they will be approved by me prior to submission the congress. third,. third, institutionalizing project review board similar to what the corps of engineers district offices use. conducting preconstruction reviews of major projects. integrating medical equipment planners and to the construction project team from concept to activation. those measures will help us in the future but won't finish denver. after analysis we inform the community the total estimated cost of the facility would be $1.73 million an authorization increase of $930 million in additional funding of 830 million. we were -- we believe requesting funds is the best approach when the difficult choices before us.

those reductions would have these effects. it would cut veterans medical care by $690 million. it would eliminate the funding for four major construction projects. this would reduce the va ability to provide additional outpatient services and will impact the following projects. the planned rehab therapy building in st. louis missouri. the initial phase of the alameda california outpatient clinic, construction of the long-sought after french california community-based outpatient clinic.

the replacement 155 bed community living center in. center in. ., maryland and would eliminate funding for cemetery expansion projects in st. louis portland riverside, bayer month, and pensacola and a new column in alameda at reducing our ability to provide burial honors for as many as 18,000 veterans and eligible family members annually. the impact of these tested veterans care and benefits is unacceptable to me and i no it is unacceptable to members of congress. chairman, ranking member members of the committee, thank you for your support for veterans and for working on his budget requests. we look forward to your questions. >> thank you, chairman. >> i would ask unanimous consent if i could put in a statement that cory gardner gave us on this issue. so with that 1.173 billion the denver hospital would pick up money for 7.9 years.

in the case -- it would also take up four years of no confidence operations. that's an awful big it. i would i would add to your list of things that were done wrong in denver that you did not have the army corps of engineers oversee the construction of the facility. i want to make sure by june 1 you have done that. >> mr. chairman, we have done that as of today. the corps of engineers is active on the ground. we are working with them in concert and continue to want to use the corps of engineers and other major projects. may i make a statement mr. chairman? this this is not really a hospital. this is a medical complex. this is what the complex looks like, and it is many

buildings, not just one very close to the medical school. school. so this is a major undertaking of many buildings, not just one hospital. just just want to be clear on that. >> your proposal has been to take a billion dollars from the care act to sink into this thing. that would eliminate about 20 percent of the care act money. the promise we have made to american veterans what we do not want wealth because of the mismanagement of gender facility. we need to have the people fired and no longer a part of the panel. >> the gentleman that was in charge of construction at va is no longer with us. >> that means you let them quietly him quietly retired he is the collective the taxpayer. >> he chose to retire the day after the interview that he had and the best of my

knowledge both in the private sector and the public sector it is impossible to call back and retirement unless malfeasance is proven and the investigation is ongoing. >> we had evidence of a whistleblower who sent an e-mail early on and so this was likely to go 500 million over budget. that whistleblower was fired by the va because of that e-mail. i i want to make sure this process of nailing whistleblowers is wiped out. how would we have that happen? >> i am not familiar with the situation you are describing but i but i would love to be able to get more information on the follow-up. we have been working with the office of special counsel to make sure all whistleblowers who have been retaliated against --

>> let me get it for the record. the person you are talking about was glenn hagstrom. >> yes, sir. the person -- [inaudible conversations] >> $500 million over budget. that person was lego and it turned out to be exactly correct. >> as i said it is acceptable to retaliate against anyone who is criticizing our operation. in fact, we believe that we want employees to help us improve our operation. the only way that can happen is if they are critical. we work with a special counsel to get certified. we celebrated with a national award some of our whistleblowers, one in particular from phoenix, and we are committed to make

sure whistleblowers are not retaliated against. it is just unacceptable. >> want to make sure we do not wipe out money for the overrun in denver and stand by our veterans. >> we just don't know how much of the money will be used and how quickly. >> mr. secretary, i understand if we wrap up the denver situation it cost $3 million a month. do you understand that to be true? >> i am not familiar with that figure. >> we do not have that figure, but we will check on it. >> let me go to mr. tester. >> thank you, mr. chairman. it goes without saying the chairman and myself and everyone in this committee knows how important this is to our veterans in our country and how we need to do a job together.

with that, i no the house subcommittee mark came in 1.4 billion below the request. they achieve this largely by freezing the major construction level of fy 15 and including a number of other funding cuts in the past. there have been folks on this side of the days that have criticized the va for not being frank about what you need for money. a lot of criticism was warranted lead to funding led to funding shortfalls and subsequently had to be addressed three emergency legislation such as choice act. and and now a lot of the folks who demanded more results from you are the same folks who refused to give you flexibility and resources you need to achieve the results that our veterans need when they come to see you. is it fair is it fair to say that the house subcommittee mark is inadequate? >> it is inadequate. it will

cause veterans to suffer. as i said in the house subcommittee hearing on the budget we put in this budget knowing that it was going to be very tight versus the demand that we face. and in addition to the budget itself we want to flexibility to be able to move money from wine out of the line item. as i said to the chairman, we chairman we can predict whether veterans will go for community care for the choice act i don't have the flexibility to move money. >> is also fair it also fair to say that due to the amount veterans getting older, you are getting a lot more demand on your facilities? if that is true, can you tell me what that would mean to the vetting -- the veterans and the families? >> the 1.4 spending cut basically means that less veterans are going to get care. the medical care is being cut by 690 million which is

the equivalent of 70,000 fewer veterans receiving va medical care. >> so as you see demand go up you're not going to be able to come" we won't have the money to care for them. >> okay. hiring. we have discussed this several times. workforce shortage. it looks it looks as if it is static at best. we could be losing ground. his injury are battling on two fronts. keeping the ones that we already have. the va needs the resources to hire good people, let them do their jobs come and hold them accountable for the outcome. i am worried that the cascading is crushing the department's ability to address workforce needs that we have in montana and i assume elsewhere.

