Good morning, Mr. Chair, and members of the committee. I'm pleased to address the Standing Committee on Health as the senior assistant deputy minister of the first nations and Inuit health branch at Health Canada.
This is my first appearance before your committee. I am thrilled to have this very productive discussion with you, and I look forward to building a good working relationship with all of you.
Before I continue, let me introduce Scott Doidge, the director general of the non-insured health benefits program.
Today I will provide you with a general overview of our mandate and programming followed by more specific information related to the non-insured health benefit program. Health Canada, through the first nations and Inuit health branch, is committed to ensuring that first nations and Inuit communities and individuals receive a range of health programs and services that are responsive to their needs. The overall objective is to improve their health status.
As you know, First Nations people and Inuit face significant health challenges. When compared to the general Canadian population, they have a shorter life expectancy, a higher rate of chronic diseases, such as diabetes, and of communicable diseases, including tuberculosis and HIV, as well as higher mortality and suicide rates.
They also face greater challenges when it comes to social determinants of health, such as high unemployment, lower levels of education and higher rates of overcrowded housing.
In addition, first nations and Inuit face historical legacies such as colonialism, the disconnection of culture, and the intergenerational impacts of Indian residential schools. The health care system for first nations and Inuit is complex. Provinces and territories deliver hospital, physician, and public health programs to all Canadians, including first nations and Inuit, but do not operate health systems on reserve. In order to support first nations and Inuit in reaching an overall level of health that is comparable to other Canadians, Health Canada funds or provides a range of health programs and services in first nations and Inuit communities.
In this context, Health Canada works with First Nations, Inuit, and provincial and territorial partners to deliver effective, sustainable and culturally appropriate health services and programs, with a view to improving health outcomes and to giving them more control over the health system.
There are five elements funded by Health Canada to support first nations and Inuit health: health promotion and disease prevention, public health protection, primary care services, supplemental health benefits, and health infrastructure support.
Today I'm going to focus my presentation on the non-insured health benefits, and drug and pharmacy components.
The NIHB program is one of the largest health benefit programs in the country. It is national in scope and provides medically necessary health benefits to over 839,000 first nations and Inuit living on and off reserve.
In addition to pharmacy benefits, the NIHB program also provides coverage for medical supplies and equipment, dental benefits, vision care, mental health counselling, as well as medical transportation to help clients access medically necessary health services that are not available in their community.
NIHB's mandate is to cover items that are medically necessary based on clinical and scientific evidence. The NIHB program does not require deductibles, premiums, copayments, or user fees. There are no annual limits for medically necessary coverage. Providers are encouraged to bill the program directly so that clients do not face out-of-pocket expenses.
Last year, total NIHB expenditures were over $1.1 billion, with pharmacy benefits accounting for the largest proportion of these expenditures at $427 million. Approximately 514,000 NIHB clients used their pharmacy benefits at least once in 2015-16, resulting in a utilization rate of 61%. This utilization rate has been constant over the last five years.
I would like to speak to you about the NIHB program's formulary management approach, which is aligned with that of other public drug plans in Canada. Whereas a private payer may provide coverage for a drug once it has been approved for use in Canada, NIHB and most other public plans take a formulary management approach whereby the coverage provided is based on clinical effectiveness, cost-effectiveness, and safety.
The NIHB program's pharmacy benefits are outlined in the program's drug benefit list, called DBL. Medications are divided into three categories. Open benefits are listed in the DBL and have no established criteria, gender, or age limitations, or prior approval requirements. Limited use benefits are also listed in the DBL with coverage criteria. Coverage is provided when the established criteria, the prior approval requirements, are met.
Exceptions are not listed on the DBL. These are drugs that may be approved for coverage on a case-by-case basis when an exceptional need is demonstrated. NIHB coverage ranges from very low to very high-cost pharmacy items. For example, low-cost blood pressure medications may cost about $150 a year per client. Biologics for diseases, such as rheumatoid arthritis or psoriasis may cost in the range of $20,000 to $50,000 per year per client, and oral chemotherapies and high-dose biologic therapies for ulcerative colitis or Crohn's disease may cost in the range of $50,000 to $150,000 per year. At the very high end of the spectrum, enzyme therapies such as Adagen, Vimizim, or Aldurazyme may cost as much as $1 million per client per year.
