of scary when you think of all the indefinites there. And it emphasizes the need for strong oversight on the part of the Congress and the Inspector General of the VA. And we can't really talk about community care without talking about its impacts on VA's direct care budget because for many veterans, care in VA facilities is veterans' care. And what they are seeing now is losses of staff through caps on workforce, the attrition of many of the skilled and dedicated men and women who have served, and the potential for lower quality if we take our eye off the ball of direct patient care through VA facilities. My feeling is that the VA has to prioritize resources for expanding access to direct care by adding and expanding existing facilities, increasing staff to reduce wait times, and supporting the VA's gap services such as telehealth, emergent and urgent care capabilities. Community care is a critical component and a supplement to VA direct care. It is veterans' care. Community care is veterans' care, no question. But it cannot supplant VA direct care for all the reasons that everybody here knows well. It is the preference that veterans have to seek care directly at VA facilities, at least for many of them through VA providers. It matches or outperforms the quality of community care in many instances, and it is a more efficient use of taxpayer dollars. So first and foremost, we need access to information. The chairman and I submitted a letter to the secretary after his appearance here with very specific requests for information that he promised to provide. There has been no response so far. We are hoping, or at least I will speak for myself, that that information will be forthcoming. It is essential to judgments that will be made about community care as well as about direct VA care. I would oppose a blank check for community care without real guardrails, and establishing those guardrails depend on getting straight answers from the department that enable us to do basic oversight, including the request that we made on the record. I will just say committee staff have not received a quarterly briefing as of yet from the Office of Integrated Veterans Care, the office overseeing VA's community care system, and I am hopeful that we will see responsiveness on that score as well. In short, information and communication must be a two-way street and not just with us, but with veterans. They are the most important constituency here, and I know they expect straight answers promptly to questions that are raised in committee hearings and also in the inquiries that we raise. So again, my thanks for being here today. And I'm going to put that record, that letter, Mr. Chairman, if there's no objection, the letter that we did in the record.

Without objection. Mr. Topping, in regard to Senator Blumenthal's comments in his opening statement, would you again remind, would you remind the secretary of his commitment? This committee is always looking for information. It's always difficult to attain, at least slow to obtain. And again, I would encourage the department to respond soon to the letter that Senator Blumenthal and I sent. It outlined simply what the secretary committed to providing, the answers he committed to providing, information he committed to providing to us when he appeared before our committee just recently. And I agree with the senator from Connecticut that lots of unknowns in the future of what we're talking about today and oversight by this committee, oversight by the Inspector General or GAO remain hugely valuable to getting the right result. And so we will, I will encourage that cooperation between an IG and a GAO, but more importantly, the continued dialogue with this committee, its members, but particularly its staff. And with that, Mr. Topping, I think we're ready for your testimony.

Thank you, Mr. Chairman, and absolutely I'll take that commitment to work with the secretary and his team to get you the information that you have requested. Mr. Chairman, ranking member, members of the committee, thank you for the opportunity to discuss the Veterans Community Care Program and the NextGen contract procurement. I'm accompanied today by Alicia Skolrud, Executive Director of Integrated External Networks for VA. VA has long been recognized for the world-class health care we provide to veterans across more than 1,500 medical facilities. In addition to the direct care system, VA has also been a purchaser of health care since before the World War II era. As a health care payer, VA partners with local hospitals, doctors, and other health care providers to ensure that veterans have access to the care they need, where they need it, and when they need it. Caring for veterans is about more than operating hospitals. It's about supporting veterans' physical and mental health and wellness, their families, their caregivers, mental health requirements, community requirements, and leveraging community services beyond the walls of our facilities. Recognizing the key role that purchased care plays in VA's ability to provide care for veterans' health and wellness, President Trump and Congress passed the bipartisan MISSION Act of 2018, which expanded access and choice for veterans and reinforced VA's mission as both a health care provider and payer. Today, VA is the country's largest single health care provider through our hospitals and clinics and the fourth largest health care payer. In fiscal year 2025, 41.8 percent of all VA health care appointments were in the community. NextGen is VA's first major procurement effort to support that program. It's our opportunity to increase competition, upgrade and modernize the provider network, enhance services that ensure veterans receive the very best care possible, whether at a VA facility or in their community from a local health care provider. We did not design NextGen alone. We talked to our veterans, who overwhelmingly want the choice to choose between direct care and community care based on best medical interest, availability, and convenience. We talked to other government agencies. The Departments of Health and Human Services and of War have decades of experience and data providing health care quality, reducing costs, and aligning incentives for better health and wellness. We talked to industry, which is constantly innovating with new delivery models, leveraging data and analytics, striving to be consumer-oriented while addressing costs that remain too high. Combining VA's history, the data, and this external input, VA successfully issued the CCN NextGen RFP on December 15, 2025. We are leading the nation with an innovative 10-year multiple award IDIQ. It's a contract vehicle which has several key advantages over traditional federal health care contracts. First, the IDIQ drives competition and flexibility by allowing both national and regional health plans to successfully bid and be awarded a spot on the IDIQ. This is the best of both. We'll have vendors with national reach and scale, but also regional plans with unique capabilities that are locally adaptable. Second, through the use of multiple rounds of task orders, it allows VA to iteratively adapt NextGen to meet veterans' evolving needs over time, changing demographics and infrastructure, and to improve VA's sophistication to manage the program over the 10-year performance period of the contract. The IDIQ is the how of this procurement, but the most exciting part of NextGen is the what. CCN NextGen is designed on five pillars: quality, value, alternative payments, utilization management, and program integrity. First, VA will implement comprehensive quality programs for community care providers based on nationally recognized measures from the Agency for Healthcare Research and Quality and the Healthcare Effectiveness Data and Information Set. Contractors will track patient safety events, identify veterans at risk of avoidable emergency visits and readmissions through predictive analytics, and while respecting their choice, guide veterans toward high-performing providers. Second, CCN NextGen will modernize how VA pays for the care furnished to veterans by implementing value-based payment models. We will begin with episode-based payments for lower extremity joint replacements, and as we gain the data and the expertise to manage alternative payments, we will introduce at least three additional models over the performance period of the contract to continually improve care. These models will shift away from volume and toward outcomes and the total cost of care, which align incentives with veterans' health and system sustainability. We will also introduce utilization management. This includes active management of inpatient admissions, emergency department use, concurrent hospital reviews, and high-cost drugs administered in clinical settings. This will reduce unnecessary hospitalization and inappropriate care while protecting veterans' access to medically necessary services. NextGen will include a program integrity function to ensure that VA services are protected and maximized. We will identify providers at higher risk of improper billing, formalize oversight processes, expand data and technology use for improper payment detection, and use independent audits to ensure that veterans receive what VA is paying for. NextGen also changes how VA pays our contractors to incentivize performance and outcomes. NextGen will incorporate incentives and disincentives based on the total cost of care, quality performance, value-based care adoption, and payment integrity. Ultimately, contractors who achieve VA quality targets while reducing costs will share in the value they create for VA and for veterans. And speaking of costs, along with the improved care for veterans, NextGen provides real savings for taxpayers. NextGen's actuarial estimates based on independently verifiable data show significant savings of 18 to 14 percent over the life of the contract. These savings range from a low end of $54 billion to nearly $100 billion over the life of the contract. These are gained by fewer unnecessary hospitalizations, improved management of high-cost services and drugs, improved quality, stronger fraud prevention and payment controls. Mr. Chairman, NextGen is leading the way in the way federal health care programs are designed and procured and operated. I appreciate the opportunity to share this information and look forward to answering any questions you and other members of the committee may have. Thank you.

