his proposal for reforming the federal budget process. the veterans' affairs undersecretary for health testified at a house hearing today about his department's efforts to improve veterans' access to health care and reduce wait times. congressman jeff miller chairs the committee. thiss just over two hours. hearing will come to order. would you like to welcome everyone to today's hearing entitled, a continued assessment of delays in veterans access to health care. this hearing marks two years since this committee exposed the

wait time scandal that has gripped the department since 2014. i'm proud of the work that we have done in those two years, particularly digging into the actions of bureaucrats who -- whose self-interest were put ahead with the veterans they were charged with assisting. the purpose of this hearing is to examine the efforts that va has taken to improve access to care for veterans and to identify where serious issues still exist. based on the bipartisan work of this committee, gao has undertaken an audit of new patient primary care wait times at six facilities across the veteran health administration. gao's review found that veterans at those facilities waited between 22 and 71 days, which is significantly more than the

five-day average that secretary mcdonald has declared to this committee earlier this month. now this discrepancy can probably be easily explained. first v.a. only tracks and monitors a portion of a veteran's actual wait time when tracking access data. instead of considering a veteran's wait time to be from the date when the veteran first contacts v.a., to requesting an appointment to win the appointment -- when the appointment takes place, v.a. considers a veteran's wait time to be from the date when the veteran wants an appointment and the date when the appointment actually occurs. this is problematic because it doesn't take into account the following -- it doesn't take into account the time it takes for the v.a. scheduler to contact the veteran to schedule the appointment. the fact that it is a regular practice for schedulers to negotiate a desired date with a veteran, or the fact that

outright manipulation of desired dates to zero out-wait times is still the most prevalent type of data money ip legislation that occurs in the department today. v.a. continues to ignore the main forms ever data money ip legislation and continues to come to congress and to this committee saying there is no data manipulation. to this point, you will not find what you do not seek. the obvious result of v.a. reporting only a portion of a veteran's actual wait time is artificially low results. i still don't understand how a culture could persist in presenting inaccurate data to this committee. or more importantly to the veterans of this country. a true picture of wait times or more importantly the veteran experience, the secretary speaks about quite frequently, can help

us ensure an adequate allocation of the resources we were asked to provide. but when this committee only hears request for more man power and more space and more flexibility, it is hard to reconcile the additional resources with the reported wait time of only five days. this discrepancy between reality and v.a. claims was captured by gao in its report where v.a. data shows that wait times were, at best, underestimated by two and a half times, and at worst 11 times the full wait time that the veteran experienced. another tactic that v.a. uses to make its wait time appear lower is to combine shorter wait times for the large pool of established patients with the longer wait times of the smaller pool of new patients.

this dilutes the wait-time data making new patients time appear shorter because they have been comingled with the other cohort. for years they have blamed long wait times on training issues, largely because it was warned about those issues as far back as 2005 when the inspector general's office published a report highlighting the improper scheduling practices and poor training process. many oig and goov gao reports since that time have found that the same scheduling problems continue to exist. yet, in the 11 years since v.a. continues to blame wait time manipulation on the very same cause, a control over which v.a. has complete control, secretary mcdonald has repeatedly ask that we allow him to run v.a. like a business. but i can assure you, if an

executive running a company used the same excuse to explain away 11 years of problems in a row with no change to show for it, that individual would be out of a job. but not at v.a. despite years of reports of confirming systemic issues, the department has successfully fired just four people for wait-time manipulation, while letting the bulk of those behind its nationwide delays and care scandal off with no discipline or very weak slaps on the wrist. another issue regarding accountability is how v.a. continues to ignore retaliation against the whistleblowers that we have relied on for some of the information that our committee has acted on. the committee has asked v.a. for all adverse actions where an employee was disciplined for retaliation against a whistleblower. v.a. provided our committee a list showing as of march 15th of

2016, only six individuals were disciplined for whistleblower retaliation. looking deeper, one of the list of employees is sharon hellman, who the committee has already shown was not successfully disciplined for whistleblower retaliation and was in fact successfully disciplined for failing to report accepting gifts. two of the other disciplined employees were listed as housekeeping aide supervisors. who are clearly not high-level supervisors. that leaves three employees to receive reprimand and one receives less than a 14-day suspension. to be clear, according to v.a., provided documentation, no employee has been removed for whistleblower retaliation. this is represented with the fact that contrary to public

statements by v.a. sunshine yore officials whistleblower retaliation appears to be tolerated within the department. so now, two years after what was and is a systemic crisis in care being brought to light, it is time for v.a. to stop using misleading data to tout wait time successes that supply did not show the real wait time experienced by our veterans. i want to hear what concrete actions have been taken, what fundamental changes have been made, and what tangible, cultural shifts are occurring within the department. advertising artificially lowered numbers does nothing to stimulate the change that is needed to improve veterans' access to care. and with that, i yield to the ranking member, miss brown, for any opening remarks that she may have. >> thank you, mr. chairman, for calling this hearing today.

following the wait time scandal of phoenix, congress passed and president obama signed the veterans access choice and accountability act of 2014. in it, we mandated that there be an independent assessment of veterans' health care. the assessment highlighted many of the things we hear from our veterans. we hear that v.a. provides excellent health care, especially health care related to the special needs of our veterans. we also hear that in certain areas, the v.a. is at the forefront of health care in this country. we also hear from our veterans that v.a. care is often fragmented and that it can be difficult to navigate and arrange non-v.a. care. we hear of long wait times and limited access. following the assessment in the surface, transportation and

veterans choice health care improvement act of 2015 we mandated a report by the v.a. reporting a plan for how v.a. could consolidate all purchase care programs into one new veterans' choice program. we received that report last year and this committee is currently working with the v.a. on the best way to implement the legislative requests. the v.a. is on track to see -- listen to this -- 6, 27360 unite patients and 9,428,000 unique enrollment in fiscal 2015. the v.a. completed 56.7 million appointments, nearly 2 million more than fiscal 2014. that is roughly 226 appoiments

per day. let me repeat that. that is 226,000 appointments per day. the number of patients that the v.a. sees would put any other health care system to shame. i am pleased that the gao study newly enrollment veterans in their access to primary care in my conversations with veterans time and time again, they said once you get into the v.a. system, the care is the best in the world. let me repeat that. once you get into the system, the care is the best in the world. it is this initial appointment that is so hard to get. i am troubled by the gao finding that nearly half was unable to access primary care because v.a. medical center staff did not schedule appointments for these veterans in a quick time frame.

the gao report goes on to say that veterans access to primary care is hindered in part by data weaknesses and by the lack of a comprehensive scheduling policy. we are at a tipping point right now as to what the v.a. would look like and the services it would provide for veterans in the coming decade. i look forward to hearing from witnesses today as to what this aspect of the v.a. would look like in the future. with that, mr. chairman, i yield back the balance of my time. >> thank you very much, ms. brown. as accustomed with this committee, i would ask that all members waive their opening statement to allow me the opportunity to introduce the witnesses at the table today. from v.a., we're going to hear from dr. david shullky and the department of health and veterans' affairs and accompanied by dr. lynch. assistant deputy under health and clinical operations from the

office of in spector general, we have mr. larry rink meyer, director of oig kansas city office of audits and evaluation and accompanied by gary abe acting assistant inspector. and finally we'll hear from deborah draper, director of the health care team at the government accountability office and i would ask if all of the witnesses would please stand so we can swear you in. raise your right hand. do you solemnly swear under penalty of perjury that the testimony you are about to provide is the truth, the whole truth and nothing but the truth? thank you, please be seated. let the record reflect that all witnesses did answer in the affirmative. dr. shullki, you are recognized for your opening statement of five minutes. >> good morning, ranking member brown and members of the committee and chairman, i'm accompanied by dr. thomas lynch, the assistant deposit undersecretary for operations and behind me the senior adviser

to the undersecretary. arrived at v.a. nine months ago and i understood when i came here this axis crisis was a priority and the status quote wasn't acceptable. it is not my objective to say we fixed all of the problems or don't have issues, but we are focused on this. this is my number one priority. this is v.a. number one priority and we're going to stick at this until we get this problem resolved. the first thing when i arrived as the undersecretary was to assess the data on wait times. there were file cabinets full of reports and bookshelves filled with data and i have to tell you, i made it through medical school okay, but i had a really hard time understanding all of this data. very, very confusing. what i didn't see was the ability to clinically prioritize which veterans needed care the first. and i didn't know how to run a health care system unless i understood that you need to see the patients that were as sick the first.

