>> the house veterans affairs committee examined the present 60 billion-dollar budget request for the va. it's an increase of 7.8% from fiscal year 2014. va secretary rob mcdonald and other officials testified before the committee at this two hour and 30 minute hearing.

>> the hearing will come to order. we are here to discuss the president's fiscal year 2016 budget request for the department of veterans affairs. mr. secretary, welcome to the committee. understand that your testimony will be a little bit different today than what we are accustomed to with reference to chart to help us better understand what you are seeing in terms of the challenges that lay ahead and i would say that is indeed a welcome change. so too is the open as you have had with me with members of this committee and this congress about your plans to change the culture at the va. as your testimony illustrates you have been extremely active in visiting va facilities. i think it's well over 90 at this point, talking with employees veteran groups in your private sector colleagues with

one aim in mind, putting everyone's focus squarely on the needs of veterans. thank you for your willingness to take the job of secretary and thank you for putting everything you have into that job. turning to the business of examining the va budget request i see some very positive things but also there are some areas where we will have considerable question marks. the committee's task will be to learn as much as possible in order to inform our views and estimates letter that is due next friday. on the positive side mr. secretary you have boldly tackled a very sensitive issue of va's aging infrastructure coupled with a more realistic budget request for va's major construction program addressing the closure of unsafe vacant or underutilized facilities begins an important conversation about

the future alignment of va's infrastructure. i have long argued that we needed a strategic reinvestment of va's construction program. that is in part what the independent assessment of the veterans health care commission established the last summer's choice act tasked with examining. you have my commitment and this committee's commitment to work with you as this conversation begins in earnest. i have several areas of concern that but i hope you and our second panel can address. first, and i'm going to be frank as i have in the past with you on this particular issue. the proposal to reallocate any portion of the $10 billion appropriated for the veterans choice program is a nonstarter. i understand there's a great degree of uncertainty about the programs utilization but in appropriating the money the congress had to work with the

best estimates we had at the time to stretch those dollars including limiting eligibility criteria for veterans. so if there is going to be anywhere up -- reallocation is going to be to further improve and strengthen the program itself and not address other needs. secondly the budget requests an additional $1.3 billion for va medical care on top of the advanced appropriation for fiscal year 2016 bringing the total proposed increase to 7.4%. at a threshold level i do not understand how this request interacts with a $15 billion that congress provided last summer for non-va care and infrastructure as part of the veterans access choice and accountability act. it would appear that there are considerable unknown variables in this area such as the degree to which the choice program

alleviates the workload and resource pressure on va, the productivity standards of va should expect from clinical workforce and the ability for va to hire professionals in an already large vacancy rate in a national shortage of health care professionals. i hope to expand on this a bit more during questioning. thirdly i know that the 6.5% increase for the veterans benefit administration principally to hire additional staff to address the workload. mr. secretary there are several of us on this committee ranking member included, who have long memories on this issue. we know that disability claims staffing has doubled in 10 years and nearly tripled since i arrived in congress in 2001. we have invested over half a trillion dollars in vbms and millions more and other systems and we provided tools to encourage veterans to file fully developed claims which in turn

enables a quicker decision. all of these investments were made with a the promise that productivity would markedly improve and shift the department away from the usual torrent of relying on an ever-increasing workforce and over time to deal with the workload. although another production improvement and backlog over the last two years it's a far cry from saying individual worker productivity improve given the resources that have always been provided to the department. again this is another area i hope to address in questioning. finally the big lesson learned last year that veterans are better served with constant and aggressive oversight. mr. brown and i have asked for a larger committee budget towards that end. one thing that you and i have talked about is the office of inspector general. i too believe that they need an increase larger than the .3% increase provided in the budget. the proposed amount is not enough to cover inflationary costs let alone be increased

oversight we all rely so heavily. again mr. secretary thank you for what you are doing and i look forward to your testimony and i look forward to hearing from the veterans service organizations on the second panel. the va system is for them and those they represent southern put on budgetary matters is critical in informing the committee on the congress on va's budget request and without i recognize ms. brown for her opening remarks. cnet thank you mr. chairman and welcome mr. secretary. i want to say that i'm very happy you are here this morning and i'm looking forward to hearing how this budget request will meet the needs of our veterans. the president has given a large increase to the va but the president has proposed an 8% increase in funding or va health care personnel construction

research and processing. given this large request i am looking forward to our discussion today and how it will assist our work as a committee to make sure that this proposed budget gives you the dollars that you need but also assures us how in congress that every dollar you receive will be spent wisely. i am certain h.r.s. to 216 the department of veterans affairs reform act of 2015 was the lava lamp. it is an important tool to assist us and you in matching resources to the needs of our veterans and ensuring that we are planning for the future to make sure that we don't let our veterans down. mr. secretary the first question i will ask is does your proposed budget give you all of the dollars you need to fix the problems that you face meet the

goals and the initiatives the department has laid out keeping in mind that funding provided by the choice act i hope we can discuss whether you have enough resources to ensure that veterans did not place an intolerable delays to getting access to health care and i hope you will discuss how you are looking down the road to ensure that veterans have the access to meet va care in the future. i always hear from veterans how they prefer va care when it's available. i hope we are going to all work together to make sure that health care our veterans prefer is available to them when they need it. this is the first year that va benefits programs will be fully funded on the advanced appropriation. veterans won't have to worry about what we are doing in congress and it won't affect how we operate.

finally i want to hear about your reform and reauthorization efforts and how this budget request will support these efforts. i also want to hear about how you are making progress in an effort to reform and regenerate and invigorate the va. too often all we care about is the problem the va is having. i would like us to also consider what we can do to fix those problems and to point out what va is getting right. i'm pleased with this budget request and i hope these dollars can fix what is wrong and strengthen what is right that the va and with that mr. chairman i yield back the balance of my time. >> thank you very much ms. brown. i would like to welcome our first panel to the table this morning. accompanying the honorable robert mcdonald was secretary of the department of veterans affairs is in german secretary for health the honorable alison

hickey undersecretary for benefits mr. ronald walters interim undersecretary for moral affairs, ms. helen tierney executive in charge for the office of management in va chief and financial officer and mr. steffen warren executive in charge and chief information officer within the office of them permission and technology. mr. secretary again thank you for being here and please proceed with your statement. >> thank you. ranking member brown chairman miller with members of the committee thanks for the opportunity to discuss b.a.s 2016 budget and advance appropriations requests. thank you as as well are joining maine and vermont last week for groundbreaking breaking town hall meeting. we deeply appreciate appreciate the president sent congress a steadfast support for veterans, their families and survivors as well as the advocacy of veterans service organizations. our nation is emerging from the longest word in its history.

