shaken up in order for any true reform reform that is desperately needed to better serve the veterans to succeed. i truly appreciate your service and for you being here this morning. and with that i recognize and welcome back the ranking member for his opening statement. >> thank you very much mr. chairman for having this very important oversight hearing. we are here today to get an update from the department of veterans affairs on the implementation of the veterans access choice and accountability act of 2014. this was passed in august and addressed a number of issues the department had with providing quality healthcare to veterans. long wait times are the problems that got us where we are today. we shouldn't make them wait for solutions to be implemented. while today is a first public update of the va implementation of this law stuff level updates

have been occurring on a regular basis since early september so i would like to thank you and i appreciate the time that you have invested in openly communicating with the staff on the house and the senate side of the committee on the implementation issues in the progress that you have been making on this implementation issues. in the va i hope it is a precedent for improving relationships as we go forward. the law provided additional resources and authorities to provide for the key improvements for veterans. timely access to health care, expansion of the internal capacity and the indication of the benefits. today i hope you will hear tangible ways that benefits. the veterans are getting the

outcomes intended. if there are roadblocks to the implementation you need to know what they are and how it can be fixed on those roadblocks. with regards to timely access to health care i am aware that the department has expressed serious concerns with the 90 day deadline on the choice program. they require them to determine eligibility authorized and coordinate care managed utilization. they've taken a phased rollout approach in order to balance expedients with effective programs. i want to understand the timing and how the department of veterans affairs is handling eligible veterans access to care through the phased approach.

it provides for the departments to augment staffing and infrastructure. i know the secretary has been out to recruiting and i look forward to how successful it has been and how many they expect to bring on board and when they expect to bring them onboard. i'm also interested in hearing how the va will implement the funds and authorities for the new infrastructure. we have seen many problems in the department of veterans affairs construction problems in the past and they look for curing the changes they're making in order to deliver these new projects on time add-on budget. with regards to accountability, and i understand that removing a federal employee is not as simple as many think it should be even with the new authority in the law. i appreciate the difficult

position that the department is and when it comes to holding employees accountable in the poor performance in the highly charged and very public environment. that being said we need to feel that the department of veterans affairs is taking the necessary action to move swiftly as possible and decisively as possible to get rid of those employees who fail the american veterans. the explanations need to be clear, concise and compelling not just to congress but american public. while much has been on the accountability provisions we shouldn't forget that also includes substantial enhancements to the educational benefits for veterans and their families. and i look forward to hearing what is being done to implement these provisions of the law as well. beyond the veterans access choice and accountability act i

know the secretary mcdonald has announced a number of reforms aimed at the cultural structure of the department of veterans affairs. many of these reflect ideas and we have discussed them in the past and i'm pleased to see them being embraced. and i would encourage the secretary to find detailed execution plans. do not get stuck in the analysis of the process and figure out what actions need to be taken and didn't take. be fearless in enforcing these reforms. and enforcing these reforms. just as the nation's veterans are fearless in their battles. once again i want to thank the panel for appearing before us today and look forward to hearing the testimony. we appreciate the time and experts and we want to thank each of you for what you are doing to make sure the veterans and family get the access that quality care and timely manner

for the veterans. i know that you've been under a lot of pressure over the last year and we look forward to hearing how it actually helps relieve that burden and what you are doing administratively to help complement. so thank you very much and i yield back the balance of my time. the deputy secretary the honorable sloan gibson is accompanied today by the acting principal deputy and the executive director of the enterprise program management office. please proceed with your testimony. >> members of the committee were guiding principles for

implementation of choice act had been to do what's right for veterans and to be good stewards of taxpayer resources. while our challenges are clear about we are turning those into opportunities to include the care and service that we provide to veterans. we are reorganizing for success to make sure that we maximize those opportunities. we call that the organization in the customer service solution that goes along with it. because we won the veterans took to view us as an organization that belongs to them providing quality care in the ways they need and the way they want to be served. simplifying the operations and improving the processes leveraging the technology and enhancing efficiency and increasing productivity a 360-degree efforts to provide veterans with a seamless

integrated and response regardless of how they come to us. since may the top priority has been accelerating care to veterans moving them off and clinics. for example, we have reduced the number of the veterans waiting the longest for 57%. from june through september we completed 19 million appointments and increase 1.2 million over the same period in 2013. over half a million completed during operation nights and weekends. we've also improved access using the non- va care from june to september we had 1.1 million authorizations for 7 million, more than 7 million care appointments in the community. that is about a 47% increase in the prior year. we appreciate the act that the veterans have access to

healthcare. we continue to make the best use of them all into the veterans high quality care that they deserve. we also appreciate enactment of the department of veterans affairs expiring authorities act of 2014 signed in late september. we will continue to work collaboratively with you and your staff to address them in implementation challenges. as we work through the rulemaking implementation process required by the law we confer frequently with the committee veteran service organizations and other stakeholders we are thankful to engage with the staff and those of the ranking member into the center and v-victor veterans affairs committee to understand your intent and to hear your concerns and to work together taking improvements on implementations. we look forward to continuing this partnership as we implement this complex legislation in a way that allows us to do the

right thing for veterans while being good stewards of taxpayer resources. among the challenges that we face in preventing the actual requirements are an estimated $400 million in unfunded requirements and resources that will be required to implement the act in the next couple of years. resources that are not provided by the act. as it is mentioned previously one of the things it does is it streamlines the process to remove or denote senior executives based on poor performance or misconduct. the va is committed to sustainable accountability in the va and employees at all levels must understand what the va expects of them in terms of their performance and conduct and must be held accountable if they fail or refuse to meet those expectations. i think it's important to understand what it does and what it does not do.

it shortens the time to resolve an appeal. it doesn't give leaders the authority to remove executives as well. and he must have standards to provide due process. it doesn't do a late if the appeal process. it also doesn't give the authority to do right a senior of their property including earned retirement benefits. only a criminal conviction for the aiding of the enemy or trigger some are provided in the statute can deprive a federal employee of an earned benefit. the objective behind the process is this removal process is for the va removal process to withstand appeal. if we failed that it has established or to the due process of expected under the case law than the system protection portals and the overturned the decision were the

employee returned to the position and direct the back page legal costs the real word. i would not be what is right for veterans or for the taxpayers. another is the veterans trace program as we have discussed with your committee staff during a dozen meetings they've identified a number of areas in the section that can present implementation challenges are potentially confuse veterans. first there were significant challenges inherent in the 90 day timeline. we have to establish the plan from a producer and distributive veterans trace cards committee chairman the patient eligibility, authorizing the coordinating care for my manager was asian, establish new provider agreements come across as the complex claims in the standard for call centers, despite these challenges the va launched the trace program last week with a responsible staged implementation focused on the delivering of the best possible veteran experience. second, we recognize the

challenges associated with maintaining the continuity of care to ensure the best possible healthcare outcomes for veterans. this is a vital distinction between the choice program and trace program and a health plan in the private sector. as an example we have made significant investments to provide access to mental-health services in the clinic as part of the holistic integrated care we want to provide. as one third of the veterans receiving the va care how they mental-health diagnoses, coordinating care concluding is a central. of the. the mental-health resource is often readily not available particularly in rural areas and are rarely integrated into the private sector primary care experience. we know that the healthcare systems across the nation faced challenges and efficiently sharing treatment information in the healthcare records in order to show ensure that for those intrigued in the va and the non-

va settings we will continue to look to share information and not knowledge with these providers. last, we modify the 30 day time standard set in the law for the purpose of the trace program access to make the wait time from the date preferred by the veteran or the date that it is medically determined by the position. while this will help to ensure ensure that veterans receive timely access to the benefits of the trace program it isn't a clinical standard for the timely care for the veteran many to be seen today 30 day goal is irrelevant it will always be to provide to every case possible in the shortest amount of time possible. that's really what it's all about. we want to provide veterans to see an organization that belongs to them and provides timely quality care in the way they need and want to be served. we will continue to work closely with the committee on any issues

