sounds bad, the department's effort to avoid sub accountability had been worse. deputy told members at the colorado delegation after the aip completed and following numerous congressional requests, the committee was provided of a 31 page summary. one va official collected over $60,000 in bonuses while over e overseeing a project that's spiraling out of control. i believe this committee and the american people are entitled to review all the documents associated with the aurora aib and to draw their own conclusion as to what went wrong and whocc.

i believe there is an understandable lack of trust in the va's explanation. i urge all my colleagues to support this motion and i yield back. >> thank you mr. coffman. >> thank you mr. chairman, i want to remind my friend and my colleague from colorado that congress and of the morning hours, approved over a billion dollars to augment and there were projects over concerns of minorities that more conditions sort of have been attached and that the funding should have been sunlightbmitted careful. i am engaged in this how we should hold the va accountable for. again, i find it a bit rich that

congress approved that funding in the middle of the night over, i think the concerns of the minority. today i am concerned that you are asking us to exercise our subpoena power when it maybe unnecessary. you have denied my request for witness for violating committee rules. how can we as a committee to work together to make the right decisionings f decisions for veterans. i am requesting today that we hold a full committee hearing on

the report so we, veterans and the taxpayers know who's responsible for this waste and management ties to the colorado department. va employees before both the administrative board and the ig provided information critical to the investigation. now, you are asking us to subpoena unredacted documents, exposing those employees to retaliation and maybie making i difficult for va and the ig to conduct a thorough procedure. in the same subpoena, you are asking us the subpoena on all

documents related to the purchase of art at the va hospitals. this subpoena is not only unrelated to the va investigation, it also seems to be unnecessary if as i understand correctly. va is working to provide you answers on the amount it spends on art. i think it is porimportant that work together to resolve this issue together and use our subpoena power only when necessary. now, if we cannot protect, whistle blowers by afemending t subpoena before we vote today, i am prepared to support the subpoena. but, only if we the minority is assured and the subpoena will be amended and i would like to see the language change in the subpoena, actual subpoena before we actually vote. >> mi want to echo this

committee. it has worked in a bipartisan way. i want to give a little back and forth because you used the word "rich," it seems too little and too late. we have been looking at this situation ever since i joined the committee. i am ranking on the over sight investigation committee. i was delighted to come out mr. coffman's district in april and assuming that the topic would be asking american taxpayers to build the taj mahal. the topic was opiate which is fine, that's an issue that i care deeply about. i appreciate the opportunity but it was not until we were on the third round of questioning and i said to mr. coffman, i got one more question that i want to ask about aurora. so why didn't we ask for these documents before we took this vote in the middle of the night?

this is a lot of money where i come from, $1.6 billion on one hospital. so, you know, i am prepared and i support the amendment with the redaction. i want to protect whistle blowers. i don't want to lose the moment here, what are we 60 days out from the election and we are worried about documents, why have we been working with these documents the entire time and is that the role of your over sight investigation subcommittees? that's just my comment. any other members wish to spout off? >> i want to spout off. >> and i concur of what you said. the question is why in the world did the va bring these documents up here. why are we having to do this. i have been here now almost eight years and you hear this over and over again from these people. they should be up here bringing

it up and we should not have to ask. they should be saying how do we make this better. we mess this up. the fact we are having to do this annoys me to no end and it is time for this to stop. >> no, but with all due respect, why are we asking for this information at that point in time. i don't disagree with you. >> i can answer that question as a chairman of the full committee. we have been asking for the document, we did not have to go to aurora to ask for the do you means. we have been asking them for over a year. i am surprised at this point to hear anybody on the neither side talks about the vote oss of the dark of the night. the fact that i was not wanting to approve the add discussiitio dollars for aurora. mr. couffman was aware of how w

debated that particular issue. i want to a couple of thing things -- just, i think i have earned the trust on the minority side. i think i earned the trust on the majority side. when i say that va has not provided us the documents in a timely fashion, i am not talking about writing them a letter on monday and asking for a response on friday in issuing a subpoena on monday. i have 176 outstanding deliverables at va right now. some going back years and the oldest is december 4th of 2012. i have not received a response. average response time now is 80 days to get a response. i would ask any person in this room to tell me if that hanging

light switcher, is it a light or is it art work? if they have claiming it is a light fixture, why in the world are they spending that kind of money for a light fixture that's exactly what the va did. they called it a light fixture instead of art work. it was half a million dollars on two things. number two, the member said i denied his request for a witness at this hearing. i want to set the record straight, that is not true. we have two witnesses, and i offered and it was declined to substitute, misinflicting for the person that the ranking member requested. i was very happy to allow that to be done. i also said that if a majority

of the minority per our rules voted to want another witness that i would accept that as well. according to a rule at a place of choosing at my time. as what's the rule says. i was told it was not necessary. we are not talking about an office of report that's coming. we are talking about the ai aiv -- we had people talked about the and the ranking member said we are going to out certain people. i will tell you, this committee has never allowed personal identifiable information out to anybody. period. nobody has ever been identified. to say that and insinuate that

this committee is prepared to do that is a red head. to talk about the overly broad language, this is the language that we use for phoenix and an exactly the language that we use for philadelphia. it is not overly broad. again to insinuate, we are suddenly concerned, i will remind some of the members who are new to this committee that until i became chairman of the department of veterans affairs have never had a subpoena served on it. never by this committee. that's ludicrous. we need to be doing our job. and, so the question of identifiable information as it relates to the aib, i get it.

i don't intend to release it and i have never released anything like that. i am willing to have that discussion. mr. woalts and i had a discussin on the floor yesterday afternoon. whether or not it is necessary in the actual language of the subpoena or what i am asking is that again, you trust me enough as the chairman of the committee not to release that information. it is not going anywhere. the problem is we don't know what we don't know about what's going on. we think we know who the folks are that should be held accountable. we protect whistle blowers every single day. we have hundreds of them across the country that we meet with and talk with and trying to

gather information. again, i understand the concern. i really do as far as releasing of the information and how we go about getting the assurance that the minority wants. i think we should be sufficient in this process and i think we are potentially hurting our committee investigation by allowing the va to reduty to act what they wanted to reduty to act and verses giving to us and allowing us to control the information which is what we should be doing. any other comments? >> i would like to yield to mr. hofm hofman. >> i just like to address an issue raised by mr. patrick. we did do -- that was done prior

to you, member kuster i have a letter here came from both of us requesting both documents. it was dated october 9th of 2015 that you signed and it has a mandate on it for friday, october 23rd, 2015. they have not turned over the very documents that you will be voting on today in the subpoena that you requested last year. so, i just want to set the record straight on it. i yield back. >> mr. chairman. the with regards to the issue of the witnesses for the commission on care report, i see no harm

and with sorting with the minorities would like us to see, additional witnesses. you only had two witnesses and your concern is the hearing is too long. i think that the main key points of contention which our witness have decented on that report. y i see no harm and actually to the contrary of a great benefit to the crewing to a full range of views being presented on what the commissioner has to say. >> but i would like to move on. i continue to wait for a request by a vote of the majority or the

minority for that particular witness wish that we have not receive. at that time, if you get that vote, i will schedule another hearing at the place in time of the chairs' choosing. >> i thank you for that. our concern is replace in time and we hope that we can get a satisfactory in time. >> how about october? >> i am just kidding. [ laughs ] >> i do want to comment on the issues of the va response. how are these things individually involved. this is not a matter of speculation about or not -- the

thousands of pages related to the construction project. it states the -- i can go on and on and it is a huge long list that the chairman has that the va has been responsive, too. he further goes onto say that the va does not intend to release the under lying of the employees' transcript. he's to ensure that the future efficacy of executive branch finding processes like the aiv. in order to get to ground truths, those charged of the

department must be able to count on employee witnesses to be completely forthcoming and candid and not just with the facts but opinions and exceptions on theories of what's happening and why. the best way to ensure complete candor is to remove any fear that witnesses may suffer for spee speaking up. to expect an opinion of insight concerns, they provide through a consecutive branch that's provided to and potentially judged and second guess by the legislative branch will chill our ability to get relevant information regarding to the root causes of our process and risk creating the appearance of politicizing of functions. i submit to you that the minorities request is very reasonable. therefore, we are prepared to

support the subpoena if you will amend this and take references to unredacted documents. hang on just a minute. let me see if i can figure out how to make it happen. i do want to satisfy, yours and the va. we are talking about whether we can insert a sentence that satis satisfies you and protect the whistle blowers. we might suggest is just take out any reference of unredacted.