the va is emerging from one of the most serious crises the department has ever experienced. we now have before us the greatest opportunity we have ever had to improve care for veterans and to build a more efficient and more effective system. with your support bea intends to take full advantage of this remarkable timely opportunity. members of this committee and vso share my goal to make the va model agency with respect to customer's experience in stewardship of taxpayer resources. an example for other governmental agencies. with efficient and effective operations would like to be comparable to the top private sector businesses. this is how we best meet the nation's obligations to all veterans. the cost of fulfilling those obligations to our veterans grows and we expect it will continue to grow for the foreseeable future. we know that services and benefits for veterans do not

peak until roughly four decades after conflict ends. this chart demonstrates the number of veterans receiving service connected disability benefits from world war i peaked in 1958. for world war ii it peaked in 1985. for korea it peaked in 1993 and for vietnam veterans it was just last year and 2014 when it peaked. it's worth remembering that today almost 150 years after the civil war ground to a hault b.a. is still providing benefits to children of a civil war veteran. we still have troops in both iraq and afghanistan and in the last decade we have already seen dramatic increases in the demand for benefits and care.

this chart shows how for 40 years from 19,622,000 the percentage of veterans receiving compensation from va was stable at a .5% but in the last 14 years since 2001 the percentages have dramatically increased to 19% more than double. simultaneously the number of claims and the number of medical issues in related claims that va has completed has soared. as this chart shows and 2009 bba completed almost 980,000 claims. in fiscal year 2017 we project we will complete over 1.4 million claims. that's up 47% increase. but there has been even more dramatic growth in the number of medical issues and claims.

2.7 million in 2009 and a projected 5.9 million in 2017. that's a 115% increase over just eight years. these increases were accompanied by the dramatic rise in the average degree of disability compensation granted to veterans. for 45 years from 1950 to 1995 the average degree of disability held steady at 30% but since the year 2000 the average degree of disability has risen to 47.7% as this chart shows. so while it's true the total number of veterans is declining the number of those seeking care and benefits from va is increasing. fueled by more than a decade of war agent orange related disability claims, and unlimited

claims appeal process come increase medical claim issues, far greater survival rate among those wounded more sophisticated methods for identifying and treating veterans medical issues demographic shifts, veterans demand for services and benefits has exceeded the a's capacity to meet it. it's important that congress and the american people understand why this is happening. the most important consideration is that america's veterans are aging. as with any population health care requirements in the demand for benefits both increase is veterans age and exit the workforce. this chart reveals an astounding shift. in 1975 pierre graduated from west point just 40 years ago only 2.2 million american veterans were 65 years old or

older. 7.5% of our veteran population in 2017 here on the far left. we expect 9.8 million will be 65 or older were 46% of veterans. that is 7.5% to 46% an astounding increase. today we serve a population that is older, with more chronic conditions and less able to afford private-sector care. we protect the benefits for veterans in recent conflicts will peak around 2055 assuming afghanistan and iraq are winding down this year. it's fair to imagine the members of congress who are present in the secretary of veterans affairs and 2175 will be debating resources that will impart health care for the family members of iraq and

afghanistan veterans. currently 11 million of the 22 million veterans in this country are registered enrolled or use at least one va benefit for service. veterans are demanding more va services than ever before. the number of all veterans who are seeking va medical care is steadily growing. and women veterans is a very important issue for us and mental health another very important issue for us have to increase to medically. over 635 women veterans are now enrolled in va health care and over 400,000 actively use va for care. that's double the number using va care in the year 2000. please see annual increases in women veterans seeking care of 9% and this trend will continue and probably even go higher. our women veterans call center now connects with over 100,000

women veterans per year. over 1.4 million veterans with the mental health diagnoses are enrolled in va an increase of 64% from the year 2015. there were approximately 19.6 million mental health outpatient encounters in 2014. that's an increase of 72% from 2005. since its inception in 200722014 the veterans crisis line has answered over 1.6 million calls and assist in over 45,000 rescues. over 1 million veterans receive services through the primary care mental health integration program begun in 2007 through november 2014. the annual number of encounters has grown from about 182000 fiscal eight to over 1 million

in 2014. is veterans witnessed the result of the result of a positive change is va is making and regain trust in the va and as the military simultaneously downsizes, the number of veterans choosing va services will continue to rise. in it should end our veterans have earned it. we are listening hard to what veterans congress, employees vso's and stakeholders are telling us and what we hear drives us to an historic unprecedented departmentwide transformation. changing va's culture and making the veteran the center of everything we do. that transformation we call by va because that's the way they want veterans to think about va. it is they are is personalized and customized and this transformation entails many organizational reforms to better unify the department's efforts.

my va focuses on five objectives which i have shown here on the bottom. first improving the veteran experience so every veteran has a seamless integrated and responsive customer service experience every single time. second improving the employee experience and eliminating barriers to customer service to achieve people excellent so employees can better serve veterans. we have no hope of taking care of veterans if we don't take care of the employees of va. third, improving our internal support systems and services. forth establishing a culture of continuous improvement is the local level can identify and correct problems more immediately and then replicate prudent solutions across their entire network. and fifth in enhancing strategic partnerships. my va revolutionizes va's

culture and reorient the department veterans. measuring success by veterans outcomes as opposed to internal metrics. we intend every veteran to have a seamless integrated and responsive customer service experience every single time. reorganizing the department geographically is the first substantial and important step in achieving this goal. in the past va had nine disjointed geographic organization structures, one for each line of business so imagine a business with nine different businesses, nine different sub businesses each having a different organization structure and a different middle management. our new unified organizational framework has won national structure as shown in this chart. this new structure has five regions aligning va's disparate

organizational boundaries into a single framework. this facilitates internal coordination and collaboration among business lines, creates opportunities for integration at a much lower level and promotes effective customer service. veterans will see one va rather than individual disconnected organizations. and last of my va is about ensuring va is a sound steward of taxpayer dollars. we will integrate systems and efficiencies across our operations to make sure we balance veteran centric service with operational efficiencies that we need the help of congress. va cannot be a sound steward of the taxpayers resources with the asset portfolio we are currently carrying. no business would carry such a portfolio. veterans deserve much better. it's time to close the va's old

standard and underutilized infrastructure. nine va facilities -- i'm sorry, 900 va facilities are over 90 years old and more than 1300 are over 70 years old. the va currently has 336 buildings that are vacant or less than 50% occupied. that's 10.5 million square feet of excess which costs us an estimated $24 million a year to maintain. these funds can be used to hire roughly 200 registered nurses for a year or to pay for 144 primary care visits for veterans veterans, or to support 41,900 days of nursing home care for veterans and community living centers. we need your support and to do the harder right rather than the easier wrong. these might be a reforms will take time but over the long term

they will enable us to better provide veterans with the services and benefits they have earned and that our nation promised them. our 2016 budget will allow us to continue this credible transformation to meet the intent of my va. the 2016 budget for va requests $168.8 billion -- million dollars and $95.3 million in mandatory funds for benefit programs. the discretionary request is an increase of $5.2 billion or 7.5% above the 2015 enacted level and provides the resources necessary to continue serving the great number of veterans who have selflessly served our nation. the budget will increase access to medical care including -- i'm sorry, increase access to medicare and benefits for

veterans. you'll address infrastructure challenges including major and minor construction modernization and renovation. it will land a backlog of claims of veterans homelessness by the end of calendar year 2015 beta will fund medical and prosthetics research and address the i.t. infrastructure modernization. we know this is a large request but it's not sufficient to meet all the requirements for 2016 or 2017. therefore the president will transmit a legislative proposal to allow flexibility is necessary to reallocate as needed a portion of veterans choice act, funds to improve va operations within a fiscally responsible budget neutral approach for veterans. as this chart demonstrates this proposal is largely driven by her uncertainty of what resources we need to fund the new veterans choice program. it's difficult to predict.