involving this legislation and i think the committee for your support and for making things better for all of america's veterans. this concludes my opening statement and we are prepared to answer any questions that you were any members of the committee may have. i'm going to jump to the independent assessment for my first question. there has been some criticism that the department has undertaken sufficient steps to fully eat with the intent of congress with regard to the assessment. the only contract as far as i know is to include the federally funded research and development center at the alliance to modernize health care in the institute of medicine. this is not an expert team of independent entities. is there a way to compete with experts you can assess each with

the 12 elements to be covered by this assessment and what if any information have been led to have been made public so far and how much money has been expended on the assessment today? spirit i will start. i'm going to pass it over to doctor schmidt. i don't think that we have all of the data with us. we contracted the entity as you stated. the different components of the independent assessment is in the organization. we specifically went for an organization that carried the specific qualification of a

healthcare organization. in fact they will be looking to engage a number of different entities to ensure throughout this process that's what that what we are doing is tapping into the very independent and objective expertise all across the private sector. >> part of the assessment they are doing will be by the folks. some of them have partnered with other entities and associates partnered with the corporation to do some of the assessments. there are some options in there that all of the options have been on board and all of the 11 assessments to the coordinating entity. they are assembling an expert

panel that will guide the assessments being done and help look at the various recommendations coming back from the independent assessments to come together with a unified comments of recommendations out of that which ultimately we will pass to the commission for their deliberation. we thought that it was the intention of the congress that this would be independent so we sought an entity outside of the va to do this and it says that if we have different people doing different parts of the assessment and i think that the healthcare nature that you want and the expertise that you wanted will be there in this essentially blue ribbon panel

they will be assembling. and my time is about to expire but i think that we need to sit down and discuss it a little bit and the congress intend was those that were not that the panel would be brought in to testify about people that were experts in their field would have that opportunity. i'm referring to the public law and the biggest concern i have about the accountability portion is that there was a 30 day requirement for notice before you remove an employee is that correct? >> that is provided in title five. >> and in the law we removed that. it says the procedures under section 743 of title five shah apply to the removal or transfer under this section, so where did the five days come from?

>> v. advice from the legal counsel has -- there is no period on the front and. >> it is very clear that we have to provide an opportunity to respond to the charges and as you note under title five that 30 days that was shortened. the view is that if we fail to provide a good opportunity to respond as a failure to provide due process. a >> if the >> if we had intended for there to be vital to keep it at 30 days if you're going to follow the law as it is written by did you come up with this appeal?

>> we understood that the intent was to move expeditiously but we also balance that against the requirement to provide due process or risk that the decisions would be overturned. it's that simple. >> i understand that the risk part the secretary keeps saying the law needs to be changed if we want people to be fired immediately. no it doesn't. the law is clear created a should be fired. and. it includes being fired and if you think it's so. because the tax payers are tiger does paying bonuses and benefits to people who are not serving veterans. >> the law requires federal employees be paid until a

disciplinary action has been affected, which in fact is in this case a removal decision, not a proposed that a removal decision. as soon as the decision is made they no longer compensate or continue to accrue benefits. >> why can't you remove somebody without pay, suspend somebody without pay why do you continue to allow them to accrue the benefits when you know that there is a problem from a personnel standpoint why don't you or why can't you do that? >> it would be subject to review by the merit protection board. again if we take action, disciplinary action with that support we will find that gets overturned. >> has anybody involved and suspended without pay? >> it's a disciplinary action.

>> thank you very much just to follow up on the same line if i understand you correctly what you are saying is we have loosened the authority to the disciplined employees and the concern you have is if you fire someone or disciplined them that you move too quickly that actually could be overturned >> is that there are two requirements that we are required to meet the preponderance of evidence standard whether it is a removal of misconduct or performance. so that's one piece. and we have to provide a reasonable opportunity to respond to the charges. what we are talking about is five days to be able to protect these actions we hope for in

overturned on appeal from the failure to provide due process. >> we think it is because we felt that was the balance between those provided in title five and the intent of congress. >> i understand the choice cards are being rolled out in phases right now. for the veterans that have waited for longer than 30 days but have not yet received their choice cards are we doing to reach out to the veterans to let them know that they are eligible? >> many of them are already being called to determine whether or not they want to exercise the option for choice. we are putting those to the veteran's choice list so that we hope as early as next week we are able to activate the 30 day

group as well and be able to content the veterans to schedule appointments were to offer them to that choice. >> and other veterans that are in the choice program, do you have any sense on how long it took them two get an appointment? >> as far as the veterans in the choice program, do you know how long it's taken them to get an appointment? >> we are five or six days into the implementation of the program. so, we know we see the number of calls coming in everyday everyday and every day and the number of authorizations and the appointments beginning to be scheduled. there is a standard stipulated within the contract within which they have to get that appointment scheduled. >> so that has to be made within five days. we had about a week's worth of

experience. i can tell you as of yesterday i think that we had about 6,000 people in the 40-mile group there was about 320,000 people in the 40-mile group and about 6,000 of those contact either healthnet or the tri- west and we have something around 40 appointments scheduled. >> are you keeping an eye to make sure that with the private sector they are not going to do with some of the va facilities have done as far as gaming upon the system on the timeliness? do you have the metrics in place? >> we do have metrics and we will be auditing and monitoring what goes on. both of them are healthnet and have done an amazing job of being a stand up this program in the timeframe that we had and i

believe they are sincerely doing everything in their power to make sure those veterans are referred into the community. as you know sometimes in the community they are also so one of the tests when the rubber hits the road with the capacity and the private sector to really absorb the patients in a more timely way than we have been able to provide that care. >> thank you. how are they tracking the use of the $10 billion that have been allocated for the choice programs? >> that will be accounted for separately under the choice program. this is actually a mechanism similar to what we set up and made for may for the excellent reading care initiative where we were allocating specific amounts of funding out into the fields so we had already established a separate accounting change to be able to record all this information so we will know exactly at any point in time but

has been expended for those choice program activities. >> you are recognized for five minutes. >> you said that an employee cannot be fired without with the chairman called a phantom five day notice for. this is not required in the letter of the law the bipartisan law that the congress just passed and the president just signed. as long as it's been documented and i think the committee bbs there is no need for a five-day notice. go. this affects to an additional appears appeals period. it allows for the old law slightly different terms allowed as well. so, no one has been fired for poor performance.

maybe for the data manipulation like we saw in phoenix arizona that i'm aware of and correct me if i'm wrong. there are now two appeals processes. the five-day and the existing process after the person gets noticed and in addition to that before setting up a new office to review administrative removals. and i have heard that this new office is going to have up to 30 people. is that, not only has no one been fired for that data manipulation, and you say that it doesn't allow for an immediate firing come as long as the poor performance has been documented it says that into the trim in native very eloquent description of what the law says >> ..

we believe will withstand the appeal process with the merit system. >> you are adding to what the law says. >> the law isn't just what city

in the statute. the law is also the case law that's evolved over a period of years around the removal of federal employees. the case law is clear. we have to provide reasonable opportunity to respond to the charges. if we fail to do that we're going to be vulnerable to these decisions. >> there is an appeals process. there is no one under the new law. >> this is not an appeals process. it is an opportunity to respond to the charges. that's what it is. it is not an appeals process. >> what happens during the five days is not an appeals? >> it a reasonable opportunity to respond to the charges. that's all it is. >> let me also make a comment here. the issues, a couple times by the office of accountability review. i'm the person, somebody didn't like what we did, i'm the person you need to blame for that. never comment you made, mr.

chairman, and you were right. historically we never failed to hold people accountable for misconduct and for management negligence in the organization. so as we waited into the situation where we had at the peak 95 or 97 different ig refused underwent, we realized we were going to have a large number of disciplinary actions to consider, and we knew we would have to go through a process of we calibrating accountability within the organization. quite frankly i wasn't willing to take those actions as they came out of the end of the igs pipe and turned him over to any part of the, turn them over to vha as norman would've been the practice in the past. turn those to vha and administrative investigative board, and do your own investigation. come up with charges and decisions. i did not think it was adequate. >> my time is about that.

