there's not many professions were 51%, you are doing just fine. you're a winner with 51% of the people like you and 49% not liking you. now, you are a winner. that's politics. [applause] but i'll tell you, the reason i barely when my race is because virginia has been tough. virginia is not the bluest state in the crowd. we are better now than we used to be but races are close because they are tough. the way i win races as i put this thing in my head and you're the underdog you are the winner. that's about. but that thought in the back of your head.

when i told hillary clinton had hoped she would run for president in april of 2014 can i said i hope you run for president. she thanked me. i said no matter what poll you see or what editorial or anybody save your the underdog, you are the winner. your time to do something that's never been done before. that's the attitude we've got to have to pull this thing home. we are the underdog until we are the winner. it's not just about campaigns. that attitude, it's not just about campaigns. i was chairman of the committee for couple years. traveled all across the country. would walk into rooms and virtually every state would sit down with democrats and we had the super progressives and the super blue dogs. we have labor and environmental us. we had students and we've senior citizens, everything. sometimes will rogers said i don't believe in organized politics, that's what i'm a democrat. but there were some unifying things in all of those rooms in all of those rooms.

one of the ones that most unified the people that i saw was we are kind of underdog people. if you think about it we kind of got a heart for the underdog. maybe to be some research out like pain or table and if i'm that's part of the human dna, right? there may be an underdog jean like sympathy for the underdog that they will find one day but democrats, we are that kind of people. in my church we say good samaritans. every faith tradition understands this story. there's a person is beaten up and lying at the side of the road is that a lot of people just walk on by. even some people who are leaders, people who are more leaders who should have known better. some walk on by not to notice. some notice it but i'm not going to do anything about it. i don't know all of you. i don't know i'll love you but i think i know this about you. that's not who you are.

you do not walk on by. we are not walk on by people. [applause] we are underdog people. we are the kind of people who when we see somebody needs a hand, even if we don't know all of the interest and even if we don't know everything that needs to be said, which is going to kind of roll our sleeves up and just wait into the situation and see if we can figure it out, see if we can be helpful. that's what we need for the next 34 days. we're trying to make history. i'll tell you one other thing. being the underdog, being the underdog -- can i tell you that hillary clinton has been an underdog again and again and again throughout her life? [applause] anybody in this room been an underdog? anybody in this room tried to do something for the first time in

your family or in your job or in your school? something that's never been done before? anybody in this room has to we look you in the face and say i don't think you're going to be able to do this, this is not for you? the time isn't right for you? sometimes the person telling you that is an enemy who doesn't want you to succeed. sometimes it's a friend who they don't want you to get your feelings hurt or your hopes up other don't want to be disappointed. sometimes that voice these you. it's not even an enemy or friend. it's in everyone of us and maybe this isn't the right time. maybe this isn't the right opportunity. maybe -- and i tell you hillary clinton has heard that her entire life? [applause] she's heard it in addition she is heard it her entire life. donald trump is one of the most recent person to say this to her. if we have that underdog attitude, where we're going to be underdog until they tell us on the evening of november 8,

guess what, underdog? you just made history. you just elected the first woman president in history of the united states and now we're we e stronger together. we can build an economy that works for everybody, not just those at the topic we can build strength in the world with stronger alliances and we can build a community of respect for everybody is welcome to round the table, everybody is valued. that's the history we will make if you and we all do the work that we need to do. [applause] now, everybody tell me the last day to register vote in pennsylvania. [shouting] >> i like this audience. i like this audience. if you're not registered, tell me where to go to go to register. [shouting] >> iwillvote.com. could we have made in asia? iwillvote.com and if you want to do any volunteering first ration into doing volunteering for the

camping already? big round of applause to all the volunteers. [applause] but he could not yet volunteered and you want to honor to do is text together or text philly the 47246. if you text, you will be gathered up and you'll be put to work and then come november 8 in pennsylvania and in virginia at all across this country we are going to celebrate being part of a generation that made history elected barack obama in 2008, made history elected hillary clinton 2016. on we will go. [speaking spanish] thank you so much, philly. go get them. [cheers and applause] ♪ ain't no mountain high enough ♪ ain't no valley low enough ♪ no river wide enough ♪ to keep me from getting to you, babe ♪

♪ been a. >> if you missed any other vice presidential debate over to c-span.org using your desktop phone or tablet. once on a special debate page watch the entire debate choosing between the split screen or the switched camera options. you can go to specific questions and answers from the debate find the content you want quickly and easily. use our video clipping tool to create clips of your favorite debate moments to share on social media. c-span.org on your desktop phone or tablet for the vice presidential debate. >> the second presidential debate this sunday evening at washington university in st. louis, missouri. watch live coverage at 7:30 p.m. eastern for a preview and then at 8:30 p.m. eastern the predebate briefing for the audience. at 9 p.m. live coverage of the debate followed by the reaction with the calls, tweets and

comments. the second debate watch live on c-span, at anytime argument at c-span net at c-span.org and listen live on the free c-span radio app. >> we will be covering a town hall with the donald trump later today live in new hampshire at 7 p.m. eastern time on c-span as a road to the white house coverage continues. hurricane matthew continues to move closer to the florida shore with the storm expected to make u.s. landfall sometime tonight. lots of congressional numbers tweeting about the storm including florida senator marco rubio who says i am pleased president obama granted governor scott's request for hurricane matthew pre-landfall emergency declaration so the federal government can help with the recovery. florida democratic congressman

patrick murphy who is running against senator rubio in the november election posted i'm urging everyone in an evacuation zone not to wait. hurricane matthew is dangerous and must be taken seriously. but he carded represents the georgia coastline tweeted to his constituents about governor deal issuing an editorial evacuation east of i-95 in bryan, chatting, liberty, macintosh, glenn and camden counties. earlier today at the pentagon press secretary peter cook briefed reporters on the hurricane that the defense department has granted approval for south, has been up to $11 million in disaster relief support in the caribbean. >> first award up to join the department's response to an preparation for hurricane matthew. secretary carter has been receiving regular briefings on those efforts and in the rest of the department will be tracking the storm closely and staying engaged in the days ahead as it threatens the u.s. east coast. in response to hurricanes impact in the caribbean and requesting u.s. agency for international development secretary carter has

granted approval for southcom who spent $11 billion of overseas humanitarian disaster and civic aid funds to provide disaster relief support including transportation sport in the caribbean, airfield and port assessments as well as airfield operations support and as the apple pointed out yesterday in his briefing with you all, u.s. southern command that oversees relief efforts in haiti and its commend barbara admiral cedrick pringle. 13 arrived in port-au-prince, haiti, just yesterday. meanwhile, northcom into discordant with southcom, fema, the state department, east coast states and others to ensure that dod as it would respond to requests for assistance from and support fema mission assignments as needed for east coast states as well as the bahamas. in addition northcom identified for facility that fema installation support bases, visit will provide staging areas

for trucks, trailers and other equipment and personnel. they are north until revealed north of charleston, south carolina, albany marine corps logistics base in georgia as well as fort bragg in north carolina. the services continue to take prudent measure to protec proter people in position to platforms other of the storm and its path. as you know the national guard trains year-round to ensure that they're ready to protect and assist citizens are disasters and emergencies. the florida georgia-south carolina and north carolina national guard are prepared for mobilization and all 4500 guardsmen have been mobilized by the respective state governors in preparation for hurricane matthew. >> every weekend booktv brings you 48 hours of nonfiction books and authors. here are some of our programs this weekend.