>> no, we cannot do that. what you are talking about is one particular area. we need to move onto the hearing. i don't know if we can do this but i would like to do this. can we take a vote? we are going to take a vote subject to on agreement. i want this done today and if not, we are going to go ahead and push and if it falls into a partisan vote, it will fall into a partisan vote. >> i request that we'll push this to next week until we get it to a satisfactory.

>> what i am asking is for you to trust me and the ranking member to work on a solution that is sufficient and if so, if we do then the vote that's taken right now, if it is procedurely approved and i think we can do this then this subpoena would be issued. if not, i am going to go ahead and take a vote. if the ranking member does not want to do that then say no. >> i just said that. >> we can work together as far as language. >> no. right now. >> it is going today. >> now? >> it is either going today with your votes on our side or going today with the majority as it is.

your choice. >> okay, here is what we are going to do. we are going to go ahead -- i am going to take a motion of subpoena. we got a lot of work here. >> we have to rule 2 m 1 b and rule 3 clause g of this committee. i will hear a motion for mr. lamborn of this issue. the department to produce all documents indicating the amount that's spent and the process of spending on art work and furnishing from fiscal year 2010 to present. as well as the entire investigative files and all interviewed transcripts and tachmetac

attachments and pertaining to the administrative and inve investigative board or aip. do i hear a second? >> we are moving forward. >> we are done. i gave that opportunity to the rank of members that i did not get. all those in favor will say aye. >> aye. >> and no. >> no. >> the opinion of the chairs, the ayes have it. i am signing the for the production of documents here by directed this issue of support of this. this concludes our business hearing fo

. i want to thank everybody from joining us on today's hearing on the commission of care and the future of the va's health care system. you remember that the commission on care was established two years ago by the veterans' access choice of accountablea e accountableableaccountableable act -- the commission's final report was delivered at the end of june.

and with us today to discuss it, and the 18 recommendations that includes our commission on chair, chairperson, miss nancy and vice chairperson, doctor toby grosse. i want to thank them for being here today and i truly want to ex per express by gratitude with them of them putting in the important work of the commission. i want to thank many organizations and other stake holders that provided statements for the record for today's hearing. the advise and councils and support offered by our va's parters par partners as we work everyday. impersonally grateful for the input that they have provided me as chairman and will, i am sure continue to provide this committee as congress moves

forward to strengthen the va health care system for future generations of america's viewers. like me, the vso's and by and large, we are supportive of many of the recommendations that the commission has made. the commission recognizes of the health care system has made strengths as well as weaknesses. moving forward, it is important to ensure any -- va under goes preserve those strengths which includes provision of care equal and equality that's outside the department's walls. va's weaknesses which includes persistence and access failures of non compliance and a lack of accountability and billions of taxpayers' dollars lost to financial mismanagement of construction projects to it

program and poor performance employees and more are growing. this is evidence not only by the commission of 300 page final report but by the thousand of pages made up last year independent of assessment. the years of work performed by this committee, the gao, the va inspector and most importantly by the daily experiences of the millions of veterans who we lie on va for care are all too often left disappointed. i only agree with the commissions calling for an integrated va community care system, modernizing va's out dated system and better managing va's vast capitol assets and reorganizing the veterans health administration central office and reviewing eligibility for care and light of the modern health care landscape and much,

much more. >> however, i disagree as the administration and many of the commission of a commission called for a establishment to provide governance and long-term direct and reforms. our nation's second largest bureaucracy care and challenges that are deserving of our detailed consideration. given the crisis that seems to erupt on a daily bases where va is concerned and any efforts to shield the va health care system and executive and legislative branch over site is a non start. not to mention unconstitutional.

the debt that our nation knows is a debt that we all share representing a combination of a unique moment in history. for va and veterans that va exists to serve. there has been a likely will be other commissions to vote in examining the va. that is providing assessable and high quality care to our nation's veterans. it is incumbent on all of us, not to let this fall by the waste side like so many have. this is not one that'll sit on the shelves that'll gather dusts. ignoring this opportunity is a dare election of our duties. the scandal of the va's have opened doors to changing this systematic culture and deeply

entrenched problems facing the va and he will care systems. translating that into lasting and meaningful reform will require a commitment to having uncomfortable conversations about how as a nation we can begin to pay the debt, we owe the men and women of our arm forces and taking risk that are necessary to challenge the status quo that have let them wanting and waiting. whoever sit in this chair after me will be responsible for and i am sure will be more than capable of moving the balfour ward and i am hopeful that today's hearing will help set the phone for that. with that, i will yield to the ranking member, mr. takano for an opening statement. >> thank you mr. chairman for calling today's hearing. since we first learn of the wait time controversies in phoenix.

this commit knee htee has been path of veterans' affairs. this gave us a good view of the va health care delivery systems and manage ing the process. a year later of the enactment and the veterans health care improvement act of 2015 requiring the va to come up with a plan to consolidate all care and programs. now the commission on care has released its recommendations for transforming veterans health care over the next 20 years. now, i am pleased to receive this recommendation but i am disappointed of the va -- and the legislation, the va has 60 day to comment on these recommendations and provided a response late to us last week.

i have already gave my disappointment of commissioner michael buck lwere not able to . it needs to be apart of the discussion as this committee weighs it forward for the va. >> no objections. with all the reports and studies that we have seen over the past two years and it is clear to me that the status quo. the va that we know is unacceptable. there is an important balance between transforming the va, well maintaining the services and support that millions of veterans rely on. now, i am concerned that some of the commissions may in fact

fact, -- much like i have seen happening with charter schools and proposals to funding of private contractors and private care will take resources away from our veterans and should be immediately rejected. shifting resources is the pay for care will have impact for our veterans. in addition to reducing quality, it could deprive the va of cutting edge medical research and it innovation. topnotch clinician training and stifling va's visit ccritical r. we cannot view expanded choice or the private sector as the panacia for solving challenges. long wait times impact private care, too. care the community should be locally targeted to augment and

not to replace the va. instead of stripping additional resources from veterans' health care, our first priority is making sure the va has the st f staffs and resources they need. downsizing, with unique health conditions and urgent mental health needs to navigate a private sector is bad policy. lastly, another big concern that i have is the cost associated not just the recommendations made in the report, but with whatever solutions we agreed on that makes the va efficient and capable of providing more timely health care to our veterans. it is incumbent pond upon us to our veterans. to defend the rights and workplace protections of the

114,000 veterans who work at the va and their co-workers who served everyday. again, i appreciate the work on the commissioner care and the commissioner care work that's done. i am looking forward to hearing your testimony today and thank you, i yield back my time. >> thank you very much. members, as i mentioned earlier, joining us as our first panel this morning is miss nancy and the chief executive officer and the henry ford health system and better known to many of you as toby, the vice chairperson of commission on care and the executive on care, i appreciate with all the hard work that you put into the work of the commission, i understand that you will be presenting oral testimony this morning, just as you both provided written testimony. with that, i'm begin with you,

you're recognized for four or five minutes. if you do go over and your red lights are blinking, we'll not gavel you down because we are interested in hearing your remarks. you are recognized. [ inaudible [ inaudible ] thank you for the invitation to discuss the report of the submission commission on care for the support of the commission over these months and extension of time to complete our work. it is truly a privilege and an honor to share the commission of the road map to improve veterans' health care for the next 20 years. i am pleased to be here today with my colleague, toby, who

also presents after my testimony. >> for 35 years, i have served in senior leadership roles at large hospitals, i have been in detroit at henry affordable healthcare 13 years. henry ford is an integrated health system with $5,020,000 employees that owns a large system as well as insurance company. and making capitol investments in our community and won the quality work have prepared me very well for the demands and complexities of the commission's work. i am proud to be here with one of our veterans, spencer hoover.