so that is the first thing we did. we changed it to clinically prioritize the veterans and that led to two stand-downs where we opened up every medical center around the country and saw those veterans that needed the care that day, on the day of the stand-down. and that led to real significant sustainable improvement. we had 57,000 urgent consults in what we call level one at the first stand-down. today it is a 77% reduction. there are 12,000 urgent level-one consults. on our second stand down, we addressed 81,000 urgent appointments and we got 93% of those gone through and resolved. this month, we're launching what we call our declaration of in depen dependence, which is the declaration of access which are nine core principles that will redesign the way we provide access to veterans. they include pretty bold moves like same-day access in primary care and same-day access in

mental health. now i will tell you, these are aspirational goals to be done by the end of 2016. but i've never been part of a change effort that started with low expectations. and i'm confident we can get these bold goals done because today we have 34 medical centers in the v.a. system that are currently doing same-day access and primary care. so we can do this, we have to spread the best practices throughout the system. we also have to make the wait times more understandable, mr. chairman, as you said. very, very difficult to understand. and i will tell you that i am -- my academic studies -- i teach my students there are bad systems and not bad people and so i said we have to change our system. and when we identify bad people in the v.a. and people lost their ways, not holding our values, we have held them accountable. we have held 29 individuals

accountable for disciplined actions, and as the chairman said four have been fired. we trained 32,067 schedules and had audited the schedulers. the joint commission has been invited and visited every one of the medical facilities. we have a new training program for scheduled to launch this spring beginning in may. but our measurement system is too complex and where i want to move this to is the veteran experience. asking veterans, are they satisfied with access. and in fact, in every medical center today we have a system called vet link. you come in and go to a kiosk and are asked whether you are satisfied with the access to care. 89% of veterans today are satisfied with the access to care throughout v.a. and i have all of your vid-- yo individual data by the way. but we have to do better. we hired 5700 new employees and

a 10% added, and 2200 square-feet of added space and a new schedule system rolled out called vse, a new veterans application that they could schedule themselves. we've allowed direct scheduling in some areas. we have group practice managers now over all of the medical centers. we are sharing best practices and access across the entire system and as you know we are working much closer than ever to our community partners to provide care. 57 million appointments last year as the ranking member said. 1.6 million more visits last year than the year before. 96% scheduled within 30 days. we're processing claims faster than ever before. 25% increase in claims process last month. we're looking forward to the comments by the gao and the ig. i have to tell you, we are not afraid of criticism. we welcome it. we want this type of transparency. in conclusion, i want to tell you, the v.a. is making sweeping changes. we are making progress. but there is significant work

that lies ahead. that is what i'm here to do. but recall, as the ranking member said, the v.a. provides excellent care every day. in fact, this year alone four peer reviewed studies showing we are equal or superior to what is happening in the private sector. we appreciate the support of you on this committee and look forward to answering any questions. thank you, mr. chairman. >> and doctor you are now recognized for five minutes. >> mr. chairman and members of the subcommittee, thank you for this opportunity to discuss the recent reports that we have issued that have addressed various obstacles to veterans receiving timely access to health care. as you mentioned, i am accompanied by mr. gary abe, the deputy assistant auditor for inspector and evaluations. two years ago, timely access to care became an even larger national focus. in 2014, we published two reports detailing the serious conditions that existed at the phoenix health care system and

provided v.a. leadership with recommends for immediate implementation. these reports brought much-needed accountability over serious access issues. since our august 2014 reports, we have initiated a series of audits and reviews, evaluating the extent to which veterans receive timely care. we have published several comprehensive reports detailing veterans experiences during their initial application and ebb rollment -- enrollment for health care and the improvement of access to psychiatrists and v.a. consult management. in addition a number of more recent reviews are in progress, including work which members of congress requested at the phoenix health care system to evaluate hiring practices of medical support assistants or the scheduleures and continued concerns about timely access to care. the national attention sparked by our reporting on the phoenix health care system resulted in a dramatic increase in the number of contacts to the hotline and the number of inquiries sent by

the member of congress. a number of the hotline contacts continue to allege inappropriate practices by vha staff that undermine the integrity and reliability of wait time metrics as well as alleged that vha initiative to provide care in the community are not working. our audit and reviews and health care inspections have reported challenges v.a. faces in administration of all access purchase care programs, authorizi authorizing, scheduling care and documenting the veteran medical records and timely and accurate medical payments for care. two reports we issued in february of 2016 highlight the problems we see n. our review of alleged untimely care at the colorado springs community outpatient clinic, we substantiated the allegation that some veterans did not receive timely care and non-v.a. care staff did not add them to the veterans choice list or the vcl in a timely manner or in some cases not at all. this occurred because scheduling

staff used incorrect date that made the appointment wait time was less than 30 days which excluded them from the vcl. in our review of alleged patient scheduling issues at the v.a. medical center in tampa, we again substantiated they were not all scheduled greater than 30 days and we also found that staff inappropriately removed veterans from the vcl and the facility staff did not cancel veterans' existing v.a. appointments when they did receive an appointment in the community through the veterans choice program which blocked other veterans from taking that v.a. appointment. my office recent lip initiated a pilot project to audit one facility to evaluate three key components of access. data reliability of wait time metrics, access through the veterans choice program and consult management. our objective for this pilot is to provide comprehensive and timely oversight for all

facilities in order to provide the facility directors within that vision for current scheduling practices. we hope by focusing resources we could audit each facility every three years as we do with our regional offices. we feel this work is important and will help provide a veteran centric view of what management action is taking to ensure things like phoenix do not occur in the future. in it conclusion, the v.a. faces challenges in providing adequate access to health care. we have a number of active projects involving pract is and procedures that ultimately affect veterans' access to the veterans choice program. we will continue to work with the v.a. to provide the independent oversight and recommendations to move the programs and iniatives forward. mr. chairman, this includes my statement. we would be happy to answer any questions you or committee have. >> thank you. miss draper, you are recognized for five minutes.

>> chairman miller and ranking member brown and members of the committee, thank you for the opportunity to be here to discuss veterans access to the v.a. health care. my testimony today is based on the gao ongoing body of work in this area, including most recently a report public released yesterday on newly enrolled veterans access to primary care. i wish i was here today to discuss better news but unfortunately that is not the case. since 2000 and in particular over the past five years we have consistently reported on v.a.'s failure to ensure veterans' timely access to health care. in 2012, we found the outpatient medical appointment wait time data were unreliable, implementation of scheduling policy was inconsistent and telephone access was problematic and scheduling resources were not affectively allocated. in 2014, we found that access to outpatient specialty care was problematic due to mismanagement of the consult process, including poor oversight and the lack of clear policies.