The non-insured health benefits program also covers selected non-prescription drugs that are not normally covered under other public plans. These include therapeutic vitamins such as vitamin B12 and folic acid, prenatal vitamins, smoking cessation products, antihistamines, topical antibiotics, non-hormonal contraceptive methods and over-the-counter pain medication.
All efforts are made to process non-insured health benefits pharmacy claims as efficiently as possible. Approximately 96% of the non-insured health benefits pharmacy claims, amounting to around 16 million claims annually, are automatically approved at the point of service through an electronic system that does not require any paper forms. Only 4% of claims require the NIHB program to seek further information to ensure that requests are aligned with coverage criteria, just like other plans in Canada. Most of these NIHB claims are processed within half a day.
Evidence-based decision-making is the guiding principle. Once Health Canada has approved a drug for use in Canada, the NIHB program must decide if the drug will be eligible for reimbursement. Like most other public drug plans in Canada, the NIHB program participates in the common drug review, CDR, process and the pan-Canadian oncology drug review process, pCODR, which provide listing recommendations to participating public plans.
Common drug review recommendations are made by the Canadian drug expert committee, and pCODR recommendations are made by the pCODR expert review committee. These committees, made up of independent experts, synthesize the best available evidence by using rigorous peer-review processes. They assess the cost of the drug in relation to its clinical effectiveness; therapeutical advantages and disadvantages; availability of comparable drugs; shorter- and longer-term medical benefits; potential costs for the health system; and input from patients, drug manufacturers, and clinicians.
Though the NIHB program does not require a CDR recommendation to cover a drug, the program typically follows CDR recommendations.
In addition to the recommendations made through the CDR process, the NIHB program relies on its own drug therapeutics advisory committee, DTAC, to seek expert recommendations specific to drugs related to the therapeutic issues of its clients. Most Canadian public plans have a similar dedicated expert advisory committee to supplement the advice provided through the CDR.
The DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB program to promote improvement in the health status of first nations and Inuit clients through effective use of pharmaceuticals. Like the CDR process, the approach is evidence-based and the advice reflects medical and scientific knowledge, utilization trends, current clinical practice, health care delivery, and specific departmental client health care needs.
The NIHB drug coverage is generally aligned with that of the provinces and territories, given that most public drug plans in Canada follow the advice of the Common Drug Review.
The program has conducted a listing comparison of NIHB versus other public plans, based on available Canadian Institute for Health Information data. According to this analysis, approximately 75% of NIHB pharmacy claims in 2015-16 were for medications that had the same listing status as other provincial and territorial formularies. Approximately 16% had a less restricted listing status than provincial and territorial formularies, including medications such as antiretrovirals and hepatitis C medications. The remaining 9% of NIHB claims were medications that had a more restricted listing status under NIHB than provincial-territorial formularies. This includes claims for methadone and long-term opioids.
In July 2010, the NIHB program secured a ministerial mandate to enter into product listing agreements, confidential agreements between drug plans and drug manufacturers to list medications in exchange for rebates. The program entered into its first PLA in October 2010, and had negotiated 42 agreements by December 2015. These agreements allowed the program to provide its clients with more open access to newer and higher-cost medications.
Joint work through the pan-Canadian pharmaceutical alliance is expected to bring greater alignment by providing participating plans with access to the same price reductions through joint PLAs. The NIHB program has entered into 24 new PLAs since joining the pCPA in January 2016.
I would also like to take this opportunity to tell you about the NIHB prescription drug abuse strategy.
The NIHB program has taken a broad range of measures to ensure that eligible First Nations and Inuit clients receive the medications they need. This important work is grounded in the design of the plan under the program, which conscientiously follows an evidence-based list of insured drugs, to ensure that medications are reimbursed based on clinical evidence.
The formularies management approach to PDA has included delisting drugs of concern such as OxyContin, Tylenol 4, brand-name Ritalin, Demerol, and other drugs. The program has also restricted the listing status of other drugs of concern, moving them from open benefit to limited use, and introducing enhanced coverage criteria.
The NIHB program—
Mr. Chair, thank you for this opportunity to join representatives of Health Canada and Veterans Affairs Canada to assist you in your study on the development of a national pharmacare program. My comments will be based on our 2016 spring report on drug benefits for veterans.
Joining me today is Dawn Campbell, the director responsible for the audit.