he served as an airborne infant infantry with two combat tours with one in afghanistan and one in iraq. he's honored with six medals and 70% disabled. spenc spencer, if you would recognize yourself. [ applause ] with me today are susan -- three staffs. john and ralph are also veterans. our commission was composed of diverse leaders and two-thirds of whom are veterans and five have served in significant house leadership roles and three have served in the va and four have been leaders ander v service organizations. we developed several principles

to guide our work and creating consensus and being data driven and creating actionable and recommendations and focusing on veterans receiving health care that provides optimal quality and access and choice. the independent assessment report that the commission is in valuable as a foundation for our work. a comprehensive system focus details report revealing of troubling weaknesses in the vha performance of capabilities. our work took place over ten months with twelve public meetings over 26 days. we sought to have the input possible and we had intense debate over the issues. our unified focus throughout the process is what is best for our veterans. i believe we produce a really

good report of transformative. the vha requires transformation which is the focus of our recommendations. there are many blairiglaring pr including staffing and facilities and information technology and supply chain and help despairty that threatened the long-term of our system. transformation is not simple or easy. it requires stable leadership and major and strategic investments and a capacity to reengineer and drive high performance. they believe that government

cannot run. veterans should have the same choice of a medicare beneficiary should have. empl we believe that vha should be invested in for several reasons. one is the model of integrated care. the clinical quality that is comparable or in some cases better than the private sector. the history of veterans focus research and medical education and emergency capacity especially rehabilitation. the role is providing for millions of complex and low income veterans that could not be filled by many markets. kna

in fact, as we have seen the implementation of affordable care acts, the shortages of primary care physicians and mental health providers of many markets across the country. our recommendation falls in four major categories. first, creating a system that integrate vha and private sectors and other providers. vha will continue to provide and fully vet the provider network to ensure that veterans receiving care from the individuals who understood and the need for access and transparency of performance and many other critical criteria. we included the fact that veterans should have a choice of primary care providers within those networks to ensure the ease of access and meeting their needs. the second category is leadership system and governance focusing on con annuitinuity to implement these recommendations.

we recommended a board of directors providing over sight and expertise that's critically needed. in the third category focusing on information technology and facility management and performance management and human resources and work force and supply chain and diversities and health care. we have a category of eligibility and focusing on the need of discharge veterans who have health care needs and retrospect and eligibility design. the objective of every commissioner throughout this process has been that our report did not and did not sit on a she shelf. we ask that you provide va needed authority to establish

integrated care networks. we are asking to address the fundamental weaknesses and providing more flexiblilitiefle. waving or suspending the -- and medical facility leases and lifting the statutory threshold and facility project and reinsta reinstating -- easing for a time limit. and establishing a line item for vhi it funding. also, creating a single personnel system for all vha employees to meet the staffing

needs of our health care system. i would like to amplify one very key point which other commissioners view as foundational. the commission saw vha as equipped to carry out successfully of the kind of long-term transformation required to invigorate health care. continuity leadership cannot be assured under governance framework marked by senior leadership. the commission believed that two fundamental governance changes were needed. establishment of board of directors of authorities and set long-term strategies and change in the process of official designated of the secretary health. we work with health economists in modelling different options. in our discussions that's been the question, should the nation invest further in va health care

system. our report answer that question affirmative and it under scores for the need of a sweeping change in the system. we do not suggest that at all that congress made a substantial investment in the system. rather we call this strategic investment in a much more streamline system that aligns va care if the community. in my judgment of the central challenge that's identified in 2014 approved access to care and improve care quality and contribute to improve patient well being. it is a vision that puts veteran first. my experience tells me that while strengthen the system while providing strengths and accountableab accountability. i would be pleased to be a continued resource of this community as you continue on your work and i will be happy to answer any questions since i

know toby will after his presentation. thank you. >> thank you very much. >> doctor cosgrove. >> as a member of my va advisor committee, for the course of my work for the va, i have become well acquainted with the department and understanding its contributions as well as challenges and meeting our veterans' needs. as ceo of the clinic and an $8 billion health care system serving our community and aware of the magnitude of the challenges facing va health care system leaders. mr. chairman, the veterans health care system must make

fans formati transfo transform transformative changes. the final report contains 18 different recommendations. today, i am going to address specific areas that includes the establishment of an integrated community based health system. >> solve metrics and information technology specifically electronic he will health records and supply change. given the commission's charge and access to care, it was concluded earlier on of reliance on and closer immigration of the private sector of the greatest -- not only improviini

access but greater choice. the commission considered and debated options of different choices. the recommended options in the final report reflects a consensus -- a private sector of pr providers. the commission agrees that the vha must establish hi high performance and community health care networks providing timely care for our veterans. as was said, if the challenges are the opportunity to describe in the final report are left unaddressed. we are concerned that our veterans are not receiving the care that they deserve. the commission recommends that the vha adopting a methodology to engage staffs and improve the

culture. this will help, but it will take significant time, effort, and resources to modernize and streamline such essential functions as human capital management, capital asset management, and leasing, business processes and information technology. the commission recommended that the vha should implement core metrics that are identical to those used in the private sector. veterans deserve to know that the health care they're receiving either for the vha or from the community provider is of high quality. that these metrics are put in place, it will be easier to evaluate the system's performance. and congress will have a benchmark from the private sector to compare both its progress and the improvement over time. congress and the american people deserve to know that vha is getting value for their investment. years ago, the vha was a leader

in the field of electronic health records. unfortunately, this is no longer the case. therefore, the commission believes that vha should transition to the same type of commercial off the shelf electronic health records as other providers. by using a proven product, many of the scheduling and billing problems would be resolved. further, these systems could help the v.a. identify areas of opportunity and utilization to promote better access to care for our veterans and promote interoperability which is critical as our veterans move to different care sites. finally, the commercial electronic health record would also allow vha to link financial and clinical information. a critical functionality for running a modern health care delivery system. the best and most prevalent commercial electronic health

record programs allow staff and patients to schedule patients' care easily and provide legitimate performance measures for wait times, unit costs, clinical care outcomes and productivity that conform to those of the rest of the health care industry. many of our country's best hospital systems have converted home-grown information systems to commercially-based systems. vha must do the same to remain in the current and engage the rest of the health care delivery system. it must also have its own leadership, specifically a chief information officer for the vha information system that allows vha to adjust its information needs as the health care industry evolves. as a vha contractor, cleveland clinic has experienced firsthand the burdensome, antiquated system that is currently in place to receive payments. we are required to provide

documentation and hard copy of forms sent via the postal services as they cannot accept fax, e-mail, or other electronic submissions. if a request results in more than 100 pages, we must burn the records to a disc because we do not have any mechanism to track whether the documentation has been received, we have heard on many occasions they never received the paper records and we have no recourse other than to send them again. the independent assessment that congress commissioned found that the vha should keep claims adjudication and payment separate from its care delivery. the health care system that the commission envisions for the vha will continue to expect exceptional performance from its network of providers and providers should expect timely and accurate payment in return. supply chain is another area ripe for vha streamlining.

the commission's report stated that purchasing processes are cumbersome, which has driven v.a. staff to work arounds and exacerbates the variation in process the v.a. pays for products. the v.a. should consolidate and reorganize procurement and logistics for medical and surgical supplies under one leader. vha has enough market share to leverage prices that could result in savings of hundreds of millions of dollars. at the cleveland clinic, we constantly evaluate and review our supply chain products and processes. today, our supply chain is working with teams of clinicians led by a physical champions to justify purchases by engaging clinical staff and the value based sourcing effort that illustrates that cost and quality do not have to be mutually exclusive. clinicians are made aware of the cost and outcomes are associated with different brands.

once the clinical staff has to justify the higher cost and understands whether it will add value to the care, outcomes based on empirical evidence, they make purchasing decisions based on value. such efforts are then integrated into patient management and inventory management to insure the appropriate use of our resources. a clinician engaged value based supply chain management practice model has allowed us to save $247 million over the last several years. we are continuing to reform our process by entering into purchasing consortium with other providers and are continually searching for improvements and cost management. leadership is the key to transformational change. the commission speaks to the need to create a pipeline of

internal leaders and to make it easier for private sector and military clinical and administrative leaders to serve in the vha. market-based pay is critical to bringing in leaders capable of taking vha to the next level. the commission also proposes that congress provide vha governance board to provide a long-term strategic vision and successfully drive the transformation process. both the chair person and i would be happy to talk more about this aspect of the report. mr. chairman, transforming a system as large and as complex as vha will require streamlining multiple services, redesigning care delivery and more. this report offers a road map to success. realizing the vision the report proposes will require new investments, both financial and in expertise, enactment of legislation and strong leadership. thank you for your attention, and i'm happy to address questions. >> thank you very much, doctor. we appreciate you both being here.