in 2015, we looked at veterans access to mental health care and found that the way v.a. calculates wait time zz not always reflect the overall time a veteran is waiting for care, the lack of clear policies precludes effective oversight and access data may not be comparable over time or between medical facilities. and most recent work focused on newly enrolled veterans access to primary care which is typically the entry point to the v.a. health care system and critical to ensuring veterans obtain needed medical care, including specialty care. for this work, we found many of the same problems as we have previously reported. we reviewed a sample of 180 newly enrolled veterans' medical reports across six v.a. medical records and found for example, for the 60 veterans who requested v.a. contact them to schedule appointments but had not been seen by primary care providers, 17 were not contacted at all because of the veterans did not appear on the appointment list which is

intended to help track newly enrolled veterans needing appointments. medical center officials were not aware this problem was occurring and could not tell us why the veterans did not appear on the list. fir further, for 12 of the 16 enrolled, veterans did not follow v.a. policy for making contact to schedule an appointment which states there should be three documented attempts by phone and if unsuccessful, a letter sent. for the 120 veterans that requested care and seen by primary care providers, we found the average number of days betwn the initial request that they be contacted to schedule appointments and the dates they were actually seen ranged from 22 to 71 days. about half were seen in less than 30 days. however, veterans experiences varied widely. with 12 veterans for example waiting more than 90 days. delays in care were due to issues such as appointments not being available when veterans wanted to be seen and medical centers failure to follow v.a. scheduling policy. and this most recent work we

also continue to see data weaknesses due to errors such as schedulers incorrectly changing dates as well as the lack of a comprehensive scheduling policy which has created confusion and contributed to the scene. in 2015, veterans health care was added to gao's high-risk list due to the v.a. problems providing timely access to care among other reasons. this list identifies government operations that are vulnerable to fraud, waste, abuse and mismanagement or in need of major organizational transformation. in designating v.a. health care as high risk, we identified a number of concerns, all chf affect veterans access to timely health care and includes, for example, ambiguous policies and inconsistent processes, inadequate oversight and accountability and poor training. it is now over a year since the addition of v.a. health care to the high risk list and to date we have seen at best little progress by v.a. in addressing the issues. we are very concerned about the lack of meaningful progress and

are concerned is heightened further because the window of opportunity under making progress under the rapid administration is rapidly closing if not already closed. the v.a. health care access problems are significant, per sittent and not only a disservice to our nation's veterans but places them at risk for harm. the status quo is not appropriate, nor should it be accepted. mr. chairman, this concludes my opening remarks. i'll be happy to answer any questions. >> thank you very much. dr. shullkin, i know you have been hard at it for nine months and i have a simple question. does it irritate you that even after your nine months, and we're talking about two years from the exposure of the wait time problem, that there is still serious problems and manipulation of wait times? >> um, i am very, very impatient

to get this problem resolved. and i am concerned that we have data out there that is not necessarily understandable by people. i'm concerned when i hear about mistakes being made and wherever we do find that there is manipulation of data, that is unacceptable and we're taking action. and so we're doing everything that we can, but am i impatient, am i upset about it? absolutely. and we are -- this is why it is our number one priority, mr. chairman. >> ex pound on the action that you're taking. because it appears that folks have said for almost a decade that it has been lack of training or improper training. that is ten years that this has been going on, or more. give me some concrete steps as to what you're doing, and have you really analyzed what the

root cause of this issue is? >> yep. well, let me first start -- it's an excellent question and a very fair question. first of all, i want everybody to be clear, we do not have access or wait times in our performance measures. in other words, nobody is getting bonuses. there is no incentive whatsoever to be manipulating this financially as there was in the past. so i think thanks to your committee's work, we make sure that that isn't existing. so i'm going to go back to the fact that in general we mostly, of our 340,000 employees, have very, very good dedicated employees. we have bad systems in place. one of the things that we've talked about is this is our current scheduling system to the right. it is dos black screen. to think this is how we're having our 32,000 schedulers have to schedule appointments, invites confusion and it invites

the ability to do this accurately. so we are putting in now, currently rolled out, the one to the left, which looks like a microsoft outlook calendar and that is important that we give our people the right tools. we're also evaluating a commercial system called mass which offers greater capabilities. number three, we are insisting that our leadership do visits to the schedulers, personally. and where they find that people aren't scheduling appropriately, they are pulling their scheduling keys. and we're doing that on a regular basis. we are talking about this and trying to do better training. we are taking disciplinary actions where we find the people have deviated and so we're just going to have to stick at this. i don't know any other faster, magical way to make this happen. and i'm frustrated by it. >> i think it would surprise many of the members to know, or maybe it wouldn't, we just saw

an example of the scheduling software that is being used, $127 million later, and we're just now looking at -- something that could quick question, gao found that almost one-third of the veterans it reviewed, 17 out of 60 did not get contacted for an appointment because they did not appear on the list. one would assume that directors at these facilities neither knew this was occurring, nor they didn't know why a veteran would not appear on the near list. so the question is, why would a hospital director not know? >> yes. well, when you read the gao report, i think it's pretty clear that we didn't do the best that we could for veterans. so that's why we appreciate the spirit and the information because it's going to help us do

this better. so we are sunsetting the near report. we are moving it towards an automatic system called welcome my va where we're contacting, reaching out to every veteran. part of the problem notice in the gao report, was we had the wrong phone numbers for some of the veterans, we couldn't reach them. when we reach some veterans, they didn't want appointments, they wanted cmp exams, we get them there. other veterans said no thank you. i no longer want an appointment. we have to do a better job, but it wasn't that every veteran that ms. draper just mentioned we failed. we failed too many. but a lot of them, frankly, those facilities just weren't able to get in touch with or when we did they didn't want the appointments is. >> okay. time has expired but i've got one more question i want to ask you. because a lot of folks have talked about accountability at the table and wanting to hold people accountable for things

they have done. in the media, there have been examples including an employee who participated in an armed robbery. a chief of staff that was improperly prescribing drugs to someone's wife a nurse who is being charged with manslaughter in the death of a veteran patient. they're all still on the payroll. similarly, according to the weekly list that va provides to the committee in the wake of the nationwide wait time manipulation scandal, va has successfully fired only four people for wait time manipulation. how is any of this possible? especially those on the front end who have been -- some of them have been convicted of crimes. >> yeah. it seems hard to believe, mr. chairman. so let me try to step through my understanding and if i make any mistake as i will commit to you i will get back to you with that. you mentioned the director, he

is not on our payroll. he's retired from federal service. it is my understanding that the person who was found with some of the criminal allegations no longer at the va. the person -- one of them actually is going through a court hearing and we're following the court's procedures on that. look, somebody who does either violate the law or violate our principles, does not belong at the va. and we clearly take that seriously. we go through a very extensive process of, you know, due process to get them there. sometimes it takes a long time. but we do not want people that shouldn't be treating veterans treating veterans. and i take that very seriously. so if there are some of those

cases you've talked about we haven't acted fast enough we'll go back and take a look at them. >> you talked about the visin director having retired. it wasn't the visin director, it was his wife that was receiving prescription drugs by the chief of staff of that particular hospital. something that hit the press a couple weeks ago, and that was the doctor that was -- had his medical license suspended for emergency reasons by the state. i believe you took action, fired that individual. now a court or a -- it's been adjudicated his license should not have been suspended on an emergency basis you have had to i assume put that person back on the payroll. >> no. >> not on the payroll? >> no. you're correct about the court action, but that does not change our administrative action. >> is that person appealing at this point your firing of them? >> my understanding is they're looking at their options in that regard, yes, sir.

>> because my question would be if that person is brought back on the payroll and subsequently the medical board goes through the normal process of suspending that person's license, how do you get that money back from that individual that comes back on your payroll? >> well, you know, i think we have to let people have their due process. but right now, we've made the decision an administrative decision not to have them on the payroll. we are not planning on changing that decision unless there's new information that comes up we would have to consider. >> okay. thank you. thank you very much. ms. brown. >> thank you, mr. chairman. mr. secretary it seems like you've been here longer than nine months. this problem that we're having with the va goes back more than ten years, you know, i've been

on this committee for 23 years. we've had problems with the va over a long period of time. and it would be a misnomer to act like these things just occurred. but what i would like to ask -- i'm very concerned about -- is the report have once again, just a couple days ago put va on the high risk list. explain that to me and what we're doing to take care of this problem. i want to get to the stand down what you all have done and the positive things you all have done. please tell me about this because i'm concerned. >> yes. well, i believe the va was placed on the high risk list probably well-over a year ago. it was prior to my confirmation. but the gao has been very clear about the reasons they put the va on the high risk list. we have inconsistent policies

