23 you go throughout the middle east, it seems to be the problem of governments solidifying political control. it goes far beyond iraq. attacking that problem is not an iraqi-spefk problem. but from moral dock row in the west and iran in the east and probably continues. but my responsenty ends with irans. but it does seem to me that there's something much more universal.

>> i have a generic question that touches on this. >> is it possible to isolate a country in the middle east and solve its problem alone. or are we dealing with border-crossing issues. that had to be thought of as a reej nag issue. every country tries to fit in. >> i'm going to take a swing at that and then i'm going to dove tail to what's just been said.

>> you could not deem with iraq alone, syria alone, israel and palestine alone. it is one region, whans in one part of the region affects the other paurt, as we have recently seen. and i think unless we have a regional strategy, we're doomed to disapointment in whatever we aticht. i just want to make one point about the iraqi people. this is about political elites using religious in fear to maintain control over the iraqi people. wech people in the united states who say iraq is not guilty a real nation, anyway.

40% of iraqis are from mixed mashages. that doesn't sound like a place that's highly sectarian to me. it is political elites in iraq that have created that narrative and that are using it for their own purposes. many of these elites who have spent the years under sadham hussein is expatriots plotting their revenge. >> so i would stop there and let my comrades have a shot at it. >> it seems to me that most

countries have -- why are they so susceptible? and it has splg to do with the fact that iraq is an ek notchic player in the location. it has to do we insecurity. his desire to get him over there to meet his own regional am bixs. there is something particularly international about iraq. it helps us think more strategically about how a solution to iraq, as pete suggests, has to fundamentally

have a component. >> again, going back to looking at matters from an economic standpoi standpoint, iraq had opened up itself to the entire region from iran, to turkey, to kuwait. had we had this openness economically, we would have experienced it. they could have built facilities.

iran could have built five-star ones: they would have had jobs. they would have improved themselves. and we would have bilked the middle class again. we have the elite, as you clearly explain. i stated, they are not millionaires anymore. they are billionaires. the poor is $6 million below the poverty line. that's an economic problem. >> well, this is the time to open it up to you, the audience.

i please ask you to identify yourselves and ask questions. >> good morning. i have no comment, but i have a general question. everybody's putting pressure to have a more inclusive government. i was wondering what kind of pressure is on mr. maliki to have curds and sunis in the future government. and i was wondering, what about the curds? what are their ambitions.

>> let me take the second question, first. the curds, as you know, the city believes they're central to their eent thand to their exno, ma'amic feature. they will never gichl it up. the cowards have a lot of votes. any government that wants the form with their votes is going to vo to give them to a cook. that remains to be seen. personally, i don't think a viable government can with

formed under him as prime minister. het's sexist and parties and factions within the country. he's seen as the central part of the problem: soo, for me, tlds be very difficult. i think the ambassador wrote a very gresing piece recently. they said it's difficult to

kompb miez with one another. they could offer things to us which we then e take to another party and work some sort of deal. well, that interplead yar has been missing from iraq since 2011. for a fact, there is no way we had as much influence in baghdad and working these issues daily. and a president of the united states who is calmed iraqi reeders nightly. he's dell gated this to his vice president. this is a very difficult problem. there needs to be a change in baghdad.

don't i don't see how we can do it. >> i would prefer to have kirkwood under the isle rk army. when the division comes to save our city and not occupying a city. i'm extremely disappointed that iraqdidn't fire one bullet. >> all though it's worth 20 off

the public opinion polls; glm t glmplt! v ev of course, just like any nation. they are moderate. they're extremists. they're secular.

>> wlast year, the high cleric has stated very, very clearly that it is time to form a new -- the keyword is new, to form a new government in iraq. that represents all iraqis. the cleric has stated that. plus, we have the drift. they're very moderate. so, yes, of course. the shiite had. she understands that there's

another set of islam. in the west,it's easier to lump it together. let's not say they're either. malicki has been able to portray himself in the kmubty, it evens as its esz because that helps keep it from defect e fekting. what we'd all like to see sd those two keds running want their parjts: so i think the

court wanted a history rock. >> the problem that i have long-been concerned about in your rock is you can be the make it with three peetss amt you can believe the make a po collision where 5 pemd are in the fwovd. what you realitily want is a dynamic environment where people feel not in this government. but i k be in the next one. it seems to me that politically in identify ro, is she coming now. >> that increases the takes, it increases the violence. they're trying to promoet sol

darty. therefore, they have no state fwh going forward. >> good morning. all of us are against terrorists. all the country ins the mid lt east. my question, until syria and iraq whooi to british a license.

>> what is your name, please? >> al huidemi. is isle. >> when will you guys stop to stop thm:

>> american favor is different. current flees. >> countries surrounded with iraq, that he doeblts want to reach this dog. >> can i just address the first part of your ish shy. i think it's important. >> you talked about while the

u.s. doesn't create an alliance with serious. there was an effort underwail between the u.s. and syria. and it seems to me there was ample common ground. he used to fulfill dairt. the syrians thought this was a way to enhance their leverage. it made the usz needs something from syria.

and then to bard gain and say we'll stop the wuss. but to offer. as a free will dresser. and oneover his whether he understand say, you know, syria can be a solution provider. his reaction to be totally conceding something. we don't have extra things to

conce concede. we willen giver if we get in advance. and that's if way this is going to go. i would agree that there are different definitions according to who's a tefr ris. and there are pop who think, well, it's not guilty that we're supporting them, we ooerts just turning the other way. we're not quite as aggressive as we should be.

>> we have to be successfully diplomatics. >> they used to transit southeasterly ya. >> are they the same wins fwh which sle came the other way. to get to a point where there are ne goal yass and not that it took to terrorize v v j i will

jis add a couple things. is that is from my time in isling. to reach out to source could be e koubsz it's interesting how these country thasz spawn jihadi's think they can do it without sni sort of come back. the oh example the. >> so the idea that varsz states

can somehow encourages go waeds waerd and as to why we don't form alliances, material rim, i rul and he said can you help me stop the froe of suicide bm rss in iraq. and they said fits, you need to isle pop jazz on the.

>> well, i would add to that list really wonder ever piece, and he has a menu of all of the various group ins iraq who fighting. around there were plenty of those that you mentioned. >> r. >> therefrom various sdpet down. iraq is filled with penal who don't want to do bun of the side

card. the om way to power this is the government worthy of their su abort and our su poirlt. >> she said it's from sauz ya ayalgtsd yeah orron. >> theism ligs can the yiet. i joined the state department n october, br to jo chblgtsds anyway u wubts it.

>> as he argue ds i if statings.

i don't disagree that that he koiz schoolboy ole don't think you could argue the else.