this is not to excuse any wrongdoing or dismiss any legitimate allegations of misconduct but a lot of folks around here are quick to go after a headline at the expense of hard-working men and women who are doing a job working with veterans even if it means less pay and longer hours. my question to you as the headman to what extent is this impacted your ability to recruit? >> sen., as you know, i have bent over a dozen medical schools and talk to candidates to become nurses and doctors. and the constant haranguing on things that have gone wrong months ago, years ago has affected the public perception of the va and makes our recruiting job that much more difficult. we have increase the salary bands of doctors, looking for the competitive pay of writers within the system. hired more doctors to mired

over 800 more doctors, 2,000 more nurses and have opened new facilities. we have to build the capability to be ready for five, ten, 20 years from now. >> they get a $60000 bonus. the bonuses like that.

how can we ever take care of our veterans. >> i believe that bonus was for 2013 are before not for recently. recently. as i said we have got the administrative investigation going on. as we get as we get to the bottom of this field figure out what the appropriate action is. >> mr. bozeman the vast majority of the personnel are working very hard. the thing that shows that is how few have actually access the program that we are trying to stand up so that they don't have to travel. when a bring up an issue that was before your time. and yet it is hard in the sense that people are losing

faith the va received an $8 million grant. they proved the parking deck project construction began. the planned parking garage. aware of the conflict at the time. august of 2013 the solar panel construction was completed. in april 2015 the va dismantled the parking lot and is still not clear as to how much it is going to cost

to put them back and whether or not they were ever able to function in the grid to begin with. so, i guess what i would like is for we have these things going on. one of the safeguards that we have? how are you dealing with this kind of stuff? >> i mentioned some of the changes we have made to the process of construction in my comments. i also mentioned that we have changed the leader. we have a knew leader named greg gibbons. he has experience across many sectors of government and has done this before. i also happen to be an engineer. my certification as my certification as an engineering training. i studied engineering at west point from the state of pennsylvania. deputy secretary is a former cfo of a bank very bright intelligent guy. we're digging into this in the strongest possible way

and i would just simply say that is not going to happen. that happened in 2012. i appreciate you bringing it up but that is not going to happen in the future. is just not going to happen. we are having design committees, outside people review our processes, using the corps of engineers, refusing the best practices available an industry today in order to make our system better. >> i think one thing that we have to be very careful of that process started then and yet i don't know how forthcoming the va was in admitting that the process was there and even now when you ask how much is going to cost to reinstall we get terms procurement sensitive, something like that. that is not a problem. >> i hope i hope since i became secretary you have seen an increase.

>> and i appreciate that. >> and an increase in our transparency is a department. i do catch instances where i wish that we were more transparent and better about customer service. >> the other thing that i would like to mention, and i want to complement you in this regard. we had a group get together in little rock to discuss reimbursement to providers that have provided outside care. you will have situations that arise in of the va where because of emergencies or now with this rule that the va owes the money. it appears that the va owes lots of people in arkansas a lot of money and has not been very forthcoming in paying his bills. that is a real concern for a couple of reasons in the sense that it is another thing that makes it such that the trust issue we talk about. the other problem the other problem, if you do not pay your bills they will quit dealing with you. and that is the greatest

thing which really will affect quality of care. can you quickly mention that? >> i will. throw in a comment. i talked about our strategies. strategies. one of them i talked about was improving internal support services. and going to a shared services model where we centralize all the people. we have more work to do, but that will dramatically improve the rates people get paid. >> yes. i would just add that we are tracking this rate of payments and help the claims are a weekly basis and am pleased to say that is what arkansas as part of them actually improving faster than other networks. you said it well. if you don't pay your bills people will say i would love to help you but i have to pay rent to veterans.

>> and again, your people were helpful and did a good job in arkansas. >> thank you. >> mr. udall. >> thank you very much, mr. chairman. let me along with the rest of the members echo your new aggressive leadership and what you are doing in terms of veterans. i really respect the team that you brought in. this more businesslike approach to what is an incredibly important issue for veterans in my state and across the country. and let me thank you, too, you, too, for the constructive dialogue we have been able to have moving the va forward as you near the end of your 1st year as secretary. as we discussed new mexico ski issues can be narrowed down to ensuring veterans have access to care.

too often they are prevented from receiving the care they deserve because of barriers to access. starting with starting with disability claims many veterans are unable to have their claim adjudicated in a timely manner. in new mexico progress to reduce the backlog is stagnating, and that is the chart i have i have behind me. i think i have shown you that before where we come down dramatically, made good progress, but it has stagnated and i am hopeful we can get the resources to make progress in reducing the backlog once again and where it stagnated and started a downward turn

>> first of all, great start. >> we publisher numbers every two weeks. we want to be transparent. >> and we appreciate that. >> as we went back into

mandatory overtime we started pushing again. that has now come down. because that has come down as of right now in april you are down the 47 percent in the backlog 3500 claims pending command 1500 of them in the backlog. you will see the continued downward slope that you saw earlier for the next three months at a huge drop-off because pretty soon every claim will be in the backlog but that won't be just for your state that the entire nation. we should have zero backlog. >> this is an important strategy. >> i have run out of time. if you could briefly. >> i would simply say that new mexico is a model. working closely with us. this is a matter we can use

tell a help telehealth to bring that expertise to the clinicians working in the rural communities. it has worked phenomenally. >> thank you. pretty amazing. thank you. >> thank you, mr. chairman., mr. chairman. >> thank you. i want to thank the secretary and others for being here today. i would like to thank you for the flexibility and willingness to work in the 40-mile. we talked about it. as you know, in a state like mine, 40 miles as the crow flies can be ours in the car this helps veterans across the country, certainly in my state. i no you are aware of this issue and greenbrier county. close three times from old. some unhealthy conditions in the facility because of there quality. and i think that i read that the bluefield mobile unit

