sometimes referred to as gaming strategies. paragraph three, and this is the key of the question, and the key of the issue, for your liststance attached is a this practices identified by a working group chartered with the system redesign office. be cautioned that since 2008 additional modified gaming strategies may have emerged, so do not consider this list a full disruption of all current possibilities or other inappropriate scheduling practices that need to be addressed. these practices will not be tolerated. are you familiar with that memorandum? >> i was not -- i am not. >> i am familiar with that memorandum, yes. >> if it is not going to be tolerated, and for over four years ago, you had eight pages of known practices for gaming the system, what action if any

-- i do not think any took place -- did the v.a. take to respond to the memorandum that to see to it that hospital directors followed their orders? >> we have worked very hard to root out these inappropriate uses of the scheduling system and these abuses. we have been working continuously to try to identify where those sites are and what we need to do to prevent that from happening. it is absolutely inexcusable. the scheduler's response validity is to nature that that program is administered with integrity. >> what do you do when you uncover one? what do you do to hold them accountable? >> the individuals are held accountable. i cannot give you an example of specifically, but if someone were found to be manipulating the scheduling system, they would be disciplined. >> would they lose their job? >> i do not know whether that is

the appropriate level of punishment or not. >> we can probably give you a little better answer to this, because you're focused on scheduling. in 2012, we involuntarily removed 3000 employees for either poor performance or misconduct. in 2013, another 3000 employees were involuntarily removed, and among them there were some senior executives as well. >> are those removals reassignment within the v.a. health care system? >> some may be reassignment. others were departures. some retirement, and others by in effect being let loose by v.a. well, i have read this entire memorandum, and there is no gray area. it is not we think this is

happening. it is we know this is happening, and there may be other ways of gaming the system. it talks about it is done specifically for the purpose of improving scores on assorted axis measures, which i guess means the way in which their performance is evaluated. is that correct? i'm going to take your direction here -- i would assume that that -- >> i would assume the assistance redesign office group -- you know what the system redesign offices? >> doctor? >> yes, the group that is weponsible for ensuring that are designing the work within our clinics and operations in the most effective and efficient way, and they have been given at theytime -- at that time were given responsibility for keeping track of access. >> and it says that the listing

of inappropriate scheduling practices was identified by the working group, so you have a group within the veterans administration that identified on the 26th of august, 2010, various and numerous practices where numbers were being manipulated for the purpose of better outcomes, i presume, in terms of how those people would be rated. it would seem to me there should have been a systematic practice where the chain of command would see to it that was not tolerated as the memo said, and was an ability to be had, including the loss of a job. did agree with you, and we institute that appropriate level of accountability. i will find out. i do not know whether anybody was physically disciplined route that issue. this has been an important thing to us for at least the last four years, and we have tried to root out those places where the scheduling system was being used inappropriately. >> i know my time is up, but let me say two things.

one is for the sake of the and cavity of the veterans administration, you need to find out if there is an accountability system to respond to this memorandum from 26 of august. i would ask for consent to cement this memorandum for the record. >> without objection. senator blumenthal? >> thank you. again, thank you to you and the other veterans who are here who are listening for their interest and involvement in this issue. secretary shinseki, can you tell me how quickly we will have some preliminary results to both the review and the ig investigation? >> the inspector general has his own timetable, and i do not have insight into what that is. on our audit, we're taking care of hosting a large facilities this week. there will be some follow-up next week, perhaps in about three weeks we will have -- then

able to us of all the data, do a good analysis, and then respond in detail the way that -- guest: can you commit within three weeks you ever report for us? >> i think we should be able to do that, but that is preliminary reyna. i do not know what data is being assembled. we will shoot for three weeks. >> i apologize for interrupting, but our time is limited. as part of your management youponsibility, don't believe and i certainly believe that there is a responsibility from the ig to complete this report as quickly as possible, in a matter of days and weeks, not months? >> i agree that it would be helpful for the ig to complete his report as quickly -- >> and you gave the ig deadline? >> i'm not able to do that.

the ig is an independent reviewer here, and once i turn this over to him, i am primarily supporting his needs here. raise the elephant in the room. isn't there evidence here of criminal wrongdoing, that is, falsifying records, false statements to the federal government? that is a crime -- >> should become a yes. >> would it not be appropriate for assistance from another igncy given that the resources are so limited that the task is so challenging and the need for results is a powerful? i will work with the ig to make that available to him, if that is his request. l, may i suggest respectfully, mr. secretary, that it is your responsibility

to make that judgment about the and withoutes, rushing to judgment, to reach the conclusions to involve appropriate criminal investigative agencies, if there is sufficient evidence of criminality, and in my judgment, there is more than sufficient reason to involve other investigative agencies here and like of his evidence -- in light of this evidence, of potential false statements to the federal government, and the need for timeliness and promptness in results to restore trust and confidence? what i'm hearing from my colleagues is the background about the systematic failures and the need for also greater transparency and accountability, so let me ask my next question -- >> the discussion i have had on resources, and repeated them with the ig to make sure -- again, every discussion of