>> i think leagues are going to be a part of government life and the speed at which and the multiplicity with which we community with each other not only in long cables à la george kennan but short e-mails, texts, social media, tweets, all that is going to be part of the body politic.

>> go to booktv.org for the complete weekend schedule. >> veterans affairs secretary robert mcdonald testified before the senate veterans' affairs committee about a report released by the commission on care with recommendations for improving the va health care system. that chair also testified on her and her fellow commissioners work and representatives from several veterans service organizations shared their thoughts as well. this is about two and a half hours. [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] >> i would like to welcome the secretary and dr. shulkin, we are glad to have here today. we are going to change our methodology just a little bit. we have to vote. one at 2:45 and one following that vote. we are going to run the hearing continuously which means the ranking them and i will wait opening statements so we can go directly to secretary mcdonald to make his full statement for the record and they would go into as much queuing as we can. when asked to leave, hopefully to be some guy can turn overdue so we keep the hearing going. so with your cooperation we will work with those two votes to make sure we don't have to shut

down. down. if we do shut down its only for a couple of minutes. let me look at everybody to this meeting of the veterans' affairs committee. we had a great hearing on the innovations taking place at the deal last week and i think today's it will be equally as good because the commission on care was a great project that examines the veterans administration in his delivery system for better spent a lot of recommendations in that are very meritorious. a lot of thought-provoking recommendations and appreciate the embrace that secretary mcdonald has given to ideas from others that come in and we talked about so many will have a great testimony for us today. so let me welcome the secretary of the va, robert mcdonald to make his testimony and we will go from there. and welcome dr. shulkin to be your force testimony as well. >> thank you, mr. chairman. chairman isakson, ranking member, members of the committee, thank you for this time to talk about these ongoing transformation of the commission on care's final report. i wish the house that allowed me the same opportunity last week

and neither i nor the veterans service organizations were invited to testify in person. athat i written statement be submitted for the record. >> without objection. >> thank you, sir. first let me thank dr. shulkin torturing the commissioner under wasn't easy but nancy did outstanding job in keeping things together. over all i see the commission's report as validation of the course we've been on for the past two years. there's hardly anything in there's hardly anything in the report we haven't already thought of or are not obligated as part of her ongoing my va transformation efforts. we differ on some details but we wholeheartedly agree with the intent of almost all the commission's recommendations. 15 out of 18. we agree on how wrong it would be to privatize va health care. privatization would be a boon for some health care corporations but at seven leading told the commission in april it could threaten the

financial and clinical viability of some va medical programs and facilities which would fall particularly hard on the millions of veterans who rely on va for almost, for all or almost all of their care. there are many things the offers that nobody else offers. we have unique lifetime relationship with our 9 million patients. nobody else offers that. our mental health care is integral with her primary care and specialty care. nobody else offers that. va health care is whole better and help your to meet veterans unique needs including care for many nonmedical determent of health and well being like education services, career transition support, housing assistance, disability compensation, and many others. nobody offers about. our research innovatioinnovatio n may be a leader in many areas such as prosthetics, spinal cord injury, post-traumatic stress disorder, ali, and telehealth.

nobody else offers that. -- polytrauma. and we sent all veterans find care they would all lose the choice of integrated companies of care tailored for veterans by people who know veterans and are dedicated to serving them. that's what va is to veterans and that's why you don't find veterans demanding community care as the only choice. the demand for that only choice comes from elsewhere. it doesn't come from veterans. veterans know better. when i tested this during my time as secretary, when somebody tells me that veterans should only have the choice of a choice program, ask them are you a veteran? and by and large the answer is no. then ask have you talked to veterans about the? i get the same answer. and i probe a little bit more and found that beneath the banner of choice are always two things, interest and ideology. so lets face it, privatization would put more money into the pockets of people running health

care corporations. it's in their interest so of course it makes sense to them, even if it's not what veterans want or need. been busy ideology that the ideologues. billy do with the issue in the simplest laziest theoretical terms, government bad, private sector good. that's as far as the thinking goes. thankfully most members of the commission were more understanding. on one point i strongly disagree with the commission at the idea of an independent board of directors for the veterans health administration. i probably don't need to say much about that since the constitution probably will not allow it but it will say that vha governance board to make any sense to me as a business executive and it would only make matters worse by complicating the bureaucracy at the top in spreading the responsibility for vha so that no one knows who is ultimately responsible. the fact is we have a governments board. congress is our governance board and of congress worked the way

it should, nobody would be talking about adding another layer of bureaucracy to be a. va is not the hold up on increasing access. we are doing that. we have been doing that for more than two years now. pas uphold on expanding community care but we are doing that, too. we submitted a plan to streamline and consolidate our programs last october, almost a year ago. what's happened to it? in pas uphold upon hiring more medical professionals are getting rid of real estate that costs us much more feature than it is worth or adding more points that care where they are needed. we currently have eight major medical construction projects in 24 major medical uses the authorization. they are already funded but we still need a green light from congress to move forward. we are not even hold on holding people accountable for wrongdoing. ask the former p.a. employed in

augusta, georgia, recently convicted of falsifying health care records. he is facing sentencing that could include years in prison and thousands of dollars of fines. all told we have terminated over 3755 employees in the past two years. we made sustainable accountability part of our ongoing leadership training. the veterans first act would help us hold people accountable and look forward to seeing it brought to the senate floor for passage. the senate appropriations committee has also approved a budget new equal to the president's request, but again we need to see some follow-through. the hold up in our very real and ongoing my va transformation is our need for congressional action. we submitted over 100 proposals for legislative changes that we put in the president's 2017 budget. no results yet. i detailed our most urgent needs him at august 30 letter to the committee. they include approving the president's 2017 budget request

to keep up with rising costs and medical innovation. extending authorities to maintain services like transportation today facilities in rural areas and vocational rehabilitation. fixing provide a grievance to get long-term care facilities from turning veterans out to avoid the hassle of current requirements. and ending the arbitrary rule that will not let the is dedicated conscientious medical professionals care for veterans are more than 80 hours in any federal a period. we also need you to act on modernizing our care -- arcade claims appeals process. under the current law with no changes in resources the number of veterans awaiting the decision will nearly triple in the next 10 years from 500,000 today to almost 1.3 million. we submitted a plan to reform the appeals process in june. we develop a plan with help of the vsos state and county officials and other veterans advocates. they are all on board.

we just need congress to get on board. i'm only after what's best for veterans. as you i'm not running for office, i'm not angling for a promotion. i could've taken in these your job two years ago but i didn't. i answered the call of duty thinking only of giving veterans the benefit of whatever at west point, in the army, and 33 years and the private sector running one of the most admired countries in the world. and i've tried to do that. two years and the transmission process my only concern is to see continue. i know nancy will tell you transformation is a marathon not a sprint. it would take several years to turn any large organization around. and to turn va around we must maintain our momentum of change and we can't do that without cooperation of congress and passage of legislation we talked about. that's an absolute certainty. mechanism, the vsos and the eight are all in agreement on this. congress must act our veterans will suffer.