Thank you for your testimony. Ms. Sea-Wright, welcome.

Chairman Moran, Ranking Member Blumenthal, and committee members, thank you for the opportunity to discuss the OIG's oversight of VA's community care network contracts. Our auditors focus on providing findings and recommendations that help VA improve the efficiency and timeliness of both direct and community care. Our health care inspectors work to elevate the quality of that health care and increase patient safety, while our investigators leverage data analytics to prevent and stop health care fraud and related crimes. In our oversight work, we routinely see VA staff committed to providing patients with the care they need, but challenges persist. As VA's reorganization unfolds, the OIG will monitor its implementation to understand the impacts on veterans, VA, and stakeholders. VA's new community care network contract solicitation provides an opportunity for VA to enhance services to millions of veterans. The OIG has noted positive steps in the request for proposals and the performance work statements, such as requiring community providers to use the central submission system for sharing medical records and to use the electronic visit verification for home health services. These changes could improve care coordination and reduce the risk of fraud. VA must remain vigilant to these new contracts to prevent the recurrence of risks previously addressed through implementation of our recommendations. The OIG reports have highlighted four general challenges in community care program management. First, barriers to veterans getting timely and coordinated care. Second, inadequate visibility over the resolution of quality care concerns. Third, workforce gaps and lack of VHA management controls. And lastly, outdated and incomplete financial systems and data impede effective payment management. Our work has identified risks to the quality and continuity of veteran care through VA's current TPA contracts. For instance, the TPAs are required to ensure the community care providers send patient records back to VA. However, this was not enforced. Also, the contract performance metrics do not do enough to help VA track where there is a lack of qualified community providers in needed specialties. Further, IT solutions could resolve delays and barriers to getting VA patients additional community care services identified after the initial VA referral. It is critical that the next generation contracts have actionable steps to move beyond faxes and flawed portals for sharing records and also create measures and reliable tools to address these and other identified problems. Regarding opioid prescriptions, Congress laid out specific guidelines for community care providers to follow. TPAs must ensure providers adhere to VA's opioid safety guidelines and conduct checks of state prescription drug monitoring programs. The OIG has identified previous noncompliance that warrants ongoing monitoring. VHA must intensify oversight of the TPAs regarding the adequacy of community care provider networks, which we have sometimes found do not fully meet veterans' needs or demand. Our previous work has also identified overpayments to TPAs or non-adherence to fee schedules and inconsistencies between the TPA contracted billing structures. All of these should be addressed in the new contracts proactively. The OIG has been in discussions with VA officials over the last three years about improvements in the next generation contracts that can enhance oversight, prevent fraud, and advance health care delivery, including the following: TPA and care providers should not require a subpoena from the OIG to turn over documents. Contract provisions should ensure community providers are responsive to VA. Community provider training and quality standards should align with VA's, and fee schedules should be established that TPAs rigorously follow. In conclusion, VA will need to strengthen its efforts to work with the health care industry and all its stakeholders to develop contracts that help veterans receive care when and where they need it. We will be monitoring those efforts closely. The OIG remains committed to providing independent oversight of VA and delivering actionable recommendations to help VA deliver the health care veterans have earned. Chairman Moran, Ranking Member Blumenthal, and committee members, thank you, and I'm happy to answer any questions.

Thank you both for your testimony. Mr. Topping or Ms. Sea-Wright, does the potential, the described efforts by the VA in these new contracts meet the requirements that the Inspector General has recommended be included as parts of those contracts? Do we know that yet? Have you reviewed to see if their contracts are going to meet your your requests or your your suggestions? And have you reviewed the suggestions to make sure your contracts are going to agree with them?

So we've done some preliminary reviews of the contract language or the performance work statement language, and it does have some good indications of that information. However, until these contracts are actually awarded and the negotiations are finalized, we're going to remain vigilant and diligent in reviewing that information.

Vigilance is fine too. Diligence is fine. Mr. Topping, you agree with the recommendations and intend to pursue them in the contract process?

Chairman, absolutely. IG's been a great partner in this. The recommendations, and there are about 98 percent of them that I fully agree with, we are working on implementing, and the rest of them we'll work it out. So absolutely, good partnership we are working on that together as we move forward.

Mr. Topping, an IG office last April issued a report about the Omaha VA Medical Center and found that the VA staff were limiting veterans' access to community care by manipulating clinically indicated dates in violation of the MISSION Act. We've heard a similar, just this week my office heard a similar allegation at another VA facility. And so I'm interested in knowing whether there's been any follow-up. But Mr. Topping, will you commit to looking into these allegations and quickly making a course correction as needed?

Yes, Mr. Chairman, we will.

I mean, we've I've had this sense for quite some time through numerous administrations that the in fact, we've I think we've learned that it's true, that there was a concerted effort to discourage the use of community care. That discouragement came from VA officials and employees and affected the capability of veterans who qualify for community care to receive that community care. Do you do you know of what I speak, and do you know if there's a problem that exists and has it been corrected or is it going to be corrected?

I do, Mr. Chairman, and here's what we're doing about that. And so as I said in my opening statement, VA is a direct care provider, that's our hospital and clinic system, and VA is a payer, and that's the community care program. These are different systems, different purposes, different tasks. What we have done in the past is combine management of these programs together. And what Secretary Collins has directed is that as an operational vertical, community care will be its own payer vertical within the VHA system. We will account for and manage the funding of that system independently of the direct care system, and there'll be leadership that is focused directly on community care. This will go a long way to remedying some of these confusion between what the role of a direct care provider is versus what a payer is and ensuring that we can meet the requirements both of the program, the MISSION Act, and anything else that Congress wants us to meet.

