they don't want to relinquish it. the problem is it belongs to the veteran. instead of saying we took an $8 million hit for non-va care to their budget, they need to say we took and gave $8 million worth of health care to the veteran. mr. o'rourke, you're recognized for five minutes. >> thank you, mr. chairman. to add to the point dr. rowe made earlier and mr. mcclain made about the success that hospitals and health organizations have and reminding patients of their visits, in the midst of this hearing i got a text telling me my appointment june 16th is at 9:00 a.m. to confirm hit c and reply. i hit c, confirmed the appointment, give me a phone number to call up if i had a question. those systems are out there not to beat the horse any more, but let's get that done. it works. and mr. chairman, i would like

to thank you and the ranking member who is currently not here, but you all in this committee have done such a great job in responding to this crisis. i think showing excellent leadership. we heard from the va directly. we've heard from the gao, the office of inspector general, hearing from the private sector. each of us in our individual capacities are listening directly to the veterans in our community. i ask we have a panel of vet vans and veterans service organizations if we are talking about veteran-centered care, we need to hear from them. and add to mr. mcclain's excellent suggestion of having a management organization identified structural and organizational weaknesses and complement that with the veterans and what they are missing in their care right now. i think one of the issues that has to be included in that review is the issue of accountability. we've talked about and described our frustrations with the amount of money that's been authorized

and appropriated. virtually lost within that system and not making its way to those veterans. i think that really is an issue of accountability. we see it throughout the performance of the va. an issue i would like to get your thoughts on, and i really loved ms. titus' idea about getting more residencies in rural or hard to serve communities like ours. is this a question of where we are going to get the doctors in the capacity we need? already in el paso, which as my colleague mentioned is about a ten-hour round trip drive from the nearest vha hospital. we have a va clinic, but do not have a hospital. our patient-to-doctor ratio is on par with syria or panama. it's a developing country's doctor-to-patient ratio. we are having a hard time

already. i like the idea of more incentives and ways to attract doctors and providers to our community, but when i meet with doctors, to your excellent suggestion of listening to the providers, they complain of having to perform functions that could much better be done by clerical staff. one doctor told me he actually had to write out a prescription for a veteran to be picked up by a van, taken to the greyhound station where he boards a bus to go to albuquerque, new mexico, five hours upstream on the rio grande. he says why can't somebody else do that? i would love to get each of your comments and thoughts about how we do more to support the current providers we already have, who by the way i think are doing be a excellent job. i do spot inspections in the parking lot of our vha clinic and talk to veterans leaving. i have not heard from a veteran yet who told me they had a bad experience. they feel they are treated like

kings and queens, princesses and princes by providers there. they have nothing but good things to say. what can we do to better support those providers? maybe 20 seconds down the line starting with mr. mcclain. >> i think once again you could bring in some people that really understand process reengineering and reengineer that process. there are a lot of things a doctor does not have to do and it's still within the standard of care. could easily be done by a physician's assistant or rn or lvn. >> you begin with that voice of the provider. we have to make sure none of this testimony sounds like we demonize the provider. the nonvalue added work steps those providers are going through today. this is not unique to any industry. >> thirdly, in section 301 of this bill, there are two provisions that will make it more difficult for doctors, civilian doctors to provide the care that a vet is asking for

with the choice card. so i would hope that you read those two passages. it's about like page 24. read those two passages and see if you can alleviate some of that paperwork burden that the civilian doctor would face if he agreed to treat that veteran. >> thank you. >> mr. chair, yield back. >> thank you very much. for the committee's knowledge, our intent is to have a single hearing in a couple of weeks with just the vsos, to not have them in these hearings, but give them the entire hearing to be able to look at all the testimony that's been provided. so they obviously are the stake holders in all this. dr. winstrup, you are recognized. >> i am grateful for this day to have arrived. it took disastrous findings within the va to get to this point. it's a step in the right direction. i can tell you as a physician,

face to face with secretary three times how we could do things better. every time i was told, yeah, we'll do that, never happened. right before this broke we set up a meeting with the four doctors on this committee, bipartisan, with several of the administrators, with the va, to talk about efficiency and access to care and quality to care. there is a different in different systems. if you have a system where many people work there are saying that's not my job, that's a problem. what you have mentioned many times today i couldn't agree with more. that's the physician input. if they can have the input how things could be better, you've got to go that route. the difference in responsibility in private practice and in other settings which is the va. if i had a patient that missed an appointment, i want to know why. also, if they were post-op, i

tell them, they've got to be here, i've got to see them. it's my responsibility. that tends to be missing if you don't know who's coming or going. measures such as standard of care are great. obviously, we need to do that. if you're seeing one patient a day and giving outstanding care, it doesn't mean very much. you also have to look at the access to care and the efficiency of operations. what you're saying today is spot on. the problem i found within the va system is you had too many people who don't know what they don't know. because they have always been in that system. they've never seen anything different. they think they are doing something great, but they don't know that others are doing it much better. that's where we need the outside input and the best practices. we are hearing a lot of the same things here today. i think that's great. ronald reagan once said if you have a message that's important, tell it over and over again. to me the best practices and efficiencies are driven by choice, which we heard so many

times today. when a patient is a liability rather than an asset, we have a problem. patients need to have choice. for me, my level of success and how well i was doing is how many wanted to see me when they know they have a choice. that's really where we need to be redriven. was mentioned before, too. the aca and throughout, we are really not addressing the doctor shortage. if you don't have providers, and not just doctors, could be nurses, pas, et cetera, you need to address those shortages in our country, and oftentimes in the rural areas especially. those are other things we need to focus on. i'm pleased the door is open to change. everybody here is open for change. i didn't know this day would come. again, i'm sorry it took what it took to get to this day. we've got to drive on. i like what mr. wahl says, get the big idea out there.

one thing i found interesting several months ago, i asked dr. petzel if va was reimbursed 500% of medicare rates with you be in the black? he said yes. some of the doctors on this committee politely disagreed they would be able to pay their bills and be in the black with the system they're running. from your observations, what is your opinion on that? >> i really don't have any data. i have not looked at that. i have no idea. >> lift up the hood on the question. when you compare yourself to yourself, there's probably not a lot of accuracy you can get. when you take a look at those organizations in the va that actually do submit data to publically-reported bases you have a way to measure against the other. when we continue to, whether it's patient perception, they use a tool called shep versus hcaps, when you see those simply don't submit the data, outcomes

data, we are stuck in this vicious cycle of, as you said, you don't know what you don't know because you are comparing yourself only to yourself. it would be like taking a blood pressure on a patient without any degradations. >> medicare used to pay 92 cents for every $1 of care delivered. after the affordable care act they are paying less than that. the reason i raise that, one provision of the bill you are going to be considering this week says that civilian doctors who take the choice card will be paid not more than the medicare rate. so it's important to alert everyone to what you probably heard from your constituents back home, that finding a doctor to take medicare is getting harder and harder. >> mr. walsh, you are recognized for five minutes. >> thank you, mr. chairman. thank you for being here today.

dr. wenstrup is hitting on it. i thought you brought up really great points. i see the books there. in our office every new employee reads good to great and we talk about organizational design and system performance and trying to get there. this was a description of a high-performing medical institution. multidisciplinary team work, patient-centered culture. is it about that simple? they followed up. this is commonwealth. i don't want to bait you on this. they followed up with this. information continuity, care coordination, transition, system accountability, peer review, team work for high valued care, continuous innovation and easy access to appropriate care with multiple entrants into the system. >> the data i shared with you today comes 100% from the commonwealth fund site. at the risk of being oversimplified, yes. >> very good.

you agree? >> i don't have any comments. >> all right. i bring this up because we've got to believe we see this and it's not as if jim collins is all of a sudden the va. they read it and they've seen it. what i'm trying to get at it is how do we incentivize this? there is first and foremost the care of veterans. there is a cost factor that figures into this. how, when we do this big idea -- i do believe if we get this wrong now, we are going to set the care for veterans the next two decades will be very difficult to change. this is an opportunity, but it must be thought out and right. it must not be driven by ideology. your position this is not the issue, if you simplify this into the public versus private sector, we are going to go down a road that looks just like this. why do you think this never went into the scheduling because this is, again commonwealth.