>> but its seems to me, the fundsmental problem, as peet has suggest ds, you have a country with loots of people who don't need outside encouragement to want to fight're people in their own country in a battle for control, influence, resources. and the answer is not that outsiders can solve this problem. but that outsiders need to create the conditions under which people on the inside of iraq can solve the problems. one of the things i find sort of wonderfully isle ronlic about the usz policy over e jicht. e e but stay out of our policy.

>> there is this army. >> we can play a smaum role. we can be catalysts for things. but i think to argue that we are the drivers of gihad and has been fr about 90 cases. days.

>> the committee will come to order. welcome to tonight's evaluation of the cure for veteran patience. during our proceedings this evening, we each hopefully increase the 5:kreecrease aqua . important to those efforts is the status of va's axcceleratin accessed secure nationaltive. the niche timp was launched in late may in response toet current weight time's process.

information suggesting that last thursday, in coordination tw the other efforts has leds to 200,000 point nous. i to have concerns about the effort to date. one of the con essentials is the continued lark of information that skong has received about the nishlgtive. >> making this in a long list of examples of va failing to act in an open and trarns parent matter. the committee asked for a recap on june 2nd. i followed up with a formal letter on june 5th: it has now

been 19 days since that request for an immediate briefings and no further information or 5:00 nol o knowledge. of our questioned to sooech. if va's work has, indeed, led to 200,000 more pay she says ths sense so far, what is left to ied. given that, how can the people have kftsds in thee larks.

>> va. claims to be taking sets in its own woshds. extend or flex clinic hours on nights and weekends. increase the use of care in the kmumpbty and riech old to vet ere rans. va has had the ongs to use these recently. sequel snow stlooes 350 vet ere rabbles died wild waiting to see i have isle skraer. we know that 50,000 veterans

nationwide it may be too rate for other veteran who is have been waiting for weeks, months and years. fw there would have been actions that could have been taken to increase ark says to betsder care sf for that, i yield to the ranking mem beryl. intradwral to accomplishing this mission, his ablt to sexily the destruction. at this time, i do not have much comforts that the ba is ache to

do that analysis. >> seems to me having a significant number of patience on the waiting list that is orr wept md and unare the va-oiz reported in january that vha officer of the report had nine

roemd dagszs. one of the recommend dalgss was to have the vpa relative develop dads it. >> it's un5:00 septemberble. while br listen, all can have how they're measuring capacity in a time line for when this will be done. >> importantly, many askigs nap resources to sunis sdmoo mr. chairman, i know that the vast

majority are hard working and ked kated. for that, i applaud them, but we till have a responsibility and duty. and i look forward to hearing from the vrksz action he's accompanied by we appreciate you both for being here tonight. dr. lirj, we apreerkuate you coming y usual jepds. >> good efing, chairman miller and members of the committee:

i'm accompanied today by drchlt carol dyne clany for help. at the outs sed, let me be the two cuss of the va. >> american veterans should know they would see the islest quality looks different. >> as my colleague stated on june ninth. it is unacceptable. members of congress, the veter ran's service orgization.

p. rv krs the teem and e reerk ri stg su portsing a prukts everything work shortsds riertszings awoon yats you wi riertszin riertszin riertszin

riertszin riertszin riertszings su port staff ratios. the difference between the estimated capacity and our current workload represents the amoubt of day asianal care we could proviemd. >> they are critical in improving timely access to kwaumt care for verer rans. we will have pluktsdivety stabd ards in place fr all physicians of the end of this physical year. va has established the nation's largest med cat home primary care. dm kmo r which peemd pea v pail for dreenls.

ledge iing. since the majority of u.s. physicia physicians received some training in a va facility. we have also reinforced the importance of team work and technological skills. to ensure that the promise of these new models achieves the goal of personalized veteran nencrik care. the work koblts and we will not be dob until this's ready ax cess to high-rmgtsz envigsz

pair. we are fully engaged. this concludes my testimony. my colleague and i are prepared to any any questions you and the other mr. >> so that we can physicians more quickly. >> are there any impediments that we, as a. >> at the moment, mr. chairman u i tntty of i you willed.

>> i think you would want us all to be rig. >> what's the kmpted cost of the salary and access secure nationaltive. and how are you funding it currently? >> right now, the cost is becoming $300 million: >> other than asking if fa tillty to look at them, to let

us know what resources we need to provide that deer in the kmubty. to date, we have distributed 312 you won ways over 0% see between 11 and j i could qualify that by sayings i think we need to

assure who capacity they have in the way of rooms. r i if you will it's knot just@physician's antsd and willingness from them. >> so you would know how long roojs would be needed, i would shshs shd. >> congressman, themp designed in a time when heltcare was not the tom nant move. .

we are still challenged by facilities not con strukted by the outpatient model of care. >> so if i went to the new that sill tid, u i can want that the doctors. >> the va has beenworking to presumption of guilt in place testimony plaits. to optimize the ablts of physicians to bro vied care. >> psychiatric con tigs that ri sided in fl frn.

>> wuj r one note in agts years. >> that is un5:00 septemberble, sir. >> it also stated in the same lett letter you can get air. we don't see its in the private sec so i recall. wds concerns very seriously. we have to reestablish our teg

rity. we had to evalwait those con sirns. i think it's important we kpups what that review shows. >> thaumpk.you. mr. michaud, you're recognized. >> thank you very much, mr. chairman. once again, thank you dr. lirj and dr. clancy for coming here this evening. we understand the accelerated access to care initiative is designed to assure access to care by enhancing resources within va facilities and also sending veterans promptly to community based care and nonva care. what is its role? >> pc3 as it develops will be another model that we can use to provide care in the community.

pc3 is just in the process of being stood up. some sites have greater availability of pc3 services than others. it is, however, an option that we can use to identify community providers who are willing to provide care and to meet certain conditions of the contract which specific that care will be provide within 30 days, that we will receive reports in a timely fashion. so pc3 is an enhanced method of providing care in the community that gives benefit to the va because it assures timeliness and assures we get records back in a timely fashion. >> i would also just add that they assure some minimal level of quality. i mean foundational level of quality in terms of contracting with hospitals that are accredited by the joint commission or relevant creditor that the plans that they are contracting with have met standards for the national committee on quality assurance and so forth and we're going to

be working with them to figure out how do we even make those standards a bit higher. >> thank you. the committee is aware that the va had conducted several pilot projects such as project hero and project dodge before implementing pc3. va also has indicated in designing pc3 it used lessons learned from these pilot programs to develop a solution which is coordinated convenience and consistency with va quality standard. my question then is now that pc3 is up and running across the country, are all va medical centers using this program as part of the solution? >> i believe the answer, congressman is when it is available and when the services are available it is being used, yes. >> so it's not throughout all of va medical center? >> in certain areas the contractors are having to