Mr. Topping, there are graphs, there are charts, there is allegations, that's I don't like that word, there is indications that the community care costs are rising more rapidly than the direct care costs. I would say that cost is in my view a misleading word. It could be more spending is occurring in one category over the other. But what I know about that is first of all, the MISSION Act allowed veterans to receive care if it was in their best interest to do so, determined by the the veteran and his or her provider, not by the VA. And there were no artificial limitations on the amount of community care that could be provided in the MISSION Act. So a number of categories by which one could receive care in the community, but one of them is, is it in the best interest of the veteran? And so I I want you to either confirm or indicate that I should be looking at additional ways of describing this. But there ought to be the opportunity to receive care if it's in that veteran's best interest. And the idea that we're spending more money, again, I don't think spending is the right word, more veterans are choosing or being cared for by in community care. I also want to point out, again, and you can correct me if I'm wrong, but what I know from information that I've seen that I believe to be accurate is the largest increases, in fact, as I understand it, there's been $26.7 billion increase in community care spending FY 19 to 23, and that the largest components of that, the number one is emergency care. So it's it's perhaps not even a decision made by the veteran. It may be where the the ambulance service is taking a veteran, what's most proximate to his or her home or where the injury or need for community care originates. And the second is geriatric and extended care. It caught my attention that extended care, which is in-home care for veterans, family members caring for them, is considered community care and included in those statistics about increasing spending on community care. And so it's really half of the increase in spending on community care has been emergency services and geriatric and extended care, care in the home for veterans. And part of that comes with the very bipartisan passage of the Elizabeth Dole Act that it provides opportunities for that care to be increased. What am I missing here? How can I be corrected? I know that the Veterans Health Administration is also here, maybe this is a question for you, Ms. Skolrud, but tell me tell me the facts here that make sense to when we have this discussion.

Mr. Chairman, I think everything you said was true, and I'd have sort of three points in response that help clarify that. Number one, there has been an increase in spending, but there's also been an increase in utilization. And those numbers that you see and that we show are not risk-adjusted. So it doesn't show the type of care that we are purchasing. So we are we are purchasing more care for veterans in the community, and we are purchasing higher cost, higher value care for veterans in the community. I think that's number one. Number two, it's not necessarily a negative. It means that we are adjusting where veterans receive care to ensure that we are meeting their needs, including locally, not just at not just within the VA system. And then I think the last point to that too is those numbers taken in a vacuum sort of belie the overall VA spending. And so while we talk about this being a 10-year trillion dollar contract that it is, over that same period, we're going to spend $2 trillion on direct care. So this is one piece of the overall continuum of care. These work together to ensure that veterans receive the care that they need, where they need it, when they need it. And so making sure that we are accountable for that is a is a different task than whether or not those numbers are right or wrong. And last point on this too is the intention of the community care NextGen program is to give VA the tools to manage the quality of care so that we know what we are getting and it's the best possible quality of care for our veterans and for us to be able to manage the cost to be responsible for that. So the tools that we need to manage this program are included in NextGen so that we can be responsive to these concerns and questions.

Thank you for your answer. I'm going to turn to Senator Blumenthal, but I would indicate that I share the concerns about the what we've seen in an Inspector General's report about quality, about medical records. There needs to be improvements that I believe your efforts here are designed to achieve in community care. It's not that it's it doesn't have its faults and challenges, and we need the VA to be watchful in regard to providing care in the community to veterans. Senator Blumenthal.

Thanks, Mr. Chairman. Since 2019, the funding for the VA community care program has increased from $9 billion to more than $48 billion in the VA fiscal year 2026 request. That's an increase of 530 percent. That's a staggering increase, wouldn't you agree?

Ranking member, that's a large increase.

Over that same period, funding for VA direct care has increased by far less, about 200 percent, from approximately $50 billion to $97 billion. Why the disparity?

Ranking member, I think that goes back to my prior comments to the chairman that these numbers are not risk-adjusted. And so what they show is we have more veterans receiving more care. It doesn't account for the type of care those veterans are receiving. And I think back to the point that the chairman made too, that they are receiving disproportionately emergency care, in-home and geriatric care, which are expensive services to provide. And so what I would say is the measure of this is not just the gross spending and what the difference is, but I'd say is what is VA getting for it? And does VA have the tools to ensure that we are getting the highest value of care for those dollars and that we are maximizing our dollars to get the most that we can? Under the current community care program, we do not have those tools. We are the only payer program, the only government payer program that does not have the ability to manage quality, to manage cost, to use value-based, to use alternative payments, to do UM, to have program integrity. We are the only program that does not have these controls. We are introducing those in NextGen. And so I share your concerns about the expenditures and the increase and ensuring that we are maximizing the value. This program gives us the tools to do that and to be accountable to the Congress, to our veterans to be able to do that.

...agree that more needs to be done to maximize oversight, to make sure that we get quality for the dollars that are being spent on veterans' care. And your explanation for the disparity is that it's a different type of care, more specialized care, geriatric care that is provided in the community as opposed to VA direct facilities. Is that an accurate summary? I'm trying to put it in...

Senator, that's possible, but there are two issues here. Number one, we don't risk-adjust that for what the care is that is received and what's driving those costs. So that's a dollar amount. What's behind it is not adjusted. So that's number one. And then number two, because we do not measure quality in the community care program right now, I can't tell you that the care is less or more different or better in the community versus direct care. We don't do that today. NextGen includes our ability to do this. That's a huge movement forward so that we can then compare. Are we getting more or less? Are we getting best value or are we not? I can't answer that for you now because the program isn't built to do that.

This chart indicates that the rate of increase in the numbers of veterans served has been far less than the rate of increase in the amount of spending. Ms. Kroviak, do you have an explanation for that fact?

No, we haven't evaluated that in our ongoing audits, so I can't speak to that exactly.

Mr. Topping, to you?

Senator, what those charts show me is that we have more veterans receiving more care. That's what they show me. The ability to dive into what that care is, whether that's the right care, whether that's the appropriate care, whether there's good value for that care, that doesn't show me that. And the program today is not built to do that. NextGen is, which is why this is so exciting for us.

Well, I would suggest that we need to answer those kinds of questions. You don't have answers right now. You say that the program isn't designed to provide those kinds of answers, but anybody running a healthcare program would say we really ought to be answering those questions. Wouldn't you agree?

Senator, I want to answer those questions, which is why we have designed NextGen to include these tools and capabilities. I want to answer those questions.

Okay. Talking about next generation, Ms. Kroviak, your report indicates that we need to, and I'm quoting, "community care providers should be incentivized to meet the same training and quality standards as VA providers." Isn't the word "incentivized" a little bit light on requirements? Shouldn't we absolutely guarantee that they meet the same training and quality standards as VA providers?

Providers, whether they're in the VA or in the community, have a standard that they are all trained to, right? But within VA, they have additional standards that they train to, the culture of the veteran, to serve the veteran. So in our position, the VA is asking the community providers to do more, to have a higher level of education or awareness of the community that they're serving.

But I guess maybe instead of just incentivizing them, shouldn't they be absolutely required to meet the same standards of quality and training and efficiency and all of the criteria that a veteran going to a VA facility has a right to expect?

If it's within the contract, yes, they should be required.

In the contract as a matter of definite provisions and requirements.

Correct.

And let me just ask you very quickly, finally, Ms. Kroviak, have you looked into amounts of overpayments or lack of contract enforcement relating to community care since the enactment of the MISSION Act?

Yes, we've done quite a bit of work in relation to community care since the enactment of the MISSION Act. That work varies from payment oversight to services provided. Our investigative division looks at fraud investigations and things that evolve from hotlines as well. In the payment integrity world, we also do annual reviews of the reports that VA provides on underpayments and overpayments to community care as well.