veterans use the program or its interaction with the medicare base budget because it's all-new. we have no long-term data to draw upon yet. our current estimates of demand range from a low of $4 billion to a high of $13 billion over the three-year program. we want to need the flexibility to move resources if veterans decide to stay inside b.a. rather than the outside of va. this is about ensuring every veteran who received the care they have earned and deserves regardless of where they choose to get it from. mr. chairman members of the committee we meet today at an historically important time for va in the nation. march will mark the 150th anniversary of president lincoln solemn promise to those who have fought in the most devastating war in our country's history. he promised that we care for those in the battle and their

families and their survivors. that is va's primary mission. it's our only mission. as the noblest mission supporting the gray assist of any agency in the country and we count on your support to uphold that sacred commitment. thank you again for your unwavering support for veterans, for working with us on these budget request and for making things better for all of our great nation's veterans. we look forward to your questions. >> thank you very much mr. secretary for your testimony and as we approach president lincoln's birthday tomorrow we are ever mindful of his commitment to the veterans of this nation and our responsibility as a congress and as an administration. can you tell me a little bit about how the $15 billion that was appropriated last year in addition to the budget how that

is accounted for in this budget? >> well sir as you know that money is obligated only when veterans use the program. so so far in terms of veterans choice program we have had nearly a half a million calls from veterans and providers about the program. so far we have roughly 24,000 veterans make appointments on the program and go outside so we obligate that money as it is. also, we are in the process of leasing 27 new facilities and that work is already underway. we are using the money to hire more doctors. we have more medical professionals. we have a net-net increase of over 8000 medical professionals.

that is in the last nine months. november was our biggest month of hiring. we hired over 2000 more medical professionals than we lost. our turnover rate is about 8% 8.9%. the turnover rate in the industry is about 18% so we are trying everything we can do to maintain the medical professionals. >> we did have a shift of over $500 million but we think the costs will shift to the choice program. >> could you explain that a little bit further? i know there was a telephone conference with staff to talk about the shift. >> understanding the program is still very new we thought some of the costs we normally see in

the fee program would be picked up by the choice program. right now though our actual results where we are seeing much more demand for the fee program on the va side of the budget. >> i would say that is a critical component to knowing whether this request is adequate or not. that is why the hesitance to do anything mr. secretary with the choice piece. again we arrived at the criteria because we wanted to have zero. in a veteran out there had a choice. that number came back from cbo at about 50 billion. we couldn't do that so that is where the 40 came from. there has to be some savings i would suspect that are derived by alleviating some of the pressure within the system by those that are going outside

because of the choice program. >> we are going to be looking at that very carefully. what we also don't understand is what level we have from veterans who did want services who weren't using these services because of the long wait times distance and there is still a lot to understand about choice. >> mr. chairman i don't know that now is the time to make a move of any funds. what i'm trying to do is subsidize the committee to the fact that there is a lot of uncertainty and in our budget we have roughly 70 line items were we have inflexibility. we can't move money from one might add him to another and what i'm asking is that we work together to have flexibility so no matter where veteran goes we can move the appropriate money

they are and make sure that veteran receives care. >> we will commit to helping you have flexibility mr. secretary almost anywhere within your agency except within that choice piece. because of the uncertainty that is there. that is what is interesting about this budget request. you talk about all the uncertainty that's out there yet we are asking for an increase in stds and asking for increases in dollar amounts. let me get back real quick, have i have one other question that i need to get to ms. brown. one of the things that i think a lot of us have asked and by no of positions on the committee have asked over and over again and i've never gotten an answer. is twofold. number one how much does it cost for a veteran to be seen within the va versus the private sector and the private sector mrs. secretary you know could answer that right away. you have a hard time answering

that within the department and the other issue is what we know whether the clinical workforce is operating at its maximum capacity and efficiency based on the workload that is out there? there has been a lot of anecdotal evidence presented to this committee that say it is not and physicians are seen as few as two patients a day which is absolutely unheard of. >> let me ask dr. clancy to comment on that but before she does let me say as you know my first trip was to phoenix and when i arrived in phoenix i discovered we were short 1000 people in each primary care doctor had one clinical room and in the private sector today a primary care doctor has three clinical rooms. we have an issue of stopping which the committee helped with the choice act but we also have

an issue on infrastructure. it's an old infrastructure. we have women veterans and we don't have currently the situation today. in boston i visited an operating room. our operating rooms are 35% smaller than they need to be. if you have an operating room which is 90 years old they don't use robots or computers in operating rooms 90 years ago. we need that equipment today to provide her veterans with the best operating surgery can possibly conduct. >> is on a productivity issue which i think is incredibly important, we have a tool and we have discussed this with representative wenstrup where facilities can look at productivity of different types of clinics understanding what the clinician is doing in this space issues the secretary mott mcdonald just mentioned and also the efficiency and capabilities of the people

around them who are supporting them. that tool has been deployed systemwide. we are right now examining some of the data quality issues and very importantly having that externally reviewed. we would be happy to come back and brief you in more depth. we think it's a good tool and at this point it's more diagnostic than it is in a place where we can give people grades for example but we also want to make sure that some of the best and brightest minds have taken a look at it and kicked the tires and so forth so we are confident as we measure productivity. i just want to reinforce what the secretary said a minute ago. some of our clinics some of the better clinics would bring tears to your eyes in terms of how well they are doing but they are really landlocked. it almost feels like a gift much less a two or three would see in the private sector. >> ms. brown. >> thank you mr. chairman. before i begin my questioning

mr. secretary understand you were in our land of last week on wednesday meeting with the nurses association. can you give us an update of how that went in also he made an announcement about the opening of a hospital in orlando. can you give us an update on that also? >> yes maam. i was in orlando and i spoke to the american nurses association and i was there to tell them about how exciting it would be to work in the va today and just like you and the chairman went with me to a the medical schools in florida to recruit we were recruiting. we picked up quite a few people who were registered in coming to work for the va. the va is the largest employer of nurses in the country and it's important our nurses are very important to us and they do a great job so that is why i was there. separately i did visit the orlando hospital atlanta medical center. there are now patients being seen. we are in the process of moving

in. we expect to have a commemoration ceremony of sorts for memorial day but between now and then there will be new clinics being set up every single week there. it's a fantastic facility and i think the citizens of orlando and the area of florida will really enjoy going there. >> thank you. dr. clancy is there a discussion on this committee about you know we have doctors on this committee and they talk about this responsibility. it's a little different working with the va because what we expect that of the va physicians is a little more comprehensive. when a person goes and let's say i'm going into a podiatrist. they can't just go in and deal with a podiatrist that is comprehensive. it's a whole different case work. can you explain that to us?

