efficiently and more quickly. >> are there any impediments that we as a legislative body can do to assist in removing some of the barriers? >> at the moment, mr. chairman, i can't think of any. >> i would simply add that -- >> sorry about that. i would add that some part of the reason it takes a bit of time is the credentialing and privilege process which i think you would all want us to be rigorous about. we're investigating ways to try to speed that up but the human resources part is probably one. >> what is the expected cost of accelerating access to the care initiative and how are you funding it currently? >> right now the expected cost that we have invested is approximately $312 million. it is being funded based on monies that we had been able to recover from across vha.

>> additional authorities? >> any authorities being granted to help speed the process along? >> other than asking the facilities to look at their processes and the efficiency of their processes, see if they can identify internal capacity, and if they can not, to let us know what resources they need to provide that kair in the community. that process has occurred. the facilities have made their requests and to date. we have distributed approximately $312 million of which approximately, $152 had been obligated. >> according to the survey of

america fa cigaretteses over 80% of primary physicians in theites see between 11 and 61 patients per day and u.s. physicians in general seen average of over 20 patients per day. can you tell us what the average daily patient load of a va primary care physician is? >> right now, the average patient load is approximately 10 patients per day. if i could qualify that by saying that i think we need to assure is that we understand what support staff our physicians have and what capacity they have in the way of rooms to facility u sill today their ability to see patients. i think it's not just the physician's ability and willingness to see patients. it's also the support that we provide them and it's the rooms that we give them so they can see patients in an efficient fashion. the range, by the way, is from 6 per day up to about 22 per day for our physicians. >> but you are the agency that designs the clinics. designs the hospitals. designs the facilities so you

would know how many rooms would be needed, i would suspect, in order for patients to be seen? >> congressman, many of our facilities are 50 or 6 o'years old and were designed when outpatient health care was not the dominant mode of health care delivery. va in the 1990's converted from an in-patient model to outpatient model and wi still challenged by facilities that were not constructed for the out patient model of care. >> so if i went to a new facility, i should suspect that this doctors there will seeing more patients than those in the older facilities? >> the va has been working to put in place templates that facilitate the delivery of care using the medical home model. so that we are redesigning new clinics in our outpatient facilities to optimize the ability of our physicians to provide care and to see patients in that model?

yes, congressman. >> one other question, if you would. the office of council sell wrote a letter to a president a veteran with a 100% psychological condition for many years. >> yes, sir. >> and in those eight years at the facility, this veteran apparently had only one psychiatric note in his chart. is that true? >> that is true, sir. >> one note in eight years? >> that is unacceptable, sir. >> despite the fact that the office of the medical inspector substantiated this occurred it also stated in the same letter it had no impact on that patient's care. can you believe that? >> congressman, the office of the medical inspector is unique in health care. we don't see it in the private sector.

it is va's arm to evaluate objectively outside the facility. concerns about the quality of care. i understand that the office of special council has raised concerns. va and our acting secretary have taken those concerns very seriously. we need to take them seriously because va is in a position where we have to re-establish our integrity. he has established a group, a commission, who will evaluate these concerns. the report is due in 14 days. i think it's important we understand what that review shows before we draw any conclusions. >> thank you. >> thank you very much, mr. chair. once again, thank you dr. lynch and dr. clancy for coming here this evening. we understand that the accelerated access to care initiative is designed to ensure access to care by enhancing resources within va facilities and also, sending veterans promptly to community-based care

and nonva care when needed care is not readily available at the va facility. what is the role of pc 3's in va accelerating access to care initiative? >> pc3, as it develops, will be another model that we can use to have vi provide care in the community. pc three is in the process of being stood up. some sights have a greater available of pc 3 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 specify the care will be provided within 30 days. that we will receive reports in a timely fashion. so pc 3 is an enhanced method of providing care in the community. that gives benefit to the va

because it assures timeliness and assures that we get records back in a timely fashion. >> i would also add that they assure some minimal level of quality. i mean, the foundational level of quality in terms of contracting with hospitals that are accredited by the joint commission or relevant creddor h creditor that the plans they're contracting with have met the standards for the national the committee on quality assurance and so forth. and we're going to be work, 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 art before implementing pc3. the va also has indicated that in designing pc3. it used lessons learned from these pilot programs to develop a solution, which is coordinated convenience and consistency with va quality standards. my question then is, now that pc

3 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 availablend when the services are available it is being used, yes. >> so it's not throughout all of the va medical centers, then? >> in certain areas, the contractors are having to identify providers and are 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 the potential of the program if it's not a mandatory program? >> it would be my hope, understanding the benefits of the pc 3 process, that it would be advantageous to the medical centers to use that program. as i mentioned, there are

standards for timeliness at providing services and standards for the the receipt of work product after the services have been provided. >> okay. how does the va distinguish between short term and long term capacity shortfalls and how does the va respond different to the long term and short term short falls? >> i think as are data becomes more reliable, we'll 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 on 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 this 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 in-house? so i think, short term pc3, none va care, provides the opportunity for us to offer propped 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 wei think we can offer t in-house. >> you're recognized for 5 minutes. >> thank you, mr. chairman. dr. lynch, in the last two weeks the number of veterans that 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 bye top story si done on his thyroid to determine whether or not he had cancer, only to be told that h 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, please, are available to the denver, va medical center to expedite biopsy poimt based on medical necessity and the possibility of a life-threatening condition. >> what you're telling me if services not be provided in less than 30 days, that's an unacceptable waiting time. and the denver va facility should be able to identify a community provider to offer those services. >> and that would be the

fee-basis approach that we've talked about. >> that's the uss 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. >> thank you. >> now, the data included in the va's bi-monthly access update, makes me worry the problem will get worse before it get better. especially in colorado. myself and representative mike kauffman have a lot of these same concerns. although the report showed the number of veterans on the 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 16 2 to 3331. what could have caused that number to double in 15 days when

around the country, it was drops slightly? >> i don't have the specifics on denver, congressman. i will be happy to try to 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. it's possible that some of the patients that were on the near list have been moved to the 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. >> you stated in your written

statement that the average number after patients 1,194. 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 require. dr. clancy woour would you have any comments? >> no. >> sorry. >> yeah. i would agree with all of that. we also -- the va's medical home and 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 know in your written testimony that the va is adopting productivity standards that are modeled on industry-accepted standards. i'm really glad to hear that but what's been the case -- what's been the standard up until now? >> sadly, congressman, there hadn'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 and in that case, either we need to identify more patients or we need to figure out a way that we can move their capacity to another facility. perhaps using something like

telehealth. >> thank you. >> ms. mccloud, you're recognized for five minutes. >> thank you. i really have no questions. i yield back. >> you're recognized for five minutes? >> thank you, mr. chairman. thank you, dr. lynch and clancy for appearing before us today. i understand that from 2008 to 2013, nonva care outpatient visits grew from 8.9 million or 9 million to 15.3 million, a 72% increase. do we have any way of knowing about the comparison between nonva care versus in-house care? it's efficacy and its cost? >> i don't have the comparative data from those years. i can tell you in the last fiscal year, we spent approximately 4.8 billion on