Do you have an estimate as to how many taxpayer dollars have been lost to improper payments or lack of enforcement?

Since 2021, VA has reported about $4 billion in improper payments of overpayments to the TPA, which is about 4 percent of the total amount paid out.

$4 billion.

Yes.

Okay. Thank you. My time has expired on this round, Mr. Chairman. Thank you.

Yes, sir. Senator Sullivan.

Thank you, Mr. Chairman. And I want to thank the witnesses for their service. Mr. Topping, I think you're doing a good job over there, and I know it's not an easy job. It's never an easy job with the VA, but I appreciate your hard work. I want to talk about the effort to move to a multi-vendor framework. And I want to be a little bit more parochial, focusing on my state. You know, we have more veterans per capita than any state in the country, Alaska. And we also in the MISSION Act were able to get a provision, I was able to get a provision, for states like mine and actually New Hampshire that don't have full-service VA hospitals to have the ability to go get community care just in the bill, right? People can go get that immediately. A lot of times the VA hasn't read the bill, right? So they're not always, it's not always easy to get those appointments in Alaska. I don't know what the situation in New Hampshire is, why those are the other two states. But it is a challenge, and I'm always reminding the VA, hey, we're different here because we don't have that. So keep spreading the word on that. That's important from my perspective. I have a concern. In some ways, I understand the multi-vendor framework approach, but I also have concerns, particularly in a place like my state where healthcare is very expensive and it's a very, very big state. You know, our experience when Obamacare initially passed, we lost almost all of our health insurers, right? We went from four in the individual market to one, and we almost lost that one. So we have this challenge where a small population, very expensive healthcare, very expansive territory to cover. And I worry that if you move to a multi-vendor framework, given the costs, it might create Alaska without bidders. And which would put veterans' access to care at real risk. So I know you've put a lot of thought into the model, but I'm concerned, like I said, high-cost remote areas in my state, you might have nobody who steps up. So how will the VA ensure that vendors will bid for these areas, these states, and in particular like mine with a lot of vets but a lot of ground to cover, high costs? And how will contracts or reimbursements be adjusted to reflect the higher costs without discouraging participation? And that issue of discouraging participation, like I said, it's a real one. We've seen it before in other settings.

Senator, thanks for the question. I love the question because it gives us a chance to highlight, I think, one of the best aspects of how we're doing this with the multiple award IDIQ. So first of all, the program itself for all of the vendors who participate in this, we will have the five pillars, we'll have the tools. And that's nationwide. But what this then allows us to do is invite bidders who are both national and regional and put them on the IDIQ vehicle. And we currently don't have that. What we've got the ability to do is pick a vendor, and we've picked two, and the current program has two. And what that means is we, A, don't have any of those tools that we've talked about, those five pillars, but we operate largely the same program in Los Angeles, California, and Phoenix, and wherever else as we do in Alaska. And that does not match. All healthcare is local.

One size fits all for my state never matches, never works.

It does not, and all healthcare is local and it's based on local needs, local infrastructure, local differences. Alaska obviously very unique. What this multiple award IDIQ allows us to do is solicit bids from vendors who do have expertise in Alaska and do have the ability to serve that region, understand the local populations, understand the differences, to bid and be on the vehicle. And then most importantly, it allows us to have a regional model that is different from the way we operate in the rest of the country. And so very much it is possible that what we would do in Alaska would be different. And so one example would be, I do not think that we would change our quality requirements in Alaska. We want providers who serve our veterans to provide the very best care wherever it is. But because of the distance, because of the geography, because of the rural nature of it, cost may be less of an issue. So we may pay more in Alaska to get the care that our veterans need. Under this model, we can do that and we can account for it. We don't have to do the same thing in Alaska that we're doing in LA. That's the opportunity.

Good. That's a good answer. I appreciate that answer. So you're going to tailor this to make sure it's tailored to meet the needs of each individual state. Let me give you another example. You know, we have a very large native population, almost 20 percent of the population. By the way, they serve at higher rates in the military than any other ethnic group in the country. So that's another reason we have so many veterans, and it's a great kind of heritage and culture of our Alaska Native community in my state and all the military service. And the tribal health organizations are often doing, I met with the Ketchikan Indian Community leadership just yesterday, and they just recently inked a compact and an agreement with the VA, which many of our tribal health organizations do. And that extends the ability for the VA to reach into real rural communities, have access to native populations and non-native populations when they do these compacts with you guys. So will the VA continue to coordinate with tribal health providers under the new multi-vendor framework? Because I think that's a model that's working and it's very unique and it kind of gets to what you just said in your answer to me earlier.

Yes, sir, we will. And yes, sir, we have the ability to do that.

Good. Okay. Great. Thank you. Thank you, Mr. Chairman.

Senator Hassan.

Well, thank you, Mr. Chairman. And I want to thank Ranking Member Blumenthal too for this hearing. And to our witnesses, thank you for being here and for your service to our country's veterans. Mr. Topping, as the VA looks to draft and commence its next generation of community care contracts, it's really important that veterans remain the focus of this effort. And that's what I think you're hearing from all members of this committee today. One particular area I want to make sure that the VA is planning for is the continuity of care. If a veteran is receiving high-quality care from a community provider and the veteran is satisfied with that care, they should be able to keep seeing that provider. So what is the VA doing to ensure that as the next generation of community care contracts come online, veterans can continue to see their preferred current community care doctors without interruption?

Senator, I think the short answer to your question is we have extended the authorization period and so that when a veteran is referred out, he or she can remain with the provider for the full episode of care. That's number one. Number two, what we've done is we've made it easier through the best medical interest for a veteran and the VA provider to select that veteran would go to a community provider and remain with that provider for the treatment. So those are the two controls that are in place now too. But what we're also able to do under NextGen, again, our ability to have regional models and again, what's going to work in Alaska is going to be different than what we're going to do in New Hampshire, our ability to adapt to the local infrastructure, the local capabilities. So for example, without a full-service VA currently in New Hampshire, we do leverage community care, particularly for the hospital systems that sit around. And Manchester sits in the Boston medical market. Unique reach and capabilities. We are able to leverage those in a way that is not going to be one-fit. We will be able to adjust to the region to be able to do that. And then as we do work on capacity at the VA in Manchester, we'll be able to do that and respond to that via this vehicle.

Well, I appreciate that and I appreciate the regional and specific approach. I do also just want to point out that for some people, the continuity of care is going to be more than quote "an episode of treatment." They're going to have a condition where they've developed a relationship and a treatment plan with a doctor with a condition that's going to last the rest of their lives. And the notion that because VA changes its contracting relationships that all of a sudden that person has to transition to a new provider, which does happen in the private insurance market and is a real problem, is something I want you all to think about because I really want veterans to be able to have that continuity of care. And in a place like New Hampshire where there are shortages of physicians, it's going to be important that we continue to focus on that issue. Does that make sense?