and procedures. we have not systematized best practices or best processes across the va the way a healthcare system should. we have out standing recommendations. i think we've gotten some of them down. there is many outstanding recommendations. we work with the gao on a regular basis. the gao was right in this regard. we have policies and procedures that were conflicting. and we're working to fix that because you can't have that. and best practices across the system is what health systems should be doing. we're focused on learning from the best and putting it throughout the system. this will make va a better system. and i thank gao for that. i'm anxious to get off this list fast. i don't agree with ms. draper's assessment we're not making progress. i know we're making progress. it may not be as fast as she

wants us to, but we're heading in the right direction and addressing the right issue. >> the stand downs. >> the stand downs are a part of it. but the stand downs aren't a way that you sustain improvements. they are declarations of emergencies. and when you have urgent patients that aren't being seen, they are emergencies, and we have to act like that. but they've led to sustainable improvement. our nine core principles of how we'll redesign access in the system. so ten we're from now, a year from now we won't be talking about this in the same way. >> when you had the stand downs, how many people showed up in the various areas? >> 100% of our medical centers were open on those saturdays. no exceptions. people asked for exceptions. i denied them. so we acted as a system in the country, thousands of people -- doctor, do you have a number? >> i think we had 5,000 employees that were actually involved in the stand down. there were 10,000 patients or so that were actually seen on the

day of the stand down. make no mistake, the stand down was only a symbol. everything was going on prior to that stand down. so we were actually evaluating open consults and pending appointments, scheduling appointments and assessing patients prior to that. the stand down was actually a way to really bring together the five points that are priorities. we focused on access, we engaged the employees. we looked to the community for help where we needed it. we engaged best practices from across the networks. and we were working to basically restore trust with our veterans. >> i just want to say the next time that you all schedule a stand down, it would be get to let the members know. because we would like to -- i know i would like to be at my center on a saturday when you all are planning. >> i know at the last stand down, congresswoman, i was in orlando, florida.

and there were members of the congressional staff there. so we welcome your involvement. >> last question, what policy directives have resulted from the stand downs? >> what we've done as a result of the stand down, we sequestered a team of people from the field, not from the central office, who have told us what needs to be done to redesign the system, so we don't ever get long wait lists again of veterans who need care urgently. and that led to this declaration of access. the nine core principles that every va medical center is now signing their name to, committing to the principles to fix access in calendar year 2016 with same-day access and primary care mental health. eliminating our recall system, which we've been using for veterans for a long time. and in making sure that we're using telehealth and expanded opportunities to improve access. >> thank you, and thank you mr. chairman.

i yield back. >> there was something i was unaware of a second ago. you testified, i think, at a subcommittee hearing on thursday about the commercial scheduling software mass that you just talked about. and i think your testimony was that it's on a strategic hold at this point. my -- $152 million is what it would cost to do that? and the question is, how in the world could a pilot cost $152 million? >> so, again, the vse, the vista scheduling enhancement solution that's being rolled out now, total cost of the project $6.4 million. mass, which we do have a contract for, it's an idiq contract. so we can implement this. the next step would be to do a pilot at three sites. it would be a ten month pilot

where you have to build the interchanges, and the cost is $152 million. the total cost of the national rollout is 600 and something million dollars. >> with that mr. lamborn you're recognized. >> mr. secretary, you paint a much too rosy picture. the system is broken. for those of us on this side of the dais we talk and listen to the people and the people are frustrated and angry that we have all of this dysfunction here in washington. and more specifically, with the bureaucracy that continues to fail our veterans. people want real reform, real change and not just talking points about how everything is about to be fixed. and i've been told to my face the problems were already fixed at the beginning of the study and what the gao documented -- office of inspector general documented was after the beginning of the study and everything's okay.

we can't have a real conversation if you won't admit there's a problem in places like colorado springs. i'm going to share with you a brief excerpt from a letter i received from a constitchuent. constituent. he wrote a respectful letter. but he's simply beyond being fed up. here's an excerpt. "sir, i speak for myself and thousands of veterans when i tell you enough is enough. he says, "stop the tough talk and for once act on the corruption and deceit going on at the clinics." he's talking about colorado springs. he ends with this letter describing a 14-month run-around with the clinic and says, "when will it stop?" so when will it stop, mr. secretary? veterans take way too much time to get their care. and they're not being able to

really have access to the veterans' choice program. which is especially frustrating because that was implemented by congress to try to stem the tide of some of this dysfunction. so the first question, mr. secretary, according to the oig and places like colorado springs, va staff did not add some veterans to the choice list or did not add others in a timely manner. what we see clearly is that besides the va altering the times for va care like phoenix and other places all over the country, it now does the same thing by acting as a gatekeeper of veterans who should have access to choice. why aren't veterans really being given the opportunity to use the choice program? >> okay. congressman, if you think i've painted a rosy picture, i failed. because i'm telling you right now, i am acknowledging that we still have significant issues

and we have a lot of work to do. and that's why it's my top priority. i'm not going to rest until we get this fixed. i am focused on it. you and i sound similar when i'm with my staff. because i'm hearing directly from the veterans just like you. so i'm with you. what i am saying, and maybe this is where you thought i was painting a rosy picture. i know we're headed in the right direction. where we had 57,000 urgent veterans waiting more than 30 days for care, today that's 12,000. our electronic wait list for level one, down 32% in the past couple months. our veterans are telling us, we can't manipulate this data. 89% are satisfied with their care. the choice program isn't working for veterans. there's no question. al we've told you that. and we need to make this system work better and that's why we have legislation before you to try to simplify and stream line to make this work better. we have significant problems. i'm hearing the same things you are.

we're headed in the right direction. but we are a long way from declaring that we've got this problem solved. >> mr. secretary, your own metrics from february of this year showed that 29% of veterans received appointments in excess of 30 days, 5% waited longer than 120 days. worst of all over 2,400 veterans are waiting on a wait list to receive an appointment. and 708 have been waiting longer than 120 days. these metrics made the clinic in my district the eighth worst in the united states. so -- and i know of at least three people who have died and it could have been because of this waiting problem. it could have been directly a result of these delays. so i don't see the va fixing it, i don't see them being held accountable.

and i just have to agree with the man who wrote the letter to my office, enough is enough. thank you, mr. chairman. i yield back. >> thank you. you're recognized for five minutes. >> thank you, mr. chairman. i'm very concerned that the vha has been placed o ton jos high risk list and that veterans are still struggling to get timely access to care. the va has undergone significant change in the past year, and it will take a continued commitment from those in this room and members of the committee to work together to make sure the va is functioning the best it can to care for our veterans. but i want to move on to some other questions i have.

dr. shulkin, in your testimony, you mentioned that one of the va's top priorities remains legislation to streamline the process for va to work with outside providers. i'm concerned that the provider agreement legislation this committee considers throws out crucial workplace protections in the order of expediency. when we marked up a provider agreement bill to ensure that the office of federal contract compliance programs retained the authority to enforce workplace nondiscrimination protections. it is the only federal office that protects lgbt employees from discrimination in workplace and veterans for their veteran status. your testimony seemed to imply that we can improve provider agreements without undermining workplace protections. do you agree? >> what i agree with is i know we desperately need provider agreements to make this program work better for veterans. it's not working well and we need them desperately to be able to do that.

i certainly don't know if there's an unintended consequence that your talking about, and so i haven't looked at your legislation, but we have no intent of wanting to impose discrimination or to take away protections from people and putting in place provider agreements. what provider agreements do is too many small providers, the doctors and small practices that are today caring for veteran, can't deal with the federal contracting processes. it's way too complex and they drop out. especially our nursing homes and our skilled nursing facilities. so, we need provider agreements to do an easy to do contract to care for our veterans and we have no intent to discriminate against our employees. >> i realize there's a need to get these providers on board as quickly as possible. i'm concerned that in the spirit of "as quickly as possible" that on two counts,

the possibility that lgpt people could be discriminated against and that our own veterans could be discriminated against, that we need to make sure we balance the providers but make sure they're not discriminatory. >> i have to tell you, i don't understand the linkage between what a provider agreement does and how it could potentially discriminate, but i will get back to you and have our legislative people help me understand that because that's not our intent. >> well, thank you. part of providing timely access to care requires having a sufficient workforce. leveraging community providers can benefit veterans, but we must be mindful of the fact there are many years across the country that face health workforce shortages in the private market as well. and that's why i'm supportive of increasing the number of graduate medical school education residencies in the choice act. can you give us a brief update

on how that rollout is going? >> well, i think it is one of the most important things you authorized as part of the choice act. we need to train more health care professionals. there are actually more medical students now than residency spots and so the va expanding these spots is important. you authorized 5,000. to date, we've only implemented more than about 380 of those spots. so, we're continuing to work with your academic partners in your districts to look to expand these. there are a couple of issues. one is the funding. so, we save our academic partners in california, would you like to expand your psychiatry program and they say, of course we would. but the funding is going to be eliminated when choice is set. what happens then. that's one of the problems we'd like to work with you on.