we've seen this in practice in hospitals. patient scheduling system uses auger rhythms. it takes into account patient availability, time and sequencing, laboratory tests procedures and travel time between appointments. if you've been in a medical system that does this, you leave with a sense of wonder. they were there to move from you place to place. is this a cultural barrier why this wasn't implemented? >> one of the issues is just that. the notion of patient flow. whether it's flowing the patient through a facility or through a series of recommendations and consults through different facilities, part of this is the efficient of patient flow, which again is a whole other hearing. >> when we do this, and we are going to have -- human nature, incentivize, oversight and

everything else that goes into this, this goes back to you and the work, i see this representing the district that the mayo clinic and hospital-acquired infections, hundreds of thousands of americans die by these every year. it's incentivized on this hospitals that don't get a handle on this and bring it down are going to be penalized in reimbursement to medicare. does that make sense? >> makes absolute sense. the data beneath that, those incentives and the outcomes with which are just irrefutable. if you look at a patient's perception of a hospital's responsive knopf while the patient is in the hospital, there is almost a linear correlation between the patient's perception. we get hung up on that. it's just perception. how does the patient know how good we are? when you pull the data, across 3,900 facilities you see a linear correlation between patient's perception and actual cases per 1,000 patient days,

associated infections. >> why do you think it took us so long for the private sector in states to be willing to put that information up? >> actually, it's our perversion to the data. when you go to the website you go to the experience or go to the quality. it's the very same data set. so when you pull the entire data set and look at those correlations, it's right there in front of our eyes. >> how do we meld va experiences in that? it does seem like we are on two parallel realities here on reporting and experiences. what would be your suggestion? >> we won't suffer from a shortage of data. it's how we bring the data together. it's the ability to bring some organizations. if you go on the commonwealth fund site, you will pull 83 or 84 va hospitals that submit that data. >> that's right. that's what i was able to do. >> i ran the custom report prior to the hearing to make sure we had a good current sense.

that's only 83 or 84 of the va hospitals. where are the others and how could we get away from this comparing ourselves to ourselves? >> the solution is out there. the will of the american people to get it, and now it's a matter of getting it in place, is that -- >> you bet. we have folks that have md and d.o. on their name badges. they are scientists and driven by good credible data, not anecdote. as well as our physicians in the va could lead to these answers. >> very good. i yield back. >> thank you very much. >> thank you, mr. chairman. i am grateful, as well, as most of the members you heard from that you're here today. i feel like we have a co-pilot now and the solution is there. we can see light at the end of the tunnel. it's been a very dark story. i don't have questions. i wanted to thank you for being here. i wanted to echo what mr. walsh just said. you see the relief in this room

around most of this place today that the solutions are there. i would agree, the attention of the american people is on this. the continuing drive by the american people to seek out the absolute best solution, the big idea, the step forward, and i think many of us today see light at the end of the tunnel. i'm grateful. when we saw the story getting darker and darker and 69 criminal investigations and kinds of things happening, i think most of us knew there are solutions there there are private sector, private industry folks that certainly are here to come alongside and guide this into the kind of success we know the va can be. i wanted to add my comments that you coming today and just broadening the light here, for us to be able to see how it can work and give us something to shoot for as our jurisdiction of oversight continues is the most

welcomed news i think i've seen since we got into this whole situation. on behalf of the veterans in my district, we're grateful. i do see light at the end of the tunnel. mr. chairman, thank you for your leadership. i yield back my time. >> thank you very much. ms. brown, you're recognized five minutes. >> thank you. i want to thank the veterans to work at the va hospitals for their service because basically the veterans to tell us over and over again once they get in the system, they are very satisfied with the service. so that's not a misnomer. ms. mccaughey. we are looking at advantaged care and tricare. >> you are referring to medicare advantage? >> exactly. >> okay.

>> in your testimony, it seems as if you are recommending that as -- >> no. i was pointing out that a large number of vets have enrolled in medicare advantage, and yet they are going to the va hospital for their care. so, in fact, we are paying for it twice. i was pointing out that literally 10% of the va budget is going to vets who have another kind of coverage. it's a tragic inefficiency when you look at we are discussing money and where to get enough money to care for vets, then you find something like that which was documented recently in the "new england journal of medicine." i'm happy to show you the article. why aren't people figuring out that such a large number of vets are paying for care, we're paying for their care twice? we are paying to the insurance companies that run medicare

advantage plans and paying again to the va system. let's at least sort it out and get it straight. that's what i was suggesting. >> i'm trying to be clear that the va system is a system that the veterans prefer. part of the challenges we experience, for example, people that don't have hospitals in their areas, all of this is form-driven. we may need to come up with additional ways to serve veterans. until recently, we have not built a va hospital in 15 years. we have not built additional hospitals. are we going to build additional hospitals for veterans or come up with a partnership that the veterans and the va -- because the testimony we had last week when we sent a veteran outside of the system, we've got to make

sure it's a certain quality of care. >> of course. >> if that continuity is not there, you are still going to have the exact same problem we are experiencing today. in addition to that, i'm a person if i have an appointment and i don't keep that appointment, there is a charge. we don't do that to veterans. if they have an appointment, and they don't make that appointment, there isn't a penalty to them. >> there is a terrible penalty to them. it's not a monetary penalty. it means they are waiting longer and longer for care. when vets don't show up for their appointments, i'm not blaming the vets. in many cases they waited as long as six month for that appointment. the fact is that they, the va hospitals and clinics should be calling the vets 24 to 48 hours

or e-mailing them ahead of time to remind them of their appointments. it is unrealistic to think a vet will remember an appointment four months ahead. >> i am saying on the other side of the world, if you don't make that appointment, there is a financial penalty you receive. >> mm-hmm. and what is your point, madam? >> i made my point. >> thank you. >> the point is we have additional veterans in the system because we open the va system up to the vietnam veteran. each one of them did not have to prove they had a certain disability. so we got thousands of additional veterans into the system. the secretary did it, and i'm very grateful he did it. now we have to figure out how to serve them. i am saying that the va system is one of the best systems in the united states. that is what i'm saying.

i read your expertise which is in the area of infectious diseases, which is a problem. the bill we have before us and i'm hoping and the chair's recommendation, and the senate bill, i hope we can work out what is the best way to move forward with the va system. thank you for your kindness and time. >> thank you. >> mr. jolly, you're recognized. >> no question. >> thank you very much. >> i want to thank the chairman and committee for allowing me to participate in the hearing. i heard some excellent ideas here. i've seen a real bipartisan spirit finding real solutions. i think it's a great morning. we accomplished a lot. i have a hypothetical question. if the no-show rate were reduced to 5% which we heard is

attainable, and physicians were relieved of the nonvalue-added requirements, which is a phrase mr. collard used, would there be enough to provide the health care needed to our veterans? >> i haven't done the math, but it would help. that would bring it closer to what the commercial expectation would be in health care delivery. >> we probably don't know this. none of us at the table have the math. it's a question answerable because the variables are real variables. >> i'll give you the 2012 report that was provided to congress on just this issue, assessing how to assess the need for additional physicians at each location. >> please are brief. >> i'm just going to give you the report. >> okay, thank you. >> mr. mcclain would you talk about the current state of

affairs regarding the transfer data between the private sector and the va, and if there are barriers, how could we reduce those barriers? >> we had a problem when we started out in project hero, we were not able to immediately input any data into the va's medical record. we maintained a network of specialists, so a veteran would be referred out to a specialist and you would get a consult and you would get a written consult report, that we ended up faxing back to the va. apparently then it was detached in a pdf form and attached to the cprs to the veterans' record. in the c box it's a different thing. we are part of vha health care system and we have access to vista and to cprs. it's very difficult. i understand the firewalls, the

privacy issues, i understand the i.t. issues that come up, but there has been a lot of work done in these commercial and civilian sector on exchange of information. i think the answer to your question is dod and va have been trying over ten years to exchange information and have been successful. >> thank you. in your testimony you used a new term, evidence-based leadership. are there models for identifying evidence-based leadership? is there some way to move forward? >> i think what you would find as you look at the models and structures that parallels to evidence-based world and that is evidence-based care. you begin with the diagnosis before prescription. the notion of an assessment prior to jumping into the fray becomes key. then the alignment towards an

eventual outcome is where evidence-based care goes. alignment of goals or desired outcomes which includes the proper training a physician would receive that provides evidence-based care. aligning of behaviors. so the agreed upon behaviors to produce the outcome. a topic we have not come close to talking about today but has been shown in the latest bills, the ability to manage the performance gap much better. whether it's -- we'll push the organized labor issue aside for a second because we have organizations that are highly organized that are very successful in managing performance and they don't let the presence of a union stand in the way. but the ability to first and foremost re-recruit the highest performers in the enterprise, ability to look for those that seek and can benefit from development and the ability to quit hanging on to the low performers that drag the rest of the industry down. we can argue the ends, if it's

nf-1, nf-2, but if it's my grandmother in the bed, that low performer is causal to a lack of good care. what that brings us to, much like evidence-based care is through research, through vetting of the data and the outcomes, the ability to standardize, the ability to accelerate that standardization. that is a quick model of evidence-based leadership. >> thank you. i thank the committee for allowing me to participate. >> thank you. welcome back. great to have you with us. members, we have a series of votes that have been called what we are going to do is thank our panelists who are with us today. we look forward to communicating with you off mike, as well. we want to help the va solve this problem. you have helped bring some information to us today that i think is very worthy of consideration. we cannot fail. as we've already talked about, we do have an opportunity that does only come about once in a lifetime to be able to fix this

for the veterans. dr. jesse, i apologize. i would rather us go vote. i don't want any members to miss a vote. we will reconvene at the end of the last vote. it probably will be an however.

