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 real-nhope we can get to that, 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 test test ved 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 and 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 are in a ditch and you're in denial that we're in the ditch. >> congressman, i'm not denying at all that we have a significant problem. if you want to call it a ditch, i will not disagree with you. >> we just had testimony -- >> we do have a way forward. i think we do have plans. i think we do need