that's unacceptable to me and i know that's unacceptable to you. what can we do to break this impasse and get things moving ask whatever it takes i will do it. just let me know what it is. thank you, mr. chairman. >> thank you very much, mr. secretary. we appreciate you testament. dr. shulkin, were you going to testify or argue for moral support and hard questions? [laughter] >> hard questions. >> i have one question. for the members of the is a right we will go continuously visit those. i will wait until the last minute to go vote and come back after i vote on vote number two sulkily between the votes went g back and forth we can keep everything rolling drive hearing and we've got three great panels headed up by secretary mcdonald we appreciate you being here. secretary mcdonald if you don't have a condition number one -- if you would like at recommendation of one. you refer to in your testimony. have any idea what you estimate the cost to implement thing recommendation number one for

the commission on care? >> recommendation one is about establishing an integrated high-performing community-based health care network. in our plant and october, i can't remember the exact number, i'm sure david will remember it, but we had different levels of cost depending upon what we decide to take on. we are already in the process of establishing that network. david, do you want -- >> yeah. this sector is referring to the plan that we submitted at the end of october 2015 where we currently spend about $13.5 billion a year in community to care, the combination of choice and community care funds. in order to do the changes that we suggested we suggested that we would need $17 billion to you because we want to fix the emergency medicine provision that so many veterans get stuck

in all, and we need the investment in infrastructure to do care coordination in an integrated fashion. we think that's the best use of money for taxpayers, that it's, it's actually an efficient plan. the commission on cares plan was far more expensive than that. >> and i think it contemplated putting the other, they be being a part of it will not work with private sectors will, is that correct? >> yes, sir. >> i think it contemplated that without the contracts we had for the two gatekeepers bu by just issuing single card, correct? >> yes, sir. we would integrate the network and would also include department of defense partners, health service and other federal partners that we have. >> this is not a setup but just like to hear your answer. is a notch in the veterans first bill that this committee passed out of unanimously by the provisions in therefore provide

agreements we're expanding opportunity are being to make it happen and make that possible? >> yes, sir. >> that was the right answer. i just want to make sure we do that. >> i said in my repaired pashtun repaired remarks are happy to help any way we can to help. >> we appreciate your continued support. >> we appreciate the committee's leadership. >> my last question is wrote a comment. they have a recommendation on i.t. come working on the i.t. system into via. the. i'm still interested in hearing how much progress you have made on interoperability and other program at georgia tech what you think y'all at a truck with the georgia tech now. i understand there's been a recent break the that is held? >> yes. >> could you comment on the? >> personal just as you mentioned, mr. chairman, in april of this year we did certify interoperability with the department of defense but under law firm council's leadership we have created the concept of what's called the digital health platform.

this is really taking where the industry is to a new level. it's going to increase our ability to interoperability with community partners which is one of the recommendations of the commission on care. and so what you are referring to is georgia tech is really a ntastic technology center. we have developed a conceptual prototype for this, that if things were looking forward to sharing with numbers of this committee that we think is really a path forward to take us to a new level. >> we appreciate the progress that you're making. senator blumenthal. >> thanks, mr. chairman. secretary mcdonald, i think in a letter to the president dated august 6 or august 2, i'm sorry, 2016 communicated you had concerns about the cost estimates, that the commission put together to reflect various options on the vha care system

model which range of think as low as 65 billion-106 billion in fiscal year 2019, depending on enrollment, management and other factors. i want to say i appreciate the commission really devoted itself to seeking to improve the va health care system, and i certainly appreciate its recommendations. but i wonder if you could explain that he is concerned with those commission estimates the? >> this is the nub of the issue with in terms of the difference between the commission report at our point of view on the network, and i'm sure nancy will comment more on that later. but the question is is how much unfettered access to the private sector do you allow the individual veteran, and who takes a spot to vote for integrating their health care? we believe that as the va we

need to take that responsibility, that when a veteran goes out to the private sector we select all of the responsibility for the health care and integrated tends to be the primary care doctor. and if we don't do that, it results in not very good care. and also dysfunctional care because it's not integrated. it also results in higher cost care because those doctors that they may go to come for so many qualified but us as being capable, a high court enough to be in the network and secondly may not follow the standards of costs that are necessary to be part of that network. >> i think the sector has said it very correctly, senator, which is we really have differences here with the commission on to report on to a count. one is a quality of care we believe it's going to be better with va maintaining take care coordination and integration

will. we believe we understand the needs of veterans best and we do support and we embrace working with the private sector. that's absolutely correct but we believe the va needs to be care coordinator. but on the cost side this would be, in my view, irresponsible just to turn people out with no deductibles, no cost control mechanisms. this would be returning us to the late 80s, early '90s where there was just runaway costs. .. they can purchase cards at 75%

of what the dha spent on is made through this purchase mechanism. only 38% of supply orders were made through standing vendor contracts which presumably would be more effective and efficient, and i've been told as well but the same issue may arise with medical devices and perhaps other kinds of supplies. that is in contrast to the benchmark of 80 or 90% of supply purchases from already existing contracts with negotiated price discounts which they can do unlike medicare and were pushing for medicare to have the same options of negotiation. what is preventing the dha from using those kinds of master contracts? >> nothing. in fact, if you recall the

hearing we had on the 12 breakthrough parties which you all kindly had in the senate, we did not get the same hearing in the house, one of those 12 breakthrough priorities is to set up a consolidated supply chain. right now, everyone of our medical centers has its own supply chain which, as you suggested is nonsensical. what we can do, what we have seen from our consolidated no order pharmacy where we do have a consolidated supply chain is our cost advantages tremendous because of the scale that we have and our customer service is fantastic. it's been rated number one because of that scale advantaged what we are doing is building a consolidated supply chain for medical centers. so far we have avoided $35 million of cost. our commitment was by december

and we will be that. >> as a courtesy to everyone in the audience, we will take a little different order in terms of testimony. i will let him do the next question and then we'll take everybody else's as they arrive when they come. >> thank you. we've come together on all kind of issues. secretary mcdonnell, you noted in your testimony about veteran choice and some growing pain, your meeting with others, lay out the challenges and opportunities that you see for veterans choice. >> veterans choice, we made tremendous progress.

when you recognize we set up a program in 90 days that affected roughly, and sent out cards to 9 million veterans, we've also made changes along the way. since the original bill, we change the way we defined distance, we've changed it to driving distance. that virtually doubled the number of veterans of being able to avail of veterans choice. originally the program was designed or we would give a phone number to a veteran and sago collier third-party administrator. my beef, and i know david, you can't outsource your customer service so we are pulling that responsibility back in. the coordination responsibility and we are now taking responsibility for customer service and we've taken third-party employees and put them into our buildings of the test in order to make it easier

for the veterans. about 22% of our payments every day now or in the community. there are about a million veterans that rely on the choice program. there are about 5000 veterans that only use the choice programs. most want the hybrid. >> they really want to know they have the choice. >> there's satisfied with the va but they want to know they have the choice. i think that is so important. >> thank you. are there bureaucratic or legislative hurdles that keep them from routinely updating facilities for infrastructure in it and providing the veterans the best karen process available >> i do think if you ask most of

our field directors, they would say there are challenges. we have seen a really strong direction toward being more responsive to the hospital leaders. she has established account executives who now work with dha were working to better and break down those barriers. this does take time because we're breaking down years and years of barriers. i think we are headed in the right direction. >> thank you, mr. chairman, thank you all for being here. we really do appreciate your hard work. the choice program has over 1 million people participating in it which i think is a good thing. you don't list that as a legislative priority as far as reauthorization.