Senator, absolutely does and I'll take that. And again, I think as Secretary McDonough implemented best medical interest, this is exactly the type of situation that he sought to address to ensure that there is continuity of care and veterans have the choice to be able to do that.

Okay. Let me ask you another question because it certainly won't get overlooked in Alaska, but I want to make sure that in all our areas, all our states that have a lot of veterans in rural areas, that we're thinking about access for rural veterans. Where a veteran lives shouldn't determine whether they can get the care and support that they've earned. And because rural veterans aren't always able to easily reach a VA facility, they often rely on community care, particularly, you know, in a mountainous wintry place like New Hampshire, it may only be 10 miles away, but it might as well be 100 miles away some days. So how is the VA planning to address care for rural veterans in these updated VA contracts and what mechanisms will you put in place to ensure that the recipients of these contracts are providing a robust network of provider options for rural veterans?

Senator, thanks for the question. And 10 miles in the White Mountains could feel like 100, that's for sure. And so part of what we're doing this and so even for rural veterans, there is a community provider usually local. And that may not be full service, but certainly there's a community provider near if not in the veteran's community, next community over to. One of the pain points on the community care contract has been that it has been difficult for providers to do business with the VA. It's been hard to get referrals, it's been hard to get authorizations, it's been hard to be reimbursed. And we have unique requirements. What we are doing in this program is trying to make VA, again, with the fourth largest payer, but to make our payer program operate like other government programs including Medicare. So one example, we use the Medicare fee schedule and Medicare DRGs, the codes that we use are Medicare. Every single provider in rural New Hampshire likely provides Medicare, accepts Medicare and provides Medicare treatment. To the extent that we can operate our program so that it operates like that and for the provider, ease of doing business with VA, that means our veterans can go local. And if that veteran then needs a higher level of care or specialized care, we may move to the VA or we may move to a specialty provider further away. But the idea is any provider that participates in other government programs, Medicare or Medicaid, can participate in VA community care and provide those same services to our veterans.

Well, I appreciate that and I appreciate that I'm over time. So I'm going to submit a question for the record on making sure that community care providers are getting the veterans' updated medical records back to the VA before the cases are closed out. I think you've recently done a look at that issue and there's a real problem. Cases are getting closed without the community provider getting the records updated back to the VA. I will also just point out for my colleagues that one of the challenges we have in rural New Hampshire right now is because of the Medicaid cuts that came along with the big bill. Two of my rural health clinics where veterans might be referred for community care have had to close. And so that's a real problem related to the Medicaid cuts that just leaves a dearth of providers in certain regions. Thanks.

Senator Hassan, thank you. You said a couple of things I want to follow up on as well. Mr. Topping, your response was pleasing to me and what you talked about is the difficulty that a provider has in providing services to veterans. And it's what we lived with. I mean, Choice, in my view, the VA has always been reluctant to promote Choice and in some instances has made it difficult to be utilized. And I understand that. Nobody wants to lose a patient and veterans, the people who work in a VA hospital care for patients and they want to continue to do so. But the MISSION Act was a replacement for Choice. And the MISSION Act was designed to make it more easily attainable that the providers in the community who would want to provide services to a veteran through now MISSION. And it was designed to eliminate the barriers that a private provider would face in dealing with the VA. The referrals, the record-keeping, the rates charged. There's just a whole list of things that we attempted to, requiring the payment of Medicare rates. And it just, we still have a long way to go. I visited every hospital in Kansas numerous times and 50-some of them last year. And I always ask this question and the answer is generally it's getting better, but we still have problems in getting authorizations. We need another referral for an X-ray or lab work. And I again, I hope that in the process, not only related to these contracts, that in the process we're simplifying the opportunity for community care providers to provide the, meet the needs of veterans. That makes sense and true?

Mr. Chairman, it does. And I have yet to meet a provider who has said that they don't want to provide care to veterans. Most providers do. It's incumbent upon the VA as the contracting agency to make this program as easy to participate in and as smooth. There are ways to do that. We've addressed that during this, in this program design, working on how we do the referral, how we do the eligibility, how we do the authorization, and then most importantly, how we make sure payments are made promptly, correctly, and accurately.

Senator Hassan also talked about continuation of care. It is an issue. I mean, I two years ago brought to the attention of the VA that a veteran in my hometown was receiving cancer treatments. He was required to receive 17 of them. After the 15th one, the VA decided that they should move the care out of the community. The first 15 treatments that he'd received in the community, the last two he was required by the VA to return to the hospital for those treatments. And the explanation was you don't live 60 miles from the VA, you live 59. The drive, I said that wrong, the drive is 59 minutes, not 60. Therefore, you're ineligible to continue to have the care provided for by the doctor, the provider that you have been using for the first 17 of your treatments. I assume this is an anomaly. I assume it doesn't happen. I assume that people have common sense, but and I don't know how you legislate this stuff, but this idea that Senator Hassan raised about once you start with a community care provider. And most recently, I would say the time and time again, chiropractic care has been called back to the VA after a veteran has been receiving chiropractic care in the community for months or years and the VA wants to change the provider by bringing it back in-house. I assume we will attempt to avoid those kind of circumstances and I mostly wanted to make sure that you know that that circumstance has existed.

Chairman, I do and I'm aware of that specific case and I do think it was an anomaly, but an unacceptable one nonetheless. One of the things that we are doing again in NextGen is the use of utilization management in which the treatment matches the diagnosis. And so part of what we've had now is the authorization does not necessarily match. These have been separate from each other. So the idea though is that when we refer a veteran out for cancer treatment, that the care that is then provided to that veteran in the community would match the diagnosis. We'll be able to manage to that and manage to the quality and the cost. And particularly as we look at how we manage this program internally, again, it's very manual now between the referral, which is a relatively well-understood clinical process, the treating physician says we're going to refer the veteran out, but then the eligibility process, the appointment-making process, the time and distance process, that's been very manual. That needs to be automated. That entire process should be relatively seamless and it shouldn't be something that the veteran has to get involved in. It should be something that between VA as the program manager and the payer works out directly with the provider. We are working on those in this procurement. Yes, sir.

I'll follow up with you in further questions about it should be to make sure it will be. Senator Duckworth.

Thank you, Mr. Chairman. Assistant Secretary Topping, according to VA's own survey of healthcare experiences of patients, on most measures, does VA outpatient care score higher than private sector care experiences?

Senator, we don't measure quality in community care, so I can't answer that question.

Okay. What I've seen is that veterans report better communication, more trust, and higher satisfaction with VA clinicians compared to private sector clinicians. And that's not in your own survey of healthcare experiences of patients?

Senator, what I'm saying is currently in the community care program, it does not have quality measures and so I cannot benchmark between direct care and community care. I can't answer that question based on data.

So why would you not collect that data on community care experiences?

The community care program does not manage data at the community care provider level, so I can't answer the question based on data.

So we're just going to trust that patients... how then do you compare community care satisfaction to direct care satisfaction? You're not taking that... you're not collecting that data? I'm confused. I'm sorry. Perhaps you can better explain to me why you don't measure patients' experiences in community care.