>> i think there are members on both sides working with you on that, as well as the medicare cap issue. >> we believe this is part of the solution. training more health care professionals in areas of need. i know for for example, we are in el paso, we're just working, thanks to the congressman, working with texas tech on the new agreement. >> well, i certainly appreciate my colleagues mr. o'rourke and miss titus and my colleagues on the other side of the aisle working together to deal with this bipartisan issue. >> yes, thank you. >> dr. shulkin, there were two pots of money. 10 billion and then 5 billion. so, the 5 billion doesn't sunset. the choice program sunsets, but the 5 billion is there until the 5 billion goes away. >> yes, my understanding is on the gme program, it has a

five-year, it has a five-ier length of time that you can use the funding for. if i have a correct understanding of that, that would be good news. >> so, it's your testimony today that part of the reason you can't get more slots is because of the sunset and that needs to change. >> the reason we're not going faster is our academic partners need to agree to do this with us. they're telling us there are two things in general keeping them from going faster. one is the medicare cap issue. the medicare cap says if you go above your number, you can't get additional medicare reimbursement and indirect graduate funding. every hospital i've worked for has been at their cap or above. the second is the length of time it take to start a program. when you start a program from ground zero, srting it often

takes two years or so. if your money is going to expire before you graduate your first group of residents, the administrators at those hospitals say i'm not so sure this is a great deal for us. those are the two issues i'm hearing. if i have it incorrect about the moneying running out, that would be good news. >> just now talking about setting up the program, somebody's way behind the curve. i would tend to believe that the bigger issue is the medicare cap issue and the reimbursement rate, but mr. miller, recognized. >> thank you, mr. chairman. i appreciate it. dr. shulkin, you mentioned in your testimony about direct scheduling. i want you to elaborate on direct scheduling. >> yes. >> that it's available to certain veterans for certain specialties. you mentioned ophthalmology and i believe one more. >> yes. >> elaborate. for the benefit of our veterans out there.

who can direct schedule? and why is it only limited to a couple of specialties? >> right, right. the way the va has done this for a long time is you go through a primary care physician, a gate keeper. so you have to be able to get an appointment with the primary care doctor just to be authorized to get a consult. i have to tell you, i practice now, i'm a primary care physician in the va. my first appointment was just to get a pair of shoes. i had to actually approve a consult to get a pair of shoes. makes no sense. so, we've started piloting program where veterans can now directly schedule without going to a primary care doctor, in audiology and optometry. it worked terrifically. we're expanding that now across the system. i think it was done in florida. i want to look as you're saying, other specialties. podiatry. social work.

nutrition. all sorts of things that frankly veterans can make the decisions themselves. they don't need primary care doctors time to do it. >> very good. >> another question has to do with walk in clinics. how many walk in clinics are out there. you mentioneded about access, same day access. is that widespread? we have a walk in clinic in our outpatient center and i think it works very well. >> where i practice in new york city, that's where i practice in the walk in clinics. we're there if anybody needs to be seen, we see them that day. what many, why don't they? >> because many, 34, have same day access in their primary care centers. if you can see your patients through your primary care center, you don't need walk ins.

the other ones do need some type of urgent care visits. we do know that in areas that are challenged, they've begun some pilots with commercial urgent care clinics as well, too, so this is part of our declaration of access. walk in clinics are a strategy to get there. >> do veterans who need same day access, do they all qualify for care? >> we don't have walk in clinics in every -- >> the ones that do. >> i can tell you if there's a walk in clinic and they are eligible for va care, they can walk in. yes. >> thank you. >> next question. again for dr. shulkin.

one of the va's legislation asks is to have flexibility to avoid artificial restrictions that impeded delivery of care and benefits to veterans. however, the va has experienced many issues in which they attributed to lack of training and education. not too long ago, the va found a budget shortfall for the same fiscal year. the va did not submit to congress a formal request for emergency funds until months after the va had already identified a potential budget shortfall as early as march of that year. this was in part due to the employees were not utilizing the $10 billion appropriated for community care by the choice program and utilizing the traditional nonva care account. the va's only solution was the potential shutting down of facilities throughout the country that's unacceptable. the question is should congress

allow such flexibility. what assurances to veterans and taxpayers have that employers will be trained this time around properly so that another budget shortfall, no threats of medical facilities being closed, does not happen again? >> yes. >> so give me some assurances, please. >> congressman, i think you got it exactly right. which is what we had was we had spent all the money in one checking account, so it got down to zero, so we had lots of money in another checking account. in order to be able to give veterans care in the community, we had to come and ask you for authorization at the last minute. what we're seeing is we don't ever want to do that again. it's not acceptable. it's not the right way to run a system. so we want the flexibility to use care in the community funds to support veterans who get care in the community. that means when we train our people in the system how to use it, we can train them there's one pot of money and now, focus

on doing the right thing on veterans instead of following rules for seven, eight, nine different pots of money that are too complex and we've shown doesn't work for veterans. that's why we need this type of legislation and we need your support in getting that passed. >> thank you very much. i yield back. thank you. >> thank you very much. you're recognized for five minutes. >> thank you, mr. chairman, for holding this hearing. the issues we're discussing are wrong in so many different levels. i'm going the talk about three, one, are your goal, two, our data integrity and three is the veterans experience. so, goals are important because it defines your success. it helps you achieve your objectives. setting a goal of 30 days is arbitrary. there is no clinical day to to suggest that's the best practice anywhere in the health care literature. and you had mentioned a term which earlier in the beginning of your presentation about

trying to match scheduling with the clinical practice. right? so, we know that illnesses are urgent, emergent and we need to take care of them right away and some others can be scheduled. maybe more than 30 days like your routine colonoscopies that you get once a year, right. i think you need to start changing your premise and getting more towards a clinical approach so you can take care of your high priorities first and not necessarily rush or take up your high priorities on things that can be done on a routine basis. the second thing is setting up goals of urgent care appointments is nonsensical. why are they urgent if you're going to wait 30 days?

usually, an urgent is what you call your walk ins or maybe within 48 days when you want to match your clinical practice with your scheduling goals. the third thing that i'm concerned about in terms of your goals is the use of the word same day access for all primary and mental health. you're setting yourself up for more controversy by not clearly defining to the veteran what access is. is it going into picking up u the phone and having speaking with a scheduler? is that what access means? is it receiving the appropriate care? is that what access means? so, the second part is your data integrity, now, we use population studies to reduce the chance that errors are done by chance or so that we can get a statistical significant accounting of whether this is a true problem and whether this is systemic. but the only way we can really rely on those population studies is if you're data is accurate. if your data has integrity and

the gao is continuing to find faults in the way that you collect data and how you're reporting it. so, you can understand why we're still skeptical when you tout the number that 96% of all appointments have been seen within this arbitrary goal of 30 days. the other thing is the way you report data. so, you're telling me that by veterans who use vet link inside the hospitals are telling you that they are 89% of them rate their access good, but you're giving me data with a very high reporting bias. of course they're going to rate it good because they're on the inside of the hospital. how about asking those that don't get access that are not inside the hospital, so tell us what their access is going to look like.