for either of you that would want to answer this question, do you agree with the president and the secretaries who have both stated that many of the commission's recommendations are already being implemented via the my v.a. initiative? >> i think that it's difficult for us to really evaluate that because we're not within that structure at this point. but i think in terms of strategies and direction, there are many areas that are aligned. but it's hard to understand within that, do they have all of the plans that will allow that to be executed? those are the questions i would have. >> dr. cosgrove? >> i don't think we can know exactly. example, electronic medical record, we don't know if they purchased an off the shelf record or not, which is imperative. >> neither do we. we're still trying to find out the answer to that question also.

this is something that probably other members won't touch but i will since i'm retiring at the end of this term, but what do you think the biggest benefit of a brack-like process within the v.a. would be for vha and also what do you think the big impediment would be? >> just a couple of comments on the facility challenge i think that v.a. has. when we looked at the breadth and depth of all the vha facilities across the country, the average age of physical plant is 50 years. to give a comparison, at henry ford, that's nine years, and across the country, it's around ten. so the issues that v.a. will face over the time in terms of their facilities and also the fact that they're very in-patient oriented today as opposed to out-patient are really significant. we think it could provide some objective view and input on how

exactly the vha facility networks are performing today, where the problems are, and where change needs to occur. it also could provide much as it did during the military closures, you know, the opportunity for some objectivity and protection from the political challenges. closing hospitals is a very hard thing to do. i have closed three in my career, and i don't wish it on anyone. it is a very challenging thing to do. and particularly for members of congress who are concerned about job loss in communities that might happen. the opportunity, though, in health care is different than the military closures. there's no substitute. so the opportunity for jobs to be preserved in communities through more partnership with the private sector exists, and also the evaluation of other capacity within that community could serve veterans better with lower cost long term, so i think it's with that in mind that we really believe this would help the process. >> i would just add to that that

i also have closed two hospitals and realize how difficult that is and how politically entangled this is a decision making process. also, i think there are over 220 facilities right now that are not in use and have not been either sold or abandoned or begun to be taken down because it's been unable to get that accomplished through the current system. >> one final thing. there was a statement made in va's letter to the president regarding the final report that indicated v.a. is not in favor of eliminating the current choice program restrictions by mileage criteria and the time restriction of 30 days. because they don't -- they desire not to sacrifice v.a.'s four statutory missions. i know the report called for a total elimination of the mileage

and time requirement. i would like to ask if you could address why you went further. >> well, as you know, choice was a very difficult discussion among the commissioners because we had wide ranging views around choice. i think we felt that we had to find a balance because we understood the fact that there was the danger of weakening the current vha system if in fact choice was too broad. but what we did do is believe that those limitations in many cases were causing really undue problems for veterans, and oftentimes, the timing involved of even being able to assess some of those limitations caused access issues. we felt that we were erring on the side of choice of primary care provider and also strengthening the v.a.'s control of those networks. because if v.a. could set up those networks in a way that really created the right capacity, the right access, without endangering the ability

of vha to continue their important mission, that was what we were trying to find. we were trying to find that sweet spot between choice and also the issues of maintaining a system that is critically important. >> go ahead and yield to mr. takano for his questions. >> thank you, mr. chairman. many of the national veterans service organizations are very troubled by recommendation number one. they are concerned that instituting choice as a core policy could lead to a large percentage of veterans to pursue more conveniently located community care. this could end up jeopardizing the viability of unique v.a. services. your own economist projected a steep migration to community care. i have one question for you both. what analysis did you conduct to test how this concern may play out, and second, the follow-up would be, and why did you not recommend pilot testing such a

radical change as this? >> well, we did actually talk a lot about how do you roll this out, and felt that probably a phased approach to really test some of the assumptions was important. there were many commissioners that spoke to that issue. the execution implementation is very complex, and it will take time. i think it will require, much as any major change does, some testing and refining and continuing to tweak this. but i think on the choice issue, it's important to balance this question of choice and making sure access is really available within every market across the country with the issue of how we're trying to also control frankly those networks to better serve veterans. so it's really finding that balance that i think is very important. >> okay, well, the commission's guiding principles called for recommendations to be data driven. what specific data did the commission rely on in

recommending that it should be organized on the principle veterans should choose to receive care from a community provider even when the v.a. can provide the veteran timely care in reasonable proximity to the veteran's home. >> if you think about the v.a. system in the way we did, it's not a question of v.a. versus the provider in the community. it's one system that should be operating in a much more integrated way, and every provider that is within that vha care system then would be able to provide access for veterans. so it's a different mindset than today. and i also think it should be balanced against all of the investments in improving operations we're recommending within the vha. >> okay, let me ask you this. as you know, the v.a. health care system is necessarily very transparent when it comes to wait times and health outcomes. how does the ford health care system and the cleveland clinic measure wait times? do those health care systems or for that matter, any private health care system, post wait

times publicly, and if not, why not? >> we actually do. we have an electronic system where people can call in to clinics and find out wait times for that day, for same-day access. the other thing we have really changed is the whole notion of access. we now believe that same-day access not only for primary care but specialty care is a standard we're setting for our health system. >> ten years ago, we instigated same day access. we now see 1.1 million same-day. and the waiting time from door to doctor is ten minutes. >> would you expect for private providers participating in this system in an integrated network to be held to the same wait time rules and requirements as the v.a.? >> yes. >> yes. >> so i'm also concerned about your recommendations to expand veterans choice to all veterans regardless of the day's waiting or distance, i'm concerned that it's financially unsupportable

and may weaken the v.a.'s health care system and increase the share of veterans care provided outside of the v.a. did the commission look at the cost of these recommendations and how this might affect the vital research and education missions that the v.a. conducts for the good of the nation? >> we did look at cost, and we have included estimates in our report around what we think that would mean. it is hard to know, though, i will tell you, there are certain assumptions as you go into the cost estimates that are based on certain assumptions that may or may not actually come true. and part of the question is how rapidly can some of the improvements in operations to improve access within v.a. be put in place. because it's quite conceivable that more patients would gravitate to v.a. for many reasons as opposed to always assuming that they're going to go in the private sector.

it's not as clear as some people would like it to seem. >> a point on the last point, there are a number of veterans who currently do not get their care from the v.a. since the v.a. improved their access and improved their ability to take care of them that they would migrate to. there's 22 million veterans across the united states, only 6 million get some care from the v.a. so the assumptions are very difficult to project. >> okay, thank you. mr. chairman, my time is up. >> thank you very much. mr. lamborn, you're recognized for five minutes. >> thank you, mr. chairman, for having this important hearing. i want to thank the chair and vice chair of the commission for appearing before us today and for the time and effort they put into this report. we have two main challenges today as i see it. first, how do we at least insure that we take what's good in the report and make it a reality? 137 previous reports on v.a. health care have already been presented and are sitting on the shelf gathering dust. second, and this is the -- maybe

an even harder challenge, to evaluate whether the proposed recommendations go far enough. we like to use words like transformation and reform, but how willing are we really to challenge the status quo and consider bold reform? we all recommend the managerial failures of 2014 that came to light, the inconsistent care, the manipulated data and other manifestations of dysfunction. and we also remember the words of the independent assessment in 2015 which found that the vha systematic problems demanded, quote, far reaching and complex changes that when taken together amount to no less than a system-wide reworking of vha, end quote. so when will we have a system-wide reworking of the vha? i have 100,000 veterans in my congressional district, and i'll say that the calls they're