nonva care. but i would have to try and 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's extremely important to have a continuity of care and health records can be transferred seamlessly and thinks what you were talking about when you were trying to do a quality check on the pc 3 and finding the community providers. what can we do to ensure that this happens? >> i think that's 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 for 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 v a. >> i know as part of the aca and the hi-tech act which passed around the same time congress created incentives for to health care providers to make the transition to electronic health care records. do you have any idea if this d digitation has. done? >> complying with the standards set out by meenlingful uss is the poch lar larer term for those settings of incentives although va doesn't get money from cms but we are complying

with although standards, yes. >> but, the private health care providers who were given incentives to di digitize the records, is the standard set fort by cms, will that provide interoperability with vista? >> it should. >> it should. >> yes. >> and in some cases, we are starting to explore this, for example, with some pilot projects to let vets get imnun conversations at a washington green'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. theoretically, physicians who been incentivized under the aca to digitize, that those standards set forth, you said it was set fort by cms? >> yes.

>> that provides the first foundation for it. >> so part of being able to facilitate this ability to access for our veterans to access care, in the private arena, would be to facilitate this inner operableability and if there were further incentives for our physicians to digitize the standards that 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 strategy i can planning effort in terms of how do we accelerate the path toward inoperability. but what the community partners do is they send a report, pc 3 makes this a little bit easier

because it's a condition of they're getting paid. and that gets attached into the vista record, essentially, as a portable, downloadable file. >> would this incentivizing in through pc 3 be helpful if we put in an incentive for them to digitize? >> that might be an option down the road for sure. >> great, thank you. >> mr. -- you're recognized for five minutes. >> thank you, mr. chairman. the 70,000 veterans contacted that were on the waiting list and the point is to remove them from the waiting list, how many were contacted and they actually spoke to a person, a va person or -- 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 queue 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 nothing contact and also, the disposition of the patient's contacted. >> if they received something in the mail, and they contacted the va, were they speak 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 and 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. >> 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 care 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 seek care so i believe we chose that as a reasonable number. it does -- >> who chose that? >> the va chose that.

it does depend on the accuity of the patient. if the patient needs to have care immediately we would provide that. if there was an you are you aur had any further insight on the ability for the community to provide care in a more timely fashion than 30 days? >> i would guess, congressman, that you and your colleagues so probably seen data from recently released surveys of how long it takes to get a new paint employment which ranging somewhere from ten days or a little bit less in dallas. up to 45 or so in boston. obviously, it doesn't have a lot to do with the number of doctors in the area because boston has a lot of doctors. the problem is, there's no industry standard. i will say that when veterans contact the facility and are given a wait time, or an expected wait time and if that's not acceptable and option, to go out into the community, they are

also counciled that if they have a more urgent need they should come into an urgent care or emergency room for more immediate care. >> on the average, how long would it take if -- to say it's decided to 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 will depend on what existing capacity is in that community. >> on the average? >> we don't -- we don't have a number for that. i would guess in dallas, it would be much faster given the data i just mentioned a moment ago that wait times there are shorter. i would expect it would be much, much tougher in the boston area, for example. >> however, i would just adds with the pc 3 contract it's the contractual expectation that patients will be seen within 30 days. >> yeah. one last question, mr. chairman. under the department of veterans' affairs health care programs everyone hasnnhancemen

2001, a nationwide staffing policy for all va medical facilities. 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 to our office of productivity efficiency and staffing. that is looking at the number of physicians that we have. the specialty of those physicians. and they're ability to provide care in an efficient fashion using this model. >> please report back to me because i feel you should have that information with aye now, today. so anyway, thauj thank you very much, mr. chairman, i-year-old back. >> mr. waltz? you're recognized for five

minutes. >> thank you, mr. chairman and thank you both for joining us again. i'm going to start out and ask, is the chairman made note of it. a lot of this stems from the ability to get information and us to do our constitutionally-mandated job. over three weeks we sat in here and after the audit several mentioned our facilities were flagged and wairp guaranteed we would be told why that was and nothing's been said and 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 with mr. matt kofsky before i came down here and we knew this issue would be raised. >> that's good foresight. i appreciate that you're thinking ahead that it's a -- >> he and i agreed that it's important that we brief the committee and we'll make arrangements to do that. and then, also provide briefings to other congressional staffs on

a vision by vision basis. >> dr. lynch, and you've been coming down here a lot and i'm appreciate of the work you do and as so many others but the time has come 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 situation. we had a veterans for eight years we weir housed. 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'll come back to the leadership and structure issue. if i asked a 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 -- >> is that a strategy or a goal? >> it is probably a goal. >> so if -- and i'll go back to this from a national security

zand point. we have a national security strategy of the defense review and then that identifies requirements. and then dod comes back to fill those requirements. do you do that at the va? because i'm getting back to that that we've been trying this issue since 2005 on measuring capacity. actually i went back. we started in the 1980's so i'm not convinced what hatched in dallas or minneapolis or sioux falls that i would get an answer. >> we're are developing a strategy as it relates to access and scheduling. we have in place, a seven-step process that we're developing that will address the issue of accelerating care. that will address the development of demand capacity models. that will dop the policies and directives to drive scheduling and access. that will relook at our

performance assessment measures so that we can dop 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 to meet -- >> where does that guidance come from? >> this is an organizational plan developed within vha over the last three to four weeks in response to the issues that we have faced regarding veteran access. >> is there white house input into any of this? sfwhoo not to mary knowledge, sir. >> mike, i want to have a specific one on the as we look at this care model and i want to give you an example that i did some research over the last week preparing for this. there's a mayo clinic phoenix

down there and prior to all this coming out it was brought to my attention they were doing some of the prostate surgeries and a fee for service they had that at capacity? is that correct? >> that's my understanding. >> they said when they would have them come in they say we can do the surgery in 48 hours. the va would say, but we have to do the ecg's and that will take six to eight weeks. so we had it going out into the community and we had a community partner ready to do it and, yet, we went back in-house again, to delay that care. how will this be different? how will what you're doing now be differ than that if you've got prostate surgeons, you are roll gists ready at the mayo clinic, how can yao speed up the prep for that practice. >> part of our nonva practice would allow those providers to do certain basic studies that are essential to their either clinical assessments or preoperative evaluation. >> through the whole package

will go? >> i would say that we would look at very high-class studies but routine studies should certainly be done in the community and not brought back to the va. >> okay. i yield back, thank you, mr. chairman. >> thank, mr. walsh. >> thank you, mr. chairman. i like that questions, mr. walls. it very much concerns me in that the whole management system of the va, the whole structure is really -- needs to be re-evaluated and i hope we can get to that -- we in that direction. because what's happening here is just not right. a couple of ideas that i came up with from your testimony here today, dr. lynch, you mentioned the fact that you were not sure how much of this -- the community-based health care is proper and it should be a temporary thing or a full thing