is it a priority or not a priority or have i misunderstood >> we look at it as part of our ability to consolidate care. we did request re-authorization in that 2015 package that we submitted on consolidation of care. >> that's good. >> we do want reauthorization. >> i would just add, i'm sure this is why you are asking, the program ends august 7 of 2017. without reauthorization, we are going to see this go backwards because we have now reached 5 million choice appointments. that's fantastic and that this program should be congratulated. we are just getting it to work. if we could get them to first pass through it will work even better. and this is absolutely a priority for us. >> if a woman is pregnant we

really need to know nine months in advance of august 7 whether or not we are going to care for her. the sooner the better. i guess that was my follow-up. it's good to know you have followed that up. you truly have done a great job. it's been a momentous pass. you have any contingency plans after august 2017. i think you can help members understand, not on this committee, but throughout throughout congress how important the reauthorization is >> we are in the midst right now of renewing our strategies for 2017. most of our leaders are at the training center right now and one of the things we talked about is the importance of

communicating that august 7 date and the nine months in advance of that. i do think it's critically important. >> just to quantify this, we spent about $13 billion a year and 22% of our of our care goes in the community. 4 billion, we would have to reduce access to care by about a third in the community. that would hurt veterans. our contingency plan, we are here to help veterans with the resources that you provide us. we will continue that mission and do the very best job possible. there is no substitute for what you have provided in a choice program. >> thank you. i do think that is something we really need to work on understanding, to make it clear how important that reauthorization is. >> that was a terrific question and i appreciate the answer. he gives us our homework before next year. >> we will stand in recess for a moment. he is on his way and will

continue the hearing. we will stand to recess until the senator gets here. >> thank you. [inaudible conversation] [inaudible conversation] [inaudible conversation]

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[inaudible conversation] >> to be here in between votes and mr. secretary, it's a pleasure that you are here with us as well. i have a specific it set of circumstances that i have addressed to you in a letter and want to follow up in this setting today. i have no doubt that what you and other officials at the va are sympathetic and concerned and want to resolve the circumstances we find ourselves in with a particular employee at a particular va hospital in our state. we have the circumstance to assess the background for my

questions. we face one of the worst examples, in my view, of lack of accountability at the va with the case of a set of systems who abuse veterans at the va hospital and potentially other veterans at other facilities within our state. he has been criminally charged with multiple counts of sexual assault and abuse on numerous veterans who sought his care and his counsel. he had a criminal record, admitted on his application for state life insurance when he was hired, the va hired him anyway. clearly he should have never been hired and never been retained as an employee of the va. he is a physician assistant, an explanation i received is that position assistance are not

considered significant risk or they are lower risk of other healthcare professionals at the va's of the vetting that should take place didn't and what he did in his capacity is to target veterans who were suffering from posttraumatic stress syndrome and he used his position at the va to add to the wounds of war of those who served our country instead of healing them. there are a number of witnesses, many of them of which wish to remain anonymous, criminal proceedings have been filed and just to give you a flavor, there are two army veteran brothers who were patients of this individual who felt they had no choice but to go back to this physician for their care and treatment in the quote was the fear of losing what i earned,

versus the fear of being sexual sexually assaulted again, i don't know know which one was more important. that's an amazing payment for a veteran to reach a conclusion. i don't know whether to go back because i might not get the care i need if i don't. the victim who asked to remain anonymous in an interview in july of 14 when these charges were filed said this, it violates veterans trust who are dealing with a number of issues and we had come back to the agency tasked with caring for our nation's veterans and it's adding further wounds to the nation's veterans. mr. sec., i want want to focus in on two aspects of this and again, i know your staff has reached out to mine, i assume in response to a letter i wrote you a few days ago, a few weeks ago, but this goes to accountability, something that you and i had a conversation about for very long time. i want to go to how does

somebody get hired with this background and perhaps more importantly, it's troublesome to me that this individual was never fired. after the inspector general's report, he voluntarily he left the va. one of the conversations we had for a long time we talked about the ability to fire people at the va and of all the circumstances i can think of, i can't figure out why a person was fired as opposed to retiring maybe there's a different aura to being fired versus retiring but i assume it also has different consequences in regards to the benefit and the future of the individual. if we could, you had leadership here last week.

i got what you would expect and i'm not discounting what they said but they have committed to a zero tolerance of assault on veterans. i know that's the case, we want zero tolerance but we have instances here in which the hiring process was faulty and the discharge process didn't take place. >> any accusation of sexual assault or molestation is unacceptable. as soon as i heard about this, i went to leavenworth. i was there and i have different data then you have so we need to get together and can compare data because from what i understand from my visit and the

documents i reviewed is when this individual, when when there is an accusation of this individuals potential of having done this, we immediately removed him from caring for patients and started the procedure to do an investigation and fire him. he resigned. we looked back at her hiring process and what i was told at the time, and you have different data, so i have to find out why i didn't see the data you may have array you got your data, there was nothing in his file that suggested that this was the reit risk and that this had occurred. obviously this is not something we would tolerate and not someone we would hire. maybe you have different data than i have.

>> our information comes from the expected general, a significant number of press accounts. criminal proceedings are now taking place. he voluntarily indicated on the application that he had a criminal history, which unfortunately, the licensor folks didn't up on either, but i assume that was reviewed when the individual was hired by the va. in addition to that, are you telling me when someone resigns they lose ability to fire him? did he beat you to the punch. >> if someone resigns, he's no longer an employee. if someone resigns, they resign.

obviously you have judicial options which is what's occurring right now with this individual. i think, i have no doubt of what facts are accurate and we would continue to ask you to use this as a learning experience, not only help prosecute so we can send a message to veterans about how careful we are, but again in my view, it goes back to hiring practices and discharge procedures and again, i would ask you to respond to my letter in writing so we can see your response. >> we will certainly respond to your letter and writing and we

are a learning organization. we do want to learn from mistakes. we want to learn from what's going right. you have the best practices, diffusion carrying this week. we will get back to you. i want to be careful not to use media reports as proof of accusation so let's let the judicial process play out. we will share with you what we know and we would appreciate seeing the documents that you have. >> my information, i've met with the inspector general. we've had conversations, extensive about this topic and i can assure you what i am reporting is not anything but what i was told in that setting. >> i've not met with mike on this. i would ask you, if you would ask the va professionals, the leadership in kansas, both leavenworth and otherwise, would you instruct them to have a dialogue with me and fully layout the scenario as they see it.