identify providers and standing up their services. in other areas services are available and pc3 is being used to the best of my knowledge. >> we understand that pc3 is not a mandatory program, how can we have a va medical center fully utilizing pc3 and utilizing the potential of this program if it's not a mandatory program? >> it would be my hope understanding the benefits of the pc3 process that it would be advan advantageous to the medical centers to use that program. there's standards for providing timeliness and standards for work services. >> how does the va distinguish between short term and long term capacity short falls and how does the va respond different to the long term and short term short falls? >> i think as our data becomes

more reliable, and as we see increasing use of the electronic wait list which has now been mandated, we will have the option to see our demand handled in one of two ways. either as a completed appointment, or as a patient who ends up on the electronic wait list. depending upon whether this is a short term increase in the requirement for services in which case the va may find it very convenient to buy that in the community, there was also the possibility that there is part of a longer term trend in which case the va may want to consider how much is it going to cost me to buy this and ultimately do we need to make a decision that it will be more cost effective for us to identify the providers and make the service inhouse. so i think short term pc3 nonva

care provides the opportunity for us to offer prompt services to veterans when we don't have the capacity. in the long term when we see trends it gives us the option of making decisions about whether we should continue to buy this in the community because of its complexity or whether we think we can offer it inhouse. >> thank you, mr. chairman. >> thank you, mr. chairman. dr. lynch, in the last two weeks number of veterans in my district in colorado springs have contacted my office asking for help while trying to see a doctor has more than doubled. one veteran described how he was referred to get a biopsy done on his thyroid to determine whether or not he had cancer only to be told he couldn't be seen for two months. i can't imagine having to wait for two months to even just get a test done when you have a possible cancerous growth.

tell me what options are available to denver medical center to experiod dit a biopsy appointment in particular especially based on medical necessity and if there's a possibility of a life threatening condition? >> congressman, based on what you're telling me, if services cannot be provided in less than 30 days, that is an unacceptable waiting time. and the denver va facility should be able to identify a community provider to offer those services. >> that would be the fee basis approach that we've talked about. >> that's the use of nonva care or the fee basis approach, yes. >> so 55 days for that type of procedure is unacceptable, you would agree? >> that would certainly be my impression, congressman. >> all right, thank you. now the data included in the va's bi-monthly access data update makes me worried this problem might be getting worse

before it gets better. especially in colorado. myself and representative mike kaufman have a lot of these same concerns. although the report shows the number of veterans on electronic wait list across the country dropping slightly, the electronic wait list at the denver va medical center where many of my constituents receive care doubled in the last 15 days. it went from 1632 to 3331. what could have caused that number to double in 15 days when around the country it was dropping slightly? >> i don't have the specifics on denver, congressman. i'll be happy to try and get that information for you. i can tell you that at the moment the electronic wait list is going to be dynamic. there are two processes that are occurring. we are working down the near

list, the new enrollee appointment request. those patients are either being given scheduled appointments or being put on the electronic wait list. so it's possible that some of the patients that were on the near list have been notified electronic wait list. but exactly, you know, why they are accumulating on the electronic wait list, i don't know but i think we have the capacity to find that out. >> okay. if you could get back to me on that i would appreciate it. >> i will do that, congressman. >> thank you. >> now you stated in your written statement that the average current number of patients assigned to each primary care provider is 1194. how does that compare with the private-sector? >> the private-sector medical home model can vary with panels of anywhere from 1,000 up to about 2,000. it depends on the complexity of those patients. it depends on the resources available and the support for

the physician seeing those patients. va patients are often older. patients in the private-sector may be younger, healthier and may not require the intensity of care that va patients may require. dr. clancy, would you have any comment? >> no. >> sorry. >> i would agree with all of that. we also -- the va's medical home in the primary care setting is also unique for being integrated in many of our facilities with mental health providers who are right there, if those needs arise. >> okay, thank you. one last question i want to get in. you note in your written testimony that the va is adopting standards that are accepted. what's the case -- what's been the standard up until now? >> sadly, congressman, there hasn't been a standard to this point. we are now using the relative value unit to evaluate the

productivity of our providers. we're using that information to determine, number one, are they meeting minimum productivity standards. number two, if they are not, why not? it could be a matter of support and available resources. it could be a matter that there are not enough patients for them to see. in that case either we need to identify more patients, or we need to figure out a way we can move their capacity to another facility, perhaps using something like telehealth. >> thank you. >> i really have no questions. i yield back. >> mr. takano, you're recognized for five minutes. >> thank you, mr. chairman. thank you dr. lynch and dr. clancy for appearing before us today. i under from 2008 to 2013 nonva

care out patient visits grew from 9 million to 15.3 million, 72% increase. do we have any way of knowing about the comparison between nonva care versus inhouse care, it's efficacy and its cost? >> i don't have the comparative data from those years. in the last fiscal erwe spent $4.8 million on nonva care. i have to get previous data to see how our use of nonva care has increased or has changed as we've seen increasing outpatient requirements. >> it seems to me that if we want to expand access for veterans to nonva health care,

it will be extremely important there's a continuity of care and health records can be transferred seamlessly and that's part of what you were talking about, i guess, when you were trying to do a quality check on the pc3 and finding those community providers. what can we do to ensure that this happens? >> i think that is a very good question and it's a challenge. right now our community providers do not have ready access to the va's electronic health record. i can't tell you as we move forward and establish more permanent relationships whether we can begin to give certain providers access to the va health care system. when i was in omaha we were able to do that for several of our community providers who gave regular service to the va. >> well, you know, i know that as part of the aca and the hi-tech act which passed around

the same time congress created incentives for health care providers to make the transition to electronic health care records do you know if it's been done with electronic health care record systems? >> i'm going to defer to dr. clancy on that question, if i may. >> i will say complying with the standards set out by meaningful use as the popular term for those sets of incentives from cms although va doesn't get money from cms but we're complying with those standards, yes. >> but, the private health care providers who were given incentives to digitize their records -- >> correct. >> -- as the standard set forth by cms will that provide int interoperability? >> it should. >> it should. >> yes we're starting with with

some pilot projects on allowing veterans to get immunizations at a walgreen's health facility. we can exchange that kind of information. so there's a difference between people meeting the same standards and being able to share freely across platforms. but that would be the ultimate goal. >> so, you're saying it should. >> yeah. >> theoretically, those standards set forth, you say it was set forth by cms, the digitization standards? >> yes. >> should provide the platform for interoperability for vista? >> yes. >> so part of facilitating our veterans to access care would be to facilitate this interoperability. maybe part of the answer would be, dr. lynch, if there were

further incentives for our physicians to digitize to those standards this would be one part of the problem, one part of the solution? >> i guess i would say that this is a very strong priority for hhs right now both cms and the national coordinator and we're actively part of that strategic planning effort in terms of how do we accelerate the path disorders interoperability. that would make it much, much easier. right now what community partners do they send a report, pc3 makes this a little bit easier because it's a condition of their getting paid and that gets attached into the vista record essentially as a portable downloadable file. >> would this incentivivizing through pc3 if we can incentivize them.