in the view of this member of congress use send the right message to the country, to veterans and to poor performing employees by removing them, not giving them an additional appeals process of five days and that setting up a new layer of bureaucracy. i yield. >> we're going to send the wrong message to veterans if we have a removal decisions overturned by if you. there is no for the appeal after that. they come back and we've no recourse at that point. we are stuck with them. we are not able to take any additional display the action. we make up all the back bay, all other legal costs and i don't think that's what veterans want or expect. i don't think that's what the taxpayers expect. >> mr. secretary, i wrote a letter to secretary mcdonald and asked for specific statute of case law that led to the department critical requirement of five days. i got a response i got no case law. i got no statutory requirement to in his response he said it

would be unconstitutional to fire a career employee without telling him or her why and providing them with an opportunity to respond. you are going to tell them why when you walk in and you've hired them. they have an opportunity to respond after the fact. again, we will beat this thing until the sun goes down and will get up the next day and we'll be doing it again. what i perceive you doing is when you give them five days, if that person wants to quit, they just quit. and in the past va has said that the disciplinary action. something happened. they are not in the anymore. that's not a disciplinary action to that person goes on to another agency somewhere in the federal government, or they put the papers in and retire. and they retire with all the whistles and bells just like happened in i think alabama where there was this great fanfare, this person did for two years of great service, when

they knew they were going to be fired but they went ahead because they had that five day notice. so that's the concern we all have anything to all work together in trying to fix it. you claim there's a constitutional requirement. we don't believe that there is. it may take going all the way to the supreme court to figure it out. but i think the taxpayers deserve accountability swiftly and directly. you would take the effort -- you wouldn't take the effort to fire someone if he didn't have it. i trust you there. again, i'm perplexed by several other people are probably perplexed as well. mr. kirkpatrick. >> i will see we provide you the case law, mr. chairman. >> thank you, mr. chairman. thank you undersecretary for being here today. my two questions will be about critical pieces of the choice act. before ask my question i just want to say i find it outrageous

and my constituents find it outrageous that sharon hellman is still collecting her salary at $170,000 after being put on leave in may. we just want you to know we are calling for immediate firing. we want that to happen immediately. now i will go to my question. a critical piece of the choice act is the $5 billion we provide for the hiring of new medical professionals. it's a competitive environment, we know that. my question goes to the hiring process, and here's why. if i'm a physician's assistant or a nurse and i want to work at the va and i applied, but it takes six weeks, three months, six months, a year to process my application, i've got to be working some going to find a job somewhere else. what are you doing to be competitive within the hiring environment for these medical professionals?

>> a couple of things. one, we know we have extensive opportunities to streamline the hiring processes with providers. bob mcdonald recently approved increased salary ranges for providers to allow us to be more competitive to attract and retain great talent. i'm aware of instances on a case-by-case basis across the country where particularly, for example, with nurses we've gone in and and market surveys in order to build a justified changing color ranges in that particular market area. we are looking now at doing that same process all across the country in every market to ensure that effect what we have our salary ranges that are competitive. we are taking hard look at the credentialing process in effect ultimately we will move to the same system that the department of defense uses for documenting credentialing so we're able to work very transparent between the two systems.

no doubt we've got opportunities to streamline. the other thing we've been doing is part of the push for limiting care is accelerate our hiring activity. oftentimes we wait until the position is vacant and then we studied it for a while. we bring it to some kind of a board and and the board finally decides and it's months before we even position. now we, particularly for certain positions, higher into turnovers we are out there recruiting and hiring in anticipation of the turnover. we look specific hiring activity during the second half of 2014, the months from april through september. i think most of this happened in the last four months of the year. net increase in nurses 1700, 600 net increase in doctors, 700 net increase in schedulers all across the organization.

so material improvement, meaningful improvement there in the staffing levels, and we will keep after that. but to your point we've got continued to improve in the process. >> my second question goes to the choice program. i know you're sending out the choice cards now. my concern is that a lot of rural veterans have post office boxes. what i'm hearing is a letter is first sent to them. after verified their p.o. box. here's the problem in my district. i think there's an assumption that go pick up a utility bill out of my district were thousands of veterans who don't have running water or electricity. they rarely go to their p.o. box because there's nothing there. what are we doing specifically to reach out to those veterans who have post office boxes? let me just say that they've offered to help reach these veterans, actually physically go out to their homes. i would just like your thoughts and comments about that. >> we are in the process of

sending letters to all of the veterans whose address, p.o. box address which a just that they may reside more than 40 miles from the nearest va medical facility, often -- offering them several easiest possible ways in order to give us of the residential address so we can determine their eligibility, the access to the benefit under the choice program. i had not considered instances where veterans don't go to their p.o. box or the opportunity for us to enlist the help of others. it's a wonderful idea and we'll pursue that. >> thank you very much. i yield back my time. >> thank you. mr. bilirakis. >> thank you, mr. secretary, for your attendance and testimony. some $5 billion was -- to increase hiring of physicians and other medical staff to improve va's physical

infrastructure. has been no report to my knowledge by the va on how the department intends to use the funds, without the proper staffing assessment, how does the department know how make decisions and which facility will yield ultimate benefits for veterans seeking the holy after the of earned and deserved the? >> i think we have shared a preliminary information with your staff on our intentions for this plan. but we will be sharing a formal plan with you as soon as that is ready. when do you anticipate that being ready? >> probably within the next couple of weeks. it should be finalized i would think that we're putting excitement together that not only has the plan but exactly what each of those line items entails. and some information about so it's more than just a

spreadsheet. we currently have plans to hire about 9600 staff with that money. some of the money is for staffing but some of the money is set aside for i.t. to things. so when we hire a new perspective the workstation to set at. when we have new space we have to put cabling and all that stuff in there. and then the balance is really for leases and are in the projects and those kinds of things. but we plan to hire about 9600 staff across the country. we've gone through a very detailed process of literally reaching out to each medical center asking him to look at what additional staff they need more space for that matter to improve access. and specifically how will it improve access. and then that plan has been

aggregated at a national level spent how far along are you without? have you reached out to every medical center in the country? >> every medical center has done. that work is base basically done antidumping put together any final plan that's in draft form right now. >> what makes the determination as to what staffing, the regional director? >> which staffing is needed as far as services provided. >> we've asked the facility can each visit to come up with a plan, that the aggregate and then we'll come back to us. >> when you mentioned facilities, hospitals, clinics? >> hospitals. we've asked the facility leadership to take on that project. >> thank you. mr. secretary, including the veterans access, choice and accountability act it authorized 27 facility leases come

including one in pasco county florida. authorizing these will improve the timeliness for veterans to receive the care they need in my district and 17 other states around the country while on encourage veterans veterans in my disk have the option to visit a one stop consolidated clinic. i remain concerned regarding the time and the completion of these facilities. what is the process for va to keep members of these leases in the district applies to -- apprised of these initiatives? what engagement with the king and the of these leases does the va intended conduct to ensure the necessary services will be offered at these various facilities equipped. >> so we have a number of leases that we are standing up. we have two that are in the works right now and don't have a number that will be coming in fy

'16. we will absolutely be working through the process with the community and the stakeholders in the kennedy both to find property in the first place, and also to make sure that the services that are being placed there are appropriate. >> the other issue, i happen to agree with you, it takes too long to get these out of the ground. and so we've looked at the typical timeline from where we are right now with an authorization in place to completion. it's as long as 45 years. i think that's unacceptable. we visited with omb. they will work with us on finding ways to compress that timeline to be able to accelerate that the we're doing things with standardized designs we're not reinvented design with each facility we look out. we've got to work through the

site selection issues because those often times at an awful lot of time and effort to the overall process. we've got to find ways to deliver these more quickly. my guess is in the private sector to be able to go from where we are to complete facility in three or four years. we've got to find a way to do it faster. >> i want to ask a couple of questions, just briefly, mr. chairman. with regard to this, just follow. will you assure me that the committee will have input on this application and the services provided? >> yes. >> you will usher me of that? >> yes. >> thank you, mr. chairman. i yield back. >> did you said it be initiated in 2164 it would be finished in 2016? >> i think the contracting action happens in 2016. out of the 27 leases, nothing is going to become we are not going to be seen in patients in these facilities in 2016.