or should be kept in the va, because the extra expense associated with the private sector care. it occurs to me is that i don't think you have any idea what it costs to take care of a patient within the va. i mean, 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 rate it's costing us, do you? >> the va actually does have a dss model that does track the amount of costs 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 rvu's? the you're doing a certain code, you don't have any idea of like, how many rvu's you produce in the va a year for the $50 billion for the va health care system we spend? so we have a pretty good idea how many are medicare, for example, how many unit we get

for the millions of dollars we're spending on medicare but i don't believe there's any comparison like that at the victim a. so you don't really know doing it within the va costs more machine 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 does not mean you have an idea. >> and another thing i wanted to bring up. there is no interoperability among the electronic medical records? that does not economist? you can't get somebody's medical record from somewhere else? that doesn't happen? is it possible? that would be the ideal, but it doesn't work that way. but i have another question. the expectations of having this rvu unit and how many physicians you need and how much

productivity they should have. are you aware the va has been informed that there's been a pipeline problem with physicians and the productivity problems for the last 30 years and the inspector jaen eight times over the last 30 years said the va needs to develop a plan and it hadn't been done? last year when i had my subcommittee hearing they told me the three yourself before they would be some kind of plan to develop physician staffing. and then, you talk about it a lot but i don't know how that would -- i don't know what you're -- >> congressman, that plan is in place. we will have productivity standards for all of our medical specialties by the end of this fiscal year. >> well, i 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 your ahead of schedule. >> i'd like to -- can you provide that? you know, in december of 2012, there was a report by the ig that said that all of the five

facilities that the ig visited were operating contrary to the va policy which rooirs medical facilities to develop staffing plans that address performance measures, patient outcomes and other care indicators. so in december of 2012, they said that all of 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 works in that fa skilt. and eileen more an.

they were testified or briefed some of the physicians in this committee. >> well, it's just so -- it's one thing to have a plan and it's actually one thing to carry out the plan. so i mean, inspector general told us in the report he went to five facilities and none of the five facilities were carrying out the policy that was in place. and you don't have any idea if anybody was -- any action was taken over the fact that these five places didn't comply with the rules? >> do you? >> i do not, sir. >> all right. i'm out of time. >> yes, you are. i wanted to talk about skip.

we now have new information that we gleaned from the audit so when does the va take in the information we learned about the real wait times as opposed to the previously-reported wait times and the increased demand thereof, and does the va plan on updating the skip plan to reflect those new data points? >> the va as we are beginning to look if the information we have regarding productivity and our resources, is also seriously discussing the space needed to address the delivery of that care. that's been undoor active discussion this week. >> if the victim a is vamting this and i imagine as you evaluate capacity you're looking at space, the need for more personnel, and 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. are you gathering all that information and putting it in a matrix so by each location cross the country, we know exactly what the underlying issues are? and how the va will approach that? and most specifically, to sort of timelines? space is something very concrete. personnel might 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 palestini accomplish what's needed? >> we already have most of that information location by location. we have physician information and 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 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 had been looking aggressively over the last several works at what may be required to either increase the efficiency of our providers or if they are functioning fishily, whether we need to consider adding additional physicians to meet that capacity. >> could you share that information with me, then welcome on the personnel side? >> certainly. let me see if i can set up a briefing for you with the folks who put that together. >> okay. on the -- what's you're, i

guess, timeline for identifying the space needs throughout the yes? >> i'll 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 the va hoo hire a doctor, and 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 some of the barriers 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're right. it clearly too long. some of this is essential. the credentialing and prif privileging process is essential but other processes involved in human resources clearly be improved in terms of 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 them function more efficiently in the hr process. >> thank you. i yield back. >> thank you, mr. chairman. dr. lynch, as part of the va's accelerating access to care initiative, you committed in the spring primary care clinic panels are correctly sized.

to achieve e the desired productivity. what are the desired standards that you're using for primary care providers? >> right now, one the standards that they're using are the number of patients per physician. they do have models that they can use to see whether we can increase the capacity based on staffing or based on room available or based on paint 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 if 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 actually be more productive in a physician that's seeing 15 established patients during the course of the day. so i think -- >> and i do follow that. how do you monitor that? >> by looking if the productivity of our physicians? >> the national level, division level tore facility level? >> at the facility level. >> given the gamining strategie and other things that have shown the data is not valid or maybe, not reliable, do we have potentially the same problems with what you're attempting to measure here? why would we not have similar problems knowing exactly what's going on with productivity? >> i think that's incred blai important question and one that we share you're 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 looming them we also need to have some independent validation that these processes are both effective and that the integrity can be assured by an independent third party and we'll be doc just that. >> that's not been done? >> not yet. because the schedules new policies. >> any of the data yao've shared has not been independently confirmed? >> the rvu data is validated based on what we're recovering from the way physician activities. >> if we had falsified data and we've shown that, the va admitted to that, the gaming strategies four years 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 that the numbers you gooiv here actually match what's happening in the real world. >> congressman, point well taken. the va does need to establish the integrity of their data.

i will take your comments back to the office of productivity issue in si and staffing. and ask them how we can validate the information we have, so that we can establish the integrity of the data and assure you of the confidence we have. >> the range you gave was 6 to 22 patients a day. that's your claim today? >> yes, sir. >> that's valid but it's difficult to try to -- >> i had a whistle blower approach my office from a facility in my congressional district is in four different places, we're lucky that way but claims their 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

informati information. at this point in addition could be possible. >> and i agree. anything could be possible. it's not independently confirmed so how do make decisions if you don't know if you're information is accurate. and the falsifying of data. and what i heard from this whistle blower and they're hard-working physicians but some are working very hard and then physicians across the hallway that see five patiention a day basically, half the day they're in sitting there waiting for something. is and obviously, when we're looking at ways to provide better access to care, ways to do that by enhancing productivity, and -- we don't have the data to answer any of these questions so i look forward to 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've got a serious problem

in the situation. >> we need to understand that further. >> dr. reece, you're recognized for five minutes. >> thank you, mr. chairman. discussion on ways and technology and innovation can increase the capacity at the va to provide time lay accessible and high-quality veteran-centered care is very important. however, today, this committee learned that the office of special council whose job it is to prosect whistle blowers and investigate the claims found the va has failed to use information from whistle blowers to correct troubles patterns of deficiency of patient care, that negatively impacts 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, unquote. the osc revealed the va's office of the medical inspector refused to acknowledge the systematic

problems of the va that exist og 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 created 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? 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. evaluation of patient requests 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 whistleblowers 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 university is one of the better va hospitals in