>> absolutely. that is their responsibility. we ask each one of our medical center directors to work with members of congress. >> thank you mr. secretary. >> thank you, i want want to thank both the secretary for being here today. this committee is poised and we hear stories, i know the hair on the back of my neck raises as it does on yours. once we get to the facts, i think it's important that the driftwood goes, quite frankly and that's probably complementary. it's important to acknowledge there are veterans who relay i on the va and congress needs to be held accountable. you submit budgets and legislative priorities that allow you to do your job and serve the veteran.

it is our responsibility as members of the committee and the senate and the same thing on the house side to carefully consider those requests and deal with them and do what's best for the veterans of this country. before you know it, the entire va system is called into question and mr. secretary, you are the front of the attack when in fact we share more than our share of responsibilities. do you believe accountability is a two-way? >> i certainly do. i provided today one of the most hard-hitting, i think, opening statements i could saying that we are in the process of transforming the va. we are seeing effective results but if we are to continue this, we simply have to get a budget and we have to get the legislation that we have been

asking for four years. >> we passed the veterans bill unanimously and got the bill on the floor. it sounds like we are going to be leaving town next week which is crazy. this is something we get to the floor on two days -- but we are where we are. you agree we have some work to do to get the faith and trust back of many of our veterans. >> we do. in fact, we measure it, i just got the measure this morning, one of the things we measure, this is very common in hospitals where people provide customer service or veteran services. we measure the effectiveness of the experience, the ease of getting the experience and the

emotion of having it. i have a chart here that shows we have made progress but we have gone from only 7% trust to 59%. we are measuring this every quarter. i'm not happy. nobody's happy with 59%, but that shows at least we are making some progress and we have a lot more to make. >> in terms of greatest concerns identified by the commission, things like leadership vacancies, staff shortages, a culture of risk aversion, what are some of the ways that the va can improve those. >> of our five transformation strategies, the second strategy of improving the employee experience, training employees, employees, giving them the tools they need right now, we have our

top leaders off-site international training facility where we are training them in tools like human centered design and leadership, we are moving to one consolidated leadership model across the enterprise which is what great organizations do. we are training them in lean six sigma and then we give them training packets that they take back to their locations and they train their subordinates and we cascade that training through the organization. that is how you change a culture, and that is what we are in the midst of right now. >> okay, so as you all know we've talked about staff shortages and leadership. right now montana has a temporary, -- i think she's doig

a marvelous job. when i had a conversation with her two or three weeks ago, she holds people accountable very well. one of the things she talked about was if we are going to get good people in the va, due process has to be withheld. this is a management person. she understands that if people at the va say i have no due process rights, somebody can make any accusation on me they want and i can be gone without an argument. that doesn't help us fill not only the leadership position but the staffing positions where there are administrative personnel or appeals personnel or whatever. could you talk a little bit about, when you talk about accountability, you come from the private sector. you understand if you have deadwood on your staff, it costs you twice as much money then you're paying. can you talk about how we hit that sweet spot so people who want to work for the va, but you

have to understand that if they make a call, if they go against that culture of risk aversion and make make a call, somebody has their back. we are training the organization and what we call values based leadership and we are trying to inspire them and i think we are being somewhat successful given what all the other people on board. >> i have changed 14 of my 17 leaders. fourteen of the 17 leaders have changed and i think we've brought in better quality people. part of this, i've done a lot of recruiting myself, as you know we went to the university of montana recruiting and i've been to over two dozen medical schools recruiting, but our applications are down about 78% versus what they were before. the kind of environment and context you are talking about does have a real impact on the quality of the people that we

get. >> i think that's important to note because as i said, the issue that the senator brought out is totally unacceptable. on the same token, i do know from past life experiences that when someone is trying to make the right call and 70 can accuse them of something and they don't have any rights, it just goes counter to the whole accountability issues. >> in my opening statement, i mentioned that we have terminated 3755 people in the past two years. i also said 17 and my direct reports are new. the only, in my opinion, the only only issue we have had around accountability has been the accountability in the legislation but also the interaction we have had with the merit systems protection board which frankly, we've all agreed that veterans first will fix.

the answer here, i think we already have the answer in front of us, how to get veterans first on the floor and passed because we've all agreed that as a potential solution. >> thank you. mr. chairman, i appreciate your leadership on this committee. a lot of you know i've told you that and i've told you that you are a first-class guy. darn we have to get this and fast. let me just, on that. forever but his knowledge, this committee did outstanding work for over a year and a half on the veterans first bill that is comprehensive in its nature and i think complete in its nature. one is what happens with choice after august of next year. the other is how do you deal with the protection board and accountability at the va. there are those people in the news media and some of my party that have criticized our bill

for not being strong enough and not making choice permanent. first of all we deal with the leadership in terms of the ability to hire and fire which is the right thing to do. the accountability, because you have that accountability, it will flow from the bottom up because the top is being held accountable. we've been able to get the buy and necessary to do that. all of us want to make sure that choice endures and choice becomes permanent. known of us want to run out of funds and go out of business, but not passing the veterans first bill today which provides for provider agreements would be a serious mistake and people are saying they don't want to do this and they want to give choice and i'm happy to do that. in the meantime, let's make the contract agreement at the

beginning of next year to take a choice program and improve. when i heard my two favorite subjects come up, i just had to make,. >> thank you for kindness and consideration of me and always please consider me an ally in veterans choice, particularly the legislation we would like to see past. i won't leave this as an open-ended question. if i thought further about your response to my comments and questions, one of the things you could look into is that as soon as the va found out about him he was taken away from patient care. as i understand the facts, he continued to be an employee after that. the day that he was -- admitted

he dealt with patients in the way that he did, my point would be that the moment in which summit he could be discharged or fired. the just removed him from patient care and kept him on the payroll. to me that highlights the difficulty in getting rid of this case, not just just bad actors, but terrible actors. >> it sounds to me like you have better information than i do and you've met with the inspector general. i need to find out what he discovered in his investigation. obviously if you have them fired, that's why we fired 3755 people. you hundred 55 people. you don't tolerate that kind of behavior. >> thank you. i think members of the committee for being so cooperative in moving forward. i think we will go to a second panel. before you leave, i want to thank you. not just for your input today

but for your leadership over the past two years. i think amazing progress has been made and we're progress yet to obtain. we are here to stand ready to help you anytime we can. >> thank you. >> we will call our second panel our second panel art representatives from the commission on care. when i got the commission's report a few weeks ago and it was put on my desk, i took it home for early reading for lots

of reasons, but i know there is a lot of thoughtful input and progress made. i want to see what the commission had to say and i want to commend the chairman and the commissioner and the other members on the work that you did. a lot of you are going to give those private citizens time to give us good advice to give the credit that they deserve. we appreciate what you've done. we will hear from both of you today and our two witnesses to testify first is nancy, is that the correct pronunciation and an attorney with esquire behind his name. we appreciate both of you being here today. we appreciate the work that you've done and you will both be recognized for up to five minutes each. if you have any printed testimony to submit it will be accepted. >> termini glickman, ranking

member blumenthal and members of the committee, thank you for the invitation to discuss the report of the commission on care, for your support of the commission and the extension of time that you gave us to complete our work. it has been a privilege and an honor to serve as the chair of the commission charged with creating a roadmap to improve veterans healthcare over the next 30 years. i have served in senior leadership rolls in large hospitals and health system. for the past 18 years, i have been in detroit michigan at the health system serving for 13 years 13 years as the president and ceo. my experience in leading henry ford which is a 5 billion-dollar, 27000 employee health system through a major financial turnaround and navigating through michigan job loss, we had major employers will still growing substantially, making major capital investments in our community and winning the 2011 national quality award, it prepared me very well for the demands and complexity of the

commission's work. our commission was composed of 15 talented and diverse leaders. we developed several principles to guide our work including creating consensus and being data-driven, creating actionable and sustainable recommendations and most importantly, our focus on veterans receiving healthcare to provide optimal quality, access and choice. the independent assessment report was invaluable as a foundation for our work. it was systems focused and revealed significant and troubling weaknesses in the capabilities. our work took place over ten months with 12 public meetings over 26 days and we sought the broadest input possible, had intense debate and dolly log but had unified focus at all time, what is best for veterans. i believe we have produced a good report that is strategic, comprehensive, actionable and transformative.