>> with that leave that primary care and care for the whole veteran if you will is the foundation of the system so for the most part we don't have people just coming in for podiatry or a hearing aid for example of very popular use of our facilities, without also checking some of their other risks to their health and so forth. we are taking a very hard look because there are two overarching goals for this year getting access right whether it's within our facilities whether it's virtually by telehealth or something like that or with the choice program but all of that is seamless and are equally high second goal is exceptional veteran experience. we recognize some veterans actually might choose to simply commend for podiatry and skip the rest so we are going to be looking at different options for doing that by way of maximizing efficiency and frankly making the veteran experience very

satisfactory. in general we have an incredible opportunity because of the entirety of the department to have an impact on health that no other health care system house. a lot of things affect health besides medical care. its its income comments education whether you have a place to live and so forth in the department has tools through vba and so forth to actually address all of those needs that we take that very seriously. >> the last question i have what are we doing working with the department as veterans transition to make it seamless and the bumps in the road. i met a veteran who has been out two years and 10% disability but the point is he can't get his paperwork from dod. what are we doing? we have asked this question for years. >> it's a great question. i have to say secretary hagel

and i are totally aligned that we want to have a seamless handoff from the department of defense to the va. that's why we have instituted programs like cap while the person is on active duty and allison can talk about that. >> congressman brown some good news to report on this front though it didn't obviously help that particular veteran two years ago we are engaged now in the mandatory program for all of our servicemembers including national guard and reserve for which there are now nearly a million who qualify for benefits that did not previously. another thing that is starting literally right now is the mandatory separation health assessment. the choice to the veteran told a session is if you are going to make a claim to be a for anything that va will do a complete separation top to bottom before you leave service

so we capture everything service-connected on the spot. the next thing i will tell you is we have moved substantially forward with dod on the system where they give complete service treatment and all the parts and pieces we have talked about before that we used to call the gold standard. for while the numbers were really high but they have come down to now about 21% of them are overdue so they are getting better and we are giving them faster and to build while the i.t. connections now such that we simply note in vbms that we have a claim the system tells the dod system we are asking for the records in the records come back automatically into vbms and are instantly loaded up into our vbms system. that is helps us tantawi. the last thing i will share with you that we have also done is we have reduced substantially those

folks waiting in the process are getting much better in our process and i can tell you the benefits district program the backlog has been reduced by a significant amount. there are only five or 10% of those two are now over 125 days. >> thank you. >> thank you very much and i yield back the balance of my time. >> mr. secretary and want to read a text i got from a friend of mine. i had a reason to deal with the v. in jacksonville this morning on a home we finished for a veteran, a guy named max handled my request. i left the conversation warming complete. very good experience. never had that before. thank you. >> may i get the names i can send a note of recognition? i am serious. >> it was unsolicited and it came in while i was sitting here. >> as you know i have given him my cell phone out nationally and i get 120 contacts today.

right now i would say 35% are positive. that's not enough. all of us sitting here at this table wants 100% of those to be positive and we are working on it. >> you betcha and i will be glad to provide you his name. >> mr. chairman you did say jacksonville? >> yeah i did. [laughter] maybe that's why they never had a good experience. [laughter] mr. lamborn. >> thank you mr. chairman and thank you for being here secretary mcdonald. i'm pleased to see you have focused a portion of your budget on construction efforts. can you tell me the status of the southern colorado national cemetery project family you anticipate they will begin accepting early burials? i'm very concerned that this project stays on track. >> we are as well. we are in the design phase right now and we think that design phase will take about a year or year and a half.

ron would elect to provide more detailed? >> congressman lamborn as you know we have made progress significant progress on establishing the cemetery in southern colorado. we acquired the 374 acres at rolling hills branch in el paso county. we do have sufficient funds in the budget right now to complete the design. completed through construction documents the final phase of design. once that is completed we will begin the solicitation phase for construction of phase one. assuming construction funds are provided in the next budget cycle and that is yet to be determined we would expect the first burials to occur sometime in calendar year 2018. >> i'm disappointed that the

timeline seems to be slipping. i will do everything i can to make sure that those funds are in the budget and i will work with other folks to try to achieve that but it sounds like there has been slipping to the right and that is disappointing. >> we are going through a complete review right now our construction management process does you no. sloan gibbs and the deputy secretary is leading that and we have the corps of engineers help. we have got to find a way to shorten these timelines that we face. we will be looking up at an obviously any work we can do to accelerate it we would like to do. >> and i will work with you if any amendments are necessary or legislative action to give you the authority to make faster progress in the future on the further projects. changing subject secretary mcdonald imagined they were five proposed regions as opposed to 21 visits.

i guess that is more efficient. his menu will have fewer personnel doing the same job is before which to me is the hallmark result of more efficiency. >> as i said in my remarks this organization is focused on productivity improvement. i don't feel we can come to you and ask for more money unless we are demonstrating we are saving money at the same time. that is why we have identified the buildings that are empty that cost us money every year. we have nine different geographic maps, each one for different line of business whether it's insurance. >> i have one other question. it goes to five regions and we haven't yet determined how many we will have but they have to fit those five regions and we have a team of directors looking at that now. everybody is trying to fit into that structure. the point is there will be more

efficiency at the middle management level. >> i hope that means fewer people doing the same job which means less budget dollars. >> we are trying to put every budget dollar weakened against the veteran experience making the veteran experience better. >> and lastly a new attempt on this but the transition between dod and va and i have 100,000 veterans in my district and mom is that many dependents and family members and the military compensation and moderate retirement modernization committee has come up with recommendations that there needs to be better transition. you have mentioned some things who are working on and that's good to hear but what can be done in the future? what could be improved to make that transition better? >> when we met with the committee throughout the work i think they have done excellent work. some of the ideas of allison

mentioned are brand-new and before that committee wrote its report, in fact when they gave us the report we mentioned some of these things and they missed the report. the report was already imprinting but this idea of the medical exam before the servicemember leaves the service that's the biggest idea and the problems we have had in the past will be able to resolve with that and also with the way we strengthen the tap program. i think we are getting better but we will continue to look and see if they're of the things we can do. >> thank you so much. >> thank you mr. secretary. it's nice to see you again and we appreciate you being here. before i asked my general question i'm going to bring up what i always bring up and that is the reno office. we have been without a permanent director for about two years. we are on our second interim. i understand they have asserted to recruit yet but if you move it would be a lot easier to

recruit a person to come and take that position. that is my first one. second the hospital built in las vegas was too small by the time was completed because they didn't anticipate the increased usage. we heard deputy secretary sablan say they were going to move some resources to help with the hospital from denver i believe it is aurora. i want to be sure you are not moving resources from a las vegas hospital to fix the problem in aurora so we can follow up with that. and my general question for the last couple of years we have focused on the backlog fixing that problem and also problems with their hospitals. i would like to see us as we move into the next few years look at other areas of benefits and make to be a more relevant to our 21st century veterans. i appreciate the things you mentioned in your testimony. one is women the second is a lgbt veterans in the third is