>> much are going to start the contracting in 2016? >> no. looking down through the 27 leases we've got -- >> leases that are way, way, way behind? >> and what we will do is work through the finalization of the requirements to inform the design process. that sets the stage for the contracting action to commence. somewhere in the we've got to get gsa to delegate authority for us under these leases. we've got to give the contractor, we wind up contracting with the time to build the facility. >> thank you. >> thank you. thank you, mr. chairman, ranking member. our veterans have spoken them and i join them in the message

in saying that anything less than the highest standard of health care that veterans centers will not be tolerated. in implementing the veterans access, choice and accountability act, that must be the sole standard by which we judge ourselves. i hosted a workshop educated 70 medical professionals in high demand specialties for the va in my district about how to work with the va and try was to provide veterans with health care in their communities. our goal is to get more veterans high quality veteran centers care and improve physicians and will continue to speak with a medical professional that attend to measure the success of the event. i received a call from secretary mcdonald which i really appreciate to discuss event. and i shared with him the lessons that we learn but i think it's important we discuss the lessons learned so all of us

the on the committee can implement these in our district as well. based on feedback we got from the debris and the vocals we did, the three takeaways was one, physicians don't even know who to begin to call. so that's not a very clear streamlined understanding of who can they call to sign up for try was on loma linda. i think helping them navigate the system clear and concise is for import. i think creating a how to guide and frequent asked questions and answers about how they can provide care to veterans would be very beneficial and start putting out, putting it out there now and standardizing that around the country.

i loo look forward to me with af you so we can create benchmarks that can be replicated throughout our country for our veterans. however, we can't recruit physicians in areas that have shortages already to begin with. areas in rural america where that's where we need the physicians in the va to begin with. in my area, i represent riverside county which has a nice the largest veteran population in the country, more than 50,000 veterans reside in my district alone. but, unfortunately, where i'm from in southern california also is one of california's lowest number of physicians per capita. we have a physician shortage. i understand part of the law is to recruit more physicians through programming. how do you plan to implement the new gene position in the

veterans access, choice and accountability act in areas with high physician shortages to begin with, like the inland empire in my county? >> i think your suggestion on a more robust communication in the provider commend is a great idea. we will take that for action. let me ask dr. tuchschmidt to talk about our effort in the gme area. >> let me start by saying that for providers in your kennedy who would like to participate in the choice program, the 800 number action has an option, option one. i know we all hate these things that option one, press one if you're a veteran, press two if you're a writer, press three if you or someone else. so they can get call of a third party administered to get that information. we are working to put together a provide information packet that will help them understand the with respect to the gme, i'm

excited about this. we have a plan to stand up 300 new resident physicians in underserved areas, and particularly in areas where we need physicians. the 300 per year. this year quite frankly i think we were all talking and were not interesting we would get a great response, given the short timeline between now and when the academic year starts. but we got 300 potential slots we are targeting for the next academic year, got over 400 requests for additional resident slots. some of those may be establish programs that want to expand those programs. some of them might want to be starting new programs. some of the maybe community medical center medical centers who want to start a family practice residency program. we are working with us. the challenge will be for those

sites to actually stand up those programs. >> i appreciate that and appreciate you prioritizing the low physician to population ratio that exists. it's time now to begin building pipelines of individuals who want to serve in the va. and the place you can find those is in the military. when i was in haiti working with the 82nd airborne as a medical director for a nonprofit right after the earthquake, there were plenty of medics that were premed. in fact, i wrote a letter of recommendation for several for medical school. if we can identify them early while there in the department of defense, put them in a pipeline program into those gme slots after the medical school, that contract with va and the department of defense, then those are the ones that would be committed to providing high quality veteran centered care in our va.

>> thank you for being here. i'm just going to go, i'm going to take the team of providing care. you'll have some work to do in your shop. let me give an example of what happened in my district recently. a g.i. doctor was hired. all cleared by the local, through the system. equidistant to keep waiting to be hired at the va but his paperwork is that some black hole in washington. so during this political campaign, i got my staff on the phone to somewhere in washington to get this docto doctor who is approved to could be seen patients. he goes out and gets another job during that time and to the va finally bumbles along and gives them hard. those things are so frustrate them. you can't that you cannot imagine how frustrating it is easy to after all this. i walked out of the va hospital monday from a ceremony.

i bump into a veteran who doesn't even live in my district is driven to a half hours to get there for his appointment is weighted for months. he got three calls to come to the appointment and he shows up that day, and this doctor is not there. the guys got severe pain in his neck. he's had a spinal fusion surgery from a surgeon was a very close friend of mine. the man needs an epidural steroid injection. he's fuming. he's got to write to a half miles back to knoxville. fortunately i have some friends there. i made some calls to friends of mine and we gave him, and these are va france i'm talking about. we then get this man and appointed a not so sweet as havd come back. that's the kind of thing that every person of this diocese every time you go to a va. my question is when is it going to stop? that's the thing i'm so frustrated with is i spent an

enormous amount of time during this october period listening to people at the va. i'll tell you what else. i'm going to work with you on this. i am a primary care doctor. intel you reform have a primary care doctors -- tip of the spear, provided you, you can't hire enough doctors to train doctors to ever get done. i look at what had to go through and what i had to go to see a patient and ranking member michaud is not your but, i don't mean on the private sector, a patient shows up, i take her of them, i get paid. if the va will write the check public page. they have incredible teams. you guys have teams put together that i could only dream of in private practice. and get they are so bureaucratic and so they can't see any patients. i wish he would sit down with a private practitioner like myself unlike some others sitting around your and let us help you show how to do that and then use that as a metric across the

country more efficient. we had a young psychiatrist from st. louis that was seen six patients a day. we can't train in of psychiatrist in 50 years. i appreciate the effort you are doing but there is a real shakeup that needs to happen. this mid-level bureaucracy is apparently filled with the slowing all this down. you need to get after that and i can imagine what it would've taken anybody what a piece of paper, a signature to a doctor working. >> let me offer up a quick thing. your story as a physician frustrates me at least as much as it frustrates you. i run into those stories still, into everything i can to clear away the bureaucratic obstacles that giving away. what we've got to do is revise the system so that we don't have to intervene either of us individually or on a case-by-case basis. i can get at this point in the story you tell me about the pattern that came for deployment

and the doctor was not there. thank you for intervening on his behalf. i want to ask transform to comment -- dr. tuchschmidt to comment on a third observation made about primary care physicians. >> let me also say i am the black hole in the central office. i admit that. that's my job to approve those. i try to approve them immediately when they coming. but as of the beginning of this month we delegated approval out in the field up to $350,000 a year. they don't have to come to me below that level as of the beginning of this month. we have come to your suggestion, then benchmarking with kaiser permanente and others. we intend, we're in the process were no of developing practice management standards and tools to deploy, to try and improve some of those processes spent my time is about up. you can't have physicians doing clerical work. you can't have them going out

and walking out and having to call to make deployment. when i saw somebody the most powerful time you had is the physicians time. when someone comes in he have to put that in the record, hit the button and have someone else do all that stuff. .. i'm willing to work with you on that. i yield back. i appreciated.