will be serving the 2400 veterans in that area. i no i no that this is specific, but if you had any other alternatives. >> i would like carolyn to comment about the specifics. i would like to reiterate what i said. facilities are too facilities are too old hvac systems need to be replaced about every 25 years our facility is too old. i talked you about facilities that are over 100 years old 90 years old. we have to decide which to close. i talked about that, and which to refurbish so that we do not have these current problems. we cannot do that with a budget that has been marked down 1.4 billion by the house and the major construction part has been gutted by almost half. >> i would say that we are hopeful for the moment that

we may be able to resolve these air quality issues. i also want to.out in terms of 40 miles that is not part of the calculation anymore so it should offer more flexibility. and the mobile units, those are the plans that we have right now. this will remain high on our agenda. >> thank you. >> it is definitely a problem. and i understand. i briefly ask you. since you mentioned access properties 306 buildings are empty. you are empty. you need help with that. how do we help you? it is not just budgetary. as a statutory? >> the president has put forward what i would call a civilian brak. in other in other words, the idea to take our facility and have an up or down vote across the federal government. i think that is a brilliant idea.

we must become more efficient. i efficient. i suggest that it be passed and we go at it. >> you mentioned that these are the my va regions. >> yes, ma'am. >> doctor clancy mentioned vision. this is va 101. are the visions gone? >> what we have done is started the process where we are aligning the visions with those regions and in doing that we are taking a new look a new look at the visions and seeing if there is an opportunity to reduce the number of visions. the issue we have right now -- and this is a huge issue that reflects the actions being taken and accountability, 91 percent of our medical centers have either a new medical center director for new leadership team where we gun leadership now, knew leaders in place. ..

we just had a leadership change at that b.a.. are you seeing anything yet, too early to tell? >> i would be happy to follow up with you on that but i want to make the point for you and your

colleagues that we are tracking the access and quality issues on an almost daily basis but i would be delighted to follow up. >> thank you for that. >> and that food be happy to invite any of you to come to our daily stand up that we do every morning we review the data and take action. >> thank you so much. thank you. >> mr. schatz. >> thank you mr. chairman. i know va is working with dod so that the two can share servicemembers medical records electronically but progress as you know has been slow p.. >> gao cited the lack of progress is an issue and added va to its 2015 high-risk list. according to gao quote the two departments have engaged in a series of initiatives intended to achieve electronic health record interoperability but accomplishment of this goal has been continuously delayed and has yet to be realized.

the ongoing lack of electronic health records interoperability limits of va clinicians ability to access records and so on. what kind of progress are you going to be making and when can we expect for you to be off of the gao high-risk list? >> first of all when i met with ahead of the gal isp put on that list. they run the largest largest health care system the country and the crises that occurred i thought it was appropriately run the list. i think the transparency and visibility is important to improvement. secondly we have made a lot of progress on the electronic health record. maybe i could ask staff to go over that but also i would like to offer the members of the committee that we would be happy to come to your offices and demonstrate the interoperability of the dod nba record. i think once you see it you will become much more conversant in the progress that has been made. >> thank you mr. secretary. very briefly if you wouldn't

mind. >> from an interoperability standpoint we depend on three levels. the first one is moving the data within existing systems greatly share market than any health care system in the world. our future is how do we get all the data into view a massive demonstration the secretary offered. today you now can see all the va data for many medical center and dod data as well as third-party provided data in the same screen so the data has been normalized. providers can look at it and they can make decisions based upon the continuum of time. >> so what means to be done? >> the two next things i need to happen as the viewer that shows the data is just viewing. we are not able to go in and change the data. that's the next generation. >> is that a big technological breakthrough? >> it's two-part. the first part is making sure their common standards so working with the office of the national coordinator to come up with national standards where there are no national standards we work with dod to put those

standards together reared. >> clinical standards? >> we are using the same definitions so a lot of effort over the next couple of years to make sure what standards are in place and when you go through and convert the data and meet the standards in the second piece is to make sure the tools are there to show the data at the same time and we can start changing the data. >> a timeframe for all this? >> be enterprise health management platform -- the. >> let me step in and deliver a threat that i have been saying to d.o.t. if they insist on having different standards standards that we will go is just the va standards because we represent a number of standards in the population but that will forge in the greed on standard and will be a va standard. >> thank you for that sir been a lot of strong work in the fight to bring a third party in the office of the national coordinator does the standards for third-party private platforms and with the access to

care act with more care going outside and it's not just the va and dod sharing but how do we get to private providers in the same standard so their data can come in and be part of that continuum. >> so start to finish do we use some of this work as you are moving along but what is your total to completion? >> the enterprise health management platform will be at 33 sites by the end of the calendar year as a demo. next generation and we will be adding capability on over the next three years until he faced out what we have today. >> enqueue and mr. secretary want to ask quickly about below half that center on the island of palau who. i have talked a couple of times that this will double plan services for 1.2 million people and tens of thousands of veterans in the city and county

of oahu. >> this is going through the planning process right now. we expect it will be advertised in the late fall of this calendar year and then the award will probably happen in the first quarter of fiscal year 2018, so it's going to take time but we are very excited about the access opportunities. >> you said dare advertise this year and the award will go out in 18? >> did you mean to say 16? >> no the actual final award for the construction will happen the first quarter of fiscal year 2018. the construction will be complete in the last part of 2020. >> my time has expired but i would like to understand why you go to years from advertising to an award from the beginning of construction. thank you mr. chairman. >> thank you very much mr. chairman. mr. secretary, i too want to thank you for working with many

of us on the 40-mile rule to change it from as the crow flies to actual driving like senator capodanno i represent a state where as the crow flies and the driving distance are two very different things. but the va still does not consider whether or not the type of care that the veteran needs is available at a va facility that is within that 40-mile limit. for example, in western main there is a va mobile unit in being a main that operates only two days a week. we are glad to have it but obviously it's nowhere near a full-fledged facility that can provide and meet the needs of our veterans. that means that veterans in