giving complaining about v.a. service haven't diminished and are about the same as it was a couple years ago before we tried to make and the v.a. tried to make some changes. they don't believe that things have substantially changed for the better. with that, mr. chairman, i ask unanimous consent that the commission report dissent from commissioner hickey and commissioner selnick be entered into the record. >> without objection. >> that's one perspective i think we should look at on an opportunity for transformation. dr. cosgrove, i would like to ask you a question about the quality of v.a. health care. according to the report, quote, care delivered by v.a. is in many ways comparable or better in quality to that generally available in the private sector, end quote. however, the independent assessment found, quote, on most major veteran reported experience of care in veteran hospitals were worse than patient-reported experiences in

non-v.a. hospitals, unquote. is v.a. care better than the private sector, the same, or worse? i know it's very broad, but it's very critical. >> it's difficult to answer that. there's only a handful of comparative studies published comparing the two care. some suggested it's better. some of them suggested it's not equal or not as good as. and i think part of the problem is that they have not been reporting the same as is reported in the private sector. and one of the suggestions that we made so that you can begin to compare the quality is to have exactly the same metrics as reported in the private sector. for example, the society of thoracic surgeons reports the mortality rates and morbidity rates of cardiac surgical cases across the country. vha is not a member of that and

does not report. that's not to say it's better or worse. they just don't report. >> okay. i mentioned earlier that commissioners hickey and selnick signed a dissenting letter. what accommodations were made to their views, if any? >> well, both of them participated in all of our discussions and had the same opportunity as everyone to put their ideas forward, which they did. and at the end of the day, we built a consensus around the report recommendations which 12 of the commissioners approved, and their dissent opinions were included on the website as well. you know, with all due respect, neither stewart hickey nor darin selnick have ever run a complex health system, and to say what we're proposing is not transformative, i think is a complete -- it's just untrue. the integration process of

creating vha care system is a significant transformative process that will take many, many years to complete. recognizing the complexities of both facilities and staffing issues and leadership and all of the components that we included in our report as well as i.t. interoperability to allow that to take place is very transformative. neither of those individuals have ever implemented a major change in a health system, as dr. cosgrove and i have, and i think we recognize the transformative aspects of what we're proposing. >> thank you, mr. chairman. >> mrs. brownley, you're recognized. >> thank you, mr. chairman. i want to thank both of you for your time and commitment on putting this road map together. i know it's an inordinate amount of time you have put in, and quite frankly, all the commissioners. i just want to thank you for it. there's much to it that i like very much, and i think it's critically important that we

have a clear road map by which we can base a discussion. i think this is really the most important discussion this committee needs to undertake, we need to figure out what the transformation is and what it's going to look like for now and into the future. i clearly believe that community partnership with the v.a. is part of the solution. i just -- particularly for primary care and some specialty care, i think that partnership is critically important. i think there are some services that the v.a. provides that the community can't provide. and so that partnership, i think, is really important. and it is, i think as we talk about this, you know, to me, i see it sort of in a sliding scale and where is exactly, you know, the sweet spot in terms of what that partnership really means going forward. so i really, really do

appreciate the report very much, and mr. chairman, i hope that we'll spend a great deal of time having future discussions on this until we can all come to, i think, a consensus in terms of moving forward. i wanted to ask, you know, a very specific question relative to the report because it certainly affects my district. in my county that i'm very close to the l.a. medical facility, west l.a. medical facility, which is a huge facility, and thank you, mr. chairman, for your leadership on moving forward with the west l.a. facility, but my veterans also are by mileage, are close enough to the facility but by traffic and getting there, you know, it can take a day to have a visit. and so we're working hard to try to expand our v.a. facility within the district. it's been authorized and so

forth, but the way the v.a. does their leasing arrangement, and you're probably aware of this, is the way the cbo accounts for it, makes it very difficult for us or anyone to approve the resources when you're counting a 20-year lease or a 30-year lease all up front. so i'm just wondering, i actually have a bill that is called bill of the better v.a. act, but what my bill would do is to sort of harmonize the way the v.a. does this, the way general services does this for other federal facilities so that we can break down this barrier the way cbo is scoring it. do you have any comments relative to that or did you discuss that at all? >> probably not specifically, but i will say around the facility questions, there was a tremendous desire on the part of our commission to simplify and make things more agile for people leading these health care facilities today.

as you know, health care is changing dramatically. there's probably as much change taking place today in the delivery of care as we have seen in 50 years. rapid changes in terms of technology and where care can be delivered safely and effectively and the ability to really create those access points from an outpatient facility standpoint. you know, we're at henry ford, we continue to built more outpatient care all the time. i mean, it's a constant effort to keep up with the access needs. for the reasons you mentioned, that's one of the reasons we took out the time limit and the distance, mainly to create -- because every market is different. sometimes you're having huge barriers that are unintentional just because of the way that market might function. >> i think that's also really important as we look at this that we have to really look at each sort of area and community and region because everybody is going to have very different needs. what about in terms of this

vision and road map, where does telemedicine fall into all of this? >> i think telemedicine is an integral part of it, and v.a. has taken a lead in many aspects. we think this is going to be something that will be ubiquitous across the country, and will greatly eliminate the need for traveling great distances. as you stop and think about the health care system in the united states, it was developed in a time where there was not a lot you could do for people in the hospital and very poor transportation. now there's a lot that you can do for people and great transportation and added on top of that is virtual visits, which are going to reduce the travel and the access and improve the access enormously, particularly in areas of chronic disease. so we're moving ahead very, very fast on that, and the v.a. has taken a nice lead there. >> one thing i would add on that point is there's also a lot of

digital health development going on today, where patients themselves can self-monitor and report information, communicate differently, and that is, i think, a great frontier as well. >> thank you very much, and i yield back. >> can i just add one thing? you know, going back to the electronic medical record. you know, once you have a commercially available electronic medical record, it allows you to make your appointments yourself on your electronic medical record, and that electronic medical record should be available to all patients. and so you have to begin to engage the patients, and one of the ways to do that is through electronic medical record. >> and i do want to salute the v.a. with the new person in charge of i.t. i think she gets what's necessary, and i hope that that progression will continue. mr. bilirakis, you're recognized.

>> thank you, mr. chairman. i appreciate it. and i thank the panel for their testimony. thank you for all these great suggestions. what do you think is a realistic timeframe for the large-scale transformations that the commission's report calls for, assuming the v.a. is already implementing some of the recommendations that claim they are making? when do you think veterans should expect to see meaningful change in the care they are receiving in terms of quality and access? >> i think realistically, we're looking at a five to ten-year transformation process, but i also think any time you go through that, you're looking for those early wins, those things that veterans can see quickly that improve their patient care experience. so there are some things, particularly in the area of technology and certainly just customer service aspects that can be improved very quickly to help veterans feel more confident in that change process.

>> very good. >> can i just add that i had an experience with changing the culture of the cleveland clinic, and it took me five years, and the organization was only 80,000 individuals. and something that is as large as the v.a., i think it's going to take even longer. >> thank you. again, we're building on that. what benchmarks should we be looking for as the v.a. implements these recommendations and do you blink the v.a. has the capability and foresight to track these relative data? >> much like dr. cosgrove does at the clinic and we do at henry ford, we have balanced scorecard, if you will, that provides data on a frequent basis that scores on patient engagement, all of the metrics that dr. cosgrove referenced that are comparable to the private sector should be available, i think, in a transparent way for people to assess the quality as well as the service provided in each v.a. facility.