>> thank you, mr. chairman for being with us today. i want to just tell a quick anecdotal story that a member of my staff was a veteran received a card last week i were all very excited. we walk through the latter that veteran street i-8 and i just want to make sure in terms of the volume of calls and questions because it was great to receive the card and it was nice to celebrate that for veterans day, but it was very clear that the card wasn't going to do anything until you went through this death of eligibility and making sure you are authorized to use the card. number one, i worry about veterans they somehow think the card has the magic to it and they go to a private provider and end up with a big note they didn't expect. number two, the question that was raised in a memo are guided by this staff about the co-pay

and deductibles and is there sufficient communication for the veteran to understand that they may end up at the financial obligation that they would not have had if they had been seen through the vi. i have another question, but i'd love to have someone address that. >> i will start out. dr. tuchschmidt may want to jump in. with the drafting of the communication, we also went not to bso's and had them not only review it, they get it in the hands of veterans and veterans review and provide feedback. so part of what you are seeing down the tension you just described between they have to take some steps to access the care that they are eligible for. and that is one of the reasons

because there is a potential liability associated with co-pays, just like the va. at the veteran is now seeking care for it not service connected condition, their third hearty insurance and different circumstances, it's accountable for that cost. we have done things in interpreting the legislation and policy decisions regulations are promulgated to make the operation of the surest program from the standpoint of co-pays book absolutely as close as we could possibly make it look to traditional non-va care. we don't want to set up a situation or the veteran is going i want to use this. i want to use the choice card. we disseminated the obstacles, but there are checked instances where the veterans could be obligated for some other costs. >> i think we have said from the get-go is that in designing this program we want to do the right

thing by the veterans. that is number one priority. is we are pretty much resolved with the va co-pay, so we will be set here at the time the veteran is being seen so they don't have an ipod it -- out-of-pocket costs. we can determine and tell actually make explanation of benefits that. with respect to third-party copayment, technically that is a contract between a patient in his or her insurance company, which we have no control over. however, the way we have tried to implement as, i think that most of the time will be able to cover that co-pay the way the choice payment is made. but if the patient highest expense of care, hospitalizations, procedures, and medigap insurance with a high deductible, the fact of the

matter is they may be subject to copayments and we've done everything we can to educate bso's, partners and we will be educating veterans to the fact that it's part of the way the choice program has been designed. >> okay. i think communication and education to the bso. the question i have and just hearing from my colleague, new hampshire as lucius recognized veterans day another wonderful legislation, turns out we have one of the highest percentages in the country. 11% are veterans in terms of the service. bassett can imagine, we have a lot of seeking surveys. the irish program has been very popular and i understand the veterans access allows for continuation of that. and the could address for me how that will happen?

it is important for rural veterans and they like it appears that works for them and i want to get clarification in terms of how it's impacted by the choice card he >> we have extended the contract temporarily while we are renewing the arch program. so what will remain in place essentially as it has existed in the past going lowered. >> i appreciate that. i yield back. thank you. >> mr. floris. >> thank you, mr. chairman. i appreciate you joining us. i appreciate the work you and the secretary have done to work with congress on this committee in particular to that the va the 21st century. a few weeks ago the same newspaper published an article about the waco research for returning war veterans.

i am not trying to change subjects because we are still on the same subject in the subject is what is the underlying root cause of the issues the va is struggling with and it turns out it is a trouble culture that needs to be fixed and needs to have a change in personnel to do that. we are not necessarily happy with the direction you go with that, but the comment has been discussed already. i would like to talk about a couple of other things. this committee in my office requested an update briefing with someone regarding the center of excellence between now and december 11th. i would like for you all skim it meant that you would do that. the second date is that the way the center of excellence totally failed and is subjected to try to find the underlying causes and tbi and ptsd and try to help

the va, for some groundbreaking research to address these critical issues facing today's war fighters. but it's just utterly failed. not one mri was produced. tens of millions of dollars were wasted in the process. a whistleblower prop this to our attention and this is where i get back to the culture. the whistleblower and some other whistleblowers who participated in letting america know about the problems faced incredible retaliation. you saw the hearings we had back in the summer were when the waiting list issue came up, and the bureaucracy retaliation against whistleblowers is just going beyond the pale. and so, i urge you to continue to work on that part of the culture as well. there is no retaliation. they should be celebrated as people make the system better.

two things and i will be brief. you'll have the briefing that this particular center for excellence and you will remember that we need to fix the culture of retaliation as part of our overall attempts to fix the culture. thank you. >> one commit will have a briefing to you as you've requested. i've said repeatedly and continue to say we will not tolerate whistleblower corporation. the special counsel of the united states. first on restoring employees who have been the object of retaliation in ensuring that they are basically made whole in that incoming and immediately behind not to do much office of accountability review to conduct the investigations into the retaliatory behavior to ensure we are holding those individuals accountable for that behavior appeared i agree they should be put upon a pedestal pedestal and

i agree to participate the theater for december are there going to be recognized into whistleblowers and i will be joining than enough for them. >> thank you for your responses. i yield back. >> thank you. >> thank you, mr. chairman. mr. secretary, i wanted to first start on a positive note. i hear from a number of veterans in my community did go to the clinic in el paso that they received exemplary care and more importantly i'm beginning to hear from veterans who did not receive that care in timely fashion and they now get appointments. i appreciate your leadership in the va. >> we've both been working on that for a while. >> you're her to el paso had an impact, so i appreciate that. i want to follow the lead and use it and it so further challenges made. i was recently at the va and

while they're asking veterans about the quality not just to care they've been receiving ran into a gentleman who is fair for mental health care appointment and it caught the day before to confirm the appointment. i have no idea how many months in advance, nor do i know how many miles you drove to be there. the appointment was confirmed today before he showed up on the appointed day at the appointed time, only to be told the mental health care providers use there to health care providers she was there to see mel underworked va and had not worked there for months. that was obviously deeply disappointing. i was unforgivable to me was he was told to go back home to schedule another appointment. luckily i was there. we were able to take into the executive suite we waited for the director tonight at the meeting and obtained an appointment the next day. said that brings me to make

question. your 10 mental health care vacancies despite all the good work and to dr. questions for having the worst three times in the country for new patients for mental health care. what are we doing to attract and retain those providers? you mentioned earlier you are increasing what you're paying. we talked about gme is. tell me more about how we'll close the gap on mental health care. >> so i think we have all of the recruitment retention efforts underway for both physicians and for nurses. with respect to physicians, we have worked to get an expert health care consultants recruiters to to help the spring

and physicians. i think the story you tell if a patient for an appointment doesn't have a provider is just unacceptable. i mean, whether there is a vacancy and somebody left or not, there should be contingency and every one of our facilities. we've been communicating mad and it just did not happen. >> i would love by the numbers to understand what you are doing and how much more you pay to attract like a clinic here in mind when you record a psychologist or a psychologist or a clinic instead of a hospital, they earn less and are offered by us. we need to harmonize those levels so we get folks to the right place? i'm sorry to interrupt, but it brings up the more important issue of accountability and the anecdote at the skype happened one year ago at the but all of their attention and focus we brought to this issue, how are

the people still there running the el paso va clinic to the chairman's point in so many others who've made this, and i 100% except secretary gibson's expectation of fully believe you are doing the right to say once disciplinary action is not overruled and we don't reintroduce that are sent to the system. but having said that, when can we expect to see these changes? industry and credibility for us and the american public to know these folks responsible for such egregious malfeasance and negligence are stealing their jobs. when are we likely to come within this calendar year, next six shooter firings would then expect to? >> go come back to you within 24 hours to answer your question definitively. i am aware of cert actions and i

don't know exactly where we are in that process. rather than give you a speculative answer and a definitive answer, i will tell you the question in my mind remains in this particular instance whether there is malfeasance or misconduct or whether we've got a situation where it's a really, really tense situation and we are not bringing to bear the resources we need to bring to bear. i will be back to you within 24 hours with the definitive answer to your question. >> thank you. i will share that. thank you, mr. chairman. >> thank you. >> thank you, mr. chairman. i'm a follow-up on the information request from a colleague to texas. he did say earlier that i guess not a single va employee had been suspended without pay. >> suspension without pay as a disciplinary action. i can't tell you. >> at the disciplinary action. >> i understood you to say

earlier that not a single va employee had been suspended without pay. did i misunderstand that statement? the >> that's exact what i said in the context of the question about suspending in the process of the disciplinary action being brought. 5600 actions were referred to earlier without pay or not. >> have any va employees lost bonuses as a result of the scandals quite >> in fact, there would be a senior executive will receive a bonus in 2014. >> respectively, have been a lost their bonus clicks >> we've had this conversation before and here. there was one instance that one employee were bonuses paid in error and we were able to use civilian language to call that back. not that action itself has been appealed under statute. otherwise was a bonus is paid,