a break here as veterans affairs committee members are heading to the house to join their colleagues on votes on tax extension bills and the bill condemning the terrorist group boko haram. that is the group responsible for kidnapping young girls in that country. you can see the house live on

c-span as those votes are now under way. we should let you know house speaker john boehner and minority leader nancy pelosi holding weekly briefings today. minority leader pelosi held her briefing. we plan to bring her remarks later. we are standing by for house speaker john boehner.

good morning, everyone.

eric cantor has been a true friend. i want to thank him and thank his staff for their service to our conference. thank them for their service for our country, as well. there is no one around here who works harder, puts more thought into advancing our principles and the solutions that we want to enact for the american people. i look forward to him continuing to lead our floor efforts here over the summer. as for the future, let me share a little bit with you. this is a time with unity. a time to focus on what we all know is true. the president's policies have failed the american people. his administration can't get our economy back to real growth and he continues to endanger our troops and citizens with his failed foreign policies. on this point, the administration can't provide basic services to our veterans.

we need to elect a congress that not only has the will to stop the president, but the power to do so, as well. every day we are showing the american people we've got better solutions. today, we'll act on two more jobs bills that will help small businesses invest and grow. unfortunately, senate democrats continue to sit on their hands and failing to act on the dozens of jobs bills sitting over in the senate. guess what? so long as the american people continue to ask the question where are the jobs, we are going to continue to be focused on this one issue. i said on tuesday the transfer of five hardened terrorists has made americans less safe. i mean that and i'll stand by it. when asked last week whether the free terrorists could return to plotting attacks on americans, president obama recently said absolutely. well, i don't think that's about half of it.

this exchange has encouraged our enemies and increased the risk to our military and civilian personnel serving around the globe. those who would argue the opposite, i think, are incredibly naive. one of our citizens greatest protections was knowing that the united states does not negotiate with terrorists. that issue now, that principle has been compromised. america's willing to make deal with terrorists, that's the new obama doctrine. in january, i urged the president to get engaged with what's going on in iraq. this week we've seen big cities in iraq overrun with terrorists. the obama administration's failure to reach a status of forces agreement continues to have serious consequence for iraq and american interests in the region. the administration's failed policies in syria, libya and egypt, and failure to implement a broader strategy for the

middle east is having a direct impact on the situation in iraq. the united states has and will continue to have vital national interest in iraq. the progress made there is clearly in jeopardy. the president celebrated our exit from iraq as his hallmark of our foreign policy agenda. our focus should be, instead, on completing our mission successfully. i would urge the president once again to get engaged before it's too late. [ question inaudible ] >> what has happened in the past few cycles? what do you attribute to this where it seems like if the wind blows the right way? >> i'll let the political

pundits describe and figure out what happened in that election. every election is different. i went through a primary process myself. you have to understand, the american people are being squeezed by obama's policies. the economy is not growing. income's not growing, we are not creating enough jobs. 2/3 of america see no increase in our wages but food prices are going up. gas prices are going up and health insurance costs are going up. there is a lot of frustration that's out there. they look to washington and wonder why we can't resolve these issues. they are hard to resolve when you've got a president who won't engage. [ question inaudible ] >> were there certain things you felt you had to do? >> i ran my race in a way i thought i should run my race,

but i'm not going to analyze that race down there. >> do you want kevin mccarthy to be house majority leader? how important is it, do you think, for unity in your conference to have a red state republican at the leadership table? >> i do think the members are going to make this decision. we are going to do it next week. i'm sure some will argue it's too soon, some will argue it's too long, but it's important we resolve this issue in a fair amount of time so that we can do the work that we were elected to do. so the members will make the decision about who the next majority leader is. >> it's a big deal for you. you talked about how important it was to have eric cantor at your side. do you want kevin mccarthy at your side? >> i worked with all other 144 members of congress. i can work with whoever gets elected. >> the issue at hand in mr. cantor's race was that of immigration. people say immigration reform is dead because your conference will not move out of fear of what happened to mr. cantor.

>> i don't believe the first premise of your question. secondly, the issue with immigration reform has not changed. the president continues to ignore laws he signed into law violating his oath of office. he did it again with release of these taliban five. i reminded the president again yesterday that every time he does this, it makes it harder to gain the trust of our members to do the big things that need to be done around here. >> are you worried about immigration as an issue in 2016 then, it's not going to happen this year? >> the president has to demonstrate he can be trusted to implement a law the way it was passed. >> you say that the people who think this bergdahl swap was a good deal are idea. the chair of the chief of staff signed off on the metric of national security. do you think the chairman of the joint chief of staff is naive?

>> they are dead wrong on this issue. releasing these five people, negotiating with terrorists is a principle we've now violated it. we now violated it and put americans at risk as a result of it. [ question inaudible ] >> was it a message at all? >> no. i'm not going to analyze what happened in this election. they are all different. i'm sure at some point people are going to hear about what really happened. >> surely you must have a take away dealing with issues like immigration. if eric cantor can be branded he is supporting amnesty. >> we don't know that that is the issue or was the issue in the election. >> on iraq, do you think the u.s. should be launching air strikes? if not, what should the u.s. do?

>> what we should do is provide the equipment and technical assistance that the iraqis have been asking for. i don't know enough of the details about the air strikes to comment whether we should or shouldn't. it's not like we haven't seen this problem coming for over a year. it hasn't, it's not like we haven't seen over the last five or six months these terrorists moving in, taking control of western iraq. now they've taken control of mosul. they are 100 miles from baghdad. what is the president doing? taking a nap. house speaker john boehner

prior to the speak per we have been showing you a hearing. the it's in a break now as committee members are attending votes in the house on a couple of tax extension bills. you can see those votes on our companion network c-span. former president george w.h. bush can no longer use his legs but isn't that stopping him from keeping a vow he made five years ago to jump from his aircraft on his 90th birthday. it's a wonderful day in maine, nice enough for a parachute jump. we watched the president jump from a helicopter about a half hour ago. it was a rough landing, but he appeared to be okay. we'll return to the hearing when it resumes in about 45 minutes live. we'll go back to the opening statements as the hearing was just getting under way.

committee will come to order. thank you, everybody, for coming to this hearing this morning. we have numerous members that are on their way, but we want to respect the time of our witnesses. we appreciate them being with us today. before i begin, i want to ask unanimous consent to allow our colleague and former committee member congressman mcnirny to sit the diaz and participate in today's hearing. welcome to today's full committee hearing, an examination on bureaucratic barriers to care for our veterans. during our committee oversight hearing in early april, we came forward with the results of a

committee investigation that had uncovered evidence dozens of veterans died while waiting for care at the phoenix don't of veterans health care system. just over two months later, we know now that in addition to 23 veteran deaths at the department linked to delays and care earlier this spring, at least 35 more veterans died while awaiting care in the phoenix area alone. what's more, a va audit released earlier this week found over 57,000 veterans have been waiting 90 days or more for their first va medical appointment, and 64,000 veterans who enrolled in the health care system over the last decade never received the appointment they requested. that's 121,000 veterans who have been waiting for care to be provided that they earned. that number exceeds the

population of several mid size u.s. cities like athens, georgia, abilene, texas, or evensville, indiana. i fear there is more yet to come. yesterday i spoke to a group of va providers from across the country at an event for the national association of va physicians and dentists. speaking about the current crisis engulfing the department, they've said va's procedures and processes are inconsistent, inconsistently applied and often prevent inefficient use of personnel. the statement echos serious calls for alarm we heard from others over recent weeks. during a recent committee hearing, dr. day, inspector general for va's health care inspection testified va suffers from, "a lack of focus on health care delivery as priority one." as a result, "several organizational issues that impede the efficient operation