our country and serve the veterans of my district. however, even amongst the best, there are 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 whist leblowers 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. >> of course. >> i would have to get the specific information for visitor or 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 3. 500. 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, doctor. mr. kaufman, you're recognized for five minutes. >> dr. lynch, how long you been with the va system? >> about 30 years, sir. >> 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 whistleblowers, and i know that you went -- when the story -- i think it was a catalyst for all this which was the phoenix va scandal, and 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 whistleblower. you made no outreach to him. you didn't talk to any veterans. 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 clean house. because you've 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 committee, with the american people, with the veterans 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 could you say -- tell me how it is a good system. >> i think it's a good system. >> really? >> yes, i do. >> not if you're a veteran. >> it's good quality care. >> doctor here's the problem. >> our system compares favorable with the private-sector in terms of quality of care and patient satisfaction. i think that, yes, we are challenged right now. we're challenged because of data integrity and we certainly need to re-earn the confidence of the public, of the congress, and of our veterans, and we are working to do that, sir. >> you're just glossing this stuff 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 are 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 just had testimony -- >> we have a way forward. i think we to have plans. i think we 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 absolutely 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. and i think that it has not been

there to serve those who have served this 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 all seem to be effective in is writing thei checks to each other. mr. chairman, i yield back. >> miss kirkpatrick, you're recognized for five minutes. >> thank you, mr. chairman. i want to 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 aging 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? we're just -- >> 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 our 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 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 let 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? >> i apologize for our slowness. 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. mr. michaud and i --

>> dr. lynch, let me just ask, is it a system that can innovate? >> yes, it is 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 frankly are tearing us up as well, but right now we're focused 100% on trying to get

veterans into this system and using all 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 waiting is 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 how to spread it, achieve the same successes as we've seen in surgery and 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

though they're monopoly pieces. when mr. waltz brings up the point of the possibility of getting surgery within 48 hours but it's 6 weeks until they can get their pre-op work done at the va, it's disappointing that surgeon can't make something happen sooner or there's nowhere to go that these types of things aren't corrected. 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 general shinseki three times saying i'd be willing as a physician to go into the clinics, go into the o.r.s. i come from private practice. i trained in a va. discuss why it is so much slower. why there are so many fewer patients being seen. never got a response, never got action on that. you talk about rvus, and for our fans watching at home, they probably don't know what those are. relative value units. so a new patient has a higher value than an established

patient. a short procedure has fewer value units than a long procedure. those types of things. when people hear that, they know what we're talking about. when did you start looking at the rvus? >> the rvus, i believe, became part of our evaluation process after the oig report in late 2012. >> okay. so just in the last couple years. of course, that's been around for a while as some type of measure. but my question is, are you measuring how many rvus per patient, per day, per month, per provider, per facility, per visit? >> yes, sir, we are. >> okay. so, well that would be nice, if you could make pick one and give me all that information tomorrow, i'd appreciate seeing how you're going about doing that. i'd be very curious. the doctor brought up a very good point when he said how much are are you spending per rvu? so if you take all the money that you're spending on these

patients and tally up how many rvus that have been built up, how much are you spending per rvu? because i can tell you medicare knows how much their spend per rvu because it's already established. so your budget is out there. you're measuring rvus but not how much you're spending per rvu. i think that's key and key you look at how many patients a doctor is seeing each day or facility is seeing 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 is seeing 30, we're talking to the one with 30 and see how we can help them get that up and continue the quality they have to have. when you're comparing to yourself, i don't thing you're getting anywhere and that's part of the problem. so my next question is, join talk about doing these evaluations of proficiency, who's doing them? if it's somebody who's been in the va system their whole life, they don't know what they're measuring. they don't compare to successful, healthy, health care

systems. 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? have they been in the va? where have they been through their careers that make them qualified to be very good at this? >> i don't know dr. mecher's history. he's met with the physicians on this committee. i think you have talked with him. >> yes. >> i think he does have a good hand 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 our system and to look at right sizing the number of physicians and the capacity that we have. >> and that's helpful, but i would definitely look at someone who's had great success in these areas. and they exist throughout our country without a doubt. >> i would just add that we are speaking to kaiser and a number of leaders from private sector systems and if you have other

suggestions, we'd be all ears. >> well, those are good suggestions, and i would also suggest that you encourage the president and the senate to confirm someone who has some administrative experience in the private sector in these areas. i think it would be great benefit to our veterans and to our country. and lastly, i do want to point out that the cincinnati va, why i represent that area, has been flagged. i have asked for why they were flag flagged and have not received my notification 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. thank you. >> miss 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. but 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 care at a cost 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 10 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? >> congresswoman, i think we can start by trying to give you the information that you asked for. and i 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 we to 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 to have accurate data on access before we can come to a final answer. >> then if we could add dr. benishek'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 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. if 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. 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 walorski. you're recognized for five minutes. >> thank you, mr. chairman. dr. lynch, i'd like to ask a question about the va staffing and productivity standards. the ig that was here a couple weeks ago made an interesting kind of 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 ft. wayne, indiana, that are not functioning at full capacity, turning patients away, sending them to non va hospitals due to lack of appropriate staffing or facilities. in this case, the va, their icu is closed. the e.r. is now using criteria over what he patients they'll accept and those they'll turn

away based on their faults. by paying for non va care in addition to operating half empty hospitals va appears to be paying for two systems of care. do you know how many va hospitalsfy that description? >> i don't. >> can you give me that number? i found the ft. wayne one quickly. >> i think there are facilities that are struggling. they're older facilities not always in ft. 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. >> and then 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 ft. 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. so who looks at those numbers? is that just a regional, statewide, or just that specific hospital looks at those skyrocketing numbers and at some place, who makes the assessment of are we paying for two facilities or are we paying for one? >> so, part of the challenge we have is that based on the volume in some of our facilities, we cannot support an icu, not because we can't afford it, because we don't have the patient volume to maintain competence. so there's a balance. and oftentimes it's felt that because of the volume and because of the competence, it's better to send these patients into the private sector. i understand your concern and we do need to look at where our costs are going and how we're using our facilities. >> we do need to look at or is somebody actively looking at this now that all this information is coming to us from the inspector general?