jackman maine could go to a hospital, local hospital that is 35 miles away, still a distance but much much closer than going to the va hospital for care or they could go to the local community health center right there in jackman to get care if the 40 miles were considered to be measured in terms of whether the service is actually available. the service obviously is not available at a two day a week mobile clinic. it is available at the community health center and hospitals 35 miles away. these are not always available to our veterans in this area due to the interpretation of the 40-mile rule. are you getting -- giving any thought to being more flexible in that area as well? >> we are in the process of analyzing it and working with

members of congress on what we discover. first of all the idea that whether or not you can get care from your local facility is actually written under the law so it's not an interpretation. that was the way the law was written so if you would like it changed you need to change the law. secondly, our initial calculation suggests that if we were to make that change the minimum increase would be about $10 billion a year. not over the three-year period of the choice act by the year and it could be as high as $40 billion a year. if we opened up that capability or that aperture for veterans so we are in the process of looking at this and what we want to do is come back to you with the boundaries on what we discovered and what our assumptions were and have the discussion if that

is a law change that you would like to make. >> there may be some sort of middle ground here because in that case i gave you where the facility is not even -- it's a mobile unit that's open two days a week it just doesn't seem like a reasonable interpretation. >> there is a middle ground point that we can take which is two and a sense change the geographic burden to give the secretary more flexibility to allow people with the geographic word and of some kind to use the choice care, the community care and that we are also working on we will come back to you with the definite -- definition of data and how many people that will affect. >> yankee. i also want to associate myself with the comments of the senator from arkansas about slow payment to positions and hospitals.

this is a problem in my state as well. the problem is that if the va ultimately denies the plane the hospital has missed the deadline for filing a claim for reimbursement to a secondary insurer such as medicare so what happens is the health care provider ends up not getting paid at all. so i really hope some energy will be put on this problem. >> as i said is one of our most important strategies. we simply have to get it right. >> thank you. and finally that 10 seconds but i have left, the va in consultation with the national association of state veterans homes began working on regulations that would govern adult daycare so that there

could be respite care for our veterans who are living at home but may be suffering from alzheimer's or other dementia is is. and that has been in process since october of 2008. it far precedes you but that is more than six years ago and for the record since i am now out of time i would ask you to give me an update. this would make such a difference to so many of our veterans and their family members and it also would reduce nursing home costs and costs at the state veterans homes so i really think this is something that should be finalized and should not have taken six years and still be pending. >> we agree and we will get back

to you. >> thank you very much mr. secretary. >> thank you mr. chairman and ranking member for this hearing today. secretary mcdonald you noted in your testimony that the va is really at a crossroads and that you struggle with significant challenges including internal management controls as well as the delivery of appropriate care. we have talked a number of times as i have with dr. clancy about how these two failures have had really tragic results in a particular medical hospital in wisconsin the talmud va medical facility. i look forward to working with members of this committee on a number of steps we could take including legislation and programmatic initiatives to correct to for these failures, to improve the quality of care that our veterans have earned.

dr. clancy your clinical investigation into the talmud va va, you have initial and term findings and i it's ongoing but with regard to opioid prescribing you found that tome was almost double the national average when it comes to rates of prescribing opioids in benzodiazepine's concurrently which is an unsafe practice of the va's own clinical practice guidelines for opiate arabi warns against. jason and -- prescribed both of these drugs and tragically passed away at the talmud va. i want to start in asking you if you believe that the va has

adequately managed implementation of the clinical practice guidelines for opioid therapy at the local va medical centers? >> i would say we made a good start and we have far more room to go and that's just what we are doing right now. the initial approach which predicts both of us to start at the network level than to go down to the facility as we have had a chance to brief you and your colleagues. this is now getting down to the individual one is an level because we can do a much better job. the irony of course is that facility of tome you're veterans are less likely to be on narcotics than the national average but they are getting high doses they are far more likely to be on the dais of being's and we are also looking at how we can start to bring this down to the individual patient level and i think of that in two ways. one is you would expect the

initial efforts to reduce the use of opioids probably were most successful with those veterans struggling to least and what we have now is a group of veterans with the most challenges with chronic pain and other complications. the second is i think that we desperately need to figure out what is the risk point at which someone transitions from taking narcotics sometimes say for low back pain as an example. is it a month? is it a couple of months? where is that point where the risk level goes way up because i think that's where pain management intervention is most like you to be successful. so we are going to have to start to customize this much further which is the whole point of the academic detail initiative that has now been mandated and will be required for full implementation by the end of june. >> i want to follow-up on 2.2 just raised in that answer.

one of the problems at talmud was obvious dangers prescribing practices were considered within the bounds of acceptable care. question one is do you believe that the current va prescribing guidelines which were last updated in 2010 are due for an update and then the second question and it may have to wait until the second round relates to driving these down to the patient level and involving the patients and their families were actively in treatment protocols. >> two quick responses. given time i'm happy to follow with more. first is the guideline which was developed jointly by the department of defense and the va will be updated this year and they will be starting that process this fall because we know on average our practice guidelines need to be updated about every five years absent

some kind of new breaker evidence. that's the first thing and the second thing is we actually now require all patients on narcotics actually sign an informed consent and that is part of their medical record every year. i would say that's a down payment on the conversation that you just reference and i'm happy to follow-up further. >> thank you. i feel like i have come in like a gust of air. first of all senator tester i would really like to congratulate you on the work you have been doing at va. you have been proceeding with due diligence and the other usual sense of bipartisan that has been characteristic of this committee to care for our

veterans so is the vice chair the full committee everly want to thank you for your job and i will do what i can to get you a -- i would like to first of all say hello to secretary mcdonald into his team here. i'm going to engage so in a bit of a maryland question. first of all mr. mcdonald thank you for the job you have been doing, which you have got a big job and i think you are finding under every rock is another rock. we found the same thing in maryland. i asked the inspector general of the va to investigate claims that have come to my attention in my constituent area. allegations that somebody had mouth cancer and was not properly to believe fed. somebody who didn't get mental health appointments and later committed suicide.