so, for those of us who know statistics and know methodologies, we are skeptical when you report some of these reports to us that may not be as accurate as possible. and lastly, when we can't rely on population data, when we can't rely on the integrity, then we go by case studies and case studies depending on the accuracy and write up and details is what oftentimes we're left to look at. so, let me tell you about case of a wounded warrior who actually works in my office who is a hero in my book. went for his yearly check up for the va. he is service connect disabled, manages well. prescribed medication through the va. after waiting 30 minutes on hold, 30 minutes on hold, the veteran was notified that because he had not had an appointment in over a year, he would have to schedule a new patient appointment even though he was not a new patient. he agreed to the appointment,

asked to schedule that appointment as well. they couldn't fit him in until 134 days later. again, arbitrary. as a result, this veteran elected choice, but they said you have to come in and do your new patient appointment before you get to your choice appointment. so, one, what is same day access mean and two, why do these arbitrary numbers exist in the first place. and three, why do they need to have, why do veterans need to have a new patient appointment? after a certain amount of time, even though they've been getting prescribed medications you know, as recent as a month. >> thank you. and i appreciate your skepticism. i think most doctors and politicians generally are skeptical of data and i think

that's a good thing. so let me very briefly tell you. first of all, you said it absolutely perfectly. the va needs to clinically prioritize its appointments. exactly what i brought into the system. we used to have 31 days of ordering a consult. today, we have two. either urgent or it's not. there is no 30-day rule for urgent care. i don't know where you got that. that does not exist. urgent patients have to be seen now. that's why we did the stand downs. i've never had a patient with an urgent care need that i wasn't getting them to be seen right away. that's our goal. get them seen right away when they have an urgent care problem, so acompletely agree and you said it perfectly. secondly, same day access. what does it mean? revolving the veteran's needs that day.

if they need a prescription prefilled, they don't have to come in. we can do that on the phone or electronically. if they need to talk about how to understand how to use their treatments, we can do that over the phone or telehealth. but patients who are sick and need to be seen should be seen that day. that's what we're working to get implemented. we have to set expectations and explain it in a way quicker than we do today. the last thing about the veteran's experience, the only thing that matters, are we meeting the needs of veterans. the vet link system we talked about asking them when they're in the system, you're right. so, we have a second survey called taps. it's what's used by the private sector industry. that asks whether you've been able to see your doctors when needed. so, we compare ourselves to the private sector using caps. internally, we use the vet link system because that's a point of care system. so, all your points are absolutely right, congressman and we take them to heart. >> thank you. >> dr. roe. >> thank you, mr. chairman and you know i have great respect for you and one of the things i

don't think i would have said if i were you is that one year from now, things would be different. not sure they will be. i hope they will, but i'm not convince. just a couple of three points. i'd like to have your answer on. one is if the va is doing its job, why do we need a stand down? why did that need to be done? >> believe me, stand downs are not the way you run a system. dr. roe, absolutely right. the reason is because you reach an unacceptable situation and the day i learned -- literally, the day i learned with 57,000 patients who had urgents consults greater than 30 days, i said there is no nothing to do but declare it an emergency and that's why two weeks from then, we had our first stand down.

because it's unacceptable. but that can't be the way you run the system. you have to put in sustainable fixes. that's what we're doing now. i looked at the numbers of schedulers. 32,000. that's plenty. they schedule ten people a day, shouldn't overwork anybody. that's way past 70 million schedulers, i mean appointments in a year, so you got that fixed. if the system works and i would like to have you guys define what an appointment is. what i finally figured out there this is look, the day i called. you, if your my doctor, i called, that's the day i'm calling to get the appointment. obviously happening was you would tell the veteran, well, we don't have an appointment the day you want it, but we've got one at 6:00, would that be okay. that's their desired date according to you guys. just, lock, just go ahead and say we don't have it until then. if it's a problem, if you prioritize, as the doctor said,

the sicker patients, then see them early. why is that hard? we make this so difficult. >> okay, so a couple things. 3 3267 schedulers seems like a lot. it's got a 25% turnover rate every year. you're constantly circulating people in and out. >> fast food restaurants sounds like. >> right. secondly, seeing the urgent patients first. that's what health care systems need to do. that's what doctors do. absolutely. that was macing from the vavt. that's what we're focused on now. it's p i absolutely agree. i think when you talked about how, you know, we assigned clinically indicated, preferred dates, that's what the chairman was talking about when he says there's this negotiation going on. that's where we're confusing people. so, so look, we need to do better with that. we can't have it be an arbitrary

way of assigning appointments. that's where we really need to move to this veteran experience. you can't manipulate data there, right. that's -- you're listening to your patients, the data is what it is. >> everybody's speaking from the same -- singing from the same song book. completely different information, how are we up here supposed to make any sense of it? question to you. what would you be recommending to the va? because clearly this is not what the va's telling us is happening, this investigation that you did. >> so that report this recent report, we made three recommendations to va. one was to -- because we think the entire period -- from the time they first request care to when they actually receive care, that should be monitored. because there's a lot that can happen between the period a

veteran requests care to when that preferred data's sent. so we made a recommendation to which va concurred that that whole period of time should be monitored. the preferred data is really an artificial measure for the veteran. they don't understand what that means. the veteran experience is when they actually request care to when they actually receive it, so that's one. the second piece is va has been without a scheduling policy since 2014 and what they've done, they rescinded the policy, they implemented a scheduling policy in 2010. it was rescinded in 2014 after phoenix. the way they've provided guidance to the field has been through memos. that's really not the way to do -- it's been really piecemeal effect. it's very confusing because they get memos. they don't know what they're supposed to be doing. you need a really good policy which sets the stage for also

really being able to do effective oversight because if you don't have a very clear policy or you don't have steps that you should be looking at in the scheduling process, it's really hard to evaluate whether people are doing right things or not and we heard a lot of confusion about that. those are some of the things in va again concur with our recommendation so there's a lot that needs to be done. i would say the other thing related to training is, you know, i know they said they trained over 32,000 schedulers. i don't know if they're all schedulers but people with scheduling keys which could be other people as well. have they evaluated the effectiveness of that training? one of the things we saw, we saw schedulers, the same scheduler, making multiple mistakes. we didn't see intentional manipulation. the question to me somehow effective is that training. where is the oversight. and, you know, maybe there's some people that lack the capability or the skills to be able to do this job.

and, you know, they need -- that needs to be accounted for. there's just a lot of things that go into this whole process. >> mr. chairman, i'm going to yield back because i'm overtime but there is one other subject. maybe one of my colleagues will bring it up. the gme implementation. we had a va come over and talk to the entire caucus and i've been walking through that in my local medical center, trying to get this done. 300. we'd like to get them out there. get these young doctors in these trained positions. i yield back. >> thank you very much. and we will. let's go ahead and take care of that. because this -- the issues that you brought up are really the first time that i've heard that and i think it's something we need to go ahead and address as quickly as we possibly can. mr. o'rourke, you're recognized. >> thank you, mr. chairman.

secretary, shortly after i arrived in congress in 2013, i noticed a gross discrepancy between what the va was reporting on wait times in the district i represent el paso texas and what veterans themselves were telling me. in 2014, because we couldn't resolve that based on the data we were given in the va and the assurances from one of your predecessors, we commissioned a third party independent survey of el paso veterans that returned results with a margin of error under 5%. that showed that instead of waiting eight or nine days for primary or mental health care, veterans were waiting over 70 days, over 80 days for those two respectively. the conclusion i arrived at and i still insist upon is that the only way to find out how long veterans are waiting for care is to ask veterans directly. we surveyed in 2015. we will survey again this year.