>> i think so. >> disir, dr. lynch, the stlarv on the waiting list -- how many were contacted and spoke to a very person. tell me what the contact was. did they have an actual conversation with them? >> we don't have that breakdown yet, congressman. we will. there were attempts made to contact all veterans, the process is that there were three attempts made. if we could not contact the veteran they then received a certified letter. we will be developing the data as we collect it and we should be able to provide you with the information that would tell you how many patients were directly contacted, how many patients were contacted by mail, how many patients could we not contact, and also the disposition of the patients contacted. >> if they received something in

the mail, and they contacted the va, were they speaking to someone immediately? >> that would be my expectation. >> but you don't have any data on that? >> i don't have the data right now, no. >> okay. now what about as far as the waiting time? so they contacted somebody, let's say, the contact was made, there was a conversation between a va individual and the patient, the veteran. how long would they have to wait for an appointment? >> the expectation is that we would explain to them how long they would have to wait for care in va. if they did not find that acceptable, we would provide care for them in the community. >> okay. now you don't have any information to give me so far, any results as far as let's say they had to wait within, you know, how long would they have to wait to get a va appointment? within the va. >> i don't have that information, but the expectation

would be that if we could not see them within 30 days we would offer them in the community. >> where did this 30 day period come from? this expectation. this policy? >> at the moment there's not science behind it. there is evidence that in the community patients are waiting anywhere from 15 to 30 days or longer to see care and so i believe we chose that as a reasonable number. it does -- >> who knows that? >> va chose that. it does depend on the acuity of the patient. if the patient needs it immediately we brother provide that. if there's an emergency we would provide it within 30 days or offer to it the community. i would turn to dr. clancy and ask if she has any further insight. >> i would guess, congressman,

that you and your colleagues have probably seen data from recently released surveys of how long it takes to get a new patient appointment which ranges somewhere ten days or a little bit less in dallas up to 45 or so in boston. obviously doesn't have a lot to do with number of doctors in the area because boston has a lot of doctors. the problem is there is no industry standard. i will say when veterans contact the facility and are given a wait time or an expected wait time and if that's not acceptable option to go out into the community, they are also counselled that if they have a more urgent need that they should come no an urgent care or emergency room for more medicare. >> on the average how long would it take, say it's decided they have to go outside the va for care. how long would it take for them to, the patient to get the appointment? >> a lot of that is going to depend on what existing capacity is in that community. >> on the average?

>> we don't have a number for that yet. i would guess in the dallas area it would be much faster given the data i just mention ad moment ago that wait times there are shorter. i would expect it would be much tougher in the boston area, for example. >> however, i would just add that with the pc3 contract, it is the contractual expectation that patients will be seen within 30 days. >> okay. one last question, mr. chairman. under the department of veterans affairs health care programs enhancement act of 2001, the va is mandated to establish a nationwide staffing policy. can you briefly describe what that policy is specifically, how does va medical centers know which physicians are needed, who they report that information to, and what is done with that information to address the staffing shortage? >> congressman, i'll have to take that for the record. i'm not familiar with that

policy or the data associated with that policy. i know that we currently have information through our office of productivity efficiency and staffing that is looking at the number of physicians that we have, the specialty of those physicians, and their ability to provide care in an efficient fashion using the ruv model. >> please report back to me because i feel you should have that information with you now today. anyway, thank you very much. mr. chairman, i yield back. >> mr. waltz you're recognized for five minutes. >> thank you. i'll start out and ask has mr. chairman made northeast. a lot of this stems from us unable to get information. over three weeks ago we sat in other and after the audit several members mentioned our facilities were flagged and guaranteed we would be told why that was. nothing has been said.

every day i get calls asking what's wrong with these facilities. so i'll ask you, why don't you take that back and let them know we're waiting. >> congressman, i actually had a discussion before i came down here tonight. we knew this issue would be raised. >> that's good foresite. i appreciate you're thinking ahead. >> he and i agreed that it's important that we brief the committee and we'll be make arrangements to do that and also provide briefings to other congressional staff on a visit by visit basis. >> you've been coming down here a lot and i appreciate the work you do. i think the time has come when you know you don't get the benefit of the doubt on anything right now and after today's osc you mentioned that was an unacceptable position. we had a veteran for eight years that we warehoused. i would call that a national tragedy more than unacceptable. i guess for me i'm trying to get at the heart of this.

i still think we're flirting around the edges here instead of getting at this. i'm going to come back to this leadership and structure issue. if i asked the director of a medical center what our national strategy on veterans was how would they answer? >> i hope they would answer that our strategy is to provide timely care to our veterans that is quality care -- >> that a strategy or a goal? >> it is probably a goal. >> so, i'll go back to this from a national security standpoint. we have a national security strategy and that identifies requirements and dod and the forces come back to fill those requirements. do you do that at va? i'm get back to this we've been trying this issue since 2005 on measure capacity. actually we started back in the 1980s. my question is, i'm not convinced by what dallas or minneapolis or sioux falls that i would get a strategy answer.

>> i think, sir, i can offer that we are developing a strategy as it relates to access and as it relates to scheduling. we have in place a seven step process that we are developing. that will address the issue of accelerating care, that will address the development of demand capacity models. that will develop the policies and directives to drive scheduling and access. that will relook at our performance assessment measures so we can develop the measures and the goals appropriate to drive our system to the appropriate end point which is quality timely care. we are developing the processes to put together program oversight and integrity to recruit people and to train them and to integrate our care processes with the nonva care

model when necessary. >> where does that guidance come from? >> sir, this is an organizational plan that was developed within vha over the last three 0 four weeks in response to the issues that we have faced regarding veteran access. >> is there courthouse input into any of this? >> not to my knowledge, sir. >> i want to have a specific one on this as we look at this care model i want to give you and example that i went and did a little research over the last week in preparing for this. there's a mayo clinic phoenix down there and prior to this all coming out it was brought to my attention they were doing the prostate surgery on a fee per basis? >> that's correct. >> when they would have them come in they would say we can do the surgery in 48 hours. va would say we have to do the ecgs and that takes six to eight weeks. we had it going out in the community and had a community

partner ready to do it and yet we went back inhouse again to delay that care. how will this be different? how will what you're doing now being different than that if you got prostate surgeon, urologists ready at mayo clinic how will you speed up the prep for that surgery which is standard practice? >> part of our nonva care process would allow those providers to do certain basic studies that are essential to their, either clinical assessment or pre-operative operation. >> the whole package will go? >> i would say that we would look at very high cost studies but routine studies should to be done in the community not brought back to the va. >> okay. i yield back. thank you, mr. chairman. >> thank you, mr. chairman. i liked your questions, mr. waltz.