of the health care system and places patients at risk have unexpected outcomes." in an article published last week in the "new england journal of medicine" a former va undersecretary for and a current staff physician at a major va medical center wrote that the data manipulation and lack of integrity, va experiences are, quote, symptoms of a deeper pathology, because simply, va has lost sight of its primary mission of providing timely access to consistently high-quality care, end quote. all of these remarks go to prove what we have already known. the va health care system is complex and its problems are even more complex. i believe that the majority of va's work force, in particular the doctors and nurses who provide our veterans with the care they need, do in fact

endeavor to provide quality health care. however, the va has failed those employees almost as much as it has failed our veterans. in correcting those failures, it's going to take a lot more than the band-aid fixes that's been recommended so far. it will take systematic reform of the entire department starting with holding senior staff accountable. va hasn't gotten where it is today because of middle management, or lack of training and professional development for administrative staff or productivity in staffing standards and outdated infrastructure. the department got where it is today due to a perfect storm of settling for the status quo. va cannot continue business as usual. it's very clear the status quo is not acceptable. and it's time for real change. again, beginning with accountability up to the highest

level of va bureaucracy, and i hear repeatedly from the va about its delivery of high-quality patient center care. but this committee, republicans and democrats alike, will not rest until we hear that same assessment from every single veteran seeking care. it's time for va to tell us the bad news, not just the good news. with that, i yield to our ranking member for any opening statement he might have. >> thank you vch, mr. chair, for having this very important hearing. to examine the various care for our veterans. this is a unique time in the history of the department of veterans affairs. we as a committee have been spom for bringing to light systematic problems by many dating back over a decade. but as we are shining the light on these problems, we must also

begin to take steps to address them. i'm proud that this committee has addressed these problems in a bipartisan fashion, and i'm hopeful that this spirit continues the hard work of finding solutions. the vha is a sprawling organization with over 6 million unique patients, utilities spread all over the country, and nearly 275,000 employees, in a $56 billion budget. to put va the largest integrated health care system in the country in perspective, vha is roughly the equivalent of five mayo clinics combined. recent admission of wrongdoing are shameful, and the practice will not be tolerated. the systematic lapse of integrity confirmed by the internal vha access audit and the va oig reports, points to a bureaucratic bureaucracy that

has seemed to have lost its way in its focus. i think these problems, the time is right to begin discussing how best to address these challenges, and the time might be now to effect big changes that will put the focus back on the veteran in a way away from the culture of complacency. in our discussion of reform, i want to make sure that we're not just rearranging the desk chairs. all the reorganization in the world will not -- will be futile without a strong base of values. i do not doubt the commitment of the vast majority of va employees. however, sometimes we all know that we need to be reminded of who we are here to work for. we are here to work for the veteran. brave men and women who have sacrificed so much for our freedom.

men and women who right now deserve better. i strongly suggest that vha develop a code of conduct, or a caregiver culture that will become ingrained throughout the organization regardless of whether there is one vision or 50. working in the va requires the utmost integrity as dr. rowe pointed out the other night, all va employee needs to do without a doubt is they have to be reminded that they are working for the veteran, not a bureaucracy. as with most things, there are tradeoffs when looking at structural reform, centralization versus decentralization, standardization versus innovation. these discussions have been ongoing for years, if not decades. i would like to think vha is an adaptable learning organization

that can make needed transformation. but let me be clear. the only way we're going to truly address the litany of problems is to look at the fundamental change within the department. and rightfully, we're all looking at ways to address the problems as we see today. i'm also hopeful that our ambitious schedule of hearings in the weeks ahead will think anew about how best to provide the quality comprehensive care to our veterans in a timely fashion. and i hope that they challenge us to think ain you about how to refashion systems and infrastructure, management and personal policy and procedures to address the access issues head-on, and to help the va live up to its ideal. i believe it is essential that we look at structural and cultural root causes that got us in this position in the first place. we have heard that the leadership of the medical

centers feels disenfranchised. we have real concerns about the effective level of accountability. we need to provide from the front line provider to the va leadership. one of the discussions we must have is over the right administrative structure of the vha. how do ensure that policies and procedures are followed nationally while making sure that the va is not a one size fit all system. we have heard many times about the excessive, intrusive administrative burden our providers experience, which takes time away from caring for our veterans. we need to do what we can to eliminate this administrative work. many are pointing to the i.t. infrastructure. there is no doubt that an outdated scheduling system contributes to the current problems and needs emergency upgrade. and we need more detail about what's happening with the millions of dollars congress has appropriated for i.t. before we can look at investing even more

money here, i want to know why the va did not do a better job in planning strategically, anticipating the needs of facility system, population, and putting in place actions, including things like i.t. upgrades to address these anticipated needs. the time is right to leverage outside expertise. there is no monopoly on good ideas. i look forward to hearing from the panels today and hope to continue this excellent discussion throughout the coming weeks. once again, mr. chairman, i thank you very much and yield back. >> thank you very much to the ranking member. joining us today we actually have two panels. on our first panel, already seated at the table is the honorable tim mclean, president of humana government business. mr. dan collard, chief operating officer for the studard group. and dr. betty mccoy, chairman for the committee to reduce infection deaths.

we do appreciate all of you being here with us today. with that, mr. mclean, you're recognized for five minutes. >> thank you, mr. chairman. and members of the committee, thank you for holding today's hearing to examine bureaucratic barriers to health care for veterans. i will focus my remarks on the very complex subject of organizational impediments in the veterans health administration that are not conducive to the delivery of good health care to veterans. in my written statement, which i ask be made a part of the record -- >> without objection, all of your statements will be entered into the record. >> i want to approve organizational alignment in the vha. but in this oral statement i want to address just one. it is the one that is probably the most disturbing to veterans and congress, and that's a failure of ethics. there is a pervasive va culture that puts personal gain in the

system over the needs of the veteran, and this is wrong. i want to make two points to the committee. let's not have congress and va just put band-aids on the current crisis without resolving the systemic causes. and two, i believe any long-term solution must include a culture and organizational assessment by a nationally recognized company. the current crisis differs from previous va crises, by the fact that it reflects a serious cultural deficit throughout va at certain levels of management. this is a culture of what should be at va. now, i want to emphasize and make it clear that from my experience at va, i found the vast majority of va employees to be competent, and dedicated to the primary mission of serving

veterans. but the culture at certain management levels reflects an attitude of personal gain over service to veterans. some major changes are required. but before making any major changes, i propose in my written statement the va be directed to contract with a nationally recognized company to conduct a top-to-bottom assessment of the current culture. a gap analysis can then be performed to determine the current state and then what is needed to move the va system to a veteran centric 21st century system. the experience will be influenced by what i will call the voice of the veteran, which essentially is direct veteran input into what this culture should look like going forward. if congress or va fails to seize the once in a generation opportunity to deliver a modern va health care and benefit system, we will all be back in

this hearing room in the future, lamenting the then current crisis. mr. chairman, this concludes my oral statement and i would be glad to answer any questions. >> thank you very much, sir. we appreciate your comments. mr. collard, you're recognized for five minutes. >> chairman miller, ranking member and committee members, thank you for the opportunity to address the committee on the issues of veterans health and underlying elements of culture and leadership. i listened with interest monday night when i listened to mr. griffin talk about when you see one vision, you've seen one vision. your questions centered around evidence in variance. in over 900 health care organizations across the country, those implementing the standard of care produce the best outcomes. they build culture of accountability and sustainability. it extends beyond evidence-based

care to a framework of evidence-based leadership. this approach ensures that leaders are not only held accountable for the right goals, but these leaders are given the skills and the tools and the knowledge to achieve those goals. these leaders ensure consistency in the workplace for the employees and ensure consistency in the care environment for their physician colleagues. and as the public has watched the vha issues unfold over the past 60 days, it's clear that the tolerance for variance is chief among its ailments. the amount of variance to standardize leadership created an unfortunately predictable outcome, as we would say what you permit, you promote. the data that demonstrates these connections of evidence-based care, patient experience, and lower costs just continue to mount. when one reviews the publicly reported data, it's clear that better health care is less costly health care. data also suggests a strong correlation between patients' perception of care and the actual clinical outcomes.