it becomes the employees property and we don't have the authority to take that property. >> has anyone gone through the entire process of moving an employee quite >> yes. >> you can provide a list of everyone but the names, but how many actually lost their jobs as a result of it. i want to follow up to questions on the va choice and how that was implemented. why exactly did you decide to implement.quite >> the fundamental concern was if we sent out 9 million cards to veterans on the fifth of november, realizing a bit late 8.3 million of those veterans would not have been immediate benefit under the act, what we would do would be to create chaos and jam the phone minds of people calling to get explanations. to prevent veterans that you have. >> i understand that. the folks that were waiting for a month, you have chosen to wait

even longer. why are those waiting, the focus of so much scrutiny, why did you decide to wait longer than those quite >> many people waiting have been working most of the ordinary course of business as part of that accelerating access to care has been about for the last five and a half months in the middle of may. >> what i am not clear on is what is the start date when you say okay, the clock is now starting. is that continue to move back quite >> start date further proof of the 40-mile section. >> is in the wait time, what has been posted and make a nation is the fifth of december. our expectations start date is sooner than not and we will post that start date within the next several days. >> you don't officially start

then. that face just waits and waits until you actually pick a start date. >> that group waits until we post regulation to say we are now at debating the 30 day wait time standard under the choice program. we do not necessarily wait for them to receive their court because if it mentioned earlier, we are populating -- >> i'm not worry so much as i never see the car, when they get the care. >> i don't remember everything you said you get a pic with a 30 day wait time becomes the start date for that second phase. >> we could've wrote the program not in such a way that would've been a disaster for veterans and we chose not to that. >> if you are still waiting for care, the disaster. one of the ride and i would go to smile has been a failure from various folks in the department. a local issue raises broader concerns, which has a limited va facility. not full services. he promised again and again to

have a full-time doctor. it's happened again and again. that just because they have limited services, if they want any services come and they still have to drive the six-hour round trip to amarillo to get services with better great hospital just down the street less than a mile away and you are saying no you can't receive it there because of limited services available at the va clinic they are. if there's a reason you've chosen to save the clinic is a restriction? you can't go pick your doctor. can you you describe to you came to that reasoning? there are veterans who would like to go to the local doctor. he say to die. he started to drive six hours for care. >> the statute was clear. to the nearest va medical facility. i would ask the question. >> in this conversation tend.

if congress' intent was to make it 40 miles from where i was. >> wait until december to take care of the wait times. we don't intend to me. >> under the current one before this half commute plenty of options. you could've let them go before august 6 to the local hospital. your va chose not to do that. >> way to budget in fiscal year 14 for non-va care of $6 billion we spent it. >> you do have the authority to go to the local hospital. >> within the constraints of our budget, we do have the authority for his team to do so. >> driving six hours. mr. gibson come you don't drive six hours for care. we've got to fix that. i yield back mr. chairman. >> mr. walls. >> thank you, mr. chairman. tippee secretary gibson and gentlemen on the thank you.

i think it's important for you to hear each of our stories. we have heard the bad and good that come out of it because we know our goal is to improve upon what is working and to make those changes. i like my colleague, mr. our work, dr. roe, finally when they couldn't take anymore, church of the mayo clinic where he was told he needed immediate prostate cancer surgery. that's the bad obviously that he waited excessively time. the good is that we called them within six hours with a fee-for-service agreement and the next day he was in for surgery. two weeks ago is that he and his family and steve is now in recovery. the family is grateful but i am embarrassed because that veteran should've been able to do that on their own and as long as the stories go and i think we all know here, that is one veteran whose wife called with no other way to go, but i do think we should note a responsiveness and

the cultural attitude on the fee-for-service and it's a challenge. you are very right. mayo clinic said it's not that he might not have waited for an initial appointment. it's just that there has to be a way to triage cases that are so critical and may convince me that there's ways to do that, to make sure if it wasn't suppressing the could've put them in there. that question to you and this commerce station should be done and is doing exactly what it should be doing, i would implement that in congress' intent is important part of that. the implementation of this law and this is one small piece. where's that intersection with the restructuring of va that we know needs to be done? is a helping? and is promoting. as a catalyst in that direction, but i don't think anybody in this committee thought it was the end. if you could articulate a little bit to me how it fits into the broader restructuring and

enables us to get to that. >> i think it gets at the very essence of creating or focusing on the veteran experience and focusing everything we do around the veteran. so what the choice program does is basically allows us to accelerate care using additional resources is a community thinks to do something congress provided to accelerate care while we are doing the internal capacity building. the points that have been brought up about primary care protocols and the number of treatment rooms and compensation issues associated with physicians and streamlining hiring practices on the occasion activity, choice program gives us the time to do that while they still deliver the care that veterans affairs. >> i see that as a central part of what we are doing. it is also clear that it dries the stories the more holistic view. we have been providing

substantial amounts of non-va care. to maintain the continuity of care for veterans and ensured that veterans are managing the care. this is beyond what the health care plan as delivering the health care. >> we need to figure out a way and how you are communicating with them because this is truly the real challenge because the ultimate cost can be very clear. steve and i think he believes it too. he could have gotten equal care for the treatment had he been able to gain in. i don't think your budget would allow if it has to go the way this one was called. and how are we figuring out how to communicate that triage and mr. huelskamp's issue is right. use of hours away from the nearest facility, it too. it wasn't that he wasn't willing to go. the crisis situation the mayo

clinic was next-door. how do they come to grips with that and a dialogue on opacity because i see it is a great series we had where he looks at his window to see for private sector hospitals another 72% capacity every day. that is capacity that could be utilized in another way. are we getting at that click >> this is really important point. we have traditionally been a provider of care and we make a decision when they can provide in a timely way to go buy it for somebody. but we are having discussions right now quite frankly that are for many people very excited producing. our future is not being about a provider organization normally. we are now entering a realm where we are quite frankly entering the health plan or the veteran, the patient decides what happens and where they go and how they get caring what you get. this is a huge cultural shakeup

quite frankly for us as an organization. i think we are now engaging in discussions about what does that mean for future? what does that mean for traditional purchase care program? the choice program of the legislation expires in three years ago so able about assigned to build our capacity. it's proposing quite frankly. >> as i yield back my time, my suggestion was on the division of the quadrennial defense review and that is what we need there. this is a small piece, but i yield back it into for that. >> thank you. mr. western country recognized for five minutes. >> thank you, mr. chairman. we're talking about the veteran streets program. where can i get information for providers or private sector providers that want to be providers whether it's a hospital system because i've had

the question come to me in my district were hospital system unlike to help with the backlog, even as it is a short-term at-bat and also willing to do it at a lower rate than the standard rates for the teachers and he the wood interior. >> so again, the 800 number that we have come at there a line bear for both veterans, but also providers who want information. we've been talking with the american hospital association but the ama with the american hospital association specifically to try and help use those two entities to get information out to providers. and a provider that wants to i am sure can contact tri-care or health that correctly. i'm happy to have them contact me and i will serve as a functionary to make sure something happens. >> it is something you could provide details i will share those that come to me and not

brown. the other question if we are trying to do the independent assessment, how much information is being gathered or how much are we engaging with the terror to really assess the va system? >> so i think as i mentioned earlier, so working with other partners in the community, said they are very committed to finding people with the right competencies to do those various assessments. there is some of them that they will do, so their expertise quite frankly is in policy and modeling. but they will have party reached out to rand corporation to do some of this work. the institute for medicine was doing part of the work. as i said, they have put together a group of health care industry from around the country

to really be private sector benchmark panel to help guide not only the assessment, so they put together a set of tools that can be used in terms of when people are doing these assessments, making recommendations, how do we know what is good and what is bad coming out of this or that group is betting that an ultimately be the group that craft the final set of recommendations to try this process. >> i think that's important. obviously we have a lot of successful providers and systems in place in the private sector, so their input is key. thank you. i yield back. >> you are recognized for five minutes. >> thank you, mr. chairman. thank you, mr. secretary for the work that you are doing. i know that my veterans at home are starting to feel hopeful, that there is real change taking place and i appreciate all of your effort. i wanted to ask a specific

question on how has the va implementing section 41 and four of two and over three and educating servicemembers about eligibility to seek va care for military sexual assault? >> so, we have already reached out and started reaching out to guard units to educate them about the services that are available for military trauma counseling within our organization. ..