Our audit examined three areas that pertain to any drug program. First, we examined veterans' access to drug benefits. Second, we looked at the department's cost-effectiveness strategies. Finally, we examined how the department monitored the veterans' use of drugs covered by the program.
Decisions about which drugs to cover need to be well documented and clearly based on evidence such as clinical research and the needs of beneficiaries. Timelines need to be established for the implementation of decisions.
In one case we examined, a decision by Veterans Affairs Canada's Formulary Review Committee to limit access to a narcotic was still not implemented two years after the decision had been made.
Pharmacare programs need to have a framework that specifies the type of evidence required and how the evidence should be considered in deciding what drugs to cover. The framework would be used to decide which drugs to pay for and how much to pay for them. The framework should require that the drug benefits be kept up to date.
Some cost-effectiveness strategies will always be necessary. These can include substituting generics for brand-name drugs and negotiating reduced dispensing fees with pharmacies. These strategies will need to be assessed regularly to determine if they have achieved the expected results, if they are up to date, and if they have led to reduced costs for drugs and pharmacy services. Particular attention should be paid to implementing strategies related to expensive new drugs entering the market.
A well-defined approach to monitoring drug utilization is also important. The approach should serve the needs of the beneficiaries and help the program sponsor manage its drug benefits program. Particular attention should be paid to the utilization of some high-risk drugs that need to be adequately monitored in order to understand the trends and their use.
Our findings on the Veterans Affairs Canada's management of drug benefits for veterans underscores the importance of the points I have outlined above.
In conclusion, as you may know, my 2016 fall reports were presented to Parliament earlier this week. I noted recurrent problems with government programs that are not designed to help those who have to navigate them and that focus more on what civil servants are doing than on what citizens are getting. It's critical for the government to understand that its services need to be built around citizens, not process. As such, I encourage the government to think at the design stage about how a pharmacare program could deliver services that work for Canadians.
Mr. Chair, this concludes my opening remarks.
We would be pleased to answer any questions the committee may have.
Good morning, Mr. Chair, vice-chairs, members of the committee, and ladies and gentlemen. I'm pleased to be here today on behalf of Veterans Affairs Canada to discuss the drug component of the department's health care benefits program. As the chair mentioned, my name is Michel Doiron. I am the assistant deputy minister for Veterans Affairs in the service delivery branch. With me today are my two colleagues, Libby Douglas, director general of the service delivery and program management branch, and Fiona Jones, manager of strategic priorities.
Honourable members, as you know, Veterans Affairs Canada focuses on the health and well-being of our veterans, and we provide many services and benefits to those veterans. While those benefits include covering the cost of prescription drugs, it should be noted that VAC plays a limited role in the provision of drug coverage in Canada. Of the total Canadian population. VAC estimates the total veteran population to be approximately 670,000 veterans. Of these, approximately 48,000 of our veterans received prescriptions in 2015-16. This is approximately 0.1% of the Canadian population. The total expenditures for the drug component of the VAC treatment program for fiscal year 2015-16 were approximately $92 million.
The authority for VAC drug benefits comes from the Department of Veterans Affairs Act and the veterans health care regulations. The treatment benefits authorized under these regulations are provided into groups called “programs of choice”. We call them POCs for short. POC 10 is the prescription drug program, and it refers to the drug products and other pharmaceutical benefits that are available to our veterans who have a medical need and who have a prescription from a health professional authorized to write a prescription in that province.
The eligibility of veterans for this program depends on factors such as their military service, income status or disability. Some veterans are eligible for coverage for drugs prescribed to treat their medical problems. Other veterans are eligible for prescription drug coverage for any illness as long as the benefits are not available as an insured service under a provincial health care system.
It is very important to note that VAC does not prescribe or dispense drugs. Veterans obtain the prescription drugs in the same manner as other Canadians. When a drug has been prescribed, the veteran presents the prescription and the VAC health identification card to a pharmacist, who will dispense the product. If the product is on VAC's formulary and all the criteria are met, then VAC pays the cost of the drug directly to the pharmacy, or in some cases it reimburses the eligible veteran who chooses to pay out of pocket.
Veterans Affairs Canada's drug coverage relies on a formulary developed and maintained through ongoing assessment of drug effectiveness, safety and cost-effectiveness.