whether you have ienpouough resources, each new discovery adds to that workload, and i would have that discussion with him again. >> let me ask, will you change thatmanagement team given the background here shows systematic failings over a period of years, not just months? >> senator, i do not want to get ahead of myself or head of the ig here. i want to see the results. i want to see the results of the audit. and if changes are required, i will take those actions. >> give this evidence that we have seen already is as powerful as it seems to be, wouldn't changing your management team be appropriate? >> perhaps. i'm still wait for

results for the audit. >> thank you. >> thank you. >> thank you. mr. secretary, i point out in my opening statement about the ig investigation about the treatment of a blind female wasran in the way she treated in the emergency room in a v.a. hospital in las vegas. have you had an opportunity to see the results of those investigations? yeah, senator, i have had an opportunity to review that investigation, yes. >> what was the conclusion? >> without revealing details about the individual, it was that she did wait too long and that there were others that waited too long in the emergency room. it did not have any estimation of the inspector and impact on the eventual course of her

illness, but it was it appropriate that a blind vector and would have to wait that long in our merchants room. >> thanks for the answer. mr. secretary much do you agree? >> i do agree. i don't think any veteran, whatever the condition, should have to wait that long in any of our facilities, emergency room or click. >> have you received complaints about wait times for any other facility in nevada? >> i'm not aware of another facility in nevada. >> doctor? >> i'm not aware of it either. i do not know the results of our either reno or the las vegas hospital, but i have not heard anything. >> will all the hospitals and clinics have face-to-face audits? >> yes, they will. >> will the v.a. conduct more thorough audits later with the ig?

if we find that there are instances where there might been inappropriate or no activity, we will certainly enjoy and -- en join the ig to come. that might be difficult to predict. >> are you talking about a continuing series of audits -- based on what we find, if there is a widespread issue here, we will have a set of proposals of sustaining looks to make sure we have rooted out the kind of behaviors that we are talking about. either alleged or in fact. thefter conducting investigations, will you make that available to myself or my staff? >> yes. >> to any member of the nevada delegation? >> yes. >> obviously with the issues with what is going on in phoenix, the waiting room, the time waits that we are seeing across the country and in my state of nevada, and of course

the disability claims backlogs we are seeing three times longer in the state of nevada, than what it should be, do you believe you are ultimately responsible for all this? >> i am. you and i had this discussion yesterday. i think i need to provide you data that would be a little more current than three times the national average on weights of backlog claims. perhaps too at one time. i am told that those numbers are down. today's members have 355 days. that is the average grade would you explain to me after knowing all thais information why you should not resign? >> i will tell you, senator, i came here to make things better for veterans. that was my appointment by the president. every day i start out with the

to provide as much care and benefits for the people i went to war with and the people that i spent a good portion of my life doing. this is not a job. i am here to accomplish a mission that i think they andically deserve and need can tell you over the past five years we have done a lot to make things better. we are not done yet. and i intend to continue this mission until i have satisfied told byhat goal or i am the commander in chief that my time has and serve. >> thank you for being here today. >> thank you, mr. chairman. the testimony states that the core mission is to provide holly health care. is providing health care still

the v.a.'s core mission, or have the goals shifted over time as they have expanded to providing other vet benefits? passedthat congress has the v.a. to provide job training housing assistance, education assistance, reduced sharessness, so can you your thoughts about what is the core mission now, and with all these other tasks that you now have, programs that you now one, are you able to focus your core mission of providing quality health care to our vets? >> yeah. providing quality, safe, accessible health care for our veterans who have earned them is a core mission. but in order to provide that kind of health care, they still

have to access the system, and that means we have to do a good job dealing with this ability claims. if we are not able to process those claims, the opportunity to access health care is something less. for the current generation it is automatic they have five years of health care from v.a. for that group, that generation of veterans, it is a little different than others. so disability claims becomes an issue here, because that then it renders the opportunity to take advantage of health care benefits. i would say homelessness is also part of our supportability. five years ago we talked about it were ass as though thing out there. what we have learned in five years because we have focused on

-- it is depression, major factors that lead to homelessness, depression, insomnia, pain, substance abuse, substance use disorders -- >> i'm sorry to interrupt, but my time is rapidly expiring. the point of my question is that all of these areas that we have asked you to address with regard to our veterans, education needs, homeless issues, all of that, whether that is making it yourharder for you to meet core mission, and that may be a rhetorical question. let me just move onto to another area. as we look at the potential need to making systemic changes g's v.a. operates, i note i testimony where he says there's is no national process to establish what are deemed essential positions to the

delivery of health care. there's no standard organizational chart for a fev. a. hospital or clinic. it is difficult to determine what clinics are doing. would you consider these areas to be a potential systemic changes that we should be looking at making to the v.a.? >> i think that is a good inside here, and we will take a look at that. part of our challenge is the complexity of the v.a. health care system. we have a series of hospitals that go from the very largest and most sophisticated, apprehensive kind of health care, organ transplants, brain surgery. 1b's, allem these distinguishing between the level of care that can be