is somebody ongoing looking at that to see this cost benefit analysis of are we paying for two systems or is that something you're going to look at in the future? >> i don't know whether we have an active exercise in place. we do need to have one moving forward. >> i just got a note from a constituent that says there must be some kind of a cnn program on tonight and that there's a new revelation, it says records of dead veterans were changed or physically altered, some even in recent weeks, to hide how many people died while waiting for care at the phoenix va hospital. a whistleblower told cnn in stunning revelations that point to a new cover-up in the ongoing va scandal. deceased, quote/unquote, notes on files were removed to make statistics look better so veterans could not have to be counted as having died while waiting for care and the quote is from pauline de winter. you've been to the phoenix facility four times. are you aware of this new

revelation? >> i'm not aware of the revelation. i'm aware that the oig is looking at all the deaths that occurred. i don't know of any attempts to hide deaths. >> i guess my follow-up question to this because i am guessing this will be big news in the morning or tonight when our constituents are all watching the late news. again, it's so hard, i guess to echo the comments on this committee, it's so hard to take the information seriously you give us tonight when there are ongoing investigations by new whistleblowers that they're taking stickers all files, removing names. still while we've been doing this, these hearings for a couple months and meres a ameri literally wondering when is this going to stop? this looks like a new revelation tonight. under all the scrutiny, all the lights, all the spirit of full disclosure, phoenix is still doing this kind of stuff and you guys have had them under a microscope and physically been there four times and this is new? >> congresswoman, i don't know the details of the accusation. >> could you provide that to us -- i think the details are

out. can you provide us the va answer to that in a timely manner? i will certainly try. as i understand it. >> thank you, mr. chairman. i yield back my time. >> mr. o'rourke, five minutes. >> thank you, mr. chairman. dr. lynch, you mentioned earlier that $312 million has been made available to accelerate access to care for veterans who have been unable to receive it thus far. where did that money come from? >> the money was recovered from funds that were not being used across va. i believe that there was some activation moneys that was repurposed to cover the accelerated care initiative. >> what are activation moneys? >> activation moneys are sometimes moneys used for new projects. i don't know the details but i would assume that it was felt that the moneys were not absolutely necessary at this time and could be repurposed to

address the immediate concern which was the provision of timely care to veterans. >> and will you or the va be coming back to congress to recover those moneys after we get through this crisis? >> i don't think that's our intention, congressman. >> okay. >> i think our immediate attention is to provide timely access to care and at the moment, we're trying to use the funds that we have. >> what i'm trying to get at and i agree with you that that should be our focus, and i appreciate dr. clancy saying that earlier. that the number one priority is to connect veterans who need care to the providers who can give it to them, but i do want to get to the chairman's question and one my colleague miss kuster brought up, which is what will you likely be asking for from congress? i think this is a time where the american people and their representatives here would be very open to a request from the va to say, to get to the level of care that we have promised to our veterans, we need "x." you know, you say that you have

provided $312 million. is there more to be found among those funds from which you've taken so far? will there be more needed in the coming days? i mean, we're really only weeks out from the revelations and as miss wolarski pointed out and others, myself included in our districts, we're still finding new gaps in shortfalls that need to be met, so i'm thinking -- you may not have a number in mind, but wouldn't you say that you're likely going to come back to congress to request additional funds? >> i can't answer that question right now. i can tell you that we are beginning to look at the resources, particularly personnel resources that we need to increase our capacity and we'll be working with the congress to develop a proposal that would allow us to hire more personnel to provide that care. i know that we're looking

carefully at the money we're spending on fee basis services. we have been able to find some central money to send those patients out. facilities and networks have also been able to identify moneys as well. it's anticipated that we will probably increase va funding on fee basis care from about $4.8 billion to about $5.4 billion this year. >> and i'd also ask you to, and you essentially committed to this earlier in previous answers but pay special attention to the providers that we have within the va system today and retaining them there. when i met with providers in el paso a couple months ago, morale could not have been lower, and a lot of it had to do with the amount they were being paid seeing so many of their colleagues leave service within the va to work with d.o.d. which paid more, to work in the

private sector which paid more. in some cases they were single parents, nurses, nurse practitioners, providers of all kinds. i've just got to think that as you're repurposing these funds and perhaps asking more from congress, i think it's really important we ensure we are attracting the absolute best within the va smg, that we're able to retain them. one primary health provider told of prescribing for mental health patients and seeing the mental health caseload coming in there which he said he didn't feel good about at all. he said this is not right but i'm not going to let that person go untreated even though i wasn't trained to treat somebody for these kind of problems. that raises a number of questions and issues in itself, but it gets back to this issue of resources for providers. i have a number of other questions specific to el paso, but we'll continue to reach out to you in between these hearings and at these hearings to follow up when we don't get an answer. i appreciate your responsiveness so far. i do ask dr. clancy and

dr. lynch and the leadership as we get through the this immediate crisis, if we lose this opportunity to address the real systemic structural cultural problems within the va, you know, i think that we will be right back here again in another couple years, five years, ten years, having this very same discussion. so while addressing care and connecting veterans to care is important, let's make sure we don't stop there. we need to address the l cultur the operations in the system. anyhow, i thank you for your answers and your work on this. i yield back. >> thank you very much, mr. jolley, you're recognized for five minutes. >> thank you, mr. chairman. dr. lynch, i want to give credit where it's due. i recently hosted in my congressional district what i called a va intake day. invited the community to come in and talk about their care, their

complement at both bay pines and haley. we had about 300 people come in and i will tell you we had a lot of people come in simply to defend the va health care that they receive. the other thing i want to compliment you on is the secretary gibson said several weeks ago the department was in the process of contacting 90,000 people who were on a waiting list. i actually heard from people by phone. one of them was told your dermatology appointment is four months away, and if you'd like, we can move that up and fee you out. so i want to compliment the department for that yourself, the secretary, as well. i'll also tell you just as a matter i've metric, we gave a questionnaire to folks. for those of the 200 that filled out surveys, of those who had sought to go outside the system for non va care, fully 50% rated that experience in trying to get the va to fee them out as either poor or very poor. expressing a lot of the frustrations with the ability to get outside the system. it was a self-selected group. i recognize that. those were some quick metrics we got. mr. o'rourke mentioned mental

health and behavioral health and over memorial day i was approached by a mom whose son committed suicide while he was waiting for mental health services. the fy '14 melcon va bill directed the department to competitively contract with non va providers in certain communities where there was a need for additional mental and behavioral health capacity as well as where there was also a non va infrastructure that could absolutely provide that. are you aware of that direction and can you update us on whether or not that has been pursued or is in the process of being implemented? >> i know that the va has been actively working with the community. they have been holding almost on a yearly basis mental health care summits to inform the community of opportunities to participate in the care of veterans. so i think we are moving aggressively to involve the community where they are

available in the care of veterans if it's necessary. >> i understand that reflects a spirit. but the department was directed by the congress, congress determines the budget. congress makes directions when it comes to how that money is to be spent. and in the '14 bill, congress directed the department. didn't ask. directed the department to have a demonstration project to competitively contract out in certain communities at the choosing of the va mental and behavioral health non va care to do a demonstration project to relieve capacity in certain areas. i guess particularly given the position you have, are you aware of that in the '14 budget? >> yes, i am aware of that. >> and has anything been done to implement that? >> yes, it has. >> what has been done? >> we have developed demonstration projects i believe at five or six of our facilities