The department operates a formulary review committee that makes decisions regarding drugs on the formulary. New drugs are added based primarily on recommendations from the common drug review process of the Canadian drug expert committee. This committee is an advisory body to the Canadian Agency for Drugs and Technologies in Health, and it is composed of individuals with expertise in drug therapy. I think my colleague from Health Canada described that quite well, so I will save you that component. This committee makes recommendations to participate in federal, provincial, and territorial publicly funded drug plans, and our VAC formulary categorizes drugs as standard benefits, specialized authorization benefits, or non-formulary products, based on their recommendations.
Standard benefits include many over-the-counter drugs and prescription drugs that Veterans Affairs Canada considers essential therapies. Approximately 80% of all drug benefits included on the Veterans Affairs Canada formulary fall under this category. All standard benefits are readily available to eligible veterans with a valid prescription.
Special authorization benefits are listed on the formulary with clinical criteria or with conditions that must be met before the drug is approved. They are higher-level or higher-cost therapies. To be approved for payment of these benefits, veterans have to demonstrate that the clinical criteria, or conditions established for the drugs, have been met. For example, a trial with a less expensive drug may be required before a more expensive drug would be approved. Non-formulary products are products that are considered not to provide therapeutic value or to provide insufficient additional therapeutic value, as compared with the cost of a comparable product.
Even so, VAC may approve these items on an exceptional basis. To be alert to potential issues with drug components of the treatment benefit program, VAC uses a drug utilization evaluation process to identify veterans who may be at risk through inappropriate use of drugs.
For example, pharmacists receive warning messages through a computer system to alert them to the potential of duplicate drugs, duplicate therapies, drug interactions, overuse or abuse.
VAC is committed to ensuring that our programs continue to meet the needs of our veterans. We were pleased that the Office of the Auditor General carried out a comprehensive review of our drug benefits in 2015 and 2016. The Auditor General's report, which was tabled in May of 2016, included recommendations to improve the program.
The Standing Committee on Public Accounts also reviewed the Auditor General's report and tabled its own report with additional recommendations on October 17, 2016.
This deep examination of VAC's drug benefits has provided the department with an opportunity to introduce changes that will result in positive outcomes for the department, Canadians, and more importantly, for our veterans.
Both reports provided recommendations on the process, management and monitoring of the Veterans Affairs Canada's prescription drug program.
As indicated in both reports, Veterans Affairs Canada has accepted all the Auditor General's recommendations and we have taken immediate steps to begin implementation.
Specifically, in response to the recommendations, Veterans Affairs Canada relies on its partnerships with other federal departments and other jurisdictions to ensure that it is effective and that it provides cost-effective solutions for veterans. This could include working with our federal partners to participate in price negotiations with drug manufacturers, and reaching agreements on selling products at lower prices.
Additionally, the department has taken advantage of this opportunity to revise and refine the operation and composition of the formulary review committee, including standard operating procedures, which formalize the decision-making process and how evidence is considered. We are also developing a framework to enhance the drug utilization evaluation monitoring.
In closing, Mr. Chair, I would like to reiterate that VAC's role in national pharmacare is limited to that of a payer for the drug benefits for a small, specialized portion of the Canadian population, our veterans. While we have experience with benefits as a result of working with partners, Veterans Affairs top priority is the provision of services for the health and well-being of our Canadian veterans.
Mr. Chair, this concludes my opening remarks. We would be pleased to answer any questions the committee may have.
Thank you for the question.
First, cannabis or marijuana for medical purposes is not on the formulary because it is not a prescription drug. It's not considered a drug, and it doesn't have a PIN. It doesn't have those criteria, so it's not on our formulary.
The OAG rightly identified the fact that we were paying a lot of money for marijuana and that the department should look into it, and Minister Hehr came out very clearly saying that we need a reimbursement policy for this. I think the committee will be happy to know that the reimbursement policy was announced and is being implemented now, as of November 22, whereby we will limit the amount to three grams per day, down from 10 grams, which was the limit before. In addition, we will cap the amount that we pay per gram to $8.50 per gram.
Now, I want to stress that it is not a prescription for marijuana, but a script, and Veterans Affairs does not provide scripts. We will pay, but it's the professional health care professionals or the doctors who work with the veterans who make the determination whether marijuana for medical purposes is the right substance to use.