it concerns me that the whole management system of the va, the whole structure of it to me really s-needs re-evaluated and i hope we can get to that, you know, at least move in that direction because what's happening here is just not right. a couple of ideas that came up from your testimony here today, dr. lynch, is you mentioned the fact that you weren't sure how much of this -- you know the community based health care is proper and should be a temporary thing or a full thing or should be kept in the va because of the extra expense associated with the private-sector care. but then it occurs to me i don't think you have any idea what it actually costs to take care of a patient within the va. i mean, you know, the private-sector is basically, we're talking about paying them at medicare rates. you don't have any idea if you're actually caring for veterans at what rates it's

costing us, do you. >> the va actually does have a dss model that does track the amount of cost that goes into the care of each patient. it hasn't been used extensively, it is available at the medical center. >> you do it for rvus. if you do a certain code you don't have any idea of like how many rvus you produced in the va in a year. so, we have a pretty good idea how many for medicare, for example, how many units we're getting for the millions of dollars we're spending on medicare but i don't believe there is any comparison like that teva. so you don't know if it's doing within the va doing it cost more money or doing it outside costs more money, do you? >> i do know that when i was in omaha we were able in our facility and across the network to begin looking at the cost of specific operations. >> begin looking. does that mean you have an idea.

another thing that i want to bring up -- something -- mr. takano there is no interoperability within the electronic medical records. you can't get someone's medical record from somewhere else. that doesn't happen. it's not possible. that would be the ideal but doesn't work that way. i have another question. the expectations of having this rvu unit how many physicians you need and how much productivity they should have. are you aware the va has been informed there's been a pipeline problem with physicians and productivity problems for the last 30 years and that the inspector general eight times over the last 30 years have said the va needs to develop a plan and it hasn't been done. last year when i had my subcommittee hearing they told me it would be three years before there would be some kind of a plan to develop physician staffing. and then you talk about it a lot

but, i mean, i don't know how that would -- i don't know -- >> congressman, that plan is in place. we will have productivity standards for all of our medical specialties by the end of this fiscal year. >> i would like to see that because when they testified they said it would be three years before they had a staffing plan. >> they are about a year ahead of schedule. >> well, i would like to -- can you provide that? you know, in december 2012 there was a report by the ig that said that all the five facilities that the ig visited were operating contrary to va policy which requires medical facilities to develop staffing plans that address performance measures, patient outcomes and other care indicators. in december of 2012, they said that all the facilities they visited didn't operate according to va policy. what has been done to change

that? >> that is what the office of productivity efficiency and staffing has been working on. since the ig made those recommendations in late 2012 they had been developing the standards for each of our medical specialties. >> you know who is in charge of that? >> it's run by dr. carter mecher and eileen moran. i believe they have been down and testified or not testified but briefed some of the physicians of this committee. >> well, it's just -- you know it's one thing to have a plan and it's one thing to carry out the plan. so, i mean, the inspector general told us back in this report that he went to five facilities and none of the five facilities were carrying out the policy that was in place. you don't have any idea then if anybody was, any action was taken over the fact that these

five places didn't comply with the rules? >> no, sir, i don't. >> do you? >> i do not, sir. >> i'm out of time. >> yes, you are. [ laughter ] >> miss brownly, you're recognized for five minutes. >> thank you, mr. chairman. thank you to the panel for being here this evening. i wanted to talk a little bit about skip and so we obviously now have some new information that we have gleaned from the audit. when will va take this new information that we've learned, you know, about the real late times as opposed to the previously reported wait times and the increase demand thereof and does the va plan on updating the skip plan to reflect those new data points? >> the va as we're beginning to look at the information we have

regarding productivity and our resources, is also seriously discussing the space needed to address the delivery of that care. that has been under active discussion this week, in fact. >> so, if the va is evaluating the capacity space being one of them, i would imagine as you evaluate capacity you're looking at space, the need for personnel, in some cases it may be very extreme, you need much more space and many more personnel and other places maybe it can be resolved by increasing hours at a particular facility. your gathering all of that information and putting it in a matrix so that by each location across the country we know exactly what the underlying issues are and how the va will approach that and most specifically sort of timelines,

space is something very concrete, personnel might not be as concrete but it's pretty concrete. you know, will you have that evaluation, location by location and a timeline of which you believe you can accomplish what is needed? >> we already have most of that information location by location. we have physician information. we have staff support information. location by location. i cannot confirm whether we have space information. but it's critically important in making decisions regarding efficiency. and we are working and discussing the implications of space as we put our models together. >> so, you will have a model of space then and timelines location by location and you say you have -- you already have that for personnel. is that what exists currently or what exists currently and what is needed in the timeline?

>> yes and yes. we have the information based on what we currently have and we have been looking aggressively over the last several weeks at what may be required to either increase the efficiency of our providers, or if they are functioning efficiently whether we they'd to consider adding additional physicians to meet that capacity. >> so, could you share that information with me then on the personnel side? >> certainly. let me see if i can set up a briefing for with you the folks that put that together. >> what's your, i guess, timeline for space, what is your time line to put together a matrix so that, to identify what are the space needs throughout the country? >> i would have to get back to you on the space issue. that's still being discussed and i don't have a definite timeline for that. >> okay. the chair in his opening comments talked about asking the

question how quickly can the va hire a doctor. so, you talked about the fact that you weren't really sure. but i'm wondering, you know it's too long. we all agree on that. can you just share with me just your, at least the va's initial thinking on what some of the barriers are and what might be some mechanisms for shortening that period and expediting the process? >> i think we're clearly going to have to work at improving the efficiency of our human resource process for handling new recruits. you are absolutely right. it is clearly too long. oftentimes we lose people during the process. some of it is essential, the credentialing and privileging process is essential. but some of the other processes involved in human resources can clearly be improved in terms of

their efficiency. i think interestingly some of the things that we're learning in phoenix as we're working with that facility to increase their capacity to add new physicians may help the rest of our system to function more efficiently in the hr process. >> thank you. i yield back. >> mr. huelskamp you're recognized for five minutes. >> thank you. dr. lynch, you committed to shrinking care packages or sized to achieve a desire productivity. what are these desired productivity standards that you're using for primary care providers. >> right now the standards they are use are the number of patients per physician. they do have model, models that they can use to see whether we can increase that capacity based on staffing or based on room

availability, or based on patient complexity. we are also beginning to implement the use of the productivity model to look at primary care and see if we can use that to take a look at not only the number of patients a physician is seeing, but the complexity of those patients and their productivity. so, for instance, perhaps a physician is seeing six patients a day. perhaps they are new patients or complex patients that have a high relative value unit. that physician may be more productive than a physician seeing 15 established patients during the course of a day. >> do i follow that. how do you monitor that, though? >> right now we're monitoring that by looking at the rvu productivity of our physicians. >> monitored at the national level, the division level, the facility level? >> yes. at thele facility level.