there's not a need to finger point but to pinpoint and inspector general came back with findings. the facilities in maryland didn't follow the outpatient feeding policy, that they needed to comply with policies related to basic protocols for mental health services. but what the inspector general did was come out with nine specific recommendations. rather than taking the time of the committee to read them, you know them. i have the report here now. could you comment on it and could i have your commitment that you will do everything you can to follow up on the inspector general's recommendations? >> yes maam. i'm a big fan of the inspector general and the work the inspector general does. when i was confirmed i had a think about 100 ig

investigations pending and i think we are down to something less than 70 now so they are still coming out and most of them date back to two years ago but we take them very seriously because they are an opportunity to improve. we remediate every single finding that they come up with and we will certainly do that in the case of those in maryland. >> did you want to say something dr. quincy? >> i just would say what the secretary said that we will follow-up on this closely. >> are you familiar with this? >> yes. >> some of it is kind of surprising. first of all i really do appreciate and look forward to staying in touch on the follow-up to the recommendations because they are not only for maryland but they are also for the rest of the country like the home feeding tube protocols, mental health response time

protocols, the basic bread-and-butter. the other is the question relating to choice and implementation of choice and i have been an advocate of that. have you all covered that in the question's? >> yes maam, but go ahead and ask and we will fire away as quickly as we can. we also covered the replacement of 155 dead community living center in maryland that has been stripped out of the house budget. >> you are replacing its? >> we had in our 2016 budget money to replace the 155 bed community center and that was stripped out of the house markup markup. >> i would like to mr. chairman, mr. vice chair, top talk with you about this. this is a facility that is

really oriented to mental health and takes care of veterans with significant mental health challenges as well as alzheimer's unit. some parts of that delving are oh my -- pre-world war i and i will ask the to validate the need and the necessity for the request. i think it's a compelling need. on the choice card i understand and it's a program that i supported to shrink the waiting list but i understand that the 8.5 veterans that have been issued choice cards less than 1% have been authorized non-va facility. would you give us the status of the choice program? is isn't working the way we hoped and if it's not working is a bureaucratic and what is the

issue here because this was meant to be an opportunity for veterans who need to work like my mountain county veterans. they are far away. the eastern shore. >> first let me start senator with a thought that community care is important to the future of the va. currently today even before the choice act about 20% of our appointments are community care meaning outside the va so this is very important to us. in the choice at its not yet worked the way we thought it would. we haven't had the number of veterans go outside the va system and use community care so what we have done is we have redefined the 40 miles, how you measure the 40 miles of driving distance. we believe that will double the number of veterans using the choice card. we think that's a big improvement. we are also looking at other improvements. we are doing marketing.

we are doing web sites. we have a public service ad. we are writing letters to veterans making sure they understand the system because many of the cards won out over the holidays and admittedly a lot of people don't look at their malibu holidays. we are looking at everything we can to maximize the impact of the choice act. >> thank you. my time is up. i would say to my colleagues the choice act does offer an opportunity which could use the 535 members of congress there are town halls and our newsletters to help with that. we hear complaints and we would like to be share with them opportunity. >> that's a great idea. >> nothing political but really about this opportunity particularly for the primary care that this could provide. >> we would love to join you in writing letters and we would love to put a link on your web site to the choice care web site

site. anything we can do to increase communication, we would love to work with you on that. all members. >> thank you very much mr. chairman. >> dr. clancy. >> listen a friend of mine i am a liver doctor at a friend of mine tells me the va approached him for treating -- treating hepatitis c. the only thing to clear hep c are those with cirrhosis. i suppose if you have cirrhosis that's great but really you want to catch it before it gets to cirrhosis because once you have cirrhosis you have a life long risk of cancer in that sort of thing. first any comments on that and then i have a follow-up. >> issuer where senator cassidy the treatment for hepatitis c is very expensive. the private sector is roughly

$1000 a pill. we get it for about $650 a pill so our treatment is cheaper and arguably we have the best protocols of any medical system so we do want to use it. but it has become a huge proportion of our budget and as a result of that we have asked for incremental money in a supplemental appropriation for hepatitis c specifically because i think it's a moral and ethical issue that we have the treatment. we know what to do and we have patients that need it because our population is disproportionately has hepatitis c and we cannot use it. >> we are doing a far better job than the private sector in terms of screening and identifying veterans who have hepatitis c and actually getting them identified. we have a cure rate that is almost as twice as high as the

private sector. >> i can't be twice as high because 90% of private sector. >> i mean the per-person of veteran eligibility. i used the wrong terminology. >> to follow up because i want to learn here. the fellow told me is what we were told to send someone out to get a prescription from an outside provider which would trigger the choice act fund of money but then they can get their follow-up once they have the hour x they can follow-up with the va. you alluded to this in an earlier part of your testimony the pot of money for the choice act is not being used for pharmaceuticals that is not fundable i am gathering. no one is treating hepatitis c except the va docs and they have room access the pharmaceutical portion of the money. is that correct?

i am asking. i don't know. >> your point is correct. the inflexibility of moving money causes us to try to do different things with different pots of money so by sending someone out we can use the choice care money and get them treated whereas if they were internal given our budget issues in the pharmacy we may not be able to treat them. >> so the pharmaceutical portion of the patient's care is also under the choice that? it isn't just the doctors visit and the surgery but it's also the pharmaceutical? >> what we are thinking through and no final decisions have been made although our doctors have very strong opinions because we have built up a tremendous capacity and expertise is that we would refer eligible veterans to a community provider but they would come back and get the medications from us. so it would be what we pay. >> going back to your protocols you have a protocol on whom to.

in who not to treat. as a doctor i would not like the panel the score needed. we will send you out here because this is how we access this pool of money but you will follow up here because we have a better protocol for management. the decision is critical at its outset if you will. shall we treat this person and have them counsel that severus sort of thing. is there no way around that? ..