provided there. it is a compass system, but --ndardizing >> thank you. thank you, mr. chairman. thanks for holding this important hearing, and i hope it is the first of many hearings. secretary, as you know i occupied a cabinet post for part of my career. there are some cabinet posts by nature, kind of a lightning rod. if you are going to be the attorney general or the secretary of state, you are going to get fired at every day. it is just part of the job description. the v.a., on the other hand, in my judgment, does not fit into that category. and the other thing about the v.a. is that because of the ranking member and chair and those who preceded them --

preceded them, it is a pretty nonpartisan committee. we do not talk about republican and democrat stuff. we sai talk about how we improve the lives of veterans. i have always applauded that. i think you need more of that in washington, not less. the other thing i would mention is that there has been tough budget cycles. we know that, and yet you yourself have come to this committee many times and said us are resourcing appropriately and generously under the circumstances we thank you for that. we applaud you for that. we are going to look at this stuff, and i go, what the heck? mr. secretary, one of the submissions we got from the was a map.gion have they share that with you, or has that come to your attention? >> i may have seen a copy of that last evening.

>> this map is entitled epidemic , and itmismanagement goes down to burlington vermont, pittsburgh, north carolina, columbia, south carolina, augusta georgia, atlanta, jackson, chicago, st. louis, austin, san antonio, cheyenne, fort collins, phoenix, just place after place after place where the american legion it has thrown up their hands and said, my goodness, what the heck is going on here? do you dispute what they are saying in this map? do you think they are saying something here that is not true? >> i'm not aware of the basis for that map, but i accept that there are places, this is here, where we have had adverse events, and i would also point

out that i do not know if in all, but in a good number, majority of those events, do were self --hey identify them initiated within the veterans administration, veterans health administration. figure out what happened, get to the root causes, and then be transparent, tell people what happened. >> here is where i am getting with this. have comearings i to, or would talk about waiting lists's, disability claims, it is one thing after another. hearingalk out of the like i have been given an explanation, so i will quiet down and let you go back to work. the change that is necessary, and what worries me about this and what worries me about what we are dealing with here is that it is

systemic, it is cultural, is thise have just adopted mode of operation as the way of doing business. do you share my concern? do you feel that the v.a. culture is such that every rule this,t out, even after you say, ok, folks, from now, we d, doing to do a., b, c, you feel that people say, how do we game that? and am sure someplace large organization you are always going to have something like that. but this is part of the reason why i engage the veterans service organizations on a near monthly basis. if there are any straight shooters here, it will be them in terms of being direct with

the secretary. this is why i have spent time traveling the country, going to our facilities, talking to them about what is important, and engaging veterans in those locations as well. the voices that are most important to me are the voices of the veterans i encounter out there. i will say there is an occasional concern that is voiced to me, and i will bring it back and go to work on it, but i have not received that systemic look that is being described. there is a distinction between a medical mistake and the relation, -- and manipulation, or cooking the books. in the case of a medical mistake, i want people to stand up and say something is wrong here. something is not working or we made a mistake or i made a mistake. to do that you have to have the confidence and honesty on the

part of the workforce, and in many of those examples cited on that map, that is what initiated our concern. many relation we will get to the bottom of -- men appear later we will get to the bottom of. >> at this point, i would like -- the senators are. yet questions -- do you have questions? >> thank you. i wanted to catch that first vote as we were getting ready. again, i want to thank you very much for being here. you have for the work done in alaska, but let me just say that some of the comments i want to follow up on that other members have had, let me first start with one. and i am struggling here. let me be frank with you, mr. secretary. we havegood work

done in alaska, and we are supposed to be able to a composting that made it improvement in delivering services for veterans. and to remind folks, having 37,000 veterans is a huge amount in alaska. the bigger issue as i have listened to the senator's note of the memo and regarding identification of the issues that talked about scheduling and other issues, we talked about trust a little bit earlier. that is important. that we have trust with delivery of services and we trust the people who are delivering services to the v.a. i will tell you from my time as mayor, if you have people that have been identified to have manipulated records, we would fire them. because we have lost trust. if they are cheating, they are

not trustworthy. if you just transfer them to another part of the government, it is perpetuating what they have done, maybe in a different feel. my question is, and i know you talked about the 2000 people, you have moved tomorrow's dismissed them a retard but i want to know on this issue, have you ever fired anybody on this issue when you find out that they are not -- they manipulated records? to me it is the fundamental question, because if it is just shifted around, we are not changing the system to improve it. i do want an answer, because this to me is a fundamental issue. as a former mayor, we would fire them. they would be gone. >> i would have to give you an answer that looked across those specific reasons that we released 3000 people, senator.

manipulation is very specific. this is something for me more recent. ofhout getting ahead decisions, i would say manipulation of data, of the truth is serious with me. >> would you fire them? >> i would do everything i can -- >> that is not a question. >> there is a process here, senator. let me cannot get ahead of it so in the end i have it reversed because of predetermination. document, it last , thet remember the memo report identified people that have been doing some manipulation. reportstion is from that . was anybody fired from that

itivity question mark >> would say if there was any manipulation that identified individuals, i would expect to have seen their names, and a list of 3000, and i cannot tell you that today. >> can you get it to the record for that? >> i will do that. let me ask the doctor. not have specific information, but we can try to resurrect whether or not that has occurred. to -- i want try to say we saw that problem when i first came in in alaska. we had backlogs, scheduling issues, a lot of things. we went after it. we went after it jointly. with a program, which is going to run out of money at the end of this fiscal year.