The department in 2007 decided to pay for palliative clients based on compassionate grounds. Over the years, that use has gone up. In 2013-14, we had 112 clients, which is not very many. Then the courts made certain decisions, and some of the regulations surrounding the distribution or the availability of medical marijuana were changed.
We finished 2015-16 with just over 1,700 veterans using marijuana for medical purposes. This year, in the first six months there are just over 3,000. As you can see, there's been a pretty significant increase, and it is not due to Veterans Affairs providing the scripts. I want to be very clear. It is more and more doctors and health professionals deciding that our veterans could have some use for it. Now, we are very concerned with the health and well-being of our veterans, and hence the minister came in with the new requirements.
To answer your questions about a decrease in other areas, we did a review about six months ago, following the OAG's visit, of whether there was—because we were hearing anecdotal evidence that there was—a decrease in opioids, or benzanines, or such medications. The review at the time did not demonstrate that. It demonstrated that our numbers are staying pretty consistent in that area, but that the use of marijuana was going up.
Now, if you look at our public reports, you will say, “Well, sir, your numbers are going down for opioids”. That is not because of the people using marijuana. We compared people using marijuana and people using opioids. Our veteran population is decreasing; we now have 670,000 veterans. Therefore, the use of opioids, benzanines, and other medications is decreasing because of the decrease in the number of veterans.
We actually did a correlation between veterans using marijuana and veterans using other drugs to see whether, in that population, there was a decrease, and at that moment there was nothing of any significance.
I hope I've answered all your questions, sir.
Thank you very much, and we'll miss you.
First of all, I'd like to thank our witnesses today.
I actually have a whole bunch of questions. I'd love to have more than five minutes, but the reality is that if we're going to be moving to a national pharmacare program, the rationale behind that is to decrease costs and have better coverage, but some of the evidence—even Mr. Ferguson's point 9—is that when government runs things, sometimes that's not exactly what we end up getting.
We've defined pharmacare. Some of the activists, unions, and groups that have come in front of us say it's a government-run, single-payer monopoly that would entirely replace Canada's current pluralistic system of federal-provincial-territorial publicly funded, government-run drug plans, and the employment-based private drug plans. One of the problems with setting this up is that a lot of the data we have is extremely old. What I'm concerned about is the cost to the taxpayers in the immediate costs, if you're moving toward this.
Mr. Ferguson, in your point number nine today, you said that you “noted recurrent problems with government programs that are not designed to help those who have to navigate them and that focus more on what civil servants are doing than on what citizens are getting”, that it is “critical for the government to understand that its services need to be built around citizens, not process” and that you “encourage the government to think at the design stage of how a pharmacare program could deliver services that work for Canadians.”
You gave an example, I think in point number four, about inefficiencies and it being two years before things are actually looked at.
I'm really concerned. We don't really know at this stage of the game how many Canadians are insured, uninsured, or under-insured. We don't know how access to newer treatments and drugs would be affected. We've seen in other countries that have national pharmacare that innovative drugs can be restricted. Under realistic assumptions, we don't even know how much cost is going to be shifted to the taxpayers under pharmacare, and we don't know indirect economic costs, for example, job losses, private sector job losses, or takeover of the private sector. We don't know what the NAFTA implications would be, how other countries are really doing this, and what we have in the pipe right now that's working very well.
My first question for you, Mr. Ferguson, would be this. The federal government only covers 2.1% of total prescription drug expenditures in Canada. How is it being done? Is it being done efficiently by the government right now? If we extrapolated that 2% to 100%, do you think the costs would be huge?
What are your thoughts on this? Maybe you can't even answer that question.
If the response of the physician points toward the criteria, we are going to authorize the treatment. If not, then we'll ask why they are not trying the first line and second line.
I would say physicians are busy people. They want to do good for their patients, and sometimes they may feel this is pressure on them, but all plans in Canada have a certain level of, I would say, limited use where you go back to the physician to ask for evidence.
As I've mentioned before, this is a small percentage. Ninety-six per cent of the claims we receive for drugs are paid at the counter of the pharmacy. The patients show up at their pharmacy, pharmacists fill the prescription and send us the bill, and the client leaves with the drugs. It's 96%.