they would not have information that might reflect on the fitness for duty of active duty service members. it's hard to try and figure out how when the patient might need to go to an inpatient unit for a couple weeks of intensive therapy that they leave their active duty station nobody knows about that. we are trying to work through those issues with the department of defense now with a clear intention of being able to implement that part of the law in a timely way. >> when you say you've reached out to set include training? >> for the training for? >> training for all of the folks

that need to know and how to present his right to receive treatment? >> for guard members would have. that was the easiest part of this that was put in place. the harder part of this is for the active duty people. >> on the dod site do you have a solution you are trying to work through with dod? >> we are in constant ongoing meetings with him to try and work through these issues and figure out how this will work. we routinely exchanged medical record information. when we would go to bill, for example, tricare for an episode of care we would submit medical record documentation. we don't believe that's what you intended. that's why we are in conversations with him to figure this out. i don't think we have locked

everything down when he to this point. >> thank you. another question is regarding your processor implementing our long-term space plan and wanting to know the steps they va is taking to ensure that there are periodic updates based on new data on terms of what real wait times are and the increased demand on services. and wanting to know the status, how that's going and should we expect, are we going to receive a new updated plan during the next fiscal year? >> i would anticipate there would be a new plan. we are doing something i think, i've been in the system for 20 something years and it will be the first time we do this. we are essentially adopting the model used by dod and other places in federal government.

for the first time this year we will be going out with planning data to every facility and asking them to begin developing requirements for the bottom up for the program. people, space, things that they need to be effective and to close performance gaps. we have a great actuarial tool to tell somebody people are going to take care of, what kind of services they need, what is likely to cost. we have to get to the next step of saying okay, to effect that what are the requirements necessary to do that. what is that going to take in each place in which we deliver care? people, things and space to be able to be effective. we've been piloting the tools and the process. we've been working action with people from the department and

office of policy and planning to do this work. i think it's going to really fundamentally change the planning process for us in terms of trying to get to the requirements that you were talking about. >> thank you, mr. chairman. i yield back. >> gentlemen, thank you for coming today. and providing answers to questions. the i want to thank secretary macdonald. he reached out with a young couple. he had been misdiagnosed in my district and his health was generating at a rapid rate. no diagnosis whatsoever. like all the secretaries they moved on our behalf on behalf of his him and he was diagnosed with cancer and they moved him

close to the hospital. he is under treatment right now in beginning to improve. i appreciate his commitment to a with it. and to echo what mr. walz just that and similar other colleagues. it adds, that scenario is good and bad. we are grateful when it happens because we just saved the life of a veteran but we can't make calls on behalf of and my district tiki 7000 veterans and their families. it sheds light on the fact this is still a very, very urgent matter. i think america's willing to give time to say we understand the comprehensiveness of this i think the want to see action. probably at the same rapid rate we do. i just want to pass that along. a clarifying question but for those senior executives that retired during the five day interim period, the new five day period, in lieu for possible removal the lead. is there anything on the record

to say they were slated for removal? is there a trail for these folks possibly left because of that? they were at least on that list the? >> whether an employee re-signs or retires, the proposed removal action once of becoming a prominenpermanent part of their. so if any of the federal agency, they were considering hiring this particular individual would see that as part of the file spent my other question which is a follow-up for many things we'vwehad before, the chevy v-8d i.t. i the bill coming up that will have a hearing on, but the new law requires technologies task force to conduct a review to look at the the scheduling system. northern virginia technology council conducted visits to observe the scheduling operations to interview the staff. do you consider the results of what the obtained to be representative of the entire system? >> i think as we've gone through the findings in the report, i

would say that it affirmed an awful lot of what we believe we knew already. it also reiterated a fair amount of information that was part of the booz allen hamilton report done back in 2008. i think it was useful and very helpful. it's an independent point of validation in many instances. the point that came up that doctorow mentioned about the need for treatment. it was one of the things that showed up in the report. didn't have anything to with the scheduling system. basically saying one of the obstacle to provide access to care is you've got medical facilities here that only have one treatment room per are part of the we will never make optimal use of our providers when we had that kind of constraint. >> can i follow up quickly. before the 2000 a report, six years later, have all the issues been addressed in that 2008 report as far as inconsistencies and recommendation?

>> from the 2008 -- no spent why haven't they? >> you may or may not recall that was report where there was, questions were asked back in may with other individuals sitting here about the report. by and large folks are not even aware of the existence of the report. i had only been up for three or four months but that report issued and isolate it went in somebody's desk drawer. >> as you recall and some hearings that have gone on in the last few years i've been here, there were a lot of information given to this committee that there was no problem what so ever with the scheduling system, with the. nobody ever said was in 1985 system. the gentleman in charge of the i.t. systems that right there and i said to you everything you need and we could go? the answer was overwhelmingly yes. even during the budget time.

here we are 2014, the booz allen report is out there, there's a mandate. where are we with the scheduling system and selected a mandatory compliance? >> the booz allen report went far beyond the scheduling system as did the other report. >> when are we specifically scheduled? >> four different tracks, three different tracks of work that are under way right now, whole series of patches to the existing system. we are on the tail end of that. we've led a contract for major enhancements to existing scheduling system. those are supposed to start coming online in the spring of 2015. a near-term solution. those include creating the ability for us to field some apps that have been created that will allow veterans to request appointments in one of the other apps allow veterans to directly schedule an appointment.

we've got to have the ability to catch it when a veteran sends it. in parallel and we think we're literally a matter of days away from a contracting action for the acquisition of a commercial off the shelf state-of-the-art scheduling system. that system in all i could will be up and running until sometime in 17 which is why we're doing these other things in the meantime. i should indicate though, and it's reaffirmed in the report, schedulers that they talk to any field said the scheduling system isn't the impediment. it's the lack of appointment slots. vegas looking back and said schedules that it's okay. we know what needs to be replaced. it doesn't provide the functionality and we're pressing to get that done. >> i yield back. >> ms. titus, you're recognized. >> thank you. and thank you for for what you been doing to try to fix these problems and implement this bill.

i like to go back to the issue of the shortage of doctors and the private sector because this is very serious and nevada. in las vegas we're at the bottom like 50 of for 45th or something for all different types of specialists. i'd like to go back to that issue. several of us worked hard to get the provision in the bill to create a new residency. i heard you say you are given i think three a year and you have 400 applicants. i want to be really reassured that those residencies are going to go to places where there is the need. i don't want them just to go to ucla because it's got a great program or johns hopkins, oh go where they need is. the second part is where there is a need is also where they may not be able to support residencies at this time. it's kind of a double hit. that's true in las vegas but we are getting a new medical school.

we've got the new hospital but we're not going to be able to apply this year. hopefully next year. can you explain how you're going to this tribute those and how, i've got a working group right now that is needing to be sure we will be eligible for some of them, what you might recommend to that group that you look at for some qualification? >> sure. i didn't you specific information about kind of what requirements are so that you personally have that information. but i think in terms of the law, we interpret it if those slots are to go to meet be added married -- under met areas and not go to ucla necessarily. not that there's anything wrong with ucla, so i think the intention is there. there are many community hospitals that established family practice residency's and other residency programs that on

not medical schools. we do not own residency slots. they are owned by an academic partner. so those slots, they set up a program and get approval through the acg me for those position. we funded them essentially. and in return those residents rotate through our institutions and we provide some of the training. i think the challenge clearly is for a place that has not had a residency program to be able to recruit and retain likely, to be able to teach, to be able to meet all the accreditation standards that acg and he has for all those programs undertake cyclical mass of residents to meet all the work hour restrictions and everything else that they have and maintain a viable program. but i can sort make sure that you get information that you can pass along. i think the best thing that you'll can you actually is

encourage hospitals or other institutions in your districts were interested in how to conduct office of academic affiliations to get information. >> maybe i could get someone to meet with the group in las veg vegas. >> i would be happy to work that out. >> related to that you mentioned you worried about these kind of middlemen organizations like try west being able to find enough people in the private sector to be part of this program. the and you t do know what you'e doing to monitor those groups to be sure they are providing the services the? >> we monitor today the referrals we make to try west.