i'm glad to hear you agree with miss draper's conclusion that the va must measure from the date the veteran first requested help to the day that appointment was delivered. for anyone who hasn't read this gao report, this is illustrated graphically on the first page in a way that anyone can understand. so i have a question about that, when will we receive those numbers and the way va measures wait times so we don't have preferred wait times with multiple points of potential failure and manipulation and we just have -- you asked for an appointment on this day, you received it on this day. number one and number two, you gave a great presentation in october on the way forward for vha that acknowledges it today. we have 43,000 authorized funded but unhired positions within the va. we're going to leverage capacity in the community. we're going to specialize on what the va should be doing best. that is something that needs to happen if we're going to resolve

the fact there's more demand than there is capacity within the va. where are we on that. so those are my two questions. standardizing of wait time reporting and where are we on october plan you announced at the end of last year? >> congressman, i've already acknowledged our systems for measuring wait times are overly complex and difficult to understand. where i believe that we need to go is to simplify this by looking at the veteran experience, by asking our veterans, are we meeting the needs of the veterans in the el paso community and that's the way that it's done in the private sector. they don't have these complex wait times. remember, we went out, we asked the institute on medicine, we've had so many consulting companies. i can't even imagine. tell us the right way to do this. they've come back and said there is no standard. so i think what va is doing is we're measuring so much right now and trying to report

everything, we're confusing the picture. so we have to get better at this and we have to simplify it and we are going to do it. i think what the gao report is talking about is the new enrollees and that's where we've concurred that we will measure the full, full wait time. i'm not anxious to start redefining wait times and getting even more data. i actually want to simplify this. on the issue of what do we node to do to go forward to work with care in the community. we need the legislation to streamline the care in the community. we need the provider agreement legislation passed. because we need to fix this program for veterans. we do need to work with the private sector. we're committed to that as well as our federal partners like the indian health service, federally qualified health centers. we'd appreciate your support. >> so on both of these issues, i would love to follow up with you to get written specifics on just

when we'll have wait times reported and the way recommended by gao and, two, i want to know specifically what is on our plate that we have to finish in order to allow you to implement what i thought it was a very ambitious proposal to make va work for every veteran. and get what you describe. which is outstanding care. which should be the ultimate focus. when it comes to my colleagues. when it comes to measuring wait times. we have introduced a bill. the ask veterans act. the ability to get objective third party confirmed wait times. the va reports for april of 2016 that veterans are waiting 13 days for primary care, 10 days for mental health care. when i say that, i almost get laughed out of the room. when we report back what veterans have told us in the surveys, they all nod their

heads. so we welcome the support and collaboration of my colleagues on this and i thank you for your commitment for making sure we report more honest wait times for veterans in our communities. >> thank you. >> i yield back. >> you're recognized for five minutes. >> my time on here is accountability. i want to drill down on a couple situations that i think are pretty striking examples and perhaps, dr. shulkin, you can clarify. apparently, what i understand, the va in puerto rico has refused to fire an employee convicted of crimes. suggested it was okay for va employees to participate as long as it was on their free time? now, i'm sure you don't agree with that. what is the va doing to take care of this situation in puerto

rico? >> congressman, i am aware of that situation and i don't -- it is my understanding and i'm very careful -- i want to give you accurate information so if i misspoke on this, i will get back to you by the end of the day. but it is my understanding that that person is not currently working at the va in san juan. >> on paid leave? >> no. that's not my understanding. again, i will personally make sure we confirm that with you but no, that is not my understanding, that they are not an employee of the va. >> look forward to that. second one, still has not disciplined the chief of staff at the cincinnati va medical center who was found to have improperly prescribed control substances. what else the status of that

particular employee at the va? >> that situation, i'm a little bit closer to. if you will recall, i made an administration decision to suspend their privileges of the chief of staff and she was actually in an acting chief of staff role. and also to remove her from that role. she is following her due process which means that the medical staff is looking at the clinical privileges and there's a due process going on on the administration decision i made. there was both an administrative and clinical decision but currently she's certainly not in that role and she's not -- >> ci appreciate that. so no access to veterans as it stands today? >> she is not in a clinical role not in that leadership role no.

>> what role is she in? >> my understanding is she's doing administrative reviews like quality reviews. >> and has been found improperly prescribed controlled substances and is still doing quality reviews? >> we had concerns. that's why we took actions. we invited the inspector general. that was my first request to come in and take a look at this. i know the dea has come in to take a look at this. >> and thirdly, going back two years. it's june 5th of 2014. here's a statement. in phoenix, wish in yaited a process to remove senior leaders. as i understand today, a number of those senior leaders are either still on unpaid leave or are working on the process.

is that the case, it's taken two years and mr. gibson has yet to fulfill that process and end that process to remove these folks that were covering up secret waiting lists that harmed up to 20 veterans? >> yeah. i believe apronproximately 30 ys ago, mr. gibson did make a decision on all three individuals. that decision was removal. they were each in their process of due process. he has a shorter period of time in which to do that. the other two are title 5 employees. we talked about as part of the accountability act. >> so june 5th of 2014. the promises made public. cnn. we're going to take care of this. as we sit here today, april 19th, still not completed the process to take care of someone and get them out of harming our

veterans. mr. shulkin, i ask you to pass on to your superiors. for some reason, the senate's still sitting on it. this is absolutely outrageous. whether it's puerto rico, since net or phoenix. still almost two years later. and we can't get rid of the folks that have harmed our veterans. they all laugh. they've lost all respect within the veterans community. and so we hear these numbers and appreciate -- and i didn't get time to ask question because i've gone over but i understand we've had 58 cases referred to the department of justice for possible criminal charges. that would be my fault for the committee if we can find out. and the disposition of those. i yield back. >> thank you.

you're recognized. >> thank you, mr. chairman. secretary shulkin, i appreciate your testimony today to say your intention in your testimony, both written and your earlier testimony, was not to paint, you know, an extraordinarily positive picture but to say it paints' picture we're on track, so i appreciate that. i have to say though in your testimony when you, quote, april 1st, or the wait time for va overall is completed, 96% of the time within 30 days overall and that's data i think from february. when i was reading your testimony last night, i said to myself, oh, gee, it must be my district that's causing the 4% that's not there. so i went back to look at the data. as of april 1st, almost 30% of

our veterans that i represent in the oxnard cbot in ventura county have primary care appointments pending over 30 days. actually, i asked my staff for the data this morning and i think based on the data in that one metric, we are the second highest cbot in the country with dover, tennessee being the highest at 48 days for a pending appointment within 30 days. we had a problem and we've had' problem and i am extraordinarily excited that the va of greater los angeles health care system has finally hired a medical center director who is permanent. but we are working very closely

with ann brown. who i believe is doing a very good job and is very aware of what is going on in oxnard. and clearly we have had trouble hiring and keeping teams there within the cbot. i think we have a contracted out facility that plays a role. the choice program is not really working too terribly much. that's not as large an option as we would like it to be. so we know these things are happening. i guess my question is if i wasn't watching this closely, my question is, is the va watching this closely, and would you have -- nobody brought it to my attention, i just bring it to your attention. so my concern is, is the va looking specifically at regional problems that is skewing your

data perhaps to really address these pockets within the country that aren't doing very well at all? >> yes. we are tracking this. i think you have it correct which is that this is very different depending upon the geography of the country you're in. so that we have some vas that actually don't have backlogs at all. and others like in your district that have significant backlogs and primary care. so we are paying attention to that. we're actually focused on that top 10% to 15%. we're sending our resource center teams out now to work with those most distressed facilities to help them redesign their systems. we're focused on recruitment in areas that really are struggling with recruitment. and so we absolutely are focused on that.

but i think that it's a relatively new direction for us to focus on those areas that have been so -- that really are struggling the way yours came from jesse brown in chicago, is one of those experienced leaders. we knew greater los angeles was one of the challenged facilities. we brought on experienced leader there and i think you're seeing that makes a big difference. but without permanent experience leadership in place it's very hard to address this in a system as large as we are. >> i can rest assured that the washington team is working directly with anne grown to help

facilitate this issue at oxnard? >> i've been out there to visit with anne and the secretary. some people thinks he lives in los angeles he goes there so often chblgs i want to say publicly that i believe anne is working very hard on this and i appreciate her leadership and she's now giving my district office regular updates but it is an eyesore compared to the rest of the country and needs that attention. ms. draper talked about -- or you talked about working directly with the gao now and a team to recognize where some of this -- some of these improvements have come from and i guess i would ask ms. draper, you know, to ask you your feedback in terms of are those meetings productive and are you meeting on a regular basis with specific agendas. >> yeah.