There is a small percentage, and we are trying to look at opportunities all the time to change our status or refine our criteria to avoid having to go back to the physician, but sometimes it is the result of a client safety situation so we will go back to the physician and ask, “Could you please explain, because we see a problem?” There might be contraindications about the two prescriptions the patient is on. We have the information. It would not be responsible to not act on that.
Most of the time we get the answer, and we process that in half a day because all this is done electronically between the pharmacy desk, our drug exception centre, and the physician's office, and we try to expedite the process. We have put a higher scrutiny on children more recently because there seemed to be a sensitivity there to make sure our rules are up to date.
The other reality is that, since we are operating in 13 jurisdictions, the fact that some provinces use different processes is a bit confusing for people on the ground sometimes. This is because most of their clients will be covered by the provincial plan, for example, and an odd case will be covered by us, and they are not totally aligned or knowledgeable about our processes.
This is one of the challenges of being a very large plan distributed across the country. We are small everywhere, so we cannot really influence the practice. We have to learn about that all the time.
There was an issue in one of the provinces recently about one product. We were hearing an ongoing complaint about the fact that we denied coverage of that. It was only in that province because suddenly the provincial plan started to cover this product, and physicians started to prescribe that product there, and we were not aligned with them. There is a due diligence that we have to try to learn about what is changing in the provincial formularies so that we can take that into account in the way we administer products.
Thank you for the question.
We've taken steps. I think the issue with Veterans Affairs is not more services. I do want to be clear. I think veterans can get the drugs they need if they are prescribed by a treating physician. Our processes are quite quick as long as it's service-related or you fall within some of the criteria.
We do have to take steps, and we are taking steps, to improve the monitoring and the management of our formularies to ensure that the right drug is available to the veteran at the right time. Those are some of the things that were highlighted by the OAG, and we have undertaken to do this. Most of it we're trying to do by the end of this fiscal year.
As I mentioned earlier, we have hired a pharmacist, and the pharmacist, a professional in medication, is reviewing the formulary and making sure that it's the right drug and that there are no contraindications. A lot of stuff that Mr. Perron talked about is there. This committee now is also chaired by a doctor, a medical physician who understands what another doctor may have prescribed and has a better understanding.
The other thing we've taken a lot more interest in, if I can use that terminology, is the whole area of opioids and benzodiazepines to make sure, as we get more into this and as we're advancing it, that we're not creating issues out in the field that other health professionals have to....
The third and the last one would be marijuana, the reimbursement policies put out a couple of weeks ago for marijuana. There's a lot more monitoring for that and closer associations with the various people in the industry.
I want to emphasize that the veteran can get drugs, and it's quite quick. It is very good as long as it's service-related or you fall within one of the criteria. A lot of the work we're doing presently is making sure our programs are being well managed and are meeting the needs.
On mental health, the department has an incredible suite of services related to mental health. We have over 4,000 mental health practitioners coast to coast to coast on contract with us. If a veteran needs help and if we don't have our OSI clinics there, they can get to the services.
We have to realize that our programs are based on need and based on the service relationship. Eligibility is very complex and we're trying to facilitate that, but generally speaking those are the two areas, and there's a series of services available. We actually pay for psychologists and psychiatrists. We actually pay the provinces to run our OSI clinics that are dedicated to our proud men and women in uniform, and to the RCMP, who can get their services.
Is there a wait time? Yes, sometimes in a certain clinic you may have to wait a week or 15 days to see a psychologist. If you try to see a psychologist in many parts of this country.... I know that there are even some provinces where psychiatrists are at a premium and it will take you a year to see one. With us, it's about 15 days. Some veterans do think it's too long to wait 15 days.
We have to understand, though, if they are in a crisis, the service is immediate. We work with the hospitals, with the doctors, with the professionals.
I think what they're referencing is that when they put in a claim with us, the whole adjudication process that I talked about earlier.... We will get them in for PTSD quickly, but the entire process will take 16 or 17 weeks. They need medical diagnostics. We're not doctors, but a doctor has to say, “You have PTSD”, or “You have a bad knee”. We cover everything.
The OAG did highlight the timelines it takes to get there, and we're working on accelerating that. I believe, without having been at that round table, that some of the comments about waiting are not so much about the treatment, it's about the adjudication process that comes with treatment but also comes with disability awards, which come with disability pensions, which come with other services. I know there is a real frustration in the veteran community surrounding some of those timelines.