So Senator, I think what you're asking about is survey data and what I'm referring to is quality data where we actually measure the quality of the care that a veteran receives in the community. In the current community care program, we do not have quality measures or requirements. In NextGen, we do. We use industry-standard measures so that we can report like with like, measure and track, so that we will know what the quality of the care a veteran receives from a community provider is and then we can data to data benchmark that against what the veteran receives in the direct care system.

Do you have data that VSOs consistently tell... that is consistent with VSOs' testimony that veterans want VA as their primary care provider?

Senator, I'm not aware of the specific survey results, but generally that sounds right that many veterans do enjoy the ability to use both the direct care system and the community care system as that best meets that veteran's need.

So I believe, in theory at least, that community care providers can serve a valuable complementary role to fill the gaps that exist for rural veterans, also skill gaps. I'm one of those veterans. I go to VA as my primary care, but I get my prosthetics made by a specialty provider that has a level of expertise that's not available at my local VA. And I think it's important to increase patient access to a wider range of specialty care providers. But however, I haven't yet seen a comprehensive plan to invest in the most efficient, effective veteran-preferred healthcare tool VA has, which is our VA medical facilities. You had given... had met with some of my staffers the other day and you said that there was going to be a $1 trillion plan for a $1 trillion investment into direct care. We have not yet seen it. When can we expect to see a part three of this VHA modernization series on direct care investments? And is that $1 trillion amount correct?

Senator, so first of all, direct care versus community care and I'll come back to community care in a minute. So on direct care, what we've done in this administration is number one, we've reduced backlogs so more veterans now have access to VA care. We've opened 25, about to be 30 new clinics. We've spent $800 million already and in this year in fiscal '26, I am investing $5 billion in maintenance, deferred maintenance on VA facilities to get those facilities up to par. That excludes minor construction, major construction, and leasing. We are investing in the direct care system over 10 years.

Can I see the plan? Do you have a plan?

Yes, Senator, we can provide that.

Can you provide that? Okay. Thank you. Community care spending nearly doubled from $32 billion in 2018 to $62 billion in 2023 over that same period. Did VA double its contract oversight workforce in that same timeframe? You were sitting at 50 percent staffing in that contracting oversight. And I worry that if you're doubling the amount of community care spending that we're keeping the same number of workforce in the oversight role. Did you double the number of contract oversight workforce in that same period?

So Senator, what we're doing in NextGen is focusing on, again, NextGen is program design, but the next step for VA is program management. How do we manage this? And what the Secretary has done is he has moved the community care team into a vertical. There is an office now designed to focus on this. We will do the cost accounting for this program directly and leadership directly for this program. We are going to build the program management capabilities. In the past, what we have done is we have taken direct care staff and folks and asked them as an extra duty to work on community care. We are focused on the program management so that we can operate this program, we can be accountable for the cost, accountable for the quality, and responsive to the Congress and our oversight.

...is that happening as you are spending on increasing spending on community care? Because I don't want to be out here spending all this money and you're still building the plane, right?

Senator, we are building that as we speak. We are in the procurement cycle. There will be awards next year for this. There will be a one-year implementation period, but we are building the program management capability. The Secretary has already directed the internal design. We are already beginning in terms of financial management to be accountable for these costs and so that we can manage this as we go forward, we award these contracts.

When do you anticipate that whatever program you come up with will be in place and operational that will provide oversight for all of these contracts that we are letting in this procurement cycle right now?

We are working on this real time and these contracts are expected to be awarded in January of 2027 and so we will be live and ready when we do that.

Okay. Thank you, Mr. Chairman.

Thank you, Senator Duckworth. Senator Hirono.

Thank you, Mr. Chairman. So I am attempting to better understand what it is that you're here to explain to us. So you already have these private contracts and you're about to go into renewals of these contracts. So what? You are here to explain what to us regarding this renewal of contracts that you already have?

Senator, yes, we're here and we're excited to talk about the design of the Next Gen RFP and what we're doing to improve the care that veterans receive through the community care program.

Well, that is not a particularly specific kind of response because of course what we're supposed to be focused on, what you are supposed to be focused on, is care for veterans. And are we basically moving toward a more of a privatized model for VA care through these contracts?

No, Senator, we are not.

Okay, because that's kind of what it's looking like, we're creating an opportunity for that to happen. And the veterans we know would much rather receive care in the VA setting. So that is what you would refer to as direct care. So I understand the need for community care because VA doesn't always have all of the providers on site, especially in rural areas. So there's that. But I think there is always this concern that we're moving toward a privatized model. And when you come and tell us that you're about to renegotiate these contracts, I'm not sure aside from I don't even know what Next Gen is. How is that different from what you're already doing through these contractual agreements with providers?

Senator, two major differences between the current program and the RFP which we are calling Next Gen, which is currently out for procurement. Number one, we're introducing five pillars into the program. We're going to have quality requirements. We're going to have program integrity. We're going to have value-based care. We're going to do utilization management and we're going to have alternative payment capabilities. Those are the five tools that every other payer program has had, many for decades. We are introducing those controls, those tools to the VA program so that we can be accountable for the cost of care and the quality of care that veterans receive. That's number one. Number two, we are issuing this as a multiple award IDIQ, which allows VA to have competition among the vendors who serve veterans. And so currently we've got a two-award system. We've got two vendors, East and West. What this allows us to do is have multiple vendors, some national, some regional, and allows us to operate regional models that are adaptive to the needs of veterans where they live, the local infrastructure and communities, and allows us to do that.

Well, explain to me about competition among providers. When I think of providers, I'm thinking of what? What is the definition of providers that you want to have more competition among?

Senator, there will be two types of contractors in this, as there are now. There will be a vendor to VA who manages the payer program. VA operates it. We're the funder, we're the contracting agency, but we'll have a vendor who will operate this program for us and be responsible for claims payment, measuring data, etc. And then we'll have the community providers themselves who will contract with these payers who contract with VA that will actually deliver the care to the veteran at the community level.

So when you talk about competition, you're not are you mainly focused on how much these levels of whatever the services that will be provided? Is it the competition by the cost of the providing these kinds of services through the contract?

Senator, I want everybody to compete for my veterans. I want everybody to compete on the quality they can provide. I want everybody to compete in the cost they can provide. And so what I want, I want payment vendors, payer vendors, our TPAs on this, our plan partners, I want them to be focused on serving VA and our veterans. And the community providers who provide that care, I want them focused on delivering the highest possible quality care they can.