to involve the community in veteran care. and we are evaluating the results. that is in process, yes. >> okay. i would very parochially tell you how wonderful the bay pines and haley system is and the fact that stone claw season starts in october and we have the best beaches in the world. to the extent that tampa fits that profile and pinellas county profile, i would encourage you to look at it. two last questions. one, for non va care, right now, those who ask to go outside, i understand that folks who need a specialty care service that's not available from within the va are likely the most candidates. what about for the va patients who simply aren't satisfied with the quality of care and ask to see a different primary physician outside the system? is that ever accommodated through non va care? >> i think the va would attempt to find the patient another provider within va if he was unsatisfied with his current

provider. >> is there any -- and i understand there's some statutory guidance, any feasibility of going outside of the va? >> in rare instances, if the patient is very unhappy, and i'm speaking from personal experience, as chief of staff, i had authorized patients to receive care outside the va. >> okay. and my last question, we just shared the story that's breaking. i know it's breaking. haven't had an opportunity to review it. i do have a very specific question. the ig talked about criminal investigations or investigating allegations that rose to criminal level. we've had several hearings thus far. were you, dr. lynch, personally aware that this was a matter being investigated that the word deceased or the label deceased had been or was being removed from files? did you have actual awareness of that, that that was being investigated? >> this is the first i've heard

of it. >> so you weren't aware it was being investigated? >> no, i was not. >> okay. thank you very much. i appreciate it. yield back. >> miss titus, you're recognized for five minutes. >> thank you, mr. chairman. i'd like to go back to a point that miss custer was making at the end of her comments. we're talking about evaluating the capacity of the va to care for veteran patients. i want to look specifically at the va's capacity to serve our female veterans. they're often referred to as the hidden veterans or the silent veterans because they're less likely to seek service because it's not very accommodating and the statistics that have just come out in "ap" story certainly show that. with regard to capacity, last year the va served 390,000 female vets and yet a quarter of the vv hospitals do not have a full-time gynecologist on staff. a quarter. with regard to quality, half of the women veterans received medication through the va health

care system that could cause birth defects. despite the fact that many are of childbearing age and the majority were not on contraception. this is much higher than would occur in the private practice. with regard to care coordination, the va oig says 50% of female veterans at community clinics didn't receive the results of their normal breast cancer exam within the required two weeks which is your own policy and even more disturbingly, 45% of those results never made it into the electronic health records data system. i mean, i find this these statistics are as bad if not worse than some of the others that we've been talking about just generally speaking. and they indicate that the issues of access to quality care and proper coordination of care may be even worse for our female veterans than they are for the general population. now, i understand you have some plan to ensure that there's a

designated female provider, women's provider in each facility. so i'd like to ask you, what's timeline for achieving that goal? when are you going to start doing train on va providers like health care concerns like drugs that can cause birth defects, and what is your plan for looking at the female population? because that's a group of veterans that is going to increase in number. >> you're absolutely right, congresswoman. i thank you for your questions. we were concerned by some of the findings reported in the story, as well. about 80% of our facilities do have a designated women's health provider. and in some of the other facilities there's been a challenge identifying someone to do that. so we are looking into training some existing staff, for example, some of the current primary care clinicians to be able to meet that role. i should point out, this is not something that we just came up with on the spur of the moment

for women. i mean, this is an area where we've had other similar sorts of training of experience training people with specialized expertise, for example, when there's a particular problem that's much more common in one facility. we figured out how to bring specialist expertise to the primary care facility. we're going to be trying to do the same thing so that we can get up to 100% as soon as possible. the issue on mammograms as i understand it in terms of the timely followup, particularly for abnormal findings, has been the focus of some substantial improvement efforts, and we can get you more details on that. the other thing i would just point out in terms of women's held is that obviously women have issues that relate to their unique needs and issues as women as well as all the other stuff that human beings get, whether that's heart disease, lung disease, and so forth.

vha is the only system in this country that actually routinely reports publicly and transparently about how we do for women and men. that is not true for any other payers in this country. in fact, the disparities are minimal to nonexistent between the care provider to women and men. i'm talking mainstream heart disease and so forth. the issue of gynecological care is one that has improved quite substantially but clearly we have more room to go. >> i think that's accurate. i'm glad it's been improving but a recent opinion by the american college of ob-gyns says there's an urgent need to continue training providers in this area, and you mentioned that you've done some work with the reporting back especially of abnormal results. and it says that they are typically informed within three days and typically is in

quotation marks. said that you don't really show how widely the improvements have been adopted or what specific progress has been made in this area. it's kind of hit or miss like so many of the things that we've been hearing about. so i am concerned that you are just going to train primary caregivers to be experts on women's health. maybe that's an interim measure, but it's certainly not the same as having somebody who is qualified in that field. and, again, i go back to these clinics that exist, say, in rural nevada where it's very hard to find somebody who's an expert or even in our urban centers like las vegas where we lack providers, and this is something we need to address. even if you send them out into the community and then you don't track their results out in the private sector or if you send them out and there are no

providers in the private sectors, we've really traded the devil for the witch. we haven't solved the problem. >> i very much appreciate that, congresswoman. i want to be clear about one thing. i wasn't suggesting we would send primary care providers to camp for three weeks and then they would be ob-gyns by any stretch of the imagination. this was more to serve in the coordinating role and be able to provide basic services but also to make sure that people got the services that they needed in a timely fashion. and i would just say that our top consultants in women's health, urgency would be her middle name, but i'd be happy to get back with you about the mammography issue specifically. >> thank you. >> i yield back. >> mr. roe? you're recognized for five minutes. >> i thank the chairman. i'm glad it's not three weeks, it took me 30 years of experience to get to the ob-gyn camp. i'm glad to hear you can't do it in three weeks.

we want to as a group here and i think you hear from both sides of the aisle, to be able to go from good to great. to be able to do that though, we have to have information that's accurate and timely. and i looked at the memo today we were sent on the rvus. i know this is not a big thing, but i think it's a symptom of what goes on in the va. if you look at a law that was passed in 19 -- in 2002. it appears to me when you look at the evaluation that they did at the five medical centers in boston, houston, indianapolis, philadelphia, and looked at the staffing levels we're talking about for specialty care services, it's taken 12 years and we still don't know what they are. i mean, this is law was passed in 2002. and it's 2014 and we're still talking about we don't know what our staffing needs are. well, that's not a complicated. i can tell you having spent 30 years doing what i did, it's not

hard to figure out what your staffing needs are. if you can't get somebody in to see a cardiologist, you need a cardiologist. you don't need another study or anything to figure that out. i don't understand, again, the accountability when this didn't happen for 12 years and then last week, last friday, we found out that 80% of the people in senior levels at the va got rewarded for doing a great job. and yet, we completely ignored this metric. it doesn't appear that there's any penalty whatsoever for not following the law. am i wrong? why wasn't this done? >> congress man, i can't speak to what happened before i got here. i can speak to the fact that following the ig report, that was taken -- the recommendations were taken seriously. we are a year ahead of time in meeting those recommendations. by the end of this year, we will have productive standards for all specialties in va.