the issue of medical marijuana. these are all big issues during these times are you talked about how many more women veterans we expect to have but really what we don't know is what we don't know and women veterans task force. >> can get it better handle on performance and the demographics and research analyst who i would like to note the va is making those two positions a priority and if we have your commitment that those would be positions that would be funded and utilized? second i would ask you mr. secretary if you would commit to whether you think the law needs to be change that prevents the va from giving the lgbt veterans the same benefits that other veterans get. they earned them and they deserve them and they just happen to live in the wrong state. i don't think that's fair and third with medical marijuana as

more and more states are legalizing medical marijuana va doctors aren't able to make any kind of recommendations concerning that. i wonder how that be a policy might be moving to address that issue. >> thank you for the questions. first on women i took down the painting in my office that it probably been on the wall since omar bradley was the administrator via an ipod posters. has a picture of a woman in service and each branch of the military. did that on purpose because this is going to be a defining issue for those of us leading the va right now. you already heard that our buildings are old. we need space to be able to create the women's clinics. we just opened a women's clinic in washington d.c.. i would encourage you to go see it. it's a beautiful clinic but it's different than where the men would want to go and of course the care is different because we

have other kinds of care. this is a very important issue for us and we are working hard to identify where we can put women's clinics with women's care. we just got a building from dod in fort mcpherson in georgia where we set up a women's clinic. this is a very big issue for us. we are going to stay after. relative to the lgbt we are following the law. if a couple is married in a given state we will give them benefits. we need a new interpretation in the law. there is an exception to that great in the national cemetery if we are able because of the legal authority i have two be able to bury partners together when they so choose and in every case we have done that we have looked at the relationship and we have granted that.

>> if i may interject i appreciate that but in state cemeteries it still remains a problem as i understand it. >> yes maam, i don't control those. >> but they get funding from the va. >> some of them. on the medical marijuana and let me ask dr. clancy to comment. >> a fair number of our clinicians have veterans who use marijuana medically in boats. they live in areas where this is legally possible. very early days for us to have medical policies but their active discussions going on now and we are trying to learn from what we know about treating differing conditions which by the way are not necessarily identical with those conditions for which veterans believe they are helpful. i think there is an incredible opportunity for us to learn from some of those experiences that we have to be careful given the variation in legal issues but we would be happy to provide more detail for the record.

>> thank you mr. chairman. >> i yield to ms. brown for 30 seconds. >> in the area of medical marijuana we have passed the bill saying that the va doctors cannot administer even at this stage says it's legal and they could be charged with -- so it passed last year on the floor. i didn't vote for it and it was an issue for congress. i think maybe you should introduce a bill but as we speak it is illegal for a va doctor to administer marijuana. >> that his crew rec's representative brown and i was not clear enough on that point. that said again trying to be responsive to veterans experiences and what they're telling us we are trying to learn from that and understand and anticipate what a different future might look like.

>> absolutely. they're all kinds of additional kinds of therapy but as you see now it is illegal for a physician to administer it. am i correct? last year we passed a bill on the floor saying it was illegal for a va physician and i yield back. >> thank you. mr. bilirakis. >> thank you. first of all i want to thank you mr. secretary for taking the position and being so accessible to us and more importantly to our veterans. again you have made a great deal of progress and we want to help you make more progress of thank you for your corporation we are here for you. first of all i want to talk about, have some questions with regard to police authorizations. first of all i want to thank you for working with me to ensure me to ensure veterans and committee stakeholders in my area in the

pasco county lease consolidation located in central florida. to ensure the success of its utilization is important that their opinions on potential locations and what specialty services should be offered were considered. i know you agree. i'm pleased to hear there will be a potential site visit. can you give me an idea when that might be? >> our staffs that this morning actually so i don't know the outcome of that meeting but i think it should be imminent tomorrow or the next day. >> thank you and again is this something we can work with you want to expedite these leases in general, the leases in general? i'm not talking about the 27 leases from last year. >> as i said sloan gibson or deputy secretary is going to the process to understand how can we speed up our ability to design reconstruct and as we go through

that if it looks like there's an opportunity for legislation we will come back to you and ask you for your help. right now we are not ready for that but we are taking a close look at it. >> my next question has to do with the future please authorizations. i understand there is a relationship between va and gsa with goocher lease authorizations not the 27 authorized last year. can you discuss what offers are being considered and that there is enough request in the budget and should the full extent of the least they required? >> i will start and maybe allen can help. at one time over a year ago now we had a blanket lease authorization which would allow us to enter into from gsa which would allow us to enter into leases easily with their authority. that has been revoked and it requires us to go to gsa for them to study our leases.

in some cases at the cost of the least exceeds i think it's $2.85 million than they actually have to take it to a committee which takes even more time. we have been working with them to speed up the process but we are trying to see if there is a totally different way beacon do it. we are applying technology to see if there's a way we can improve the process even more. >> gsa has been working cooperatively with us. we are working on getting those processes right and making sure we all are working under the same standards for scoring so i think that is progressing well right now. ..

a couple of things in follow-up, and follow-up and then i'll be working with the chair. but one is we want to stay in very close touch with your team is in touch with the rest of our facility, particularly addressing homelessness in west la and then we're suggested to have a follow-up hearing you come back. so we can stay closely

engaged. >> this is a team sport. we all need to play together on the same team. veterans being homeless. the largest homeless population in the country. next not evident frustrations. >> we got the land in 1888. >> i want to go to the opposite of the country tonight talked briefly about the veteran's choice program. make sure that the veterans

choice program whatever happens elsewhere, will continue in the state. this is critical for us because we have got folks. they don't they don't travel the distance is that my colleague such particularly of late. can i ask about how the veterans choice act is working in those states? you mentioned briefly about hiring new physicians and medical personnel. >> i want to make sure that the believes the system of the future of the at work the va an outside care.

in the last year we do a 550 million appointments and outside care. this was about a year ago. we are believers in that because that is the way our veterans will you serve the best. it was misinformation. there was there was never his intent to get the choice program were somehow. it was simply asking for recognition that we have seven new line owns a budget , imagine your household, checking account for gasoline a checking account for groceries. the price of gasoline goes down by half. your hungry but you can't move the money from the gasoline account of the 3rd account. i can't work with veterans and have the flexibility to do that.

very hard to achieve customer satisfaction when you have all these restrictions on how you can take care of customers. that was the only.i was making. it's early day. i've had nearly 500000 calls and about 24000 appointments. will let you know. >> we invited over. congressman brown congresswoman miller they went through our daily -- we're something we call a daily standup. secretary -- deputy secretary gibson leads it and i will let you to come

over and watch us to the. i would argue that it like if you confidence in the data and you can see the tram lines. >> thank you. >> mr. secretary, in the budget submission for the office of general counsel congress the conference defending against complex litigation such as the construction projects in orlando and denver the lost the case on every single.for the hospital in my district. the only way the construction could continue was the contractor demanded

that the va construction management personnel be kicked off the project. project. they come in and take over the project. and so i i think this is characteristic of the glossing over the extraordinary problems confronted by your department. mired in bureaucratic incompetence and corruption. there's know substance. there substance. there is no substance. >> am highly offended by your comment. >> i fundamentally believe as unfortunate as it is then at the end of the day at the end of this president's term that you we will not have made a difference in changing the culture of this organization by virtue of the fact that you continue to gloss over his problems. >> am offended by your comment.