twelve of the commissioners signed the report signaling bipartisan support. the three who didn't sign had divergent views. one thought we had done too much and too thought we had too little transformation. they require transformation which is the focus of our recommendations. there are many glaring problems including staffing, facilities, i t processes, supply chain and health disparities to threaten the long-term viability of the system. perhaps even more importantly, the lack of leadership, strategic focus in a culture of fear and risk aversion threaten the ability to make the transformation happen over the next 20 years. transformation is not simple or easy. it requires stable leadership, expert governance, major strategic investments in a capacity to reengineer and drive hype performance. some of our commissioners belief in moving to a pair only model.

they leave the government can't run a health system and that veterans should have same choice medicaid beneficiaries. we believe va and dha under current leadership are making progress. we are aligned with most of our recommendations and we believe that they should be invested in for several reasons. one, the model of care delivery. then the clinical quality which is comparable or better than the private sector in most metrics. third the history of clinical innovation, medical education and emergency capacity. fourth, the specialty programs and fifth the role of a safety net provider as millions of low income veterans. it may not or could not be filled by the private sector in many markets as we know, even with the affordable care act, access to primary care and mental health across the country is still very challenging. our recommendation have fallen

into four major categories. one fully integrates the private sector and other providers including the dod and other providers. dha continues to provide care coordination and all of the providers in the network. secondly, the leadership system and governance. a particular emphasis on continent continuity and an oversight to a board of directors. third is the operational infrastructure, supply chain, hr and workforce and healthcare equity. finally eligibility eligibility. focusing on other than honorable discharge for healthcare benefits and design. we clearly do not like want this report to be on a shelf.

we ask that you make our report come to life to enable legislation that was included that requires your action. we are mindful that some of our recommendations have cost implications and we work with health economists in modeling different options. we do not suggest that congress has not already made very substantial investments in the system. rather we call for strategic investments in a much more streamlined system that aligned va care with the community. i would be very pleased to be a resource for the committee as you continue to work on these issues and also look forward to your questions. >> it's a pleasure for me to be with your today and addressed the work. it's a pleasure because for five years i sat were tom boeing is sitting behind you the vast majority of va staff at all

levels are highly committed to the veterans they serve. like many of us, i was concerned to learn of the issues that came to light regarding manipulation of wait times for appointments at the medical center. i am happy to have been part of the effort to better understand what had gone awry in finding solutions to those problems and in the future. service on the commission has been an interesting experience for the commissioners brought their various backgrounds to this venture with one characteristic in common. all of us were permitted to assuring that this country's commitment to its veterans was well met. we may have differed on how to do that, but the good faith was helpful. under our chair, each commissioner had an opportunity to express his or her priorities and defend those. the final report includes 18 recommendations.

some are good ideas. some are included because one or more felt strongly about it. the white house made it clear to our chair that they would like a consensus report. i signed up with that expectations. i had had a full and fair opportunity to express my concerns in open session. among the many things i learned was that in negotiations, for all of the give-and-take, you have to be able to take what you can, hold your head high and declare victory one more time. that is what i would like to do here. over nearly a year that we met, we discussed a broad array of problems within the ba. many of those were long-standing. we discuss those with senior va leadership who themselves

realize their issues beyond their ability to address. by shining the light on those we may have provided the impetus to the staff to raise such issues. some quick statistics regarding veterans and the va. in 2008, there eight, there were 26 million veterans. today there are about 21 million. in 2008, the budget of the va was $68 billion. dollars. today it is about $175 billion. in 2008, va had 240,000 employees. today about 368,000. the number of veterans is in precipitous decline. we lose about 5 million a decade the total number of veterans, about a third use the va for some or all of their healthcare. many just for prescriptions. by written testimony, i highlight some of the specific issues in the report that i had problems with. i would of course be pleased to

discuss those with the committee what i wish we had done, for a number of basic questions that i wish we had addressed. some of these are things that no one wants to touch such as why do we have a va healthcare system at all. this is something that a number of people asked me. we need to do things that are injured in training or combat but the fact is most of those being treated in the system are suffering the same illnesses most of us can expect to experience with the passage of time. there is nothing uniquely veteran about those injuries or diseases. they are in most communities and there is ample surplus to treat them in the community hospital. some say there are veteran specific injuries like spinal cord, ptsd and brain injury. in fact, annually, automobile

and driving accidents cause more sei patients than the dh treats. most of the veterans using the system are medicare eligible. if they use the community hospital, they can bill medicare if we are committed to having the va healthcare system, who should be eligible to use it? some people assume once you have put on a uniform they are entitled to free healthcare for the rest of their lives. no need to worry about health insurance ever again. i don't think this is what we want. the system was established a few years ago for those with the service-connected disability. treatment of those disabilities was the first priority of the va system. priorities also included veterans a very low income. is there a better way to articulate eligibility so that the veteran and the american taxpayer pair can better understand what the va healthcare system is trying to do. who is obligated to provide care ? i was struck by the fact that

the gatekeeper for most va care is a primary care physician. the medical education establishment is just not turning out a lot of primary care physicians. that is a bottleneck that is only going to get worse. over the past several years, there has been significant changes in the way healthcare has been delivered in the united states and that too will continue over the next several years. was it success. some of my colleagues believed we can only count as basic success if the administration and congress adopted the entire document as we have presented it i personally am willing to declare victory with secretary mcdonald and undersecretary for health and their staff that are now making those changes. thank you. >> in light of the fact that the committee members have been cooperative, i am going to

continue to deviate and go on a and not recognize myself. >> thank you for being here. to either one of you or both of you, if you would, it's my understanding. it. [inaudible] it concerns me that there is little or no oversight. in west virginia we have quite a number of veterans as you know. doctors outside the va network can be trained in military and veteran culture. i'm concerned that many are not equipped in dealing with them. as a non- va doctor, are they able to spot of veterans with ptsd?