>> >> so if there is no way to expand coverage and i thank you for your indulgence. >> speaking from the vice chair personal -- first of

all, the reason to stay in one place. in is seen as the inability to have flexibility here is what i am suggesting with maya leadership what is it that you need from us to give you the flexibility to do that? and whether the impediments? we authorize if we could do something because of the doctor patient relationship the tissue can buy in bulk and now there is

bureaucratic rigidity with fat senator cochrane. >> but this is us bigger issue to put our doctors in the position to make decisions about somebody's life or death. but this is an important issue because with the choice program we allow the veterans to choose i cannot move money from virginia care to choice care or back but yet we have introduced the invisible hand. but i cannot move money to care for them so my biggest

nightmare is i have money in the wrong pocket. you would not run a business this way. >> can you help us? >> i would love to. communicate with the chair and the ranking member. >> they're both supportive. we have talked with both of them. >> is right on the head and the challenge will be that congress is the problem on this. congress pointing fingers at the secretary to say you did not promote the choice act you know if if we keep it in there you will not promoted by bikinis the flexibility of transfer in both directions say to you for taking time with us today.

with the choice program let me add another wrinkle for you to ponder in a way that works. you are going to have to prove to extend the reach of the choice program to have that ability. that would have been to your laundry list. but with car travel that would help one that is not exclusive but it plays out in places like chicago or los angeles but that car

ride brings you into a new york city. but they should not make it. with the d.h. ways because technically they could cat in their car to get to manhattan or the bronx. in touch with those basic numbers you have assigned based on knowledge that you are bringing people into the program as possible?

>> the geographic burden statement in with that geographic burden that could solve the problem you are describing perot but we're looking to reinterpreted and we will work with you on that. >> west haven facility first of all notwithstanding the weight time so are the backlog that we could get veterans in on time but it is an old facility that needs to be replaced it still has more in style betting that is of a big deal in the competitive endeavor where. if you don't get the ability

touche transferred dollars to the extent where else do you go for these capital dollars? and they will go unused potential if you don't get that transfer authority. >> we have 70 line items talk about the mark upon the construction bill to cut in half. it is ironic that congress passes the lot to tell us what to execute if we don't get the money then i cannot make it match and when i look back at 2014 before i

became secretary it was of mismatch the way the agency is run not looking at customer needs i will give us much more focused but i need though wherewithal to do that. i cannot print the money myself. the choice is to decide day different benefit profile or provide the money that is needed for what you have already approved. >> have the second question but i will save it. thank you. spirit by have several questions the whole committee does not need to hear this and i faked you for your service.

-- thank you for your service as to make welcome to the community i appreciate the opportunity we had to visit last week's items are appreciative you have the time to visit with katherine hoover is not only been of leisure to work between federal systems to provide for the innovative level of care. i am excited about this proposal. as chairman and ranking member i do think as some point it would be wonderful for this committee for the veterans around the country to understand the model w

seeing in alaska to give large spaces in limited facilities to figure out through the community health centers providing a level of service to veterans headed is the media. working with the secretary i think we can look to some models that could work is in rural parts that will provide the benefits that veterans have honorable leader and in a way that is good care closer to home but when i am on the road ahead will face occur when i am away from home.

with our native people so it is something of a light year talk to the committee further a and in that vein we do have these partnering setter going on and the range of choices is good to recognize we have a range of choices within the system that still has the structure i worry of records and sharing data to make sure that the separate rules within these programs don't cause more confusion or limit with their abilities to access. i think secretary, can you

give me any greater assurance how we are coming along with a more fully integrated system with this unique model bc play out in alaska? to make we have work for a single model that is integrated. we have five different ways a veteran can get care in the community. of those each has a different reimbursement profile. red river in montana he recognized the town hall meeting everybody there wanted arch as a system. but it pays medicare plus a choice, pc three so everybody loves arch but not the other such you get to the right to integrated system redial providers of board to go to one

integrated system and we will put that together to come to you for no question in to get those providers on board. >> the sooner that can be done it is to the veterans' benefit. >> that would is working well is our sharing arrangements alaska is the most enthusiastic proponent so we are thrilled about that. >> i appreciate that and know we want to work with you but we had an opportunity to sit down to talk about the realignment because i am concerned as i look at these divisions it

looks like the territory is almost identical to the ninth circuit court of appeals looks like. we have been fighting to break that up sending them a heads up with what vj covering thousands of miles the concern the regional offices can provide for that level of care that veterans expect i have several different questions i would like to ask as the talk about how we focus on reducing the backlog but at the end of the day have you heard three or sat with me or what have you provided me?

the office's work hard and we're not pushing them to close out constituent cases. sometimes it is hard but if you have one great success it makes our staff feel better that we have to reduce the numbers to forget customer service we forget not only the satisfaction to the veteran but of the a employees who gets satisfaction into know they have of level of care and if they cannot feel they are doing that the difficulty of recruiting and retention will continue. >> we agree entirely. this is why we do this.