been hear six months. you been hear longer than i have. i find it ironic that when i went to la i went to la to solve a lawsuit your busy calling for hearing him him him advise you as to how to the extraordinary problems. what you need to do is focus on providing the health care benefits and get out of that construction management business. >> each major construction project is hundreds of millions of dollars over budget and years behind schedule.

that's a problem. >> we work very closely with the corps of engineers. a good friend and has been helpful. he is told told us he does not want to responsibility. were doing it in denver and we appreciate your help. >> i hope you can make a difference. >> maybe if you want i'll give you my cell phone tonight you can answer some of the calls or go on the websites and see what the veterans are saying. i run a large company, sir. >> this organization to reflect the value am not sure what.

>> i need your help. >> mr. secretary, let me begin by thanking you for your service. of only been in congress a little over two years i really feel that you personally have said a bar for in fact facing the future future so that we bill the better va and do better for the veterans we serve. case in.a few days after so meeting with. a meeting with the incredible staff that work under mr. danzig we ensure that we had in there to begin with.

and ensure that we had someone they're to be transformational. so want to thank you. i also want to thank you for your willingness to work with us to do better. no need to focus on the past $1 billion. we can't do that anymore. we have partners like texas tech the public hospital toll brothers providers all of whom are desperate to work with us. i would like your commitment that were going to do with the short

time that we no that you have with this administration put together a plant so that it is unstoppable. can i have that commitment from you? >> as we talked for their and went to the texas tech site but we want to do in el paso is exactly what we did in los angeles got everyone together will work together to get this done. i look forward to working with texas tech department of the army. currently our facilities connected the beaumont. >> thank you. i also want to thank you for the presentation you made at the outset. he placed her current problems in context.

not all of them some of the them originate the va the commitment in afghanistan and iraq and he in terms to those veterans and 2025. 10,000 servicemembers there expect more us casualties. in a state of perpetual war. funding the assets. the cost the cost to care for them and their family and their children. i hope are all keeping that in mind. a much larger cost.

the component to ss va healthcare process. an independent assessment. let us find implementing the findings and assessments. no know when that's supposed to conclude. >> thank you, representative. required a number of assessments which thankfully we think i'm incredible gift. last week and i spoke to blue ribbon panel they have assembled will take a look across all of the assessment working very hard to make sure that that happens in a looking at all aspects of the operation. >> dollars in the budget to implement the recommendations?

>> we expect that this will be a core part of management. for the recommendations is actionable and relevant. were very much looking forward to those. >> thank you. >> if a man going to go back to something that was touched on briefly last time that's what we actually spend. that's what i asked him not knowing the of how many rvus per year that the va generates is a common term

used both in private sector and in the va. and then with the total cost. but total cost the domain just what the dr. is getting paid. administration, physical plant. it sound like mr. gibson several long way from coming up with that number. how much do we spend on everything to do with healthcare that was generated? i'm curious why we can't come up with a number is a wonder sometimes we really determining committees and more cost-effective to refer out rather than bill that? is pretty easily defined. the doctor's and paying for the physical plant and staff malpractice and all those other expenditures. we are being realistic if we don't look at the overall picture.

>> that's a system we have to develop. where in the process of doing that. the department has had a history of working to a budget that working to a demand or customer focus. congress will provide a budget and that's what apartment we worked for. were actually making some relatively large changes your you can tell but the process of doing that, that was a big undertaking. >> if we no what the budget is rather health administrators and cost can't that give us something to start with.

as the project out i'm looking down the road. i'm here for the same reason you are. we have to come up with those numbers. effectively especially when it comes to dollars. >> that's part of the independent assessment. one of the wild currency of the country are quite familiar with cost per private sector. fixed cost versus variable costs. that's the.that was in the overall opening statement. if. if i could have been very hard. as secretary mcdonald said

what we provided as well as will we send out to community partners so forth in the something like it possibly with a different name. >> i look forward to seeing those types and numbers. that has to be our guide. >> everyplace is going to have a little bit different demand. i would forward working with you. >> i i was here for three

terms anonymous challenges them, as you.out your opening remarks. a lot more services required. i'd like this to give a brief update on the backlog. please be brief. >> absolutely. the backlog is down national. a toy 5 percent. we have been producing now the claims perspective we started this transformation effort.

a quality we have not traded for. it's a big percentage points in is now up at 96 percent. we have not put off nonreading. we need first-time claims that opens the door to more follow-on nonreading opportunity. 1.32 million claims last year and as he saw on the chart the disability level is now on average of 47.7 percent. you have a wider opportunity for many more veterans. since since we last saw you your commitment have you back down 67.3 percent.

there doing much better than they were. they also done also done much better on the mail issues we think this whole committee moving let us down. thirty-two days down the eight days. that's a phenomenal saving. >> trust but verify. >> thank you. following up the challenges you said almost a quote that the va is not ready for legislative help

on this issue. i i would like to see if you think public-private partnerships will be beneficial. >> as i said in my remarks strategic partnerships is one of the five points. historically va has not had as many strategic partnerships. one of the 1st things i found we did not accept the help. so they came from the private sector. secondly, relative secondly relative to construction a lot of changes have been made. probably since the last time you on the community. a lot of times the design was done by architects. the whole design committee

reviews it. i would not because there architect streams are very expensive. secondly elected that entire process where we're training, doing a better job training project managers a number of steps are being taken. as the congressman said we are now working with the corps of engineers and then asked them to do a complete review as well as what part of the process they could help us with. >> on the parochial issue have been temporary structures put up. some of the basic requirements disability

accessible bathrooms have not been met. his basic requirements. >> doctor abraham

a record which is open source, free to everyone as well as crowd sourced in terms of the innovation. crowd sourced innovation occurs at a a much more rapid pace than any company can protect there own innovation rate. their record is open source, source, crowd sourced in terms of innovation. i was at the ama convention talking about the importance of private sector providers using a record so that we can do a really warm handoff working pretty good the warm handoff.

>> it's early days. >> is their when they get their and that we get the annotations back in as part of the work we're doing. >> here to for some of the providers were giving the veterans health records that the entire record where the provider only needed the last discharge summary. >> we need something certainly more seamless and more efficient. >> many that interoperability. >> thank you. >> if i could submit for the record for charts so we have

31 partners, uc davis medical systems. there also is a way of sending the e-mail to that 3rd party provider. we would send the full medical records the va record in the dod record together. modify it so that we can provide that to the third-party providers. they are able to send the url. >> do you have a timeline. six months, 12 months? >> these documents are what is happening now. using the existing systems. they are about a year away.

when have a choice issue with respect to veterans opting in. somebody outside of the system. using the viewer that we deployed last year to add in the capability. >> my 2nd question going back to the efficiency even with that is there a measurement for a provider on a daily basis that we can access or you can access and get us? chairman miller said it's not anywhere close to being acceptable. acceptable. as a physician i know what one exam room can see.

having multiple organ system issues. >> the answer is yes. >> as you get to see last week and the secretary invited anyone who wants to come. it is much more available. understand that some of our providers are also doing research and so forth. all aspects as possible. we post this publicly every two weeks. >> and punishment to the long-term, but if that physician or that provider is not push himself a little bit he is pushing a little bit more? >> i think the word would be motivating.