further, there's data that correlates the specific questions bike preparation for at-home care with the likelihood of a readmission. a review of the vha facilities that report show that only a handful appear in the top, and unfortunately too many in the lower ranks of health care. one begins to see definite trends. a study published recently by the university of alabama at birmingham showed clearly the correlation between the level of employee engagement and likelihood of the creation of work-arounds, which equals impact on safety. i was reminded of that as i read the various reports of what i now know from the whistleblowers about the veterans' wait lists and the related mortalities. health care systems in the united states have driven improvements by implementing best practices across their systems. when organizations identify a best practice, they move quickly to put the practice in place across all 205 facilities.

this includes patient safety protocols, caregiver-to-patient interactions, and leader accountability platform. i was concerned when i heard the witnesses on monday the time they thought it would take to make change. the biggest obstacle to achieving high performance is not achieving the needed urgency. mr. walls, i think this was part of the answer to your question about the big idea on monday. no matter what's decided, the va must embark upon change with a never before seen sense of urgency with a prove n outcome base. an organization already excels into an area where they are sub par. for instance, imagine if the vha electronic medical record which is hailed as cutting edge could be the impetus for creating the scheduling software which is today archaic at best. imagine at the high performing

facilities referenced in monday's testimony that stand out as models could be those models, and indeed replicated with what was exceptional leadership and culture. we wouldn't have tol raid the operation of 21 different navys or armies, air forces, marines or coast guard when these veterans were on active duty. why do we tolerate 21 versions of veterans health today. they put in systems of verification and validation of skills for both front line sailors and soldiers. we find safe, effective, timely health care to be no different. finally, we have to make sure that the veterans health administration doesn't continue to fall victim to this disease process known as terminal uniqueness. many health care organizations work with an organized labor environment. many have large geographic foot prints thousands of miles from where the care is being delivered. many organizations serve a large

indigent or disadvantaged patient population. yet these organizations find a way to not only survive, but thrive. i ask that this committee would compel the secretary and his leadership team to move forward with urgency, implement evidence-based approaches across the enterprise, ensure methods of verification and make sure this supports leadership development to ensure the consistency. i ask this today not only as a health care professional, but as the son of a deceased marine corps veteran whom i saw all too often let down by the va. thank you. >> thank you, mr. collard. dr. mccoy? >> thank you. i'm betsy mccoy, former lieutenant governor -- >> if you could check the -- >> and chairman of the committee to reduce infection deaths. i spent a good deal of my career in infection prevention in hospitals. i admire many achievements from the va in that area. but i'm here today to express my concern that this bill passed in

the senate yesterday, the mccain/sanders bill, will not save the lives of vets stuck on the wait lists. this bill as currently written is designed to protect union jobs, not ailing vets. in fact, the va is run largely by unions and for unions, and one of the culprits is this 316-page union contract full of mind-numbing rules that prevent assigning an employee to a new task, a new work shift, a new building, or reprimanding someone on the staff for misdeeds, or just poor performance. nine months ago, the va rolled out a $9.3 billion initiative to allow vets who are stuck on wait

lists to access civilian care. but the unions fought it as hard as they could. the american federation of government employees labeled it in their newsletter "the worker" an attempt to dismantle the va brick by brick. that's not true, but they vilified it that way. and this current bill sabotages the ability of vets to access civilian care in three ways. first of all, it requires -- and i'm referring to section 301 starting on page 21, since i'm sure you'll be reading the bill -- it requires that any vet wanting to access civilian care get a letter from the secretary of the va confirming that the vet has waited an unacceptable amount of time for treatment, or lives more than 40 miles from a va medical center. good luck getting that letter. i talk to vets all the time who have contacted the va, called

them, e-mailed every day for six months and couldn't get a reply. secondly, if the va does manage to get the letter and get the choice card and get to a civilian doctor, then he has to hand the card to the doctor, who is instructed to call the va and get prior approval before treatment. good luck getting somebody to answer that phone call. and thirdly, most preposterously, this bill states that this choice program will end in two years. in other words, a few hours after the va manages to finally get the hotline up and get the cards distributed to vets, it will be over. so, there is a way to solve this problem and put the vets in the driver's seat. and i'm going to credit the rand researchers with this idea, because the fact is, that almost half of vets stuck in this waiting list are seniors, they're 65 years or older and

almost all on medicare. if they were encouraged to seek non-combat related care, age related care, such as bypass surgery, angioplasty at civilian hospitals, particularly teaching hospitals, it would reduce the backlog by as much as half, solving this national crisis. and in many cases, vets would get better care, because the mortality rates at the teaching hospitals associated with many of these va medical centers are much lower. they're high-volume hospitals and they do these age-related procedures all the time. what's holding the seniors back is lack of knowledge about that resource, and secondly, the co-payments, the out-of-pocket expenses. we could give those vets who are already on medicare a special va medigap card. it's budget neutral. you're already paying for the care. yet it would allow them to access better care.

it would reduce the wait list, and allow vets who fought for our freedom, it would allow them the freedom to get the care they need. thank you for this opportunity. >> thank you, dr. mccoy. mr. collard, i'll start with you. but anybody that wants to answer this question, feel free. each member will have five minutes for -- and we also have a round much votes. that's why evening hearings on return nights are so good. we don't get interrupted with votes. but my staff recently obtained an e-mail, in the supervisory chain, how many levels there are between the scheduler and the secretary. and of course, the scheduling clerks called medical support assistance shows 12 layers of bureaucrats and middle managers between those two people. is that surprising? >> it's not surprising, but it's

clearly an indicator of the issue. on the private sector, you wouldn't think about care that could be rendered in a safe, timely fashion with 12 layers of leadership between someone in the trenches and someone making a decision. it also creates the greater opportunity for the variance in communication, the variance in setting expectations that -- the layers just create the permutations within the va. >> anybody else want to comment? >> and how about the time it takes, all that communication? this is time. you know, one of the studies that just recently came out showed that when an older vet is forced to wait 90 days or more for treatment, it increases the risk of stroke by 9%. that's a study right out of the boston va medical center. so this time is critical to saving the lives of these vets. that's why they're dying in these wait lines. >> tell me, if you could, how

does this structure compare to your experience in observing other medical centers? mr. mclean? >> i don't have a lot of experience in viewing other medical centers. humana is a medicare advantage company. we do a lot of business with the va. we have seen the difficulty that we have as a contractor, and also getting certain answers and certain things changed or done for the betterment of the veteran. >> mr. collard? >> we would find traditionally no more than three or four layers. i was with an organization yesterday, and it was the traditional structure of a senior leadership team, directors, managers and right to the front line. >> i think you also -- i think, mr. collard, you may have, and others may have alluded to this as well. the number of health care networks that exist across this

country, 21? i mean, you've got a large network, i mean, system. how many networks should there be? i mean, surely it should be broken up somehow. but 21? >> even if the number stayed 21, the ability to standardize across the 21 is really the key. there are -- you know, health care is always local, no matter whether it's private sector, health care is always local because we're serving local veterans. the ability to say whether it needs to be 21 or 6, 9 underpinnings when you lift up the hood on that is the ability to standardize across no matter how many divisions that you have. >> dr. mccoy? >> yes. one of the problems is really quite simple. and it's been pointed out in many of the reports that have been submitted to consciogress the last decade, including the

one on monday and the one presented by the general accountability office in march of 2013, and that is, that vets are assigned an appointment, and then months go by and nobody calls them to remind them a day or two before the appointment, that they're supposed to come. that is a practice that is always done in private sector medicine. every doctor's office, every clinic, every hospital calls patients and reminds them to show up for their appointment. the result of this failure is that in some departments like ophthalmology, according to the gao report submitted to you last march, the no-show rate is 45%. so when you say you don't have enough appointments and enough doctors, almost half of them are going to waste. and yet why, every year, does another report have to remind the va to call the patients, and nothing is done about it. >> my time's about to expire. but i'd like, if you could, as

succinctly as possible, what's the greatest single barrier that exists out there today to providing timely health care? >> i'm going to go off what mr. collard said, standardization. you've all heard it. if you've seen one va, you've seen one va. and there is too much, i guess flexibility, or variability in how services are delivered and how veterans can access services at each of the va facilities. >> when you standardize your practice, you create greater predictability and outcomes. whether it's an attorney, a finance expert, a health care expert, they'd all agree that when you standardize your mode of practice, you create greater predictability and outcomes. i think it's the outcome that ultimately that this panel has to address and not just the process of care measures that we're talking about. the. >> dr. mccoy? >> yes, i'd like you to focus on

the falilings of this bill. you'll be compromising with the vote you took in the house to create a final bill. and that final bill that you create has to remove these practical impediments. otherwise you are not passing a bill to give vets access to civilian care. it will be a charade if they have to get a all right from the secretary, and if there has to be a call made to get prior approval for the treatment. just remember that, please, as you compromise with the senate. thank you. >> mr. michaud, you're recognized. >> thank you, mr. chairman. mr. mcclain, one of your recommendations is to ensure that all vha employees from clerk to clinician to senior managers are evaluated based on outcomes for veterans who are seeking and receiving care from vha.