not because of the stock options but because of the inspirational mr. and for those who have protected us we cannot lose sight of that it is more than numbers bet said gentlemen behind me. exactly the reason i gave out myself phone-number during the first national press conference in september and i listen because you have to keep that visceral empathy of what we're trying to you do. it is very personal. >> the key for your dedication i do have questions for the record. >> i have visited with you before about legislation with the access to extended

care to make sure we can encourage nursing homes to take the a reimbursement by eliminating the small business contract requirements but they don't have to you deal with with reimbursement and to undergo a separate inspections we would just ask you to comment hundred vans that legislation. >> we think that is the way to go with veteran now comes thank customer experience there is so much red tape in the sense people trying to work in the system were their prisoners of the

system rather than reading their visa we're in favor of that legislation. >> that is very helpful mr. secretary many were represented to say if we could get this passed it would be very helpful and i appreciate your willingness to help. in from local providers that you ted shawn in a number of responses as a co-sponsor it is similar veterans access to do community care. but the ada is to get closer to home and they have to go long distance but in my

state we have one health center that covers north dakota and western minnesota but it is 800-mile round trip and to have real geographical issues for that affordability. >> to do that as quickly as possible to determine how much will accuse community care really don't know how many want to use community care but we know that definition will double the

veterans to take a vantage of it but we do to find that out the second to i want to reinterpret the geographic burden to have more flexibility to provide the ability for people to go to a community care. to defy it does us virginia facility that would be costly than billion dollars or $40 billion per year and that choice act is $10 billion. spee mcfadyen important area.

with there 40 miles of the v.a. health center but if you have the roselawn businesses it is a problem. if they have open heart surgery than maybe i a understand. but but the difference is that they can provide is cost-effective because the veteran ray have to your travel you will pay for the travel with a very senior person it isn't only about

the background as the figure out how to do it there is difference between part pontian a way to do with that makes sense. i look forward to working review on it. >> mr. secretary good to see you again for the last year introduced legislation for the caregiver support services. but often that i want to work with zero to make sure has the resources to take on the additional workload but to have a significant increase of funding asking for additional resources tear higher mower support

coordinators' do you know how many more caregivers you will need to support those karen needs to take care of veterans coming into the program? >> and not know exactly the we are very supportive of the legislation you have written. there the unsung heroes. and then not to take on work because it is a conundrum as i have been to several college campuses.

and then it could to work with you. >> it is vital. and that the emergency room at this medical center has radically cut back operations because of staffing problems for the medical center has repeatedly pushed back from full-time operation is now it will then be until next fall. and i am concerned about that request of access to care in that region. last year i asked the secretary an undersecretary of there were programs at the spokane and medical

center and they assured me there were not. the medical center is not getting the job done what will you do to restore services? >> i have been hearing that tenures the american legion has some ideas how we could work with the hospital's with those salaries paid to people their air free could recruit top-notch talent we could have that facility in local hospitals with emergency care. >> this has been ongoing for

ever i want to your talk with you again however we do it. >> i accept full responsibility i have been over a dozen medical schools to the osteopathic convention we are the canary in the coal mine we need more primary care doctors who live in rural areas and mental health professionals we're working extremely hard to do that to give say monetary incentive we will work very hard and tell the get that facility at. right now the veterans affairs committee of critically important it is

to meet the needs of the growing population i was the list to work for their quality care act that can go a long way to provide safe than private health care for women. the virginia already has the serious backlog there is said need for more space dedicated to gender specific care so what will they do to meet that treatment space over the next few years? >> some of of budget that was ted dramatically was slated for women's clinics. we're hiring a the gynecologist in other specialties to staff the

assailant 11% of veterans are women it will be 20% by 2017 so we have to get this done many buildings are over 70 years old with a single gender bathrooms we have got to get this fixed and that is why the construction budget was as high as it was >> i appreciate that. >> let me talk about the hippopotamus you guys ask for $5 billion but where do we go from here? >> our in-state is to finish constructing a medical complex under the

supervision of vague our record of the engineers? period they would complete the project we plan to use that army corps in the future. >> my position is to work with senator gardner. >> we agree in fact that deputy secretary was out yesterday and was there seven times since he has come into that position. >> dr. clancy rand at the hearing on march 30th i.m.

the member of the senate only and security committee we heard incredibly powerful testimony from of family is of veterans and lost their lives as well as whistleblowers but now several months into this investigation we are hearing what was not explained before not based on testimony but somebody to care much after the hearing to say my husband was treated there i have concerns so i want to stress how important it is to have that investigation be expanded and to have your

assurance is duse degree we can follow-up of the conduct of your investigation to follow the evidence where it leads. >> you have my full commitment. >> let me just add i would associate my comments because a lot of veterans where use that facility so to make sure we fix the kid doing and -- candy land. >> with treatment for paint, a secretary mcdonald not only do we crack down on

inappropriate years but the alternative to the narcotics for pain management calling for alternatives cent complementary medicine is. here in the appropriations committee for those that would help veterans deal with acute and chronic pain. >> as dr. clancy said the reason it is moving down the are the largest user of alternative approaches in the country with tremendous excess with yoda and electronic stimulation anything we can do to

provide a different approach as i a tour of our facilities i am always inspired by those people who'd teach yoga in one location there was an arts instructor who helped to use art as the way to allow people to become themselves without to opioid use we now use equine therapy in massachusetts so anyway we can prove a successful program we want to do. >> we're also doing a lot of research to understand which will predict a better response to alternatives to rue narcotics it is backed

tuesday informed -- to the informed family. >> talk about the v.a. one of the things i have observed if you were born and raised in a rural environment you will make a commitment in your career and it is true with the the day -- v.a. zaph offered a provision that was included increasing over five years the number of residency positions and it is my ender standing in the first year of implementation briefly

ever like you to give a status update. >> first thank you for that additional capacity but we did not think we could start residency positions from one year from this july because of the ramp up but we went to our partners to say you have additional spaces? we don't know the uptake so every year for the national match it is like the dating game were the slots that tend to go unused but one of the other areas that we were gone is to figure out

working with facilities and communities to do what you just described but may not have that infrastructure is but had we get them that faculty support to get the proper education? it is a very exciting opportunity. >> also osteopathic doctors that tend to be in several areas today less than 1% of our doctors are the zero -- d.o. i spoke to the convention it hopes to get more to relocate. >> we will keep the record and tell april 27 some members still have time to

submit questions. recharger and. [inaudible conversations]

baltimore police commissioner spoke to c-span earlier this year about corruption on the force. the entire interior is is is available on c-span and.org.