there are bright of things to go after. we can fix this problem. we saw challenges, and the biggest challenges is we've -- is if we do not hold people accountable, we will never solve this problem. sometimes you have to have some heads roll in order to get the system to shape up, because sometimes they know this is going to get transferred, i will still get paid. what is the real penalty? >> we are not in disagreement here. >> great. i just wanted to prove that clearly. let me again say, mr. chairman, i know this is just one of many opportunities we will have. you're waiting for the report. that will give us more opportunity. reporteful that ig when it comes out there will be immediate action based on the report menotti further study of the report. ig says here are the problems, we need to get after it, because if we do not, the v.a. in this

country and in alaska will be the ones who lose out. you recognize that the veterans will be on the back end of this. >> thank you, senator begi ch. >> senator? >> thank you. mr. secretary, your testimony, you said i invited an independent investigation by the office of inspector general to conduct a comprehensive review if there are any ideations, -- allegations. if they are substantiated by the responsible and timely action will be taken. how do you define response will and timely action? >> there is a process to be able to implement those findings. decisions regarding those substantiated findings.

i will tell you i will be aggressive and assistance i can make it. there is a process here that is not entirely under my control. >> i am sure you are aware of the ig report regarding the mismanagement of inpatient mental health care at the atlanta the medical center that was released april 17 of last year. i am sure you are we're at the report regarding the unexpected patient deaths and the substance treatment program in the miami v.a. health care center, because that was released on march 27, 2014. he willg's testimony give later, it is both miami and tlanta standards of kept safe.e

would assume you would find miami and atlantic as unacceptable, and if you will, tell me what we have done in a responsible and timely manner to remediate that problem? >> in atlanta, there've been seven disciplinary actions, including the retirement or removal of three senior officials. >> and miami? >> miami and still is in proces.s we will do this as quickly as we are able to do. >> thank you. >> thank you. two questions. number one, you have heard serious problems about waiting times at various locations around the country. i think dr. petzel informed us the last few years we have seen two million additional veterans

come into the system. million new patients have arrived since 2009, with a net increase of 1.4 million. >> i would the suspect that some of the patients are coming in with some serious problems in terms of ptsd,? >> yes, sir. >> let me ask you a civil question. to what degree does the v.a. not have the resources to address that increase in patients? in a lot of patients coming in certain parts of this country, and are we seeing we think this is you do not have the resources? what is the answer? >> uh -- ability ton, the provide appropriate access to these group of veterans depends on several things rate one is the people. do we have enough people.

are we using these people effectively. are we using all the other things available to us, telehealth, fe-basis program, etc.. one of the things we are going to do is we are to look at this place that are having access difficulties as a result of this and make a determination as to whether or not we have adequate resources there. do, but wenow is we need to look carefully at those places where we are having access issues, to see if it is a resource problem. >> that may conclude, and -- >> may i add, this is not a once and done or whenever we have a crisis we do. this is an ongoing set of looks at ourselves. our patient load. grows each year complexity of the issues, as you describe. this is an ongoing assessment that we tried to get into the budget process so there is an

orderly decision-making. >> at me thank you for being here. -- let me thank you for being here. i would like to call up our second panel.

>> the v.a. is a little bit different than other agencies, because while there -- while it serves all the people in our country, it has a very special constituency. people who have put their lives on the line to serve our country. representatives from many of the major organizations. thank you very much for being here. are all interested to hear about your experiences with ca health care services. you know more about it because your people access the system every day. i look forward to hearing your suggestions and your criticisms of how v.a. can do better.

i would like to remind each of you to keep your oral presentations to five minutes, and of course, your false statement will be printed in the record of the hearing. our guests today are daniel r, the national legislative director for the disabled american veterans, the chief policy officer for the iraq and afghanistan v america, the president of student veterans of america, the beauty director of national legislative service veterans of foreign wars, and the executive tractor for policy and governmental affairs of the vietnam veterans of america. i want to thank all of you for your honorable military service and for being with us today. commander, we will begin with you, please. >> good afternoon. yesterday we learned of a

veteran in vermont who died while trying to get mental health care from his local v.a. his wife complained he would have to wait for hours just to be bounced around to different counselors. the american legion expressed our concern about his very issue for the house veterans affairs committee at the beginning of april and again before this committee at the end of april. our testimony is a matter of public record. members of this committee, on behalf of the 2.5 million members of the american legion, plus another million of uxiliary, thank you for allowing me to share my views. two days ago i was in phoenix. i hosted a veterans hall meeting which lasted almost four hours. 200.s attended by over 60 two spoke passionately about scheduling issues and other concerns at the hospital. i will be happy to sit to scuff the details of that meeting

during the question and answer time if you want to hear more about the session. i'm here today to help you understand why the american legion believes the v.a. needs to address deficiencies and let you know the american legion fully supports the department of veterans affairs. we supported the creation of the veterans administration in 1930 and fought hard to get v.a. elevated to cabinet level in 1989. we donate hundreds of thousands of hours each year to the v.a. along with billions of dollars and have scores of claims representatives. we have fund a brain research center in the center and are representing 750,000 veterans as they file their claims. >> the allege of the secret waiting list in phoenix that are now being investigated along with the 40 or more patient deaths have rocked the veterans' community.