mr. collard, you also urged the va to focus on leadership. my question to you two is, the overreliance on metrics has been mentioned as one of the factors leading to the current wait time problems. how do you distinguish between metrics and outcomes, mr. mcclain? >> thank you very much, mr. michaud. my short answer to that would be that most of the metrics that are reported today in vha, and there are hundreds of them, are process oriented. and simply checking a box or doing something versus actually measuring what that accomplishes, or the outcome, and so my point in making that was that we should be rewarding and measuring outcomes for veterans, good health outcomes rather than simply checking the box and doing a process. >> i would add that it's just

the shear size of the numbers of metrics. if you went the hr route and pulled a middle manager's will valuation within the va today, you would see metrics scored by the dozens. if you think about that many metrics, how can a leader give any proper attention, and proper priority when you have a weighted evaluation around those that are outcomes versus process. you have the ability to create focus, and priority, and that's what i would say is not just the metrics, but the shear number of metrics that we're looking at. >> thank you. is it valid to have a strategic metric, mr. mcclain? >> i think it's valid to have a strategic goal, as to what the outcomes might be. and be measured against that goal, i think that's valid. >> mr. collard? >> i wanted to point out -- >> mr. collard, would you answer? >> go to the cms website and you'll see one of the metrics that the private sector is paying a lot of attention to

right now, readmissions. we know a tactic like a post-hospitalization phone call has the ability to reduce readmissions. and yet what we don't do is we don't measure the post-visit phone calls they make. in the publicly reportable website you would find the readmission rates for folks within certain disease categories. >> thank you. within the va, there's raised concern that there are inadequate numbers of extenders and this cases physicians to spend undue time with paperwork and routine clinical work. mr. mcclain, what does the private sector use as a benchmark for the physicians to physician to extender ratio? >> it varies depending on what type of clinic. our involvement are with the community based outpatient clinics. we operate 34 of those under contract with the va. and so we have a -- we utilize

va's, for the most part, panel size of 1,200 per physician. and then the support -- the medical and also administrative support for a single doctor would be somewhere in four or five support personnel for that doctor. >> mr. collard? >> i would defer to mr. mcclain. thank you. doctor, my question for you would be, i'm interested in your comments for the va paying for patients already covered by medicare advantage, and the potential for the government paying for care twice. what policy changes could remedy this situation? >> well, it's very interesting that such a large percentage of vets actually have insurance. only about 10% of vets being

treated at the va are, quote, uninsured, and it's probably tragic that they weren't included in the affordable care act. but nevertheless, many of these vets who are insured, either with employer based insurance or medicare advantage or regularqzñ cases better outcomes, not always better, but often better,

and it's budget neutral for us, as a nation. it's budget neutral. >> thank you. incidentally, under the affordable care act, 3,000 were denied access because our government refused to extend medicaid to the 70,000, which 3,000 were veterans. thank you. >> a live picture from the office building on capitol hill where shortly the house veterans affairs committee has been meeting to discuss increasing access to health care for veterans. the house earlier this week passed legislation giving the va secretary the power to use private hospitals to address veterans' needs. the senate passed similar legislation yesterday. that will now head over to the house for consideration. members of the committee will return here shortly to hear more testimony. and we'll have live coverage for you. the ranking member, we understand, is in the room now waiting for the committee chair. while we wait, remarks now from house minority leader nancy

pelosi earlier today during her weekly briefing. >> good morning. >> good morning. >> how has your week been? good? last weekend i was in normandy. we were observing the 70th anniversary of d-day. it was quite wonderful to see the patriots. we spent most of our time with the veterans, hearing their stories, and the rest. yesterday, members of our caucus sat down for our regular roundtable meeting with the veterans service organizations. we heard how their suggestions about how we can work together, they want us to work in a bipartisan way, and that's what the senate did yesterday. so we're very pleased with the

bill that passed overwhelmingly. the va reform legislation. they cautioned us that this is only a piece of it, a, and one piece of it that they hadqj quickly. we've introduced that bill, and we could pass it immediately here, too. or we may be going to conference on the jeff miller -- chairman miller's bill. but hopefully we'll have something very soon, and can

celebrate the fourth of july with a bill signed by the president, either by sending over -- sending over the senate bill, passing in both houses. 93 senators voted for it, so hopefully it will be given consideration here. in any event, we have another alternative. unfortunately, the senate did not do the same thing for student loans. earlier this week, the president took action to address the crushing burden of student loan debt that is weighing on the lives of america's families. 71% of those with a bachelor's degree have a debt -- average is about $29,400. perhaps you are among them. when we had the majority enacting legislation that had cut in half the interest rate, 6.8% to 3.4% for the sub si sized stafford loans, we ensured

graduates can manage loan repayment and created the american opportunity tax credit, maximum of $2,500 for eligible families and students. but we really must take action now to go further. the miller bill in the house, and the elizabeth companion bill in the senate, we were hoping would pass. and that is the bank on student emergency loan refinancing act. i think that's some kind of an acronym, but i get these acronyms all mixed up. but it starts with bank on student -- bosel -- does that mean anything? no? i don't know why it says bank in the beginning. but nonetheless, it would allow ml millions of borrowers to refinance their loans at lower rates.

the republicans in the house and senate, both houses -- >> joining us on our second panel from the department of veterans affairs, is dr. robert jesse, acting undersecretary for health. thank you for being with us today. thank you, also, for indulging the committee members while they went to vote. and with that, you are now recognized for your opening statement for five minutes. >> thank you, sir. i thank the ranking member michaud and the committee. i'm actually really pleased to be here. i sincerely mean that. i thought this morning's session was fantastic. there were a lot of incredible topics that were discussed. as you know, i have a prepared statement. i'm not going to read that. because i want to respond to some things from this morning. i do want to say a couple things up front. >> your statement will be entered into the record. >> thank you. i would be remiss if i didn't start by just saying, we know that we have let veterans down, but we're going to make it

right. there's been a breach of trust. many patients have been waiting too long. we need to fix that. it's unacceptable to the veterans, it's unacceptable to the american people and we apologize for that. we apologize to the veterans, to the vsos, congress, you all deserve better from us. we own this, we're going to fix it. we'll do it with diligence, we will do it with haste, and we'll do it with integrity and unparalleled transparency. i think from several of the hearings we've had, and moving forward, you will begin to hear certainly how va's moving to provide care for patients. we believe we've identified patients who are still waiting through the processes you have. we're bringing them in. if we can't get them in for care in 30 days, we'll find care for them on the outside. that's the most important thing that we have to do. it's our most important focus. you mentioned that there are ongoing investigations, people will be held accountable.

i want to say one thing, that i am very concerned. i care deeply about the other employees in this organization that have been doing it right. there are 270,000 employees in vha. and the majority of them come to work every day, driven on a mission. a sacred mission. they have to do the right thing for veterans. they work for veterans. close to 40% of them are themselves veterans. we have to acknowledge them, and their health and well-being are very important. we need to know how this organization failed. and i think and i hope that's the topic for the discussion today. how did the va bureaucracy -- i don't like that word -- how did the va organizational structure get to where it is today, and how has that impacted on what's happening in the va. we are going to need help. we're not going to fix this by being a little better ourselves, we'll fix it by the robust

discussions that were held here this morning, and learning from the mayo clinics, learning from the kaisers and others. we're, frankly, having those discussions going on now. this really is a time to reset. this is the, i think a crucial moving forward moment. if we don't take the opportunity of that, we'll be remiss. there was a lot of talk this morning about patient centered care. our plan moving forward, which is we've been inculcating across the organization for the past year, is that we are going to have patient proactive personalized, not just patient center care, patient driven care. i think that's a very important distinction. with eneed to move from being the model of finding a faster and fixing it better to one that treats the front end of disease prevention and wellness. standardizations is incredibly important. i agree absolutely with mr.