>> at the facility level. given the gaming strategies and other things that have suggested and have shown that the data is not valued or maybe reliable do we have potentially the same problems with what you're attempting to measure here? why would we not have similar problems with knowing exactly what's going on with productivity? >> dr. clancy? >> i think that's an incredibly important question and one that we share your concerns and also recognize that since integrity of data has been a problem for us, we not only need to clean up our policies and stream line them but that we also need to have some independent valid addition thvalidation that it can be assured by a third-party. >> that has not been done? >> not yet because the scheduling new policies -- >> any of the data has not been independently confirmed >> the rvu data is independently

validated. >> if we have falsified data and we've shown that va admitted to that, the gaming strategy four years ago admitted that was going on, i don't know how the data could be valid or reliable in either case based on what dr. clancy just said. i'm trying to find out how you can assure me the numbers you gave here match what's happening in the real world. >> congressman, point well taken. va does need to establish the integrity of their data. i will take your comments back to the office of productivity efficiency and staffing. and ask them how we can validate the information we have so that we can establish the integrity of that data and assure you of the confidence that we have. >> the range you gave was six to 22 patients a day. that's your claim today? >> yes, sir. >> that's not valid? >> i think -- that information valid.

i think it's very difficult to, to try -- >> i had a whistle blower has approached my office from a facility and i am and my congressional districts were lucky that way claims there are primary care physicians that see as few as five patients in an entire day. that would be definitely outside the range. do you have any other -- could that be possible? >> i would have to look at the information and evaluate it. i, at this point, anything could be possible. and i'm certainly willing to look at any -- >> i agree. that's my problem. when you say anything can be possible, this is not independently confirmed. how do you make decisions when you don't know if your data is accurate. gaming strategies, we've heard actually the iffalsifying and wt i've heard from this whistle blower there are some that are working very, very hard and then physicians across the hallway to see five patient as day which basically is half the day they

are sitting there waiting for something. and obviously when we're looking at ways to provide better access to care, ways we can do that by enhancing productivity, but we don't have the data i think to answer any of these questions and so i look forward to you showing us how the data is valid and reliable, but if this whistle blower identifies physicians not working as hard as they should be, we got a serious problem in the system. >> congressman, we need to understand that further. >> okay. thank you mr. chairman. i yield back. >> dr. reese, you're recognized for five minutes. >> thank you, mr. chairman. the discussion on ways technology and innovation can increase the capacity of the va from provide timely accessible and high quality veteran centered care is very important. however, today this committee learned that the office of special counsel whose job it is to protect whistle blowers and

investigate their claims found that the va has failed to use information from whistle blowers to correct troubling patterns of deficiencies of patient care that negatively impact the health and safety of our veterans and they failed to correct these troubling patterns of these deficient patient care practices. they describe, quote, a culture of nonresponsiveness. the osc revealed the va's office of the medical inspector frequently refused to acknowledge the systematic problems in the va that exist or acknowledge how they negatively affect veteran care. in other words, it was an institution centered and not a veteran centered response. we need to create a veteran centered culture of responsiveness. the office of the medical inspector of the va needs to either come forward with a serious explanation, or get out

of the way so solutions can be found and implemented and veterans can receive the care they need when they need it. today we're talking about accelerating access to care. what we need is an accelerated access to high quality care not inadequate care. my question is how are you ensuring that the care to veterans is high quality? you know, as a physician in clinical practice we have quality review mechanisms. and some of these mechanisms begin with credentialing, board certification, risk management continuing medical education requirements, and evaluation of patient requests, and also chart audits. what systematic method are you ensuring from your health care providers or the system in order to ensure high quality care? >> congressman, i'm going to

defer to dr. clancy to answer that question. >> so, you often hear it said that once veterans can get in, they often think that the quality of care is very good and, in fact, by the numbers, whether you're looking at information reported to hospital compare we use the same metrics or same metrics used to evaluate health plans as a system vha looks quite good. in addition to that, at a very high level we have all of the regulation that the private-sector has plus additional investigations by the inspector general, the gao and other parties. so we have quite a bit of oversight in that regard. va before there was a famous institute of medicine report on not harming patients to err is human actually stood up a national center for patient safety. as a result of that and other efforts there's a very, very

strong focus on psychological safety and encouraging all employees to step forward. if you see something say something, we actually have a video about this that has been shown widely up the line. and i think secretary gibson was very, very clear with respect to whistle blowers where you started out here today and in accepting the office of special counsel report. >> so, you know, i think that there are definitely good practices. and loma linda hospital is one of the better hospitals and serve the veterans in my district. even amongst the best there's always issues we need to improve. and if there's a report saying that there is a culture of unresponsiveness to these grave scenarios, that is systematic, then i think that we need to get to the bottom of it and figure out where is that disconnect between the whistle blowers and

the responsiveness of those responsible to make sure these practices don't happen. let me get to the next question. do we have a count of full time equivalent primary care physicians per veteran ratio within the visits? >> yes, i'm sure we do. >> do you know what it is? >> it would vary by visit. i would have to get the specific information for visitor for a facility. >> are they used to determine where your resources are spent? >> they are certainly used in association with information regarding demand to make resource decisions, yes, sir. >> the national recommendation is one full time equivalent physician per 2,000 americans. to be considered medically underserved it's one full time equivalent physician per 3500.

so it would be important to determine whether a physician per veteran ratio reveals an underserved va system per area so we can start addressing these underserved areas with priority. thank you. i believe that's the end of my time and i yield back my time. >> thank you very much, dock are the. >> mr. kaufman. dr. lynch, how long have you been with the va system >> about 30 years. >> how long have you been in senior leadership? >> about a year and a half. >> you know, what surprises me and i certainly commend the va for having this access to care initiative. i think the problem is that, and i think we need to be convinced because what we're asking is the same people that drove us into this ditch, to figure out how to get us out of this ditch, and

what amazes me is the fact that in the leadership with the va, all of the issues that have come forward through whistle blowers. and i know that you went -- when the story -- i think it was a catalyst for this, which was the phoenix va scandal, i think you personally went down there to look at it. i mean you didn't -- >> i've been to phoenix four times. >> when you testified before this committee you went there, you came back, you didn't talk to the schedulers that were actually doing the work, you didn't talk to dr. foote the key whistle blower. you made no outreach to him. you didn't talk to any of us. you testified to that effect here. and so we're counting on you to get us out of a ditch. i just don't think it's going to happen. i just don't think you can do it. i think what we need, is we need a new secretary of the veterans affairs that's going to come in and going to clean house.

because you have been in the system for a long time. and you're not outraged. the reality is you're not outraged. you have testified before this committee a number of times, always been defensive. always been defensive. covering concealment, escape and evasion. those are terms i learned in the military as a ground combat officer and you have -- you've used those brilliantly i think before this committee. and the va has not been transparent. has not been -- you know, has admitted a lack of integrity. so tell us how we can count on you and the leadership team that exists there now to get us out of this ditch and to be honest with this cheat and with the american people with the veterans that you're here to serve? >> congressman, i value the va system greatly. i think it is a good system. i think -- >> it's not a good system. how can you say -- >> i think it's a good system. >> really?