Well, the thing is that there are certain areas of commerce that's not particularly activities that lend itself to competition. I mean, competition is usually on things like price where you look at product A, product B, and you know what the price is. But in the medical field and the care and all of that, it is not that easy to discern. So I like the idea of competition that's supposed to probably give us the best bang for the buck, but I don't know how easy it is going to be to determine whether we're getting the best services for the buck. So I have a question about that. I mean, you explain everything in a way that sounds reasonable, but the question would be how would these things be implemented at a time when VA is cutting its people? And who's supposed to oversee all of these contracts and make sure that A, B, C, D, whatever your five points or whatever, who's supposed to be providing that oversight when you are cutting back on VA employees and there's a hold on the vacancies, filling of the vacancies? See, when you put a hold on it, it's like these vacancies go away and it's like, oh well, there's not a problem. But there's always been a problem with finding people to work for VA. I certainly know that in the Hawaii situation where it's really hard for us to keep, especially primary care people, in Hawaii and there's a lot of movement. And when you get rid of the positions, I don't know what that says. I mean, does it make the bottom line look better? I don't know. Why would you do that? Why would you freeze the hiring of people that the system needs and where these vacancies have existed for a long time, obviously needing to be filled? Why would you put a freeze on hiring?

Senator, Next Gen is about the program design of community care. And what VA is now working on while this procurement is out is the program management, ensuring that we have the structure, that we have the people, that we have the expertise and capability, including tools and technology, to be able to manage this program effectively so that we can achieve the outcomes that we are all looking for on this. And we are competing on this. We are competing on quality. We want the very best care that can be provided to our veterans and we are competing on cost. We ultimately want to lower the cost of this program.

Well, it's nice that you have those goals. It's implementing and getting all of that that I have some serious questions about. Thank you, Mr. Chairman.

You're welcome. Senator Sheehy.

Thanks for coming today. Great to see you. Before we get to community care, health record transfer from active duty. Where are we on taking active duty service members who have a very finitely documented healthcare records when they are separating? There's no reason that once they separate those health records should be thrown in the trash bin and then they have to get a whole new physical examination done, not just for their disability claims, but then also for the VA to have their healthcare records on file. I think it's about time instead of having them show up with a car and then taking that car apart and spending six months building them a new car, they're getting out of the DOD with clean healthcare records. They should be able to take that departure physical exam conducted by the DOD and have it seamlessly transfer to the VA as their induction physical with the VA to eliminate that leap of faith and that gap that so many veterans fall into as they're getting off active duty and being awaited to be ingested by the VA healthcare system for both disabilities as well as healthcare. So would like your comments on what the path forward for that could be.

Senator, I think so number one, this is called the zero-day record issue. This is something that Secretary Collins and Secretary Hegseth are personally engaged on and have met. Deputy Secretary Lawrence is leading this for VA. I know that there was a meeting between Department of Veterans Affairs and Department of War on this issue yesterday. We are looking at how we do that and how those records automatically come over and that this would be seamless to the service member who then becomes the veteran, but these records come on day one or zero day.

Yes, good. And as the CFO, you'll know that'll save you a lot of money that you can spend on other things instead of having to pay for another health exam to happen that's already happened before. You can direct your focus on providing the care needed. Community care, as has been referred to, has been the law for a long time and the general assumption, in fact I just left a meeting of Montana rural hospitals, is that in the opinion of a state like ours that has not just rural healthcare but frontier healthcare, that the VA has intentionally made itself a very hard customer to do business with as a payer. And for these hospitals, a number of hurdles they have to go through both to qualify potential veteran patients to come in and in a state where it could be the difference between a 30-minute drive and a five-hour drive, having to wait weeks or months to get the care they need because they're waiting for authorizations is unacceptable. So how are you going to knock down those barriers that are blocking veterans from accessing community care, specifically in the very rural environments in places like Montana?

Senator, access to care should be seamless for the veteran and particularly in a place like Montana where you've got very rural areas, where you've got rural care, where you've got the community providers who want to participate in the program. They want to be part of this. VA has made it difficult. We've made it difficult via the referral process, the eligibility process, authorizations and then payment. The goal of this program is to make this program operate like the other payer programs. And virtually every single rural provider that maybe you've talked to and has been in your office is a Medicare provider. They treat Medicare patients. VA uses the Medicare fee schedule in this program. And so it already looks like and pays like Medicare, but it doesn't operate like that. So to the extent that our processes and that our requirements match those, it makes it very easy for a provider to do business with us. And that allows the veteran to go down the street, whether it be rural community, town over, whatever it may be, and access care. The goal of this program and our ability in this and how we manage this is to make this seamless. And even things like measuring quality. We spend a lot of time talking about that too. How VA is going to measure quality in this are industry standards. Everybody already does this who is providing care. It makes it easy and it makes it seamless to provide care with for our veterans in this program.

And you know, follow up to any of you who care jump in, but I think, you know, when you look at that, that ease of access and pay, you know, TRICARE and the DOD, no one's perfect, but they have a system that if you talk to most active duty or reserve members who have TRICARE or healthcare systems, they're like, listen, TRICARE is easy. I mean, it's seamless. And those members will tell you, yeah, this is pretty seamless. As an active duty guy who's married, my wife is active duty, you know, we dealt with that for years and it's frustrating that why is the VA also a federal agency that's obviously closely affiliated with the military as far as personnel, how come one can be so easy and the other doesn't? So I would just encourage you, let's not reinvent the wheel if we don't have to. There's systems that are in place that work that the federal government has been using for decades. If we don't have to build something from scratch like we've been doing with the electronic health records for like 30 years, let's just use something that works already and put it to work because the veterans are tired of waiting for community care to work for them. So thank you.

Senator Sheehy, thank you. I now recognize the ranking member.

Thank you, Mr. Chairman. Just a couple of quick questions. Mr. Topping, I think you told the committee staff that the VA used the $6 billion in supplemental funding last year to cover payouts and expenditures related to the deferred resignation program and early retirement requests. I think the VA now says that none of these funds were spent on the deferred resignation program or terminal leave payouts. Can you tell me how the $6 billion was used?

Ranking member, I did not say that to staff. What I said to staff is that we used $581.1 million on these deferred resignation payouts. And of the $6 billion supplemental appropriation, $5.8 billion of that was used to purchase community care services and $200 million of that was to purchase medical equipment.

So the vast bulk of it was spent on community care.

Yes, Senator.

And Ms. Kroviak, does your office have the access it needs to all the information that you need to make proper evaluation of community care?

So for Office of Audits, we have had no issues with obtaining the necessary information to support our audits. However, our Office of Investigations has had challenges getting necessary information from the providers directly, which is why we've asked for that language to be included in the contract with regard to eliminating a requirement for a subpoena.

You need more information from the providers.

Correct.

Thank you. Thanks, Mr. Chairman.

Mr. Topping, do you intend to include a provision that is as it was just described to make sure that the providers fulfill a responsibility to provide information to the IG?

We do, Mr. Chairman.

Thank you. And we've talked a lot about measures of quality, actually the absence of measures of quality. Is there a standard way of maybe an IG issue as well, how do you define what's the criteria for determining quality of care? How do you measure it?