i think that level of transparency and having a scorecard that focuses on regular accountable results is very critical in this process. >> for example, we report almost 100 quality metrics to the federal government on an annual basis, and in fact, we have quarterly scorecard meetings with all of our department heads going over all of these metrics, and i think you have to be completely data-driven, metric organization in order to achieve these transformations. >> thank you. understanding that not just one solution will solve all of the agency's shortfalls, how, or if you had to identify the single biggest problem, the biggest problem, what would that be effecting the v.a. health system, and what is the solution to that problem? >> you know -- >> single biggest problem. >> i think all of us felt this truly is a systems-oriented

approach that many of the recommendations are interdependent. but if i were to put one on the table, i would talk about leadership sustainability. because it is virtually impossible, i mean, toby has been at the cleveland clinic how many years? >> 13. >> yeah, and both of us have served in ceo roles, 13 years in our organizations. when you have turnover in the undersecretary position every couple of years, it's very difficult to sustain change. and i think that really is holding back the kind of transformative work that potentially could happen and obviously needs to happen. >> i think -- do you agree, doctor? >> i would say that it's one thing you can do rapidly that will change the organization, and that's the electronic medical record. that can be done in a short period of time. the rest of the transformation is going to be much longer. >> thank you very much. i yield back, mr. chairman. >> ms. kuster, you're

recognized. >> thank you, mr. chairman, and thank you for being with us today. this is a critically important report and certainly at the heart of what our role is, so we appreciate the time that you both have put in and your wisdom. i want to dive right in. i spent a great deal of time with my veterans and visiting our clinics and hospitals during the august district period. and you talk about data driven, and i agree with you. i just want to point out one example of an unintended consequence that we face, many of us around our districts. and that's with regard to the heroin epidemic that's threatening the country. what we discovered, and this is broader than the v.a., but that the use of quality metrics with regard to bringing down the pain surveys, bringing down the numbers inadvertently

incentivized physicians to push opiate medication which then led to high rates of addiction. we have a wonderful project that the white river junction v.a., dr. julie franklin, getting out in front of this with our veterans. i met with a number of them using alternative remedies for pain maintenance, pain medication, including acupuncture, yoga, all these different criteria. and i just wanted to see if you would comment both on the risk of being so data driven that you have unintended consequences, but also your view on alternative remedies within the v.a. system.

>> much like dr. cosgrove does at the clinic and we do at henry ford, we have balanced scorecard, if you will, that provides data on a frequent basis that scores on patient engagement, all of the metrics that dr. cosgrove referenced that are comparable to the private sector should be available, i think, in a transparent way for people to assess the quality as well as the service provided in each v.a. facility. i think that level of transparency and having a scorecard that focuses on regular accountable results is very critical in this process. i think certainly other alternatives are going to be part of it. also i think education, expectations of patients is going to be an important aspect of beginning to change that. but this is an epidemic. in ohio, it is a huge epidemic. >> you've been very hard hit. we have a bill we are hoping to get attached as an amendment that would provide a pilot project for vas to do this type of alternative remedies for pain management, try to -- we've had a reduction at this one hospital.

50% on opiate prescriptions. i got to tell you, the one-on-one conversations i had and the quality of life for people whose lives have been turned around. so i just want to bring that one up. >> congratulations. i think that's a great piece of work. >> good. thank you. the other one is you talked about the safety net provider. i think that's an important consideration that we can't lose sight of. many times as i visit our veterans facilities, it is the lower income veterans who don't have access to private care can be don't have access to private insurance. this is their provider of choice. you mentioned about a shortage of primary care and mental health professionals. my colleague mr. o'rourke in el paso will discuss that. we also have a bill about physician assistance coming out of our military. i just welcome your thoughts on that approach where we can sort of grow our own and use the skill set of veterans coming out

of our military. great experience. and how we could put that to work to reduce the shortage of providers. >> i would say that the military providers are tremendous workforce for health care. we've hired over 1,000 veterans in the last five years because we recognize they are highly trained, experience and a great culture. >> great work ethic. >> great work ethic. we're delighted to have them. we actually recruit both nurses and physicians assistants coming out of the military and go to the bases to do that. >> great. >> i would just add the concept of growing your own is very important within the va system. the dedication of the veteran workforce is incredible and an opportunity to really leverage that makes a lot of sense. we are looking at similar issues of growing our own in areas that we simply can't find the talent that we need. thank you for your good work and thank you, mr. chair, for

indulging the shameless promotion of my two bills left to be attached as amendments going forward. thank you. >> i understand you did a field hearing in aurora, colorado -- [ laughter ] >> and it was excellent. it was great work. i want to thank my chair. >> dr. rowe, you are recognized. >> thank you. i want to start out by thanking the committee that put this together. it was a remarkable piece of work. thank you for taking the time away from your shops. all the committee members. this is probably the most important piece of work i've seen in my almost eight years here in the congress to really make a difference if we can implement this. during the convention, instead of spending most of my time politicking, i spent afternoons at cleveland clinic. and certainly i want to talk about brak in a minute. the way you evaluate your needs is you build the needs to the entire health care system and the entire health care system is undergoing radical changes in

the u.s. right now. shifting from the big concrete silos to outpatient, more and more surgery. 100-bed hospital today can do what a 500-bed hospital did 30 years ago. i think the va's still stuck at the 500-bed. a couple things. let me just summarize what i've heard so far. one, i believe to move this system forward we need an integrated care model that involves the private sector and the va sector in primary care. two, dr. cosgrove, you pointed out to have an electronic health system that's 20th century -- remember this, three years ago where dod and va tried to make these two antiquated systems interact and they could not. i've been all over the place trying to see how these experiments failed. a modern system solves a lot of the scheduling problems, payment problems, data problems that you talk about right now.

they've done a remarkable job of working around these problems. but there's new technology out there. the dod made that decision. the va set there right and tried to convince the dod to put in a 20 or 30-year-old system andthy didn't do it. they took it off the shelves. i think that would be something they need to do. that solves your supply chain. all those things -- helps -- that doesn't totally solve it but helps solve it. lastly i think is the brak. it may be my last term, too. you can vote for the brak and brass tax and maybe you won't be here again. i think we have to sit down and evaluate what those assets are and where -- look, where you can get the best care. the best heart surgery is at cleveland clinic. it is about providing the best care for veterans. i think that's what this is all about. not sustaining a bureaucracy but providing the best care and where that care can be given most cost-effectively. i admire what you have done. to say our committee has not provided the resources for the va.

when i came here in 2009 we spent $95 billion, $97 billion on all va care, cemeteries, disability and health care. today it is $165 billion without choice. i would say that congress has done a job. it's just -- we've gone from 250,000 employees to 330,000. in the private sector, you've had to figure out how to do it more efficiently with less people because your revenue, i promise you, has not been going up like it did. you've had for better manage. i commend you for that. my last question. do you think if we can come to the consensus -- those four things i pointed out. and it won't be easy. if we pass it, do you think the va can carry it out? and i know that you said -- i hate to put you on the spot, but you pointed out that leadership is the key for transformational change. is that leadership there? >> you know, i think leaders get better over time, also. the current leadership has been

in place a very short amount of time, actually. and i have, i think, made some progress in key areas and have set the right tone for improving access. but i also think they need some time. it's hard to judge whether that can happen unless there's sustainable leaders in place which is why we recommended the idea of five-year terms for the under secretary and having that individual actually selected by the board of directors so that that process can move forward and that individual feels the support of a group of people that are really trying to move transformation forward. i recognize that that may be unconstitutional. there may be ways around that that can help with oversight. but -- >> that hasn't stopped us from doing a lot of the consultation. so -- the question is do you think we can? because i think this is a remarkable document. i think it has a chance to put veterans and doctors back in charge of their care and not a system. i just wonder if you think we can do it.

because if you could, i think you would truly transform the health care system that veterans receive. >> i think it is going to take time. this is not going to be quick. this is going to be incremental. and it is going to take continuing change of a very big system. >> i think the key one is making a decision on vhr. i think that one is one that begins to solve a lot of these other problems. you are trying to do with different software systems that now don't work well together. >> i would just say one other point to move to that. we have -- and many people around the country have learned that you can't maintain a electronic medical record in an individual facility. it is moving too fast. that's why the commercial aspect of this has kept up with the changes and made them uniform across the country. so i think it's absolutely imperative. >> thank you, mr. chairman. i yield back.