>> given the issues on access is not a problem. everyone is looking at this data locally and regionally and nationally. >> thank you, mr. chairman. it's really is one of the greatest honors i've experienced in my life. thank you for being here when i look around, some of the most honorable, patriotic command professional people i know. and i have to say it certainly somewhat subjective, but subjective, but over the last year we have had difficult conversations. they were they were difficult because all of us understood the implications of our actions impacted veterans. but trying to find solutions, and i can say from my experience, and i think it's the one you're

hearing your the professionalism and a a willingness to fix this has been greatly gratifying. it feels to me like for the 1st time in a while the department has its feet back under. it's not that we're ever going to stop alley accountability. i accept that and believe your challenges right. we're in this together. we bring up these parochial issues. those are the things that there talking about. i go back to what you said, this is a unique a unique opportunity. this window we will close. as the nature of politics. we need this is on it. i can tell you from the folks that work out there i just came from a meeting a meeting with the group. the nurses.

they want to get this right. them around i care about that. we freeze there pay and tell them the va is not working, they know that's not true. i hear this feedback, from the groups. i just want to go on. i think there is new ideas out there this new model. i want to tie it all together. the 1st thing i worked on was the age a pain management and this comes back again and again mainly because it ties in on so many levels. i think it's timely that yesterday we signed in the clay handbill one step. i recognize the incredible work that is already being done, but it might be an knew way of looking at this new approach that ties in with why we bring these

solutions these are all connected. i agree with you, i've been hear eight years. i own some of that. so what i i ask is when we provided move forward on something, if we figure out a knew model command before we wait for it to run its course we correct and self correct. i know because i for one have bought into your vision of transformation. i want to be that partner and want to make sure i did pass a peace of legislation that added more your plate and did not improve the care of veterans. >> we are very much in favor we partner with everybody who wants to do it. i have the opportunity with the writer of american sniper the leader and team rubicon and talked about the

fact that we are the canary in the coal mine for american medicine. we see things because of the battlefields are veterans go on waiver for the american public. mental health is a big issue any veteran committing suicide is disastrous. the work that you have done gives us more residencies, the ability to pay back student loans. the average medical school student is graduating with about 185,000 and that. the care act, we that. the care act, we can repay from $60,000.20000. i'm working hard to try to get more residencies for mental health and to get greater throughput. but you no of the 22 veterans who we estimate commit suicide today 17 of them are committed. so one of the things i'm working on what we do have

treatments for posttraumatic stress, no how to alleviate it. we just need to get those people connected. >> to all of you unthankful. thank you for working as partners. there are difficult conversations because our veterans are counting on us to have those conversations. >> thank you, mr. chairman. i want to thank you for the opportunity to have breakfast and share with you the concerns of some of our veterans who because of our geographic and economic isolation don't share and all the benefits they are entitled to. our veterans who make up 10 percent of our entire

population have issues that are basic and comparatively small. generally taken for granted. in a nutshell they need a cemetery. we we have no flights. we need access to better health care. the local hospital has no caps can come in a cancer specialist. our veterans must always seek care off island. obama care most of our veterans do not understand always out of merchandise. there's always complaining as to why it is we don't get merchandise and services provided. medical records to even apply for benefits. mr. sec., what i would like to ask you is the va budget submission has identified an expected increase in claims receipts for fy 2015 at

1.3 million in fy 2016 at 1.4 million. .4 million. these figures represent an increase of 17 and 20 percent respectively over the 1.1 4 million claims received in fy 2014. can you please explain what factors and information you considered in determining the anticipated volumes of claims receipts for these two years? >> absolutely. let me tell you that the large portion of that is not going to be the brand-new veteran who is now leaving service transition to us but the fact that we have done so many veterans claims and heavy veteran is entitled to come back which is about 67 percent of our workload meeting is the majority of

our workload, not the original claim. so as a result you can come back and get another. largely attributed to the increased expectation for supplemental claims. and so that is where the majority of it is. >> thank you. >> if we can i would like to bring our over and sit down with you and go through all the issues we care very much about every veteran. >> that would be great. >> thank you, mr. chairman. mr. secretary, i want to thank you for your extraordinary lead over the last six months and feel very confident that the letter of the va is being repaired.

we certainly believe that we are on a good trajectory for really writing the ship. i really want to thank you for that lead and want to thank you also for today's presentation in the analysis and the presentation because i do think it absolutely demonstrates what the challenges are within the va both in the short and long-term and the fact that all of the challenges that we all must collectively tackle for our veterans. i was very excited to go home this weekend and talk to my veterans in ventura county and to let them no that an important milestone has occurred here including a new clinic in oxnard for veterans. it was cool it to me that our veterans were underserved when i 1st went into congress.

and i think this clinic will indeed right and wrong and that our veterans will be better served. so i just wanted you to speak to that because of why my veterans in ventura county to here from you directly your agreement to the need of this clinic and what the time estimates will be to acquire the lease and build out the facility. if you could comment on that i would appreciate if. >> first of all i apologize to you for not visiting ventura county when i was in los angeles. that was a relatively a relatively quick trip when i was there for one reason why to get a settlement with the committee to get the homeless veterans of the streets of skidrow. i will counsel ventura county and get together.

perhaps this will be a good topic. as deputy sec. gibson goes through and looks at our construction i'm hoping that the kind of time we have seen in the past. we will work together. right now i i don't have any estimates but we will get together with you and work on that. the meat to have meet the needs of veterans. >> very good. did you just described briefly what the process will be in terms of our stakeholders, veterans stakeholders, veterans being included in this process. >> absolutely. just like of done everywhere else gone by bring together all the stakeholders were members of congress veterans service organizations, mayors because as i said earlier and i really do mean this this is a team sport particularly in the case of homelessness as an example

we can do the right thing unless we can have all the dodgers want more willing to rent at that rate crystal have homeless veterans. for me what we did in los angeles will be a prototype of what we hope to do everywhere else call the committee together with the local mayor and work to improve the situation. >> thank you very much. i think is more progress to be done. this year's tony tony 15. ours is curious. they set an ambitious goal. your predecessor set an ambitious goal in terms of the `. just your comments in terms

of meeting that goal. >> we think that goal is doable. one thing that is really clear is we do need more people, even people, even though the productivity is up the inflow is so great command is grown so much. and the repetitive appeals has created a workload issue we had to work mandatory overtime a prescription for disaster. i do have some experience leading large organizations. as a result of that we have got to get what you i find even further productivity improvements which we're working on by going into the entire digital record has been a big big improvement. one of the nice things about it is we don't have need any