are they aware of the exposure? they may not disclose certain symptoms if they are uncomfortable so these are all valid concerns. i am speaking as i go around to mike clinics and hospitals. i. >> guest: a lot of the veterans. what had been done in the past is unconscionable, the wait time and all the stress. i think everybody recognize that. when i talk to the the veterans, they still want veteran care. they demand it. i've asked them, i said you know, if you can't get it, they say no no, they take care of me here. they know what i need what i need. they know how to treat me. that is my concern. in the future how do you see them striking a balance to make sure they receive access to care and that the care received his high quality. how can you say that will happen >> one of the things that is very important about our recommendations is that we are not proposing the current system of having a separation between the private sector and the va. what we are proposing is a more

innovative model. >> who's going to coordinate that? >> the va. >> the va, the network has to select the providers and in the report we include several elements of that including not only their education and their experience, but also their military competency and about 70% train in va medical centers. it's possible that we can create a very well-equipped set of primary care physicians when needed. we also suggested that every market should be carefully evaluated in terms of access need. more primary care physicians in the community might be needed in some markets versus others where the va has adequate numbers to provide that for veterans, perhaps they would have none. control of the va care system that we are proposing is the va. that includes betting the network, it includes having high

criteria for participation and it could be different in different markets based. >> i have a question for you. >> let me just say one other thing, to address a different part of your question. can people be trained to be sensitive to the veteran experience? the answer is yes. i just turned around to rick and i know they have a carved, a holdout card that has a number of questions they encouraged doctors to ask a person who is a veteran to elicit some of that. there is training available. >> our clock is running. the commission that you characterizes a path that will move the va to be more like tricare. i had spoken to a lot of my veterans and they argue that when tricare started offering

more low cost insurance to military retirees, they saw cost starting to rise. they pull you in and they hit you on the other end. and many of our veterans are concerned that care outside the va is going to lead to less money going to the va unless services offered. and less services than we have committed to them. ten or 15 years down the road, i want to keep the promise we made our veterans, especially those with unique injuries, ptsd. my question to you, you, do you think the characterization of the commission on terror wants va to be like tricare? if true, what would you suggest congress to consider when thinking about that future of the va healthcare. >> actually, senator, one of our commission members from the commission report, if we do this, will be draining money

away from the va facilities that are needed? i don't frankly have an answer to that. would it be likely that copayments would increase? >> we can base this on what happened previously. if that's the case, i would say yes, our veterans have reason for concern and they should have reason for concern because we would go down that path. >> if i could comment on that, i think it's important to see the balance of the report. what we are suggesting as primary care choice when needed within that va care network, we are also suggesting significant improvements in the operations of the veterans health system. >> my biggest problem is opiate. if you have a doctor over here in the va trying to wean them off, how is that going to help. who's going to coordinate that? >> the va. they have to. >> i'm concerned about that.

that's the biggest problem we have in our state and the biggest problem with veterans right now. if you have a doctor they should be treated by pain with the pill versus alternate care, you have serious problems. that's what i'm afraid of. i really truly am. >> the va needs to have clinical standards for the providers that are part of that va care that are consistent. >> sorry to take more time. >> you are always timely into the the point. thank you for that. i'm just when ask one question and make one observation. to establish an expert body to develop recommendations and benefit design, tell me what that means. >> i think the feeling on the part of members of our commission was we did not have the time for the focus on eligibility, but many people

felt it was time to do a comprehensive review to really evaluate it as a whole and take a look at eligibility standards today. there were members of the commission that felt, for example, some of the lower priority categories were not necessary. : the volumes are very low and there are potentially a challenge of maintaining those programs and they could become a resources within the

community. there were a number of thoughts about how to best utilize the capacity. and really look at the eligibility program. >> with the eligibility for a non- honorably discharged veteran was that part of the discussion. did you make a definitive recommendation on that. >> it was included in our findings it outlines for other than honorable they would be put in a tentative fifth category until he could be evaluated but it wasn't to provide the care for veterans that often had reasons for being put in that category that have nothing to do with their service in the honorable service that they provide.

i would be a case-by-case basis. >> if you have a veteran who has have multiple deployments and has served honorably for an extended. of time comes back to the states and he says he's have it and accept and other than honorable discharge but one of the other categories perhaps that was in part caused by his multiple deployments would be unfair to leave him out of the va care system. >> thank you mister chairman and i want to think the panel thank the panel and all of the great work that you have done and everybody that had contributed to the report i want to begin by thinking senator mansion for his passion on this issue with regard to opiates. were having a similar challenge in alaska and i actually want to think we are a big summit in alaska the

challenges and heroin challenges the summer and we have very top doctors i want to thank both of you. i didn't really see in a lot of the recommendations but i know it's in there because it's a really important topic and when you talk about the delivery of care the issue of course that i'm very focused on is the delivery of care in rural i apologize. i really miss having the secretary there. i would love to be able to chat one of the breaks.

i was back home in my state over the summer like all of us and a lot of the communities they seem to have a very different approach and some of the far-reaching communities we don't have roads and the unique challenges. and some of it relates to how the va reacts in the tribal organizations in the far-reaching communities but one of the things i saw i went to a number of communities there seems to be a very different standard even depending on the veterans next to each other. on some of them said i can go

right down the road to the local clinic or the native health organization. others say i have to fly to anchorage or seattle. that can cost thousands of dollars just to get to these. the va pays for all of that? others say know you're on your own. so i'm just wondering on this issue how much you looked at and what recommendation you have. more broadly with regards to consistency and delivery because it does seem very different even in the same communities different veterans have very different experiences. >> first of all what you're describing is the challenge of veterans health care system that is so diverse and covers the entire country to be able to provide of where veterans live and work.

we felt like it was a major driving force for a more integrated model. it is easier access to integrate other federal providers which could apply certainly within the native american community across the country. the consistency of care in this country applies and challenge that you describe is true with veterans and non- veterans. we have them within 200 miles for women who might be trying to deliver. it is a challenge and that's one of the reasons we feel it is very important to take a local look in each market to try to provide better access the question of why some veteran has be a pay for it

that might be in eligibility kind of determination which i can't respond to but really looking at the diversity of markets and how to best provide the care especially when they're moving it's not as if they are stable. the facilities available in each market are quite variable as well. they might have outpatient facilities that can accommodate a lot of needs something not. the need to move for more inpatient and outpatient care is something we are seen across healthcare today. certainly something we have conversation about. >> are there recommendations that relate to this in the commission report the concept of the care system really incorporates some of the questions that you ask. >> does it focus on the extreme rural communities thank you mister chairman.

>> are you okay on time tom thank you mister chairman i want to thank you for all of the time and energy you devoted to this very important work to both of you mr. harvey, i think you have a raise in passing one of the central questions that faces us why have a separate healthcare system and i think you've heard some answers here which we see in our daily lives when we visit the healthcare facilities not only do veterans want to be with fellow veterans but there are ways that veterans care is enhanced by professionals who see them literally daily

hourly, for the same kinds of wounds, injuries and so forth i might just add in an area that is receiving more research there was an article just yesterday about studies being done on hospitals and measures of their quality and how when consumers are better informed not only about the metrics of outcome but also about how they are cared for the outcomes are better when the emotional or social factor is part of the measurement. in all kinds of ways i see the healthcare system is not why should we have it but it offers immense opportunity to

actually leave -- leave lead the nation in terms of quality and provides an opportunity to really attract the best in the brightest in the challenge it faces i think one of you stated in your testimony is the same challenge that the rest of our healthcare system does. we need more psychiatrist more equipment more affordable prices more pharmaceutical drugs where you can negotiate so it mirrors the rest of our healthcare system. but i haven't seen so far and maybe you can talk a little bit about it consumer protection making sure that