we understand six additional v.a. locations have been identified in wait time manipulation. the allegations in phoenix were not the only reason the american legion decided to call for leadership change at the v.a. they were the final straw in leadership failures that include, construction delays and cost overruns, patient deaths, atient infections due to unacceptable waiting times. failure to create a joint health care record for -- used by the department of defense and department of veterans' affairs and refusal to answer to nquiries and disclose relevant truths. senator mccast cull is concerned at the st. louis v.a. and wants

to get to the bottom of it. the list continues to grow. when are things going to get better. a day cannot pass without problems and diss with delays and quality of care challenges. while we wait for things to get better, hundreds of thousands of veterans are waiting for decisions on initial disability claim or appeal which prevents them from receiving treatment. while we wait, service members are falling through the cracks due to the inability to create a single interoperative medical record. while we wait, officials in v.a.'s central are preventing them from being transparent. while we wait, veteran suicides continue to plague our nation at 22 per day with no clear strategy on proactively addressing suicides. i would like to thank you for this opportunity to speak with you today and welcome your questions.

>> thank you. >> chairman sanders, ranking member burr, thank you for inviting us to testify about the state of v.a. health care. d.a.v. remains concerned about allegations that v.a. employees or management took actions to skew the picture at some v.a. facilities. we support the ongoing investigation by the inspector general and will demand full accountability for anyone found to have violated the laws or failed to follow and enforce v.a. rules and regulations. we also support secretary shinseki's initiative to audit all v.a. facilities to determine whether similar problems are occurring, however we strongly recommend the v.a. include outside third party experts to increase its objectivity and correct and help regain the full trust of veterans and the american people. mr. chairman, no health care

system is perfect and medicine is far from an exact science, veterans have earned the right to expect the v.a. health care system to provide high quality medical care. while it may be weeks or months before the investigations and audits are completed, we continue to have confidence that the v.a. led by secretary shinseki can and will correct any problems identified or uncovered. this secretary has a track record of directly and honestly confronting problems and working with stakeholders to correct them. mr. chairman, we continue to believe that v.a. provides high quality health care for the vast majority of veterans treated each year and veterans are now and will be better served in the future by a robust v.a. health care system than any other mad ell of care. the real challenge facing v.a. and the root cause of the problems being reported today have to do with access to care

rather than the quality of care delivered. for the past decade, d.a.v. and our partners and the independent budget have pointed out budget shortfalls in construction budgets. in the prior 10 v.a. budgets, funding for medical care provided by congress was more than $5 billion less than what we recommended. for f.y. 2015, the recommendation is $2 billion more than than v.a. requested. you did call for an increase of $1.6 billion for f.y. 2015, but based on available information today, it appears your senate colleagues will not significantly increase the administration's inadequate request just as the house already failed to do. similarly over the past decade funding requested by v.a. for

construction and the amount appropriated by congress has been more than $9 billion less than the recommendations. for f.y. 2015, the v.a. budget request is $2.5 billion less than the recommendation, which was based upon v.a.'s own analysis. we agree with your views and estimates for the past two years where you stated that the administration budget's request for crux has been and i quote clearly insufficient to meet the identified end needs, but unfortunately congress took no action to increase construction funding. finally, v.a. needs to better utilize its purchase care authority. a.v. believes whenever a veteran is not able to get care, v.a. must take responsibility to find alternative means to provide and coordinate such

care. however, since each dollar used to pay for none-v.a. care that is less to hire new employees to treat veterans. v.a. must provide accurate estimates of the additional funding required and congress must appropriate those dollars. even with sufficient funding, ow will non-v.a. care be coordinated? there qualified providers in each community. giving a veteran a plastic card and wishing them good luck is no substitute for a fully coordinated health care. looking at v.a. and putting it into proper perspective the entire system of health care, we continue to have confidence that veterans are well served by seeking their care by v.a. we remain confident that working

with stakeholders and congress can, will and must address these challenges. american veterans deserve nothing less. >> tom tarantino. on behalf of iraq and afghanistan veterans of america, i thank you for this opportunity to share our views and recommendations regarding the current state of health care with the v.a. we have been a leader working on behalf of veterans and families to ensure that v.a. meets the needs of our community. it has been confronted with challenges and many have been overcome but still too many remain. serious allegations of misconduct have arisen from several medical facilities indicating that records are being doctored to falsely portray wait times. long wait times are alleged to