and we will be able to use those moving forward to make decisions about where we need to supplement support for physicians or to provide additional physicians. >> let me just ask the question again. is there any accountability at all? i mean, because, this 12 years went by. this information should have been available to you all where you could use it to help prevent what just happened. so, anyway, i want to also go on to a couple of other things. mr. o'rourke brought up. i totally agree with this. is that really, there are two issues at stake. the backlog is not going to be a big deal. we can fix that one very quickly i think. and today, i got a call from memphis, tennessee, a physician down there put together in three days with the university of tennessee system, with the methodist hospital, they'll see any veteran, primary care or specialty claire, including oncology, in 72 hours. they can do that. our group can do that. it can be done across the country. so the backlog is very simple to solve. a much more difficult decision

is the culture of the va where we go 12 years, we don't follow what the law is. where we reward people at senior levels for doing i don't know what. maybe some of them did a really good job but others clearly did not because we see the failings right now. let me just give you an example, a brief example. i went to my eye doctor today right here in the washington. i had a little retina problem. the doctor said he had been trying to get the va here, a retina specialist to help out. had a patient who was supposed to see a doctor in january this year with a retina problem at the va. it snowed that day. the doctor couldn't get in. so they made the next appointment in june, that's this month. well, when the guy finally saw him at the va, they rushed him over to the retina specialist because he had an attached retina. for five months he didn't get treated. we had another call today, this physician i talked to in memphis had a fellow to took eight months to get to an oncologist

outside the va. recommended a biopsy. that took four months. the man has cancer. they probably can't treat now. that's not -- we cannot have a system that treats our veterans this way. and we have a system out there, a private physicians who want to help. they want their veterans like me and dr. winstrop and others. this young man here -- i should show you this when we get through today, dr. lynch. i want you to see this because they want to help. i think they're there to help. i think their intentions are right. i think your intentions are right. i truly believe that you want to make things better for veterans. we do have the second one. the first one, the backlog, we can take care of that. i have no doubt in a year we can get that. six months we can get that fixed. that second one, the culture in the va is going to be much, much harder and take hard work and honesty and transparency from the va senior people so we can help you go from good to great.

i yield back, mr. chairman. >> thank you very much, doctor. mr. michaud? >> thank you. when you consider the costs as far as putting out services to the va, do you also consider the savings, i.e. we heard from chris doughty in charge of the arts program. actually we're able to save the va about $600,000 during that pilot program for mileage. so do you consider the cost savings, as well or just the cost comparatively? >> i think when we look at how we manage excess -- excess demand, we need to determine whether we can provide that service more economically within the va or whether it's better for us to buy that in the community. i think that's an important decision. we do know the community costs. we can calculate. we do have the information to determine what it would cost us to hire those physicians and to

provide care in the va. i think if we can do it more economically, and at less cost in the community, then that would be an appropriate thing to do. >> yeah, but considering all the factors, it might cost "x" within the va for a certain specialty care. might seem costs more outside that same specialty care, but when you look at the savings with imburstment, it's more cost efficient to do it outside versus inside. so do you look at the whole cost? >> yes, sir, i think we do, and we will. >> okay. my second question is, of the three key elements of capacity, supply for clinical providers, amount of services providers can deliver, modern i.t. infrastructure. of these three, which one poses the greatest challenges to the va? >> i would say based on our aging infrastructure, our greatest challenges are providing the physicians

adequate space to see patients, and giving them the support they need to see patients efficiently. it's hard to separate. i think i.t. is a challenge as wells but i think we to have an electronic medical record. it's not a perfect record. it's in the process of evolution and improvement. but i think our greatest challenge is our support for our physicians and the space for them to provide care in an efficient fashion. >> okay. and my last question is, when you look at the wait list, i know some facilities have automated system where they call in, it's automated depending on how long it takes them to get through the menu, they might hang up. say the heck with it, they're not going to bother. are they counted into that wait list? and if so, how can you track them? >> people call into the va for a number of reasons. so it's going to be difficult to know what they're calling in for. we do measure, however, abandonment rates and do measure

a time to answer our telephone system. we're working to improve those so that that won't be a problem. >> thank you, mr. chairman. >> dr. wenstrup? >> mr. takano. yes, sir. >> so i'm a little confused by interoperability of records. can you help me explain about there is no interoperability? >> well, this is a case where you're both right. the second stage of the so-called meaningful use, this is the series of stepped incentives, right, that cms has put in place, incentivizing private sector providers to adopt electronic health records and the like. not just to buy the stuff but to actually use it in such a way as to improve quality of care. that second stage of meaningful use actually requires the providers be able to share some information with other

providers. so you're right that meaningful use is actually a path to getting us to a place where we can share all the information. i think it's fair to say that many providers are finding this challenging. so the doctor is also correct when he says give me a break, because if you're thinking about actually just uploading all information from one to another, that's actually much, much steeper and likely a bit far off, but i think your original assertion that, in fact, the incentives put in place by the high-tech act are are setting us in the right direction and i wanted to make the point that vha is complying with all of those. >> my understanding having spoken to some physicians who do work at va hospitals that they do appreciate the vista medical record. quote, and i'm quoting him, the information is all there. and it seems common sense to me that if the records are integrated, that that enhances the integrated care within the system.

so within the va system, doctors can -- >> absolutely. >> -- pass this information around. >> yes. >> and so the concern that was raced in many hearings was the lack of interoperability with d.o.d. and their medical record system and the billions of dollars that we've not been able to spend in a way that we have interoperability. if you listen to situations and cases where service members and veterans, their health care was greatly compromised. and so i've been listening in these hearings and understanding that the challenge with being able to move into opening greater opportunities for our veterans to use access non va care is this interoperability challenge. but, so that's why i was raising

the question. so it would seem to me that if we want to move more in this direction that we're going to have to encourage private physicians and care groups to be able to communicate with the va's record system. >> yes, and so i think your other question or statement was that if this were written into the pc3 contracts, that providers who had met the meaningful use requirements and so forth would get preference or to the extent that they could contract with such providers that would be a good thing. in terms of coordinating care is a very fabulous idea. so we'll take that back as well. >> thank you. i yield back. >> mr. brownly? miss titus? mr. jolly? >> sure. mr. chairman, i just have a very quick follow-up. dr. lynch, i want to go back to the fy 149 appropriations question i asked you for a point of clarity. i understand you mentioned the

va is in the process of working with outside providers. is that just a general statement or are you suggesting that the demonstration project congressionally directed in the fy '14 budget is currently being implemented. >> it is being implemented, congressman. can i get you information on the sites where that is being provided at this time? >> yeah, you certainly could. there are about six or seven of us that wrote a letter to the secretary on may 7th asking for an update on the implementation. i know you've got a lot of letters coming your way right now, but it is a matter of concern because it was done with such specificity. even the criteria were put in the congressional report as to how the centers were to be evaluated. so i just want to make sure we're talking apples and apples here that this is the fy '14 -- >> let me work with our office of mental health operations. >> that would be great. >> get you the information that you need and make sure that we are talking ands and apples. >> sure. i'll leave a copy of the letter. it was may 7th.