more space. we can hire additional people. people working on digital files. >> in fact, congresswoman, i want to thank the entire community. we would not have been able to accomplish this without the support of the committee and every person not. you saw the the growth of the requirement from 2,000. thank you chairman and ranking member for being here long enough to see us through the growth. i want to tell you that there is a savings application to this. working through the agreements on what we do with half million cubic feet of keep peddling no longer touch. equal attend mount everest and to the empire state buildings, we don't does that anymore. 95% of everything we doing now is in a paperless environment. when we do we have some potential savings in the

tune of $30 million in your that we can bring back to you and say this is what the benefit is buy or not needing to house all those cabinets and all those things anymore. we're anymore. we're already realizing the $2.4 million savings is simply shipping costs. >> my time is often i yield back. >> thank you, mr. chairman. appreciate the opportunity. i would like to ask a few questions and then discuss the choice program which is important to me. my district includes 63 counties and touches for different and create some problems. distance is the main problem email contract from a veteran _-dash 340 miles one

way for cardiology. if the va choice program can provide something closer for him then we need to relocate how we implement. the one thing i would like to ask you and there is concern with providers for veterans are looking into taking advantage of that is the fact that it's only temporary. are you and the administration committed to making this a permanent option? >> as you know, we have had an external program. as we look toward a future where the network is both va care and outside. we're also going to an analysis, given the relatively low rates, but i don't want to assume that is going to continue for our talking about how we can do a better job marketing it and also if we should look at that 40 miles and change the interpretation of it get get cd_something differently

so we can make sure the program is robust. >> and your thoughts? >> i'm all for it. i'm all for whatever it takes

>> you can get your services and driver hundred mi

all the brave men and women that work so hard deserve the help. what they don't deserve is a knee-jerk tried to band-aid on a gaping wound fix. i appreciate the thoughtful way you are approaching his reforms. they're going to serve the men and women who protect us in the long run. i have a couple of quick questions. you mentioned the 22 veterans who commit suicide everyday. seventeen of them had not

access any service. we spoke about this. how are you going to reach out? >> there are number of things we have to do. we have to eliminate the stigma parameter healthcare. i'm thinking that this is a for to his moment in time because american sniper is the largest selling war movie the starting to do that. that's why i went on the charlie rose show last night to talk about this. we were together in el paso and looking at a private sector hospital. there was a neon sign at the top of this one building to the said mental health clinic and i was in a car in the parking lot. i i turned to him and said of course. of course there's not a car in the parking lot. what we do is take our veterans through the primary care physician into the mental

health treatment and as a result of that the stigma doesn't exist and they may not even know there talking to a psychiatrist. we have to get rid of the stigma. we have to reach all the veterans. we have the ability to put on tv a public service campaign that the council worked with us pro bono to get people signed up. i don't feel yet that we are ready for that. our capacity is so strained if we were to get more people into the system we might have issues. we have to train the american public. public. if you see somebody you think as an issue we have an acronym. seeing and recognizing the individual may have an issue, i like you can call and we go immediately and action.

the medical exam is also a big help but we have got to get our arms around the 17 veterans and care for the. >> i know that there was discussion in terms of the facilities in california that are vulnerable to earthquakes. earthquakes. the va is just outside my district but i still claim that is my own

again thank you so much mr. secretary and your entire team and i yield back my time. >> dr. bennett check. >> thank you mr. chairman. thank you secretary vilsack for being here with your team.

i think a lot of the members this morning hemperly asked a lot of great questions and touched upon a lot of issues i want to talk about. i want to commend dr. wenstrup for bringing up the cost of care and that's something i'm very concerned about and i wanted to ask a few more questions about when you think you are going to have an idea or is this independent review of the va system, is that going to help look at that number because i know i'm very concerned about it and continuing to implement access to care locally and can you elaborate on that a little bit? >> sure. in addition to the external independent assessments which we anticipate will be here around august or before then we are commissioning internal work internal contracts and so forth from some of the leaders in the industry to figure out how do we get to some of the questions you raised in your recent hearing

when he presented and so forth. one of the issues we struggle with in terms of cost is this reliance factor for some veterans use va for some of their needs but they go outside for others. my uncle recently told me he got his hearing aid but by and large given where he lives it does not go to va for most of his care. it goes closer to home so that's part of the issue that we have got to work through as well as this issue of fixed and variable costs and again i think this is why the secretary raising this issue of costs that are a drag on the budget in terms of getting to the issues of access and veteran experience are so important. >> i think that is what dr. westrich was talking about come the cost of these half billion dollar hospital overruns, that all adds to the cost of taking care of the patient walking into a clinic and i just want to make sure that all these costs are

included in that because we are supporting a bureaucracy. are we supporting way too much of a bureaucracy for the care we are getting out of it? that's my concern. >> it's a fair question. >> let me ask another question here and this is something else we have talked about in our subcommittee as well is the management of pain within the va because i know it's been over a year since we have talked about this in my subcommittee and is opioid medication and the high doses and a number of prescriptions written and then this recent incident with aig and talmud. what has been going on in the va recently to try to address pain management? is there a better pain management system? is there a referral to pain management specialist? tell me what's happening more recently and how are we going to

put an end to the practice of using opioids on a chronic basis for people with chronic pain? >> ls dr. clancy to get into the specifics of one of the things i want want to stay in the beginning is we take this opioid use very consistently and we track it. one of the things i'm most proud of that we do in the va that i don't see as much of in the private sector as we use a lot of alternative approaches and alternative medicines. we use acupuncture. we use yoga. we have used electronic devices that have been shown to be effective amongst some of our veterans. anything we can do to get that veteran off of opioids is something we want to do and we are developing quite a broad array of tools that we can use that allow us to reduce the opioid use. >> well i mean that sounds great mr. secretary but i think if you

look at the numbers of people on the alternate treatment versus the opioids you would find there are a lot of people on opioids compared to the number of people on those therapies and it's great you mentioned those things but it seems to me there should be a lot more people having access to pain management specialist that are being treated by their family physician or other primary care physician. >> so really incredibly important is this issue. i think as you know from your prior hearing and i'd be happy to refute in more detail we actually track opioid use per facility. each facility has a dashboard since we launched this initiative. we have seen a trend line go down which is a good thing but we are also looking at the prescribing patterns of individual physicians to see to make sure an overall positive trend that is going down isn't masking some practices that we

would consider suboptimal. we are supporting a lot of research in this area as well because for some patients the combination of nsaids and so forth -- >> apparently the situation contradicts what you are saying here today and i just want to be sure that we maintain the high vigilance on this problem. i'm out of time but i appreciate your efforts. >> thank you. >> thank you very much members. ms. brown has one final question. >> thank you mr. secretary. thank you for your service. i have one question. just a few minutes ago the congressional order came out and i don't know whether you have seen the article va health care and i guess they do this order for two years. seems like they were rehashing a lot of the stuff that is going on. i appreciate you going on television and we need to respond. in our town hall meetings we