be the result of 40 deaths while waiting for care at the phoenix medical facility and since phoenix more allegations of misconduct at other facilities from coast to coast are painting a similar picture. these nepts are not new nor are they apparently unique. it is time for new pressures of accountability and oversight. our members are outraged and want to know that they are being addressed and personnel are being held accountable. v.a. needs to deliver quality care in a timely manner. we expect them to comply subpoenas. full and swift compliance will be a good first step in not only figuring out what happened in phoenix and how misconduct will be addressed and just like the secretary we are awaiting the results of the inspector

general's investigation of alleged misconduct in phoenix but we can't sit around while the investigation is under way. applaud the full audit of 1700 points but we expect action in weeks, not months. we support encourage concurrent investigations that are clearly independent of v.a. veterans need to see the secretary step out in this issue and lead we want a proactive secretary. controlling the public message is critical and if the secretary cannot do it, veterans will continue to lose faith in the v.a. system. accountability is a fundamental preliminary necessary for any organization. mismanaged care that such a thing is missing from all levels at v.a. secretary shinseki has started to emerge publicly and address these allegations, but we need to be clear that short-term reactive mers will not get rid of the problems. v.a. has a long way to go to

earn back the confidence of millions of veterans shaken by this growing controversy. although recently exposed by whistleblowers, long wait times at v.a. are nothing new. the g.a.o. has conducted studies and their findings center around lack of oversight, inadequate training, in other words, weak leadership. long wait times are one thing. they can be solved with a combination of people, time and resources. they are solveable as long as good leaders have the tools and information they need to fix it. that does not seem to be the case. instead of leaders coming forward, they appear to be fixing the books. this is indicative of a culture of failed oversight and no accountability. theons were highlighted and worst thing that can happen is he sense that the v.a. is so

inefficient that veterans lose faith. the right answer to this is not to cover up problems but to solve them or keep them from happening in the first place. this isn't just a matter of communication. it's a matter of lives. estimated of 22 veterans who die by suicide, 17 have not sought the care at the v.a. it is absolutely critical that veterans who need care feel encouraged to seek it. in order to improve care, legislation such as the suicide prevention for american veterans and the v.a. management accountability act should be enacted into law immediately. our membership and the veteran communities needs to be assured that despite these issues the v.a. is there to serve them and any charges of misconduct will be addressed and swiftly corrected. we need to ensure we need the

full scope of mismanagement and cover-up. this is why we are proud to work with you to protect whistle plorse. v.a. employees can come forward. mr. chairman, we appreciate the opportunity to offer our views on this critically important and urgent topic. we look forward to work with you to improve the lives of veterans and their families. >> carl blake is next. >> chairman sanders and ranking member members, on behalf of paralyzed veterans of america i thank you for the opportunity to testify on the state of the department of veteran affairs. no group of veterans understands the full scope of care provided by the v.a. better than our members, members who have incurred a spinal chord injury.

let me begin by saying that we are deeply disappointed by the number of reports from around the country that suggest that veterans' health care is being compromised. there are serious access problems in the v.a. i would like to associate myself to the comments made by senator isakson and senator begich. when cases are found, serious and appropriate action should be taken. if that means people have to be fired, so be it. that's what has to happen. however, we believe that a thorough analysis to understand the depth of the situation across the system should be completed before any final decisions about the v.a. leadership are made. at this time, p.v.a. stands behind secretary shinseki and he is committed to fixing these problems and should be afforded the opportunity to get it right. the narrative that has been

created by the media does not necessarily reflect what is happening inside the walls of the v.a. health care system. committee wants to gauge what is going on and how the quality of care is being delivered, i would ask you to spend a day walking around inside the local hospital talking to veterans and discussing their health care experiences, not sitting in front of a pre-selected panel of veterans to support sweeping jenlizations and to stoke public outrage. the fact is that the v.a. health care services are excellent. patient satisfaction services support that assertion. the primary complaint we hear all of the time from veterans is how long they had to wait to be seen for an initial appointment or to receive care. at its core, this is an access problem, not a quality of care problem. these are not the same thing. and to be clear, sending veterans outside of the v.a. to get private care is not the

solution to this problem. it might be part of a solution, it is not the solution. particularly for veterans who rely on the v.a.'s specialized services. the fact is there are not comparable services to blinded care, amputee care and the wide weert -- variety of care. a snapshot of the v.a. spinal chord system injury of care. we identified serious staffing shortages that exist, particularly on the nurse staffing side. the site visits that we have conducted with our medical services team were nearly three decades provide us unique authority to affirm those problems. those staffing shortages severely limit access to the system while placing the delivery of health care to veterans at risk. insufficient staffing and by extension insufficient capacity

is ultimately a reflection of insufficient resources that this administration and previous administrations have requested for health care and insufficient resources that congress has ultimately provided. he independent budget has made recommendations to adequately fund v.a. health care for 28 years. for the last several years, congress has ignored our recommendations and we are now discussing how could this have all happened. i would agree with you who indicated what the heck is going on when he looks at this and considers the budgets that have been requested. the great irony of this hearing today is the discussion about is the o.i.g. adequately funded to do these investigations? is the v.a. health care system adequately funded to deliver timely quality care?