collard, that people say, well, standardize, you can't innovate. you can't innovate if you don't standardize. we're still processing around the structure that provides a level of standardization, that allows disciplined improvement. centralization is important. it's best when it's standardized. it's not equivalent to standardization. if you standardize business practices, that's great. you get efficiencies of scale. and you get an operational consistency that's important. but there are other ways that are important. for example, the mail-order pharmacies. the pharmacies have for the third year in a row won an award for pharmacies. what it did, it freed up the pharmacists that got them from out behind the counter to out in the clinics, and doing medicine

reconciliations, adherence to the regimens which in the end improves the outcome. there was talk about competition. competition these days in health care is choice. if we're not the health care agency, if we're not the delivery system that veterans choose, then we will have lost. and coordination care is important. and in talking about a big idea, one of the things we have learned is that to relentlessly drive an organization in performance measures, that are processed measures, will not get us where we need to be. we want to drive this organization on value. value is quality over cost. quality is in the eye of the beholder so there's multi-dimensions to it. it's the opportunity cost, the emotional cost of getting care. but we need to make that equation right for the veteran. for you all as our oversight board. and for the american public. because if we are not a value to all of you, again, we will not have met our mission.

so thank you, sir. again, thank you for the first panel. i thought it was excellent. and i'm prepared to have a further discussion. >> thank you very much for being here, dr. jesse. my staff asked the office -- and i know this is not under your purview -- but what i asked for is, asked the office of congressional and legislative affairs to provide an organizational chart for va's office of mental health services to include accompanying names and titles on the 18th of april. on may 7th, my staff was informed that this deliverable request would require either a letter from me, as the chairman, or to go through -- now, get this, members -- a freedom of information act request. i sent a letter that same day. however, i still don't have it. so either a chart doesn't exist,

or va doesn't want to share it with the committee. what do you think about that? >> well, i -- first of all, i apologize. there's no reason why you nor anybody else shouldn't have an organizational chart. i'm actually surprised they're not available on the web. but i apologize you're being put through that amount of effort to get it, and i will get it to you. >> by close of business tom will be appreciated. can i have your perm assurances it will be? >> i'll certainly try. >> i heard you put "try" in there, but there's no reason we should not have it tomorrow. or if it doesn't exist, you're correct. during a recent visit to the columbus mississippi seabok, i understand that many prefer to use the tuscaloosa medical center because it's a closer proximity. it was mentioned that there's a

memorandum of understanding in place to allow this choice for veterans. so i guess my question is, in a supposedly integrated system, why is there a need for this type of bureaucracy in order to cross a vision line? >> i don't know the answer to that. i don't -- particularly if there's a memorandum of understanding that people can go back and forth. i think since the days of dr. kaiser, we've said it's one va. veterans should be able to choose which va he goes to. so i don't have the explanation for that. >> if you could, also, for the record, gather that. >> yes. >> the other thing is, why are veterans who cross lines c categorized as new rather than an established patient? >> that, i know they're not supposed to. i looked into it a little while back. i had been at the clinic up in south dakota, and i was walking past a waiting room and there

was a gentleman sitting there. and a guy says, guys in suits, they must be from washington, get in here. so i went and talked to them. and their comment was that they love the care they were getting in south dakota, but nobody, retired people tended to go to warmer places in the winter, and their only complaint was they went somewhere else, that they were not recognized. even though they were going to the same place over and over again. i came back and looked into that. there is a process that people are supposed to follow to do that. and apparently we don't have that methodology as clearly as it needs to be. it should not happen. if you're in the va, you can be found. but i'll also say that there is a -- an initiative to not only do that avos vha, but across all va. if you change an address in benefit side, that gets pulled over into a master index. so that the entire agency sees

each individual as one person. and not having multiple -- we need to do that to make this seamless. >> when vha issues a policy letter or a directive, how does that instruction flow from the central office to the field? >> the technical process is that, as the directives get signed off, by the undersecretary, then the distribution route goes through the networks. so it goes through network operations, down to the network directors, and then from there it tiers down to the facilities, into the field. at the same time, the bottom -- the last line of virtually every director, at least the ones -- the clinical ones i've been involved with, will have who your point of contact is, if there's questions. so there's ways to move -- you know, clarity and technical expertise, back to the folks who are trying to implement that

directive. >> and my final question, and i'm running out of time, but the committee's been told repeatedly that the va central office, policy is often transmitted outside of any authority chain, and often viewed by many va medical centers as voluntary. is that true? >> i certainly hope not. a directive -- you know, a directive it is a directive. they're very explicit statements about what's required. if there are -- if there are options and opt-outs, they would be placed in that directive. i think the key principle needs to be that directives are not ambiguous, that their intent is clearly defined, that the metrics by which they're going to be measured are clearly articulated. and that there is a solid and defined methodology for ensuring that they are in fact being met.

and the intent of the director has been met. >> thank you. mr. michaud, you're recognized. >> thank you very much, mr. chairman. thank you very much, dr. jesse, for being here. my question is, you heard earlier dr. mccoy, and for the record, i mean, dr. mccoy is not a medical doctor. raised a number of concerns with the choice card provision in the sanders/mccain bill. do you see any bills with va's ability to provide veterans with eligibility, verification, such as choice cards, to see non-va doctors? >> you know, i don't know explicitly, but we've been doing this -- there are several different methodologies for non-purchase, non-va care, the term seems to be used all encompassing. when we give someone a fee card, it is the authorization for you to go out and get your care. and there are some limits around

that. it's not a preauthorization, but there are bounds about what care can be provided. if it has to exceed that, they get authorization. i believe that's the way it works. it should not be an inhibiting factor. and i think you heard from fill lip makulsky the other night that if that were the type of case, it would not be a call to a random number somewhere. we would have the health resource centers run by the business office managing that. i would presume. so until we have the regulations around it, it's a little bit difficult to speculate. but we have the capability to do that. >> when the va does it today, do you have any problems with verification? >> well, i'm not going to say it's perfect. but i think, you know, for most cases, it's effective. you know, we've been looking at

better ways to do it. project hero and project arch were set up for that, to see if there's a better way to get the distributed care out there. >> the project is in maine, veterans -- they love the way that's been working. >> yeah. >> the vision structure has been under scrutiny for a few years now. i understand that vha has reduced the number of headquarters staff through the -- through the realignment effort. is that process finished? >> well, i'd rather think of it as a work in progress. so there was a task force, a group that looked at this, and clearly there was wide variation in the size of each of the visions that could not be explained on the size themselves, meaning the total number of veterans, or their purpose. because their purpose is inherently the same. what this group did is they came back and clearly defined the core roles that needed to be in

each vision office. and some limited amount of flexibility around that, which was fundamentally driven around the size of the vision. so we went from a variation of, i think at the low end just under 40 people in the office to a high end of 160. they're all now between, i think, about 55 and 65. clearly defined roles. this is what you must have in there. a little bit of flexibility. but there is not an ability to continue to flex up that staffing without coming in for further review. it's a work in progress, because it's been pushed out this year. we'll see how it works. we're constantly looking at it. if it needs to be smaller, we'll make it smaller, or if it needs to be bigger, we'll make it bigger. that's what we did. so we tried to standardize at the vision level. >> thank you. just to follow up on the chairman's comments about getting a directive from central

office, and having the visions carry through with that directive, and these are -- you know, i've heard comments that the folks are more concerned about the directors' interest in how things are run versus the secretary's, because the secretary comes and goes. and i've also heard on the vba side as well, when the american legion went out to do their system worth saving, brought note to the fact -- to the va employees, that's not what central office said you should be doing. in response, this is the baltimore, maryland, vba. we're doing it the baltimore way. so i think there really is a problem in some of the areas, and i would encourage you to make sure that when the

directive does come, that it's followed through. and the other note i want to say since my time's running out, you look at the department of defense, they have the world divided up in seven different regions. and i question whether or not we need 21 visions throughout the country. and on that note, i yield back, mr. chairman. >> thank you very much. >> thank you, mr. chairman. dr. jesse, welcome. i'm looking at the organizational chart of the va. i guess this is the veterans health administration. and i'm wondering, if a physician within the va wants to lodge a complaint or make a suggestion, where on this chart does that occur? i don't see a place that has physicians. >> there are two places, actually. on that chart, there is a doctor

who is the deputy undersecretary for policy and programs. and in that is patient care services. and rolled up under patient care services are much of the physician based -- and other clinical services. >> i guess the reason i'm bringing this up is i worked at the va. and i talked to many va physicians and they complain they have very little recourse when they have suggestions for changes or complaints within the system. i notice here on the chart here that the office of nursing is right here under the -- reports directly to the undersecretary. >> yes, sir. >> why isn't there a similar place for doctors? >> so, the physicians work through programs. so the office of -- >> what i'm trying to get to, it seems the nurses have more input to leadership than the doctors do. the doctors often have suggestions that make -- that