>> made a very clear to do of a good job and make the mistake i will back u.s. support you i will do that if you do something corrupt i'll hold you accountable and the first run so i make it clear i will stand for them as they get the job done then not to be unconstitutional to hurt the community. >> without reasonable suspicion they cannot use an ordinary traffic stop to search of for evidence of crimes in a related to the stock. -- stop.

your argument next this morning by rodriquez obverses the united states. >> mr. chief justice said that pleases the court the issue that starts is whether after completing relating to a traffic stop without individualized suspicion can hold a driver for a drug sniff the specific question is whether the officer was entitled to piggyback an already completed traffic offense with probable cause for the investigation of

nothing more than a hunch. >> but as you point out the argument of probable cause that it is nothing more than a hunch but the court of appeals runner absolutely they did not reach that question. and the day left it based on their proving it was inaction. >> counseled you concede it is all right if the dog's death took place during a traffic stop if there were

two policemen there already? one writes the ticket while that is taking place? >> no problem if all of that was done before the traffic ticket was written if the dog was taken around a car prior to the completion of the traffic stop and the ticket. >> mr. o'connor. if he stops somebody for a broken taillight there are increased where are you going? there are a lot of questions you check if the person is driving a stolen car it has nothing to do with a broken

taillight. >> but if he did it after he wrote the ticket? >> at that point no. >> he can only do that before he writes the ticket. >> what if he isn't giving a ticket? than just a warning? you went a little over the line and be careful. by the way that would be part of this stuff. so all those questions that he should be allowed no matter the question. all the steps of the receipts taken in connection

with a traffic stop then it must end that nothing more could be done until after it is issued? is set the length of time or the formal act that cut saying's off? >> it is the formal act of the traffic stop once that is done but that is not clear. with justice scalia hypothetical i will not give you a ticket but i just want to ask you a few questions. it seems and do your argument it is not admissible he made a decision not to give a ticket but on the other

hand the first day checkout their warrants? eric i finished writing the ticket but first i go back to verify the license plates. is that permitted? >>. >> but to have that wrong presumption there are certain tasks involved that includes checking for warrants and checking identity and generally with identity it also has to do with where are you going and

where you are coming from. >> my question for you it cannot be the formal act of writing the ticket but the act related. when you finish the of this. >> exactly right. >> view and tied it to handing over the ticket but you say just writing it. it is not the formal handling of the second. with the justification rand four the stop spinning a bed

just to assume that you embrace the assumption that if you have up proper license if the car is stolen, all of these are impressed with the mission with the basis for this stock is a broken taillight. how does that have anything to do with a broken taillight? >> those that have been accepted. >> dogs sniffing was accepted as long is this an before what? >> completion of the ownership and that includes not just a broken taillight with prior arrest.

and whether the car is stolen. but not beyond a dog sniffing? >> you have expanded the mission for everything that is within the task that is part of the traffic stopper of the dog sniff. >> is the broken taillight. all the rest is added on and you let them. why don't you let them add that don? and their traffic stop includes the questions.

then you have a formal rule. that these is open to the question. but that would be acceptable. if we tie the traffic tickets after that is a shared as long as incompetent will delay the handing over the ticket until the dog sniff is completed.

>> it is great for your client. if that is the question. it is one of the options. what does that accomplish? >> once the stock is down in the justification is done. >> so i have to wait for the

dogs sniff? >> but then to say i prefer that. and though the dog sniff brokers. effect is your position. if that is a question of when you do it is said during? is okay if the traffic stop is done. you cannot possibly be that. >> conclusively.

>> i wanted have the dogs the five will call into headquarters to set down the dollar that could take 45 minutes he adjusted sit there because the traffic stop does not terminate until i give you a ticket for you will allow that? >> the formal handling of the ticket is not the end. >>. >> host: i have not turned it over yet spur car will not give its you and tell the dog comes. that will be 45 minutes. >> now. is is done. if the only reason 70 kept to the ticket. >> the reason is for the dog to come. but that is past the traffic

stop. >> you were not applying a formal test. i thought he said it is a formal test delivering the ticket is the determination. what is the test? how long? >> the formal test is when the mission has been accomplished if you pull somebody over for a traffic offense what is necessary to complete it. >> i need to think about this. i rubio back to ponder and think about other tickets i have given in the past the dog will be here in eight minutes i need to think

about this in 10 minutes is that okay? >> that is not okay at all. he must be diligent of the traffic stop is misleading headache over the ticket is not the end all. i was pulled over for a driving offense but if he is pondering he is not being diligent. >> we ponder all the time when we think we're being diligent. [laughter] >> that is my diligent that is the question if that

office our pockets the ticket and tell the dog comes with a time of the stop. >> can you ask for the registration? they said licensing and registration. is that okay? [laughter] >> i have friends that say of course, that is okay. >> is a permit to use the traffic stop? >> but it is the vehicle itself not only do you have the driver the driver of history the car, all of those. >> if you saw the car swerved i don't see why you

need the registration of the car. >> i think you do it is part of investigating the traffic offense saying is that has been accepted or adopted as things the you could do at a traffic stop there are times you go beyond the traffic stop if you go beyond the traffic stop even measurably beyond it then you have violated the drivers' rates and is unconstitutional.

>> but this particular violation is the irascible offense. >> no. with the driver then to impounded the car. i think that is correct. >> regards this here is what we do know. because of the task completed but the officer says everything that needs to be done is finished no question in order to

continue to be detained with that new justification that we did not get in this case. . .