>> yes i do. it's good quality care. i die dr. clancy -- >> doctor here's the problem. >> our system compares favorable with the private-sector in terms of quality of care and patient satisfaction. we're challenged right now. we're challenged because of data integrity and we need to re-earn the confidence of the public, of the congress, and of your veterans. we're working to do that, sir. >> you're just glossing this sufficient over. >> i'm not glossing over. >> you ought to be outraged. >> i take this very seriously. >> you're part of the problem. i just don't see you as part of the solution. i don't see you able to get us out of this ditch and we're in a ditch and you're in denial that we're in the ditch. >> congressman, i'm not denying at all we have a significant problem. if you want to call it a ditch i will not disagree with you. we do have a way forward. i think we do have plans. i think we do need to re-establish our integrity.

i think we can do that. we can salvage a system that does provide good care and make that system provide timely access. >> i'm stunned you would call this, with all the information that's come out, and i don't think we're at the bottom of all this yet, that you would call this a good system. i think it's absolutely stunning. and i just -- i think that the veterans administration is the most mismanaged agency of the federal government. i think that it has not been there to serve those that have served our country but the leadership of the va has been there to serve themselves. and with had testimony before this committee about all the bonuses, all the bonuses, despite the incredible bureaucratic incompetence and culture of corruption, that's the only thing you are effective in is writing checks to each other. mr. chairman, i yield back.

>> miss kirkpatrick, you're recognized for five minutes. >> thank you, mr. chairman. i want thank you and ranking member michaud for continuing to have these hearings. i feel like we're not getting to the bottom of this. and dr. lynch, we've had a number of hearings. you've been hear a number of times. and we've heard that -- i just want to focus on the scheduling delays. that's the problem that we're trying to get to the bottom of. this committee has heard there's five reasons for this scheduling delays, that there was an unexpected surge of new patients. there was not enough funding. obsolete facilities. obsolete technology. a lack of patient extenders and personnel. a lack of consistent policy across the system. but that just further describes a problem, and my question is,

why? why did the va not anticipate a surge in new patients? we know we have an ageing population. why did the va not have enough funding when we've given them all the funding that they've requested. so, you know, we're starting to think as a committee that this is a systemic problem, but we're still just not getting to the bottom of the why. can you answer that for me? >> i think part of the reason may be relatively self-evident. we were not getting good data from the system. we didn't have a good measure of those patients that were waiting. >> but why? why? >> i think we know why. i think we've acknowledged that the system was not honest. we were not getting the information we needed. we had performance measures that were misguided. and we need to reform that. so we have accurate information

and we can resource or system appropriately based on demand and capacity. i think we have the tools to do that. i think we have the information to do that. we need to assure that our data is accurate. we are working very hard to do that. we are making demands on both our visit directors and division directors to make sure the practices in their clinic are according foil. we acknowledge we'll probably have to have an independent third-party confirm that that information is accurate. because at the moment we have to verify to you, we have to justify to the american public that our information is real and accurate and we can provide timely care and we can give the information that we need to assess demand and capacity. >> well, i appreciate your answer, but i feel like we're still not getting to the bottom of this. and leapt me just say, why is the va so slow?

why are they so slow in responding to mr. waltz's office. why have they end so slow in responding to this committee? just why, why, why. is it because there aren't enough incentives? >> it is not correct. i think we do have to work with this committee and we do have network with congress if we're going to build a better va system and we do need to give you the information that you need. >> dr. lynch, let me just ask it is a system that can innovate? >> yes it's a system that can innovate and we've shown we can innovate in the past particularly in response to crisis. if you look back in the mid-1980s there were concerns about surgical care in the va. the va developed a risk adjusted model of outcomes assessment that has now become the model for the private sector. in the 1990s va was criticized. the va innovated with the electronic health record.

that has now become a standard for the private-sector. i think we can innovate and i think we have an opportunity here in va to respond to this crisis with an innovative model of staffing, of assessing demand and capacity that can become a standard for the industry as well. >> please do it. i yield back my time. >> if i could just add one thing to what dr. lunch just said. i think all of your questions are critically important and tearing us up as well but right now we're focused 100% on trying to get veterans into the system and using all the tools available at our disposal. there will be time for the why questions and the much tougher analytical questions that all of you are asking about how do we fine tune capacity and demand but right now the number of veterans wait cigarette an emergency and that gets the highest priority. that does not mean anything else is off the radar screen. and i just have to say in response to the innovation question i did have the pleasure

and opportunity of visiting division one which encompasses the state of maine and some of the innovations they have tested and deployed up there are really terrific. i think our challenge is out how to spread to it achieve the same successes as we've seen in surgery and in other areas. >> thank you. thank you, dr. clancy. >> thank you, mr. chairman. you know, as we sit here and talk about all this i think a lot of times as people are watching, it almost seems like we're talking about patients as they are monopoly pieces. when mr. waltz brings up the point of the possibility of getting surgery within 48 hours but it's six weeks until they can get their pre-open work done teva it's disappointing the surgeon can't make something happen sooner or nowhere to go, these types of things aren't corrected and i'm sure these have gone on for years. you know, there's a lot of things that we're hearing tonight and you share our

concerns. when did you start? when i got here i went to gener gener gener general senseki three times. why are so few patients being seen opinion you talk about rvus and for our fans watching at home. rela receive value units. new patient has a higher value than an established patient. a short procedure has fewer value units than longer type procedures. when did you start looking at the rvus? >> the rvus, i believe, became part of our evaluation process after the report in 2012. >> that's been around for a

while. it's some type of measure. but my question senior you measuring how many rvus per patient per day per month per p? >> yes, sir, we are. >> if you could pick one and give me all that information tomorrow, i would appreciate seeing how you're going about doing that, i would be very curious. dr. benechecck brought up a very good point when he said how much are you spending per rvu. if you take all the money you're spending on these patients and tally up the rvus built, medicare knows how much you spend per rvu. you're measuring rvu but not how much you're spending per rvu. it's key. i think you look at how many patients or a facility is seeing is each day. there's more than one way to

measure these types of things. in our practice, if one doctor is seeing 60 patients and a similar doctor seeing 30, we're talking to the one with 30 and see if they can get that up and continue the quality they have to have. when you're comparing to yourself, i don't think you're getting anywhere. that's part of the problem. my next question is, when you talk about doing these evaluations of efficiency, who's doing this? because if it's somebody that's been in the va system their whole life, they're don't know what they're measuring and don't compare to successful healthy health care systems. so who is doing this currently? >> right now, it's being done by dr. carter mecher and eileen moran. >> and are they from the private sector? have they been in academia? >> i don't know dr. metra's history. i note he has met with the physicians on this committee.