i would suggest the answer to that question is no. >> veterans get the absolute best health care when they need it not when it is convenient. p.v.a. members and all veterans will not stand for anything less.

i thank you again, mr. chairman. i would be happy to answer any uestions you might have. >> student veterans of america, mr. robinson. >> thank you for inviting student veterans of america to submit our testimony on the state of v.a. health care. s the advocate for students of higher education, we are sharing our perspective with you today. i would like to address the veterans for whom we are gathered today. we have student veterans of america honor the service of your loved ones and stand with you seeking answers. student veterans of america is a network of over 1,000 chapters on as many campuses coose all 50 states and three countries. they comprise veterans with the

majority having served after 9/11. paramount to their success is the ability to remain healthy and utilize the health care system provided by the department of veterans affairs. in this testimony, we speak on student level issues of health and well-being with our main focus being on higher education. as the g.i. bill makes up a major portion of the benefits, we believe it is essential to consider education and the role it plays in the life of veterans who may be receiving health care. as a former commander in the army with service spanning three decades and current leader of a large organization, understand how difficult it is to be responsible for many locations and work forces. i also understand the position of older and younger veterans as i have served along side, have led and have been taught by both. many of these friends and former

leaders of mine ensure they are made abreast of the issues they face while accessing care. some veterans are student veterans are as diverse of our nation and progressing of degrees. likewise, our members have millions of experiences with the v.a. and other large institutions integral to their success on a daily basis. they are allowing the v.a. for their livelihood, health care and future success of themselves and their families. this support system for student veterans may be understood by looking at three levels of support which we term the three pillars. we encourage this committee to focus on these three pillars. pillar one, institutions. institutional support for student veterans is an important aspect of maintaining a strong pipeline of successful veteran candidates. pillar two, individuals. establishing an environment for

the student veteran to interact with the institution and the community as a determining factor of well-being. pillar three, communities. established network across university offices, academic networks and career services enables the student veteran to make the transition from the campus to a fulfilling career. it is the firm belief of s.v.a. that the v.a. has overhauled the benefits process and that the same level of production should be sought within all components of the department. over the last five years, secretary shinseki has led the v.a. as it brought g.i. bill processing times down. and in the at the same time, v.a. has paid out more than $40 billion in tuition and benefits o 2.1 million veterans and

families since 9/11. we recognize the v.a. has a long way to go. it is our sincere hope that the secretary is able to achieve the kinds of outcomes across the department that he has accomplished for student veterans with the implementation of its benefits programs. as v.a. believes that secretary shinseki is dedicated to american veterans more than ever. the v.a. has seen substantial improvements over the years. while the recent allegations are disturbing indeed, we would encourage the secretary to take swift action when the facts become clear. this would demonstrate his continued commitment to veterans who utilize the v.a. system. we thank the chairman and ranking member and the committee members for your time, attention and devotion to this cause. as always, we welcome your feedback and your questions. >> thank you very much.

ryan gallucci, deputy director of the national legislative service, v.f.w. >> thank you, mr. chairman. i wish i didn't have to be here today, but on behalf of the 1.2 million veterans, i thank you for the opportunity to share the v.f.w.'s concerns. simply put, v.f.w. members are outraged that the health care system that i use may be doing harm to my fellow veterans. what is more frustrating, nearly a month after these allegations, we still do not have the facts. we don't know who the veterans may have died in phoenix. and veterans wait for care or paid for it out of pocket. regardless of what comes out in phoenix, wyoming, atlanta, chicago, spokane or elsewhere, v.f.w. knows that veterans have died while waiting. so what happened?

the v.a. tells us the situation is improving but to the veterans affected, this is not good enough. over the last month, we see the v.a. may not be living up to its obligations to provide the best care. veterans deserve the truth, not about wait times and investigations. the v.f.w. has been frustrated at the situation, and we have been reticent to condemn individuals without the facts. whistleblowers first brought problems in phoenix to the attention of v.a. and congress as early in 2010. cnn broke the story. why are we still waiting? the v.f.w. told the veterans to call our help line to voice their concerns and connect with some of our service officers to help. while some said they were satisfied, most painted a picture of a v.a. health care system that is overburdened and overresourced and sometimes

paranoid. in north carolina, a veteran told me he can see his primary doctor once a year and sought health care elsewhere. a small sample of the hundreds of concerns, and the outpouring of concern was alarming. what is causing this failure, lack of resources, personnel or leadership? the v.f.w. will conduct town hall meetings talking to finalizes, we will invite you. veterans and families are losing confidence in the system that is designed to support them and care for their needs. if one veteran is not receiving the care he or she needs, it is one too many. we demand answers and we want those responsible held accountable in all levels of leadership. with this in mind the v.f.w. it believes it may be time to

commission a review. we hope v.a. would not deny care, but there have to be reasons why it is so long to be delivered. the culture may be focused to fit funding at every level. if this is the case, the culture must change. leadership at every level must have the confidence that if they have a need, they can ask for it to be addressed. we know capacity is an issue. the partners on the independent budget highlighted the need to increase budget capacity. utilization was at 80%. 2010, 122%. 119%. that affects v.a.'s ability to deliver care. when there is a lack of resources, they make tradeoffs. the v.a. health care system was commissioned to those who bled for our nation. the stewards of this system have