there were seven of us who signed it. i'll put it in your hand tonight. appreciate a response. thank you very much. >> miss kirkpatrick, you're recognized for five system within the vha, something like a hotline that a veteran can call and someone gets back to them about their complaint? >> dr. clancy, do you want to take that? >> yes, every facility has a patient advocate. they get complaints, they get all kinds of calls and that is actually tracked in terms of time to resolution and so forth. all of the pitch epatient advocates come under patient cultural transformation. we have begun working with them how can we learn more from what they're hearing because we're noticing that a number of private sector organizations are

taking to heart how important and useful it can be to learn from the patient themselves. >> is that looked at nationally, nationwide? it doesn't just stay at the local facility? >> yes. there is a national database. >> then my second question is, are you consulting with the vsos on how to engage innovation in the system when it comes to scheduling these appointments? >> we have not been communicating with the vsos. i think we certainly have been looking at ways that the vsos can help us understand how the veterans are perceiving our care and the timeliness of that care. i think there's a huge opportunity there. >> i agree. and, you know, chairman miller, i think it might be good to have a hearing where we hear from the vsos about their suggestions about how to fix this problem. i yield back. thank you so much. >> thank you very much, miss kirkpatrick. we have one hearing that will be

coming up in several weeks that will be specifically geared towards the vso and it's at that particular hearing that we will invite the secretary to be here to hear their recommendations as well. dr. reese? >> miss custer? >> joe o'rourke? anybody else? mr. wells. sorry. you're recognized. five minutes. >> thank you, mr. chairman. thank you both for being here and listening to the testimony. i appreciate where you're at. i sat here almost in the exact same seat for 7 1/2 years. just like you with the vsos and the va as partners and advocates to get this right for veterans, but i'm going to come back to -- and i oftentimes in those years preface it that i'm your staunchest supporter but i'll be your harshest critic when it needs to be. dr. clancy, mr. owe rushing,'rot it up. this is the time to think fundamental change. this is the time to think big.

i found it interesting that you focused, dr. clancy, on the triage which of course needs to be done with these veterans right now and called what we have done a second order question. i would argue had you done that before we would never have had phoenix. are you both clinically credentialed? >> i'm not currently -- well, not clinically credentialed at this time. >> can you see patients? >> i cannot see patients, no. >> dr. clancy? >> i haven't. i haven't for a number of years. i've actually looked into what would be required -- >> but you're both doctors? >> yes. >> and we don't have enough doctors. so i'm going to say what vietnam veterans of america made this suggestion to you and you said -- and the question was asked, do you have a contract with them. this is what they said you needed to do to fix this in phoenix. all vsh staff need to see patients four days a week. get out of the administrator's office and go see patients. if you're serious about this triage, i would think you would

be turning over every stone to find a physician who's already in the system. the reason i'm bringing this up. it may not seem like a fair question, but the ability to call fundamental cultural change a second question, we'll get to it. you can multi-task. get that done. that is of course a priority but not addressing this we're going to come back here again. and that is more of a statement. and believe me, it pains me that we're at this point. it pains me of all the good work we do gets erased by this but it once again confirms to me this is cultural, it's leadership, it's structural and it runs deep. i yield back. >> thank you very much, mr. walz. following up with your line of questioning. how many physicians are there in the system who don't see patients that are in administrative roles? >> i don't know, mr. chairman. >> would you find that out for us? >> yes, sir. >> thank you very much. and in your -- in your testimony you mentioned that -- or in

answer to a question that somebody had about how much money was being spent to help solve the backlog problem, i think the number you used was about $312 million being made available for your access initiative, you mentioned the funds were centrally located. can you give me an idea wr the funds were supposed to be spent? >> i will get that information for you. >> is the $312 million part of the planned $450 million carryover that the department had already budgeted for 2015? >> i can't answer that, mr. chairman. i will get the information for you. >> i can answer it. >> it is. >> it is. and i guess the big question is, almost half a become dollars cisi city -- a billion dollars sitting in the bank. why do we have a back log the size of the one we've got? how did we get here? i mean, i don't think anybody

even to this day knows how the culture became so corrupt that people would falsify records and in some cases i believe criminally, that we would cause veterans to wait months and years, that we would -- and, look, that's $500 million for carryover this year. we've had a couple of years just recently that have been a billion dollars carried over. and i don't think the public understands. people are running around saying more money, more people. more money, more people. $500 million sitting there that could have solved this and nobody within the central office or the department was blowing the whistle saying we needed to spend that. it's almost as if they were trying to keep it for a nest egg for next year because if you carry it over, then it goes into the base budget. and we've got to fund it again.

and that's how the bureaucracy grows. so with that, thank you so much for being here. we appreciate both of you. members, thank you for attending. this hearing is adjourned. today is primary day in five states. utah, colorado, oklahoma, new york, and maryland. in addition, there are runoff elections in south carolina and mississippi wherein couple bent thad cochran is up against chris mcdaniels. there's a replacement for trey radel who resigned. we'll have concession speech from the mississippi race. that, plus analysis from reporters and your calls, tweets, and facebook comments all tonight on cspan 2. what i have right here is a partially processed plant that i've cut down into sections that

are the right lengths for hanging, and then i took off all the big families, and those are sent to the kitchen to make edibles. they have a small amount. they get that for a really good price from us. then these little leaves here, that can be dried and made into joints or it can be sent to the places that make extractions and made into hash and that sort of thing. and then wyatt here we have the finished bud, and this is sent over to cure and hang to dry and then cured in buckets for a couple of weeks before they sell it in the dispen sari. >> washington journal looks at the recreational use and sale of legal marijuana from colorado with guests from denver and your phone calls. live friday morning from 7:00 to 10:00 eastern on cspan. the white house held a summit looking at some of the challenges families face in the workplace. we'll hear from white house advisor valerie jarrett, labor secretary thomas perez and vice

president joe biden. pleats welcome senior advisor to the president, valerie jarrett. u.s. secretary of labor, thomas e. perez. and the president for the center for american progress, mir mira tanden. >> well, good morning. good morning, everybody. good morning. let's hear from you. i can't believe you are here. i'm delighted to be here with my co-host, tom, who you will hear from soon. welcome to the first ever white

house summit on working families. so the president's goals are simple. he wants to make sure that every hard-working american gets a chance to get ahead and he also wants to make sure that our 21st century workplace reflects the needs of those 21st century families. and as we know, the demographics have changed over the decade. now we know that women make up nearly half of the work force. 40 -- yes, indeed. you can clap whenever you want. 40% of moms are either single bread makers or the sole primary bread winner for the family. that's a major change in our demographic. the majority of our children live in families where both parents work and so what we need to do is to make sure that our workplace changes both in policy and in culture to reflect those changes. isn't that right?