Thank you. So in the community care, in a managed care setting, quality of care is measured differently than in a direct care setting. It's just as important, it's equally as important, but it is measured slightly differently. In our setting, we are not handing over lives to the responsibility of the TPA. We maintain the responsibility of the veteran. We are not capitating lives or anything like that. So the veteran's outcome measurements, their quality metrics, that measures both internal quality and external care quality. So focusing on the outcomes of our veterans, whether that's cancer treatment or cardiovascular or diabetes, whatever those disease pathways may be, the outcomes are what we want to make sure that we're measuring and that will be indicative of both direct and external care.

And that's the outcomes are whether a person got better, whether they recovered, whether their lives were extended.

Exactly. The outcomes, their direct outcomes from their disease pathway. And also in external care, there are national quality metrics, core measures, CMS measures, inpatient hospitalizations, your length of stay, your hospital-acquired infections. There are indications that are national metrics that we can pull systematically that the TPAs in our Next Gen contract, we are going to require them to pull that. When you get down to direct providers like primary care providers, it does get more difficult and that's where you have to you need to rely on the outcome of the veteran's disease process. I mean, you really that's ultimately the measure of quality of care. Did the patient get better? Did the service did the care work? So all of that is what's really exciting about what we're building is that that will be wrapped into into the Next Gen and we don't have that now. We just don't have capabilities to visualize those outcomes.

And when you say we don't have that now, what you're really saying is we've never had that. I mean, it's never been since the MISSION Act or maybe since Choice, the ability to compare hasn't existed, but even within the VA direct care, that quality measure has or has not been present.

The VA in direct care has a very robust quality metric system. I can't speak to it personally, but there are people who can and it is it is very robust for veteran outcomes. I'm saying that that's indicative of both direct and community care because veterans are getting both. So if their outcomes are good, then then you know, that's measuring both. The what is new in our current legacy contracts, we do not require the TPAs to we did not put into those contracts to measure quality. We have put that into our next generation contracts, so that that is something that we then will be able to hold the TPAs accountable for and we'll be able to get that that information.

The current existing contracts, they have an expiration date and is there a plan that then what you want to replace those contracts with will be available to replace it at the correct time?

Yes, sir. As we approach the there's a rolling termination of the contracts. There are they don't all end at one time. So they the first contract will end at the end of this year and we will have to work with OGC and SAC to make sure that we that we bridge those or have plans in place so that by the time the next generation of contracts are in place, there's seamless coverage.

And no one's raised the topic of dental care and I believe that's becoming a new opportunity within the contract. Would you explain that to the committee?

Yes, sir. So in current state, our two TPAs dental is within the medical contracts. In next generation, we have pulled dental out. It is a specialty niche kind of service and we feel that a one national contract for dental will allow us to build a more robust network and be able to we've had some IG investigations with regard to dental payments. It will allow us to fix those situations, make sure that our rates are consistent. So there will be a national dental contract.

Does dental care for veterans cover the wide gamut of dental care, like...

It it does. There are and I will have to phone a friend on that. I can't speak to all of the dental coverages, but it is a robust services. There are robust services.

Mr. Topping, one of my legislative priorities, a significant one on this committee, remains adoption of the ACCESS Act. It would build on the MISSION Act and in my view help the VA deliver better access, convenience, quality care in the community, particularly for veterans with mental health and addiction issues. I would I want to express my appreciation for the feedback and technical assistance that you have provided in the ACCESS Act. The ACCESS Act passed this committee last year with bipartisan support. The ranking member and I are working together to reach an agreement on how to get it passed in the Senate. Does the VA continue to support the ACCESS Act and if it is enacted this year like I hope it will be, would the ACCESS Act help or hinder the goals laid out in the RFP?

Mr. Chairman, so ACCESS Act was the first firefight I was dropped into after being confirmed and had a chance to work with your staff. Everybody supports the goals of increased access to mental health treatment for veterans. And but when we came in, there were issues with how would we do this, how do we pay for this, how do we operationalize this. And the team spent a lot of time working on how we would do this. Number one, the goal on expanded access is absolutely the type of thing that VA can and should be working on and one of the things that VA does particularly perhaps better than even in the community, VA's mental health treatment. And so that's number one. But then paying for it requires on how we're going to operationalize that. And so one of the things that the staff that we all worked on were what are the tools that VA needs to operationalize this type of program. And so where we've landed on are the types of things, regional opportunities, the ability to the ability to pivot pilots that may be different in different areas based on different requirements, different capabilities, infrastructure. Those are the tools and capabilities that are built into Next Gen. So the things that VA would need to do to operationalize in a fiscally responsible way on ACCESS Act are built into Next Gen. We have that capability in that contract. And so if and when ACCESS Act is passed, VA stands ready to implement that.

They are compatible.

Yes, sir, they are.

Thank you. Senator Blumenthal.

Just a question, I should know the answer to it. Is there a lot of variation among the contracts that you have with individual providers at present?

Ranking member, there's great variation. And so VA holds the contracts with the TPAs who are payment vendor. Our payment vendors hold the contracts with the individual healthcare providers. And there are great variations in that. Some of those variations are good things. They're regional variations. How we're going to provide care in Connecticut is going to be very different than rural Montana, for example. But some of those are because we've got different systems, different requirements. That makes it very difficult to administer. And that's why in this contract with the multiple award IDIQ, the ability to have national vendors and regional vendors who serve with VA, it allows us to use vendors that have specialty, have networks in an area that may not have it in another, but that may be able to improve the quality of care and the cost of care that veterans receive. So that's the intent of this. That's the point behind the multiple award IDIQ.

So the Next Gen, Next Generation of contracts will have some variation as well?

Variation is not a bad thing. Variation adopted to the needs of the community, to the infrastructure, to the needs of the veteran, including VA infrastructure, where we have VAMCs, where we have clinics, where we don't. Variation is not necessarily a bad thing. Having a program that can be flexible, that can do different things, managed in a different way in a rural area versus an urban area, that's the ability we have in this contract that we currently don't have in the existing community care contract.

But the variation may be to accommodate specific needs in different communities, but the standards should be uncompromising, correct?

Senator, the standards should be the same and the goals should be the same. And the goal is the highest quality of care for veterans at the lowest cost to the taxpayer.

And the oversight should be as rigorous in contracts in Connecticut, Montana, all around the country.

Senator, VA is committed to building the program management capabilities to ensure that we can operate a contract of this size and complexity and be accountable for it.

Thank you. Thanks.

And that that conversation ended up where I where I like it, where I like it ended. But the standard of care would be the same whether it's direct care within the VA or its community care, true?

Yes, sir.

Okay. Is there anything that any of you would like to say that you haven't had the opportunity to say and with greater brevity than any Senator?

Mr. Chairman, we're delighted to have the opportunity to come in and talk to you about this program. Thank you.

I'm pleased that you're here. We're pleased that you're here and again, I think this is another in a series of hearings that we've had that have been very beneficial to the committee. Senators who would like to submit questions for the today's witnesses or additional statements to the record have one week to do so. And we would request our witnesses to respond to any questions for the record received following today's hearing in a timely manner. Speaking of timely manner, please remind the Department that we are still awaiting responses to previously asked questions. With that, the hearing is adjourned. [Gavel sounds.]