>> mr. o'rourke, you're recognized. >> thank you, mr. chairman. i'd also like to thank the chair and vice chair for their work and sacrifice of their time and, frankly, their commitment to their day jobs in order to be able to fulfill this commitment to the veterans in this country and to the american people. really appreciate the way in which you conducted the review and made the recommendations. so just want to add my thanks to all my colleagues. i'd like you to discuss what i think is the most pressing crisis facing our veterans and the va. the single greatest unmet need right now in the system, and that is the tragic number of veterans who are taking their lives every day in this country. the new data from all 50 states is that it is 20 veterans a day who are taking their lives. think that's the single greatest

opportunity to stop these preventable deaths. if we take this seriously, confront it, and organize to provide far better care that's being delivered to veterans right now, as i hope you remember from our discussion. in el paso, because of the high number of veterans suicide, the inability for too many veterans to be able to see a mental health care provider. never mind the wait time, originally estimated at 14 days. we now know it is over two months on average. but one-third of veterans in el paso couldn't get in at all. that has prompted us to propose a solution in el paso that we're trying to pilot right now to focus va care specifically -- that care that's delivered in house -- on those conditions that are unique to service or combat. ptsd, traumatic brain injury, traumatic amputations.

military sexual trauma. there is a lot of list of these that i believe we want someone who knows how to treat veterans, perhaps only treats veterans and active duty service members, knows things to look for, questions to ask, the treatments to prescribe. is there a way to resolve that idea with this idea of a network where you do leverage capacity in the community? and for those conditions perhaps that are not connected to combat or service, we prioritize community care. but for those conditions that are unique to that experience of being a veteran, we make the va the center of excellence for treatment of those conditions. love to get your take on that idea. >> actually, we agree with that. the recommendation that we put forward really focuses on those unique capabilities of vha absolutely being supported, invested in, continue to grow and develop. because it is -- it has been shown -- my understanding is

that it's been shown that those veterans that actually seek care within the system end up with much lower suicide rate because they're being managed, their care's being managed and they are in touch with health professionals who provide that kind of support on a daily basis which is really critical for those types of needs. but, unfortunately, it's how do you embrace and get people in to the system who otherwise may not be willing to go there. i think that's one of the challenges. you're right about the fact that in the private sector, doesn't mean that people are well equipped to handle the complex mental health needs of veterans. in fact, in many cases we have the same problems, if not more acute problems, of having enough ment health providers in our community today. >> i would just say, think there are a couple things we have begun to recognize. one is the shortage of mental health providers.

increasingly i think you will see virtual visits begin to augment the shortage and help the shortage of mental health providers. similarly, group visits and group therapy for those individuals. we've found both of those to be very useful. >> i think as long as we can prioritize that excellent in care around those conditions, especially those that could potentially lead to veteran suicide, and are able to reduce the number of veterans who take their own lives, improve outcomes, improve access, i think the system that you're proposing makes all the sense in the world. we learned this summer that the vha has 43,000 positions that are authorized, have the funds appropriated for, but are unhired today. and we're fools to believe that we will ever hire all 43,000 of those. so let's prioritize within the va on those areas where we can do the most good, make the greatest positive difference for those veterans. for me that's clearly mental health in reducing the number of veteran suicide.

and then we face another issue which you raised which is how do we produce enough countries -- enough doctors in the country generally to ensure that we have capacity for veterans in the community. but i think if we can leverage the two, what we should do really well in the va, with what exists in the community today, and follow our ranking member's lead in creating more graduate medical education positions, then i think we are going to be on the path to fixing this. my time is up. but again, thank you for your work on this. really grateful for the effort. >> mr. chairman, thank you so much for the great work you did. i don't know exactly where to begin with all the things that have come up today. which strikes me about many answers to the questions is your comment about the leadership and

how critical that is to transforming the va. having not so much political appointee at the head, but like a regular hospital, a regular system that people are on the board. i was on the board. and a continuity of care over a period of time so that these things can be developed. i think it behooves us to make that happen. i see that as a challenge to this committee to take the bold step necessary to basically implement your plan. i don't say i agree with everything, but if we don't do this, we're going to be faced with 30 more years of the same thing we've been doing now. i think that's the critical take-away from this very important commission's work. and the thing that you said, dr. cosgrove, the other think i take away, is the critical need for an i.t. system that makes sense.

to me, that's your testimony of the two of you. is leadership, and the immediate action on an i.t. system which really can't be changed. i just want to bring up a question that always bugs me. and that is, when you estimate the cost of implementing these things, how did you estimate the cost of the va care? because when we try to figure out what the va is actually -- what it actually costs the va to see a patient, in the private sector we know what it costs to see a patient. all right? the va doesn't do that. how did you estimate that? because we haven't been able to get a figure on that. >> let me just say that one of the things i think that probably struck all of us that are in the health care industry was how little focus on cost va has. that was sort of shocking because we live in a world where we have to constantly focus on cost per unit of service, cost for a full episode of care over

time, creating population health management techniques so that we in fact can understand cost and whether we're contributing to value and improvements in quality. and that doesn't exist today within a budget oriented va system. i think that's one of the challenges as we looked at this cost question of how we move forward. i think one thing that probably should have been in the report that wasn't was this notion of getting more cost oriented in terms of some of the -- >> my frustration here is, what does is cost for the va to see a patient? there is like no clue. >> and in fact, if you look at the model and what's changing in health care today, we're getting away from the volume oriented kind of measures. we're trying to focus on outcomes of care, clinical results, as well as are we making a difference in terms of the efficiency of care that we provide.

so i think this is part of the transformatio transformation. how do we get metrics that are more comparable so that in fact we can determine the effectiveness of the va system over time. but i would add that i think -- if you view this in phases, there are ways to test some of these assumptions and begin to look at those cost elements that could be projected out over time so that you can really see. the other thing is this issue around facilities. if all the facilities had to be replaced versus creating this integrated model, there is a lot of potential cost savings around cost mitigation over time that i think would help. >> the only thing further i want to bring up, it is related to the way -- the status quo of the va, now one of my big complaints is that working there, i have very little input as to how things worked in my clinic or in making sure that things ran efficiently. it seems like others who weren't really involved in the patient care were making the decisions

as to how many staff to have, how to make the staff flow. patient flow and all that. i think that would come with the leadership changes. but is there any other comments you would like to make on that? >> yeah. i just think that you need to bring physicians more into every aspect of delivering care and running the organization. i gave the example of purchasing. previously physicians were not involved in that. we found tremendous efficiencies by bringing them in. and without involving physicians in leadership of the organization, i think you're missing an intellect and a set of knowledge that is necessary to have high-quality organization. >> thank you very much for your work and it is up to us to get this show on the road. >> thank you, doctor. >> mrs. rice, you're recognized. >> thank you, chairman. would either one of you want to

be secretary of the va, by any chance? just out of curiosity. [ laughter ]. >> i had that opportunity. thank you. >> so i just want to echo some of the comments that mr. o'rourke made. we recently had a veteran take his own life in the parking lot of the north port va which is so disturbing. so i couldn't agree more with mr. o'rourke about this being such a top priority for the va to handle. i also totally agree that the two issues in terms of accountability and the electronic health system, records system, are critically important. i mean every single hearing that we have, the number one issue that we talk about is accountability, whether it is for treatment of -- how whistle blowers are treated by higher-ups, wait times, the enormous cost overruns for construction projects. the list goes on and on. if you could just address the

whole issue of how you would create a more effective hierarchy. the board of directors, how would they be chosen? why do you say that the undersecretary of health position should be one that has a fixed time limit versus the secretary, someone similar to the head of the cia and the fbi. if you could just talk more about that. because to me i -- i mean i don't know if that will get to changing the underlying culture of the thousands of employees who are under the secretary and the undersecretary. but if you could just talk a little bit more about that. >> sure. well, first of all, culture starts at the top and there is absolutely no doubt in any organization that the tone that is set and the way it's deliberately carried out every single day in decisions in how leaders respond appropriately to the needs of an organization.