we know how quickly they can place patients. we quickly or how often those authorizations can return because they can't find a provider. the good thing about i think the choice program. so we set up pc three really to be our preferred provider network. and try west and health that established contracts with those providers. under the choice program you have provided i think a really good tool in terms of the provide a group authority that we have which allows, the better will be able to choose any willing provider that meets certain criteria. they have to be a medicare provider, federally qualified health center, et cetera, et cetera. once that's done triwest or health net will be able to reach out and get an agreement with that person for the choice program even if the provider doesn't necessarily want to be part of the pc-3 network.

i think the one issue we have that does need to be addressed expeditiously is the fee structure in alaska. not many willing providers in alaska that are interested. i know you all are aware of that and your attention to do in a timely way would be really helpful. >> just really quickly. you are talking about expanding and improving and changing the va, as mr. walz was suggesting this is just the beginning of the end. i hope you will look at those maps that divide the country up into different regions. and nevada were split and three parts for vha and then put the same time we are in california for vba. they just don't make sense. will you look at the? >> we don't think it makes sense either. >> good, thank you. >> dr. benishek, you're

recognized. >> thank you, mr. chairman. thanks gentlemen, for being here this morning. i think mr. o'rourke incident of this veteran was told to go home and call back for an appointment, just the fact that what happened to somebody really emphasizes to me they need for change in the culture. the that an employee thought that would be satisfactory but i do you all realize there's a lot of work to do to change the culture. i want to talk about a couple of specifics. i used to do colonoscopies at the va. i think there's still a backlog of colonoscopies within the va. how many veterans -- have been waiting 12 months or longer for screening colonoscopy? dr. tuchschmidt, any of you? >> i can ge give you that numbe. >> i wish he would.

the associated number of cancers discovered. to me, the cohort of veterans we have fixed the age group for colon cancer. i know in my own circumstances we found more advanced cancers and should have been found because of the delay. is there anything in particular that you're doing to address these backlog? >> two things. the first thing i would say is that under the choice program that you all generously gave us, veterans will be able to go out for that care today. >> are they being told that? >> we are, if you're in the 40-mile group come you've already gotten your card and been informed of the benefit. we have pulled the list of patients were waiting for appointments or procedures. >> i'm concerned about this

40-mile thing. like, for example, my district with most patients are within 40 miles of the of the syllabus or may not be any doctors. the minute any facility to do a colonoscopy. that type of thing. i'm concerned we're not going to get the care yet because they're technically within the 40 miles but there's no provider. are the people going to get the care they need in a timely fashion? >> if we can't provide that care within 30 days of a clinically appropriate data of the veterans prefer day to go to the choice program. we will offer them the option. so we are pulling people today who are waiting more than 30 days and, electronically and we will be providing the list. >> that's what it wanted here. when i was a pity they were doing three a day. when i came they started doing 10 today. same staff and everything.

that kind of stuff is still happening within the va. so what is being done to make sure that the performance numbers, in order to address these backlog the people are doing things efficiently and effectively and have the tools to do that so we are not having these backlog? what's been happening there different than in the past? >> we have put a number of practice management tools in place. we are training and educating supervisors on how to manage some of these kinds of issues. we have -- >> who is in charge of that? is that you? >> no. it's -- >> is this happening different in each different region? >> national program under philip makovsky to go to develop the training materials and to roll out this program. addition to that we have opportunity to. i can tell you in g.i. in the last half of the year the productivity amongst gastroenterologist increase in the double digits.

spent by 10% you're saying at least? >> about 15 or 16%. >> that's the type of things i run across talking to physicians within the. it seems be a lot of inertia indicating change it done. >> let me touch on the promo. we are accelerating care across department. every morning we didn't happen to me this morning, every morning at 9 a.m. there's something called the access to care standard. senior leaders from vha and from all across the department are in our integrated operations in and we are going through hard data about steps that are being taken to accelerate access to care, all across the entire organization. report outs on wait times and appointments and the like. once or twice a week we have the senior leaders from particular medical centers joined by dtc

and they deliver a specific report on the things they're doing to deliver to accelerate access to care. i was in birmingham monday and tuesday, and over the last couple of months they've gone in looking at their appointment blocks and have created an additional 900 slots across 14 different clinics, all of this using some of the productivity tools that dr. tuchschmidt is talking about, to be able to manage these requirements. this is a fundamental change for va. managing requirements, as opposed to managing to the budget and somebody gets seen, they did the same. >> we can -- if you look at our completed appointment today, 90% of our appointments are completed within 30 days. >> i'm not going to trust you with all those numbers. i would like those numbers for colonoscopy. >> i will get you those. >> thank you.

>> thank you, mr. chairman. dr. tuchschmidt comp committee where one of my top priorities is a symptom of the conference committee to produce transit was inclusion of private medical education residency slots and i was pleased to see that 1500 additional spots were included. i also represent riverside county as does doctor louise and i share the same issue that ms. titus has innovative. just be clear, the process you followed, you've reached out exclusively to those medical schools at a pre-existing academic affiliation with the va medical facilities, is that correct? >> i am not sure that we only reached out to facilities that we already have relations with. i think of a general announcement out so that other partners.

we were out looking and we are interested in having partners that are not currently affiliated. >> your interest in going beyond those medical schools that already have existing relationships with the va? >> yes. some of those medical schools me, like the way we program in the northwestern part of the united states may, in fact, be supportive i like the university of washington but they run many rural residency programs. we are definitely think for new affiliates. >> are you interested in thinking outside the box maybe funding residencies that may address ambulatory care? may not be centered at a hospital? >> the answer is yes, but as i said we know there are many community hospitals that will run family practice residency programs. so we got to her interest in those kinds of partnerships. >> i'm glad to hear that. will the va central office determined both the number of

slots going to a vision as a whole and the number going to teach medical facility or medical school? in other words, will you be delegating this decision to the vision in terms of, or you will you be making correct decision -- >> no. >> i like ms. titus would be interested in having folks on the va come out. we have a new medical school, the newest that university medical schools established. and we have as i mentioned, the ninth largest veterans population by county in the country. we certainly would appreciate and ability to locate some of these slots at a public university medical school that is subsidized by the taxpayers that ostensibly would offer probably less expensive

education. further inducement for those medical students commit to locate out of the va. >> the happy to have it done. >> i hate to be doing mr. or representation but the shortage of psychiatrists within his district -- mr. o'rourke, is there no medical facility in his district now that currently trains the va doctors? >> that i can't answer. i can to you there's a shortage of mental health practitioners of psychiatrists and mental health, advanced practice nurses and social workers in the country in general. we went through enormous hiring process t the fuse ago hiring about 3000 mental health practitioners into the va organization to i live in oregon and i can say that i know we have recruited most of the mental health practitioners often times out of some of those counties. we have actually about a year

ago took the kind of caps off of hiring a psychiatrist in terms of salary so that we could make much more flexible hiring decisions, competitive decisions with psychiatrists spent this whole issue is very salient here because there's a 60% chance, greater chance to position will locate where they do the residency. so it's important we don't prove it to pre-existing agreements of medical schools with of the hospitals that would look to alternatives so we ended decisions to locate into communities with r&d charges. >> important point. >> thank you so much. >> mr. jolly, you're recognized for five minutes. >> thank you, mr. chairman. thank you all for being here today. thank you, secretary gibson, i

want to say thank you for the spirit with which are trying to bring change and and a secretary mcdonald has as well. i the question, on the vba side, so i apologize to come at you from a field. we've all had the stories of vha waitlist and human consequences of those. i can do you at least in our district the sheer number of concerns on the vba side, and the wait times on vba. not really a specific question which is kind of a question about changing culture since you arrived in secretary mcdonald with all focus on vha. my concern is there's this painting, this will take, we'll talk about vba a few months now. what is being done on the vba side? is there a plan for future action? >> sure. we continue to be very much on track for eliminating the backlog that is disability

claims from more than 125 days since submission. by the end of fiscal year '15. i remain confident that it's going to happen. ..