improve the quality of patient care. the physicians i talked to, i just talked to a group of va physicians yesterday, and they're, frankly, telling me that they get reprimanded. and they had this retribution if they try to change the system. have you ever heard about that? i've had physicians say they've not been allowed to talk to me by their superiors, they're not supposed to talk to me. >> let me -- >> is the policy of the va to not allow physicians not to speak to members of congress. >> absolutely not. >> i'm glad to hear that. >> and remember, that if i -- >> if i -- >> as a clinician -- >> why would it be that physicians have been told not to speak to me? >> i have no idea, sir. it's not right. physicians have the right to speak to anybody. >> that's what i would think. >> there is a mechanism through -- surgeons have the office of surgery, dr. gunner

has been a stellar leader in that. emergency medicine has the -- >> this is occurring now, today. yesterday. this pattern of veteran -- or physicians within the va being told not to speak to congress, being told not to rock the boat, because if you try to make productive, it will make somebody else look bad. this is a direct quote from physicians that work within your system. >> sir, i also work with those physicians. and, you know, much of the improvement occurs at the local level. we identify best practices at those levels. we use our -- leverage our network capability to distribute them. there is no reason that physicians should not and cannot communicate freely. how can we have improvement if people don't feel they can exercise -- >> that's the situation. that's today. i was at a meeting, where there

was perhaps 50 va physicians, and the common theme of the discussion was that they were afraid to talk to me, and what can be done -- i'm afraid to tell you what's going on at the va, doctor, because doctor, because everyone has told us they will be punished and they will be put through onerous peer review situations that were obviously punitive so they were afraid they wouldn't be able to practice outside the va. i'm just telling you what's occurring. >> that's inexcusable, and i will -- >> can you pledge to me if i speak to a va physician and he complains to me he was reprim d reprimanded you will help me make sure this whistle-blower guy doesn't get punished? >> well, we don't tolerate punishment of whistle-blowers. we absolutely do not -- >> but i'm saying it's occurring today, dr. jesse. if i have a physician who talks to me -- because they were asking me yesterday, doctor, how can you assure me if i tell you what's going on that you can stop me from getting fired? and i had a little bit of trouble telling him that i could

promise him that he couldn't get fired. do you understand what i'm saying? what i'm asking you if somebody comes to me with that complaint, can you promise me they won't get fired? >> sir, i will promise you that they won't get fired for complaining to you. i can do that much. i can't speak to individual situations. all right. sorry. >> but also understand that if we do find that somebody has directed people not to talk to members of congress, it is a crime. >> it's inexcusable. we don't accept that. >> it is criminal. >> yeah. i think the voice of the veteran who we serve, the voice of the line people working with veterans every day is crucial if we're going to improve this organization. we have to be listening. >> you're recognized for five minutes. >> thank you. sir, in florida we serve almost 600,000 veterans. we are the third largest

population of veterans in the country, and my question goes to i personally think the va system is an eight or a ten, but when i -- first year i was teaching, the principal said if you're an eight or a ten, where is your room for improvement? so i'm starting out saying i think the system is very good. what are the recommendations you would have for some improvement because i don't think the entire system is damaged as i hear, and i do think there are things that we could do. i remember when secretary brown, jesse brown, when the veterans from the northeast came to florida, we serviced them, and we didn't get reimbursement. the reimbursement stayed in the north. so i know a lot about the institution, probably more than anybody on the committee.

>> so how can we improve? well, the first thing we can do, as you heard earlier today, there are many va facilities that are top achievers, incredible performance, but not everybody is there, and the first thing we need to prove is to get everybody up to that same level. second is, we say we are a quality organization, but i constantly remind our staff that there are multiple domains to quality. one of them is access and one of them is timeliness. so if you can't have access, you can't even have quality. so fixing this access problem and doing it immediately is key. third is equity. you know, if there are inequities in the delivery system, we've got to identify them, we've got to figure them out, and we've got to make them go away quickly. so as we improve the standards of all hospitals, raising all boats up to what we know we can achieve but also ensuring that

access, quality, equity are uniform principles of how we do that work. >> we had a hearing, the florida delegati delegation, on the va this morning and one of the recommendations at one time the va could just, i guess, hire a doctor, and now they have to go through a different system. >> i'm not sure what you mean. we have a process for kre den shalling and privileging physicians. it's not unique to the va. every hospital in this country will do the same thing. our process is actually -- the credentialing process is pretty good but we're working with dod because they have one, too, but it's different from ours and trying to establish a credentialing process. in the conversations around tell health where you have people practicing across state lines, you can have a uniform set of

credentialing. that takes time. the one thing that is unique to va is that physicians especially but i think almost all employees have to go through security and background checks, and that takes some time. what we're trying to do and, in fact, we learned a lot of lessons if you remember last year when we had the hiring initiative to plus up the mental health workforce, we learned a lot about the speed of hiring and the challenge but simple solution is don't wait for step "a" to fix before you start step "b," before you start step "c." parallel process, you can cut down that time. if we don't do that, we lose people while they're waiting to get their job. >> nursing is another example that it takes so long for us to process a nurse. and how do we advertise? do we advertise just in the va system or how do we do it? >> there's a requirement, i believe, that all federal jobs have to be posted in ---ed a a

feder -- at a federal website but i know when i'm reading the richmond paper there's always ads for the va looking for nurses there. everything goes into a website, but, in fact, you use local resources. we also have executive and physician recruiters as part of workforce services that go out and reach out and try to find these people. we leverage them in the mental health initiatives, and they were very effective. >> one last thing, we've had lots of discussions of how we get additional va doctors into the system and what can we do as far as i guess the medical -- what is it? the medical -- so that they can get, i guess, forgiveness on their loans when they work for the va or whether -- in florida, for example, a lot of our interns go out of the state because we don't have the -- what's the word? they go out of the state -- residency. and so we don't have those

slots. what can we do? >> there's two things you're asking about. one is for people who have large med school debt and the average is pushing upwards of a couple hundred thousand now if you don't have help somewhere along the line is can we do debt forgiveness. we have some limited authority. it's insufficient. particularly where we want to place physicians in underserved areas which is the real challenge, it's less of a challenge -- people want to stay around where they did their residency so in urban areas with bill medical schools it's much less hard. we've been working with hersa who has the program where they pay scholarships and loan reimbursements to people who work in designated underserved areas. many rural, but not all. and it doesn't make sense for us to build another organization within va to replicate that process if we're going to go that route, which i think we should if we can. we've got to make sure.

but to tag onto them. they've already got the infrastructure in place, they can move out immediately, and then the other piece is increasing residency slots. va is highly supportive of the residency training programs in the u.s. i think you heard earlier about 70% of physicians get some of their training in the va system. we've expanded that in certain areas. there's still not sufficient -- well, for mental health it's not that there's not sufficient residencies. in fact, some of them have closed because there's not sufficient people going into them so how does one incentivize that mental health community that more physicians would want to go in there. and that's not a question that va can anticipate but we can support the slots when we need to. i think there's -- the other piece of this and it was also mentioned earlier is how does one leverage the use of both nurse practitioners and

physicians assistants and the like, and it's our intent within the organization that people practice to the top of their license, and so i think supporting pa schools, supporting nurse practitioner programs, we have the va nursing academies which are useful to bring nurses into the va system. we're also training people in interprofessional train sog that doctors and nurses train side by side and learn to work as teams, and people who go through that find that as a very satisfying career move, but we've got to start that early in the training programs and not wait until they grd wa graduate and then try to retrain them to a different way to practice. >> thank you very much. my time is up. you've been very gracious, mr. chairman. >> earlier you made some comments about responding to congressional requests and such. could you restate what you stayed about that? something about criminality or

criminal if you didn't -- >> i don't think i used the word criminal but i don't think it is excusable that a physician thinks he cannot talk to his member of congress. nor do i think anybody in va should be -- >> will the gentleman yield? >> yes. >> very quickly, if you can hold the clock, what i'm referring to is them being directed, not that the physician or whoever the clerk may be and obviously it's in the investigation that a committee is trying to do as it relates to its oversight responsibility in congress, so i wasn't implying that the physician was but it is our understanding at the committee that there have been people who have been instructed not to talk to congress. >> well, do you want -- i can maybe put some context around that because -- >> if you just hold the clock and go ahead. >> okay. so right now, yesterday, today, this past week, as you know, va