i think that is very, very important. as we look at the va and you have again someone who is really running the health system, at least the way we understood it, it run by the undersecretary of health from an operational standpoint. and yet that position has turned over repeatedly. so the ability to set that tone and follow through on a whole host of strategic initiatives and making decisions on a daily basis gets cut off. then the next person comes in. and it is very hard for an organization other than to hunker down and sort of wait for the next leader. very hard for an organization to embrace those kinds of changes. the board is, in our view, very important, first of all, a board stands behind that individual and helps them be better. they are there for a broad base of input, expertise, again that level of accountability which

happens on a more regular, routine and organized basis. so that board is sitting there saying, we thought this was your strategic plan. it is not to usurp congress but it is to get that performance up. congress is ultimately responsible as the power of the purse and all of the other suspects of your authority. but the idea is to bring some health care expertise in and other leadership to engage that ceo on a regular basis to make the kind of changes that are necessary. >> thank you. dr. cosgrove, the electronic health records, just what has been the problem within the va in terms of addressing that issue? >> the va started out by developing one of the first and best electronic medical records. and over time, i think they suffered from the same problem that massachusetts general hospital did, johns hopkins, mayo clinic, henry ford, that

they could not keep up with the changes that were needed across the organization. so they -- there was -- there are now 130 versions of that electronic medical record across the system. and that has fallen behind in its capabilities and also has not added the sort of capabilities that you now see commercially available. this is -- it is time to do the same thing that many other organizations have done and abandon the homemade project simply because there's not enough i.t. expertise within the organization to keep updating it. >> right. well, i want to just echo what every member of this committee has said, which is to thank both of you for really your herculean efforts. my hope is that all of us here are going to be able to see the wisdom of your report and begin

to implement it in a way that is not partisan at all because the bottom line is, giving the kind of health care to men and women who serve this country that they deserve. thank you very much. thank you, mr. chairman. >> thank you very much, mr. kaufman, you are recognized. >> thank you, mr. chairman, and thank you both for your tremendous work on this. just incredibly important. i'm looking at recommendation 10 when you talk about changing the culture of the va. it is such a corrosive culture. if we look at the appointment wait time scandal, manipulated to bring them down, by denying veterans care and maintaining a secret waiting list so people could get cash bonuses. number one, nobody was ever prosecuted for that and there was systemic. number two, nobody was even asked to give back their bonus. and so when you have a system where it literally takes an act of god to fire somebody, and where it seems like the only

people who are disciplined and fired are the whistle blowers who bring these problems forward. i mean it would seem that the root of the problems at the va are -- lie in the culture of the va. i just wonder if you could respond to that and some of the internal discussions maybe you had that aren't necessarily in this report in terms of the range of views on your commission. >> well, there's no question the independent assessment report commented significantly on the problems of the culture of the va. i think we felt very strongly that in order to change culture you have to make sure, again, sustainable leadership has to be in place and leadership that people have confidence in that are going to make those tough calls and those decisions that are appropriate. >> but if the leaders -- it become so difficult to get rid of subordinates -- >> i'm not sure i believe that. >> then over time people just don't even try.

>> well, that's the problem. people, frankly -- i've seen it in our own organization. people say, well, we can't fire people. i say oh, yes, you can. you have to work at it. you have to make sure that you're going through the appropriate discipline process, that people are given due process, which is important. but that you have to do it. that's about leadership development at all levels. that's not just at the top. that's front line supervisors, that's managers, and people that really are going to make those decisions on a daily basis about the quality of their workforce and their decisions and getting it done. >> also seems like the leadership of the va, that leaders when they are responsible don't take responsibility when wrongdoing occurs and are never held accountable. so we're talking about not just the rank and file but we're talking about -- >> but my sense was that a secretary was fired over that. and when that did happen, that's when secretary mcdonald came in.

so i think clearly there was a decision made that reflected the seriousness of the problem in phoenix. but i also think people need time to change that culture. >> i think you also have to invest in leadership training and bringing people along. i think it goes into couple categories. i think it goes into the category of experience with feedback, which is difficult and painful sometimes to get and to give. and the second thing is they have to have a certain amount of intellectual training that goes with that. and it may fall into the 80-20 or 90-10 leadership. nonetheless, you need an active leadership and training and education program which is not available now. >> i don't know how we ever really have a full discussion about transforming the veterans health care administration when we don't know what their costs are for any given specific

procedure. and we have -- as a committee we've requested that. and it is stunning that they either know it and don't want to give it to us, or they don't know it themselves. what do you think the case is? do you think they just don't know it or do you think they don't want to give it to us? >> my sense is that that needs to change. and, frankly, i think it's been based on a focus on a year by year budget process as opposed to, in our world we rely on revenues to set the level of expense so we have a very strong focus on cost. this is a very different model. i think, frankly, it would be helpful to think about how to get that cost focused more directly built into the process of the budget and how they justify expenses. >> i also think there is a matter of collecting the data. and if you don't have the data, you can't understand it. that data includes the severity

of the illness, all of that that goes in to determining how much cost per veteran to take care of them. >> thank you, mr. chairman. i yield back. >> thank you, mr. chairman. i, too, want to echo my thanks to both of you. you did exactly what we were hoping would happen in that conference committee when we created the commission of care and the request for it, that you would come up with specific recommendations to improve veterans care but you would also help facilitate a national dialogue that was sorely missing in a transformational type of way. i represent the mayo clinic in rochester, minnesota, too. they're, like many of you, will say there are different models. but there are certain fundamentals that are true throughout all these organizations and how they deliver that, educational clinical practice, and that focus on leadership. the one thing that i think is so refreshing about what you came up with, i hit on a couple of

those points you brought up, i remember ten years ago asking why we did a quadrennial defense review with an understanding that the world of 1986 looks entirely different than the world of 2016 from a resource allocation perspective to how we would defend this nation and all of that. but never done on the va. so we plodded on year to year, year to year budgets. we actually did something i thought was somewhat innovative and it took a stretch from this congress to do advanced appropriations to give a little more continuity to that, to make some decisions like your organizations make decisions. but it challenges us in ways that we haven't been. i also want to thank you. i think you are doing a very good job of stressing this, trying to remove this simplistic argument of public versus private sector or the idea that va health care can be discussed in a vacuum outside of health care in general. this gives us an opportunity to wholistically change the entire system and we know that there are going to be assumptions that maybe don't pan out the way we want. lo and behold we find in the aca a lot of people didn't have health care insurance before

like to go to the doctor now and some were sicker than we assumed in some cases. those things have an impact. instead of just fretting or pointing fingers, let's come back and find a workable solution. that's going to challenge all of us. i want to hit on the first one, this one just has me tied in knots, the board of director issue. i absolutely hear where you are coming from. if i go to the mayo clinic, they will say, this is a great suggestion. i can guarantee just like you're saying. because they may be saying, tim, you may have some expertise in geography, china, artillery, but have you ever run a large health operation? as a member of congress it is our job to try to gather an learn as much information and we are ultimately responsible for oversight. there is a real hesitanciy to give away what feels like giving away that authority but the need to put that in there. this has been challenged on the constitutional issue and challenged for all kinds of reasons. how important, if i could ask you, do you believe that mechanism is for transformation? how -- if we're going to fight this fight, it is going to be big.

and it is going to be transformational with the big "t." how do you see it, if i asked you, if we do this and you answered a little earlier, do some of these recommendations separately but you really need to look at wholistically, how important prioritized is this board of directors? >> i will tell you that probably of all of the recommendations, this had unanimity among our commissioners and i think it was felt to be, if not the most important, one of a very small number of the most important recommendations that we came up with. >> i completely agree. it is a fact that you have over 500 people trying to run the va seems a little more. >> this may be on the achilles heel of democracy that we're responsible to the taxpayers, we ultimately have to do that, giving away that authority even to a secretary is very, very hard to do.

then giving it to another layer in there. but i am with you on this that i am certainly willing to have this discussion. behind you there is a whole room full of folks who have spent decades supporting veterans. they're not in opposition to this. they are there to ask these hard questions about this recommendation, how is it going to impact. but my question to you, too -- i could not agree more, sustainable leadership. i've seen it at the macro level and i've seen it at the and i've seen it at the micro level. in the va and outside of this. it is absolutely critical. we have is to restore some trust that people want to go to work there, that it is not this assault on the integrity of everyone's there and to see a unified commitment to getting this. how many of these things do you think should be implemented even if they could be through internal rule making on the executive side? i always make the argument on this that i think we're bet egg off if we do it, we keep responsibility, we have ownership and we have the american people behind us. it takes a while, but do you see that we should just enact some

of these and get moving or should we have this national debate and fix it through this way? but i think that our staff really identified in the report those areas where congress really does need to take action, and those areas we felt could be done within the executive branch. but the truth is i think everyone in this room acknowledges, this is a bipartisan issue. these are our veterans. it's critically important that we find a way to deliver better health care and we felt strongly that in the area of leadership and governance that new structures were needed in order to provide that oversight, whether it's the i.t. project. i will tell you, at henry ford, we had a special committee of our board to oversee the implementation of the epic system. >> well, i thank you for that. i think i echo you, this physician leadership piece i really have buy-in on that.