there are policies and procedures designed to monitor the quality of care outside the va healthcare system can be applied to the va healthcare facility but what about the healthcare outside the va walls and the choice which was program comes into play. >> one is the more unified and integrated outside providers are within the system i think the greater the opportunity is to really evaluate performance set clinical standards and apply the same approach that is within the va for the care that is received in the community. that is a important different concept where the traditional

ways that they have paid for care in the community. within our recommendations we also suggested that performance metrics need to be very comparable that we should have the same metrics of performance within the community as within the a. and that those metrics should be a requirement of participation really is a bedded provider within the va system. the more that it becomes the model i think it begins to allay some of those fears about cares mean provided differently whether it's the issue of pain management in the opioid use or the other elements of care that are provided. >> mister harvey did you want to add anything. >> you mentioned and we address this in part of our report that business of cultural competency of the healthcare provider understanding that this

veteran has have a particular type of experience in being sensitive to that and as i said perhaps when you are out. i know they have a card that they suggest using with various questions asked the veteran patient to elicit some of the experience so that met as you are factoring this into the diagnosis in the analysis you have that as part. the cultural competency and understanding in understanding the military background is an important thing that you get through a system like the va. your neck and get it at washington hospital. thank you so much. we will go to panel three. thank you mister chair. thank you for being here in the work on the commission. i want to thank senator mcdonald and his team we have

meetings last week a lot of the people that are here were in my office giving me an update on the transformation and the progress they think it's great work. i have to give special things also to senator mcdonald. the following day to give me a report on the toxic substances in the program i think we are making we're making progress. i appreciate the continued work. thank you both for being here. i'm going to jump to three of the recommendations where i think the va may have some concern. i noticed in notes that my staff said they had one note on discussion about privatization i never miss an opportunity when i see a word like that mention to mention that i do not believe that it should be completely privatized i don't know of any

u.s. senator who feels like a full privatization is a good idea. i think there's an opportunity for veterans to choose that. and it lets them choose whatever pathway is a right the right and necessary to provide timely care. i believe we agree with that. and i do say that because anytime i see privatization there's somebody saying that they want to give it to the private sector. i think there is a therapeutic value to some present until i see evidence to the contrary i would never support it. i do think there is a lot of opportunities used and that is what were getting at. recommendations in number four has to do with an engineering resource that i used to work in management consulting. i think they might have some concerns with it. has less to do it with the end result and more to do with the process we have a lot of

senators of excellence that are emerging. i visited national --dash feel i did a survive visit. i was very impressed with the results. it was one of two programs around the state. i think it is a management consulting i would be less interested in creating other groups and organizations with managers and communication channels and ways to create a web of subject matter expertise that we can leverage. that probably has less to do with that concept and more to do with the implementation but i will go to the department for that. i do have any comments on that particular recommendation. >> i think we've heard in terms of the response that the specific component of the va that we recommended be the center of this performance improvement work it may not be the choice.

that's not a big issue for me. but i think about how to drive the culture throughout va and focus on clinical and business profit improvement. insults. there is a great project there. that they've done which was lean process design it was in my state. i see an emerging number of best practices that we need to execute and proliferate. in an orderly way probably the one you don't have me. it's the closest thing to the board of directors. if we add another layer. they get monthly floggings

from two different groups. and i don't know that that is necessarily productive. i would not want to share that with anybody. i just think it is something we should look at and maybe we will drill down in the recommendations. if we have that layer down i think it could be another level of extraction maybe the members of a whole i have invested a lot of time with the leadership in understanding i think the more we learn about it the better off working to be. i would have to read more into the recommendation to make sure it's not putting it away. they will follow up on recommendation 17.

on bad paper. and they been great on this issue. i think there is no doubt that there the nature of their separation their behavior was driven by something that was a a temporary injury or permanent injury that we simply didn't know. we talked about it before. it's more the means rather than the ends. continuing the flogging. we appreciate you all very much. we appreciate the ideas that you put forth. in your testimony you talked

about the ongoing leadership challenges facing the organization including a distressed time. under the secretary's appointments. i would like to get your thoughts on how they can get after the risk version that is really a difficult problem and you might also as you do it comment about the senior leadership if you have any thoughts if those are working or not working. the things like the diffusion of excellence. is that getting down to the shark tank competitions. what other steps that we should be taking to try to

improve the culture. it is something that the commission has sent a lot of time on. they're making really significant not so much of the leadership of development but having continuity at the top for more than a couple of years. it's very hard to change culture when you don't have a consistent pattern of leadership at all levels starting at the top are concerned was they have oversight with parties. the board of directors. to head healthcare expertise overseen the transformation process.

there is a culture of safety around speaking up which is critical in any transportation and those were the ideas that we really tried to move forward in a recommendations. and sometimes i think they're fantastic. they are working with the professor from the university of michigan who i know very well i have taught him this class. on what they have done to really engage the teams i think it's fantastic. see make you highlighted the long-term challenges they had had with it particularly relates to scheduling. can you talk a little bit about that. to try to get a scheduling system. a lot of money what is your sense regarding off-the-shelf

solutions again how do we make progress. i personally was very impressed and other's that i had spoken to. my concern is that the va for the reasons that are entirely clear to me seems to have just head a terrible time what we are now saying is you should do the business practices with

a choice of doctors. it will do coordination with the veterans. and it will do scheduling and all of those things. and proof of concept. since they have not been able to get the scheduling. the system is an old system. it has been replaced by other systems. you want to do it right. if you cost lots and lots of money. thanks to both of you for your

testimony and for your months of hard work of the commission. we appreciate them very much. we will welcome our third panel. we look for to hearing from all of them. [inaudible]

tree and one tree and one [inaudible] as a witness is prepared to testify let me make an observation if i can. on behalf of the committee i want to tell how invaluable the health and support has been. we have never have a situation where they not ready to come forward. we appreciate many of the

things developed comes the american veterans we are delighted to have you all. the secretary and i both enjoyed -- enjoyed being there. the veterans of the foreign wars. we recognize him up for five

minutes. in members of the committee. the american we thank you for calling them. the report contains a fundamental flaw which will be addressed. it was stated in his dissent the choice for the millions of veterans. they also recognize in the best they cannot keep up.

the networks must be developed. in a way that preserves the capacity. they cannot sustain the infrastructure they also oppose it. we believe the commissions analysis is faulty they support this recommendations. the estimate was cultivated using medicare rates. they gave no consideration to

how medicare rules would apply. they are not restricted as a matter of time they are able to dedicate each patient. medicare on the other hand only provides it for ten or 15 minute consultations which would deny veterans full call quality of care. it is scored by the properly. it would be triple if not more and it is unsustainable. a better proposal is found in the plan to consolidate the care program. it supports allowing them. they would empower veterans to make informed decisions. by identifying the best performing and enabling the better coordination of care.

it rests on the principle of using resources to supplement resource gaps. it has the potential to improve and expand the access. however, they are able to involve that. as it stands. they can file an 1151 claim. in the entry. no such protection exists. the same regardless of where they receive their care. finally, we recognize that the cost for these reforms remains a significant concern. it was will well-received on both sides of the aisle.