so there are five criteria from removal. this is capacity. a third piece is the action plan. fourth is monitoring and then the fifth is demonstrated progress. what's happened thus far is that va provided us a draft action plan in january and it really addressed one of the five areas and we felt that the action plan was not sufficient. so we have -- we met with them, provided them comments and then we referred them to an agency where we felt like has done a really good job making progress on their high risk status. they've gotten the action plan and we've committed that we'll begin meeting with them starting the end of the month and then monthly. i think they're trying to get on target to get us an action plan, a reliable feasible action plan by august. and that includes having metrics that we both can agree so that there's progress made. there's a lot of work to be done and i think that we're going to

work with them to provide feedback. it's a little difficult for us because we have to straddle the line of independence. but we can provide feedback and direct them to other sathcys where we feel have made good progress on the high risk. >> thank you. i apologize for going other. i yield back. >> that's all right. dr. abraham, you're recognized. >> thank you. my respect for you personally is great and i know in my heart of hearts you want to get this right. my concern is like ranking member brown said, this is way before your time. it goes back ten years plus. so my concern is the culture of the va. this may be a bridge too far to actually fix this problem within the va system itself. and it may be time to look outwardly to a private sector to do the scheduling. if 89% of the veterans are sats fieds with their care once they

get there, we certainly want to enhance your ability to treat those veterans with the expert care that we know the va gives our veterans population. but we're talking today mostly about the scheduling issues where the va has the ability or lack of resolve to get rid of the poor scheduling employees. your turnover rate you said 25% that's hard to keep a quality employee on task with that going on. with the $152 million to implement the software program, you dangle that in front of private enterprise, they are going to be knocking down your door to do this. just a thought and maybe a pilot program or something could be on the agenda just to compare how the private sector does on the

scheduling, not the health care for the veteran but the scheduling for the veteran to get the appointment. just a thought. you said that you guys are hopefully going to each visit every three years and you look at data, reliability, the veterans choice program and implementation. and i guess the first question the data you're getting from the va, the old adage, garbage in, garbage out. if you don't get the data that you need and you don't just the data that you get, it's hard to make informed decisions. the question are you satisfied, are you comfortable to date with the data that you're receiving from the va on this issue of scheduling? >> no. we can't to see the data unreliable which is one of the reasons why we're going to

implement this vision approach, national reviews are great where we sample so many facilities throughout the country. but we think if we can push this down to a local level and feed this information to the vision management and give them an opportunity to take control and make changes, we think that's going to be more helpful. but the 96% and the data that has been discussed today, we don't see it. i mean every facility we go to, it's not accurate. >> and my next question, it's a quote, i want to make sure i get it right. it says in a february 2r5th, 2016 letter to the president of the office of special counsel said that the va oig's investigation whistle-blower disclosures regarding wait times in illinois and shreveport, louisiana, were inadequate. the oig investigations found

evidence to support the allegations that employees were using separate spread sheets outside of the va's electronic scheduling and patient record systems. however the oig largely limited its review to determine whether the separate spread sheets were quote again secret, unquote. please explain why the oig limited its review. >> so that review was conducted but our investigative staff. i was not directly involved in that. i am aware of the concerns and i know my boss has made sure that we try not to interpret the allegations too strictly. and you know, i can ask the office of investigation to get back to you on their response. >> i guess my follow-up question, were there any criminal charges sent it to the doj for prosecution that you

know of? >> i would say no, i don't know. i know there were some and there's been discussions but that's outside of our office. >> thank you, mr. chairman. i yield back. thanks. mr. zel dan, you're recognized? >> april 7th, usa today story starts with supervisors instr t instructed employees to falsify patient wait times at va medical facilities in at least eight states. was that accurate? >> i've reviewed 72 ig reports. 11 of them were found to have intentional manipulation. that would be accurate but it's not representative of the majority of their findings. >> and of the supervisors, how many of them have been fired? >> we have for a tote oval all of the oig reports, when i add up going across that, we have 29 individuals that have been

disciplined. i think chairman miller before had said four have been fired. i'm aware of five who retired under investigations. so rather than letting the investigation go forward, they decided to retire from federal service. >> when you referenced the number of 29 disciplined, that is from this usa today story? >> from the 72 ig reports that i have reviewed. i sort of -- i manually counted them up as we went through each of the accountability actions. >> have any supervisors who instructed employees to falsify patient wait times, have any not been disciplined? >> i suspect of people investigat investigated, there were many more than 29 probably. lots more that were investigated and the evidence did not suggest that there was discipline that needed to be imposed. >> are you saying that there were supervisors who instructed

employees to falsify patient wait times who have not been discipline sdi disciplin disciplined? >> of course the investigations that we've done they found intentional manipulation, we would send in our office of accountability review to do the investigations. everybody that was found to have an a or found to have a behavior that required disciplinary action we have. >> no one hasn't been disciplined. >> i wouldn't say that. >> we're going to circles. of the supervisors who instructed employees to falsify patient wait times, have any not been disciplined? >> you know, i don't know the -- i don't know what your denominator is. anybody that has, accused of

manipulation we've investigated. when we found there's evidence of the manipulation, we've implemented discipline. >> i am not aware of anybody that we found that we haven't implemented disciplinary action. sometimes after the action they've appealed and those actions have been overturned. >> but no supervisor who you have investigated who has instructed employee to falsify patient wait times have not been discipline sd disciplined? >> you know, congressman, i feel like i'm being asked some questions about -- you'd have to ask me individuals. >> i'm asking about anyone. >> well, look. >> has anyone not been disciplined? >> these disciplinary actions have been going on well before i got here. what i -- all the information i

have -- this is not any responsibility to implement the disciplinary actions. when i've reviewed the reports, when i find that other people have taken disciplinary actions against individuals, i'm sure there are many more that have been accused of supervising. i don't know how to answer your question. >> well it's a simple question. there was a usa today story said supervisors instructed employees to falsify patient wait times in at least seven states. you say you investigate it and if you have evidence to back it up then the person is disciplined. i'm skoog through this process if anyone hasn't been disciplined. we're talking about patient wait times while we're here. we have issues with patient advocates, they won't get someone on the phone, they'll leave a message. many times won't get a report back. reports of calling a suicide hotline and getting a voice

mail. a backlog of appeals the committee is concerned about. greatly concerning numbers the denver va hospital construction project. i have a constituent, john mitchell with over 20 years of service, army ranger in vietnam with over 16 years of service with special ops. we suffers from traumatic brain injury directly connected to his sufs. one from an accident in a mail tear vehicle, another bun from a parachute fall. and because the va lost his file he's being denied his benefits, 20-year veteran, vietnam veteran, special ops, he's unable to take care of himself and we're getting all of these different cases but the only time it comes to light to the committee is when the committee brings it up to the va. the va needs to bring the issues up do the committee beforehand. when one example after another

doesn't come to light until this committee brings it to light or the usa today does, if it's not initiated by the department of veterans affairs, it looks like a coverup. so you say that someone who violates the law or violates of principles doesn't belong at the va, that goes straight to the top of the people who are violating the principles of the va. it's greatly concerning that it's this committee responsible were the inspector general, the media responsible for bringing it to light and you don't do that for was. i yield back. >> thank you. mr. coffman, you're recognized. >> thank you, mr. chairman. just a question about the appointment wait time schedule because i think we're getting different summaries of it in you will. so wasn't the -- you said that

it wasn't about cash bonuses but you didn't put a date on that. i guess that the policy had changed. but what was the policy in 2013 when this issue came to light? >> congressman, i wasn't here then, but i believe that there was wait times as part of people's performance evaluations. and so dr. lynch, am i correct in that? >> yes. >> so there was a potential of a financial bonus if people hit certain, certain criteria. >> sure. >> today that doesn't exist. >> so you allowed -- people were allowed to retire who were under investigation, who were complicit in manipulating