i think you have talked with him. >> yes. >> i think he does have a good handle and a good understanding of the rvu system and productivity. i think he has very innovative concepts of how we can use that to resource or system and to look at right sizing the number of physicians and the capacity that we have. >> and that's helpful. i would definitely look at someone who's had great success in thesers and they exist throughout our country without a doubt. >> the we are speaking to kaiser and a number of leaders from private sector systems. if you had other suggestions, we'd be all ears. >> those are good suggestions. i would also suggest that you encourage account president and the senate to confirm someone who that is some administrative experience in the private sector in these areas. i think it would be a great benefit to our veterans and to our country. lastly, i do want to point out that the cincinnati va, who i represent that area, has been

flagged. i have asked for why they were flagged and have not received my notification yet as to why. and certainly somebody knows why. so i hope we get that the very quickly, as well. i look forward to seeing one of those reports on the rvus, as well. >> yes, sir. >> i yield back. >> mr. custer, you're recognized for five minutes. >> thank you very much, mr. chairman. thank you dr. lynch and dr. clancy for being with us this evening. i think what all of us are trying to do is to be helpful. i think our chair opened the hearing asking how can congress help you, and our challenge is that this whole process feels like a rubick's cube. every time we think we've got a piece in order and we think we understand what the problem is, is it not enough physicians, then we offer to help on that, but maybe that's not the problem. it's the space problem. if it's not a space problem, it's the support staff and the list goes on and on. i'm very fortunate to have

experience with the va in new hampshire. my father-in-law got very excellent care within that system. buff obviously, the concern that we have is that that be replicated for every veteran around the country. so the focus of my comments is, how do we ensure access to high quality karat a cost that the taxpayers can afford for every veteran? and i've spent 25 years in the private sector on policy issues. i know this isn't easy this conundrum of high quality care access and cost. it's sometimes a wobbly three-legged stool. but in your case, it seems that the problems of scheduling and wait time data has called into question the whole basis for your staffing and capacity calculations. and i think dr. lynch, you just mentioned this. you're trying to match supply and demand, but you don't have

an accurate picture on the demand side and so trying to determine what the staffing model would be is of limited use. and when you tell us the average is a physician seeing ten patients a day, does that include the data that we've heard in this committee of 50% no shows? so is that actually a physician that has 20 slots per day but only ten patients walk through the door? and we want to help you with this. we want to get the policy right. we very legislation that we're offering this week. it will be bipartisan that's about getting residents involved. give you greater capacity. we would be happy to help talk about what the space issues, but how can you help us with where to start helping you? >> congress woman, i think we can start by trying to give you

the information that you asked for. and a apologize if you have not seen that. we have provided a briefing to members of this committee on the productivity model that we have. i acknowledge that until we can assure the accuracy of our scheduling data, that information is going to be flawed. although i can -- i am confident at this point that i think beat do have reasonable information on productivity and we can begin to use the productivity information to begin to look at what we need in the way of additional staffing to increase the efficiency of physicians or in those practices that are very efficient, who we may need in the way of additional physicians. so i think we have a start. but i think we need to gather more data. i think we need told have accurate data on access before we can come to a fine answer. >> and then if we could add, ben

benecheck's analysis about the cost in house and outside the va because it's difficult for us to make that recommendation as to how to you make these adjustments. you know, we want veterans to be seen in a timely way, but it's not unlimited, you know, the funds that can be put toward this. it is less expensive within the va, then let's expand your capacity. if it's less expensive outside the va, then let's use private facilities but we're not able to measure this at this point. >> no, but i think that all of the information that you've heard and we look forward to briefing you more on on the productivity and staffing will be a huge puzzle piece here that will be foundational to getting to this second order question. after the emergency of addressing people waiting in line right now about what kinds of resources do we need, and the issue that dr. lynch brought up

a couple of times about make or buy decision at the very local level because that's where it needs to happen, the answer to that is not going to be thumbs up thumbs down all the way. it's probably going to be make in some areas primary care, for example, and buy in some other specialty areas and so forth. and a lot of that will be a very dynamic relationship with community capacity and so forth. >> my time is up, but i do have a specific question i'd like to get to later about women being served in the va because i think that's a unique situation, as well, and problematic at best. so thank you, mr. chair. i yield back. >> miss hoa lo ski. >> dr. lynch, i'd like to ask a question about the va staffing and productivity standards. had the ig that was here a coup weeks ago made an interesting kind of an assessment. he pretty much said be careful what you wish for to our committee on this issue of fee

basis care versus va care. i did investigation in my state. i learned there are a number of va hospitals including in the one in fort wayne, indiana that are not functioning at full capacity, turning patients away, sending them to nonva hospitals due to lack of appropriate staffing or facilities. in this case, the va, their icu is closed. the er is now using criteria over what he patients they'll accept and those they'll turn away based on their faults. by paying for nonva care in addition to operating half empty hospitals va appears to be paying for two systems of care. do you know how many va hospitals fit this description? >> i don't. >> can you give me that number? i found the fort wayne one quickly. >> i think there are facilities that are struggling. they're older facilities not always in fort wayne where they're in larger communities.

sometimes they're in smaller communities. the population they support is small and oftentimes difficult for them to support an icu. those are difficult decisions but we need to look at our facilities where they are and we need to assure that we're using them optimally. >> i guess my follow-up question would be what the ig warned us about which is who is looking at those numbers to figure out, for example in, fort wayne, those numbers for fee basis care are skyrocketing every year. once i found out there's no icu and there's using criteria who they can take and can't take, they may have to send somebody to cross the street for a risk basis procedure because there's no icu. who looks at those numbers? is that regional or statewide or that specific hospital looks at the skyrocketing numbers? who makes the assessment are we pay reggie for two facilities or are we paying for one. >> part of the challenge is based on the