been entrusted with a system that cannot fail. it is failing, it is their duty to fix it and hold employees accountable ffment they are unwilling to perform the mission, it is their duty to ask for help or step aside. in addressing any failures, we must resist any suggestion that it is a fundamental failure in favor of an alternative model. it relieves v.a. of its responsibility. last year, the president met with john hamilton and promised he would not leave. there was a letter sent to the president. we learned last night that the president shares the concerns of the v.f.w. we ask the president to live up to its word and congress to do the same. we cannot wait for the system to slowly improve. this demands immediate action. the mission is far too important and users of this system, we

will not allow it to fail. this concludes my testimony and i'm happy to answer any questions that you or the committee may have. >> rick weidman is the executive director for policy and government affairs of vietnam veterans of america. >> thank you for the opportunity to be here today. let me say one thing that has troubled us for a long time and that is is the lack of truthfulness on the part of some people in senior grades at v.a., both in shading the truth and hearings on the hill, but also reporting up. and there is something that baffles all of us from the v.s.o. if i lie to our national president, i'm toast. i'm out of here and fired and you're gone, pal. i agree with that decision. you can't run an organization and certainly not a medical organization where people do not

tell the truth to their superiors, because otherwise if they don't have good information, they can't manage properly. i will say it is our firm contention that the majority of people who use v.a. get good to excellent care. the problem has to do with access and with poor quality assurance. it is very uneven. are not fact is there off clinicians and it is a national gouse to walter read. it is a question of too many clinical needs. and what happens, distortion in the system and breakdown of the sequencing of care and that is what was wrong with the care. that's what's wrong with the care at v.a. there are not enough clinicians and getting people the care

exactly when they need it is not happening. the question is are there enough resources and we have to say we don't know. what we have been saying for five years is when the budgets started to go up, largest increase in the health care budget for v.a. since the end of world war ii, that too many middle-middle people where positions were being created. congress gave that huge increase to v.a. to hire more direct service providers, more doctors, more nurse practitioners, more clinicians and counselors, et cetera. but it ended up that in some places the resources deployed. it may be there has to be a supplemental, but we would urge that the review and facility by facility review with everybody who is not directly involved inpatient care, you have to

justify that position and why and how it adds to the overall enterprise of delivering quality care to veterans in a timely manner in a place where they can access it. part of that problem with resources is we have said it ever they started using the formula, it is a civilian formula and does not take into account, what they use to estimate the amount of resources that they would need. .nd we have exposures to things but chemicals and on and on. what it means is that when at v.a. hospitals, the average presentations are things wrong with an individual is five to seven per individual. the formula was built on a

middle class p.p.o.'s and h.m.o.'s and they had one to three average presentations of things wrong with them. which means that the burn rate of resources at v.a. is much higher. that's particularly true as old guys from vietnam age and become from re aged and uncles korea and fathers from world war ii. presentations per individual of o.i.f., o.e.f. veterans is over a dozen for each individual that comes through. so the point is, we need to reprogram some money. pass the have management accountability on this side of the hill and reprogram money and frankly go for a supplemental if that turns

out that it's needed. in the meantime, we would urge everybody, every hospital, something we have been urging is screened -- screen everybody at the hospital for the five major and v.a. has yet to do one of these screenings on a mass basis and do it for the five major killers. ung cancer, prostate cancer, colorectal cancer and bladder cancer and heart conditions. if you screen everybody, then you don't have the kind of situation that developed in phoenix. i thank you very much. >> in general, we all are aware

and no one here dispute that there are serious problems and serious allegations, but some of you have said that the quality of care at the v.a. that your members are receiving are good to excellent. are you agreeing. is the quality of care, is it adequate or is it not? we know there are all exceptions out there. >> we would agree with your assessment, mr. chairman. the overall quality of care after they get into the system and actually get into the hospitals and clinics are very good. >> yes, mr. chairman, our members believe the same thing, quality of care when they get in is excellent. >> we find their experience with the v.a. while a bit negative, their actual individual care is

incredibly positive. that's also including the use of their g.i. bill. >> mr. blake? >> my comments spoke for themselves, senator. >> i would agree with my colleagues once the system has been accessed that quality is good. >> i would agree that the issue lies within access. to expand on this a little, one of the things i wanted to point out. i said i use v.a. and i was there last week. sometimes the person you get on the other end of the phone may not understand policies or proper procedures. when i see my clinicians, they offer me top-notch care. >> generally good to excellent. the problem has to do with case management and access to the system. >> let me ask another question,

and we all recognize, everybody up -- at your table and everybody here, that anybody who is lying in the v.a., anybody cooking the books in the v.a., unacceptable. there is not much debate. but i want to ask what seems to be a problem not all over the country but in many parts of the country and all of you referred to it is access. once people get into the system, the quality of care is pretty good. the problem is access. we have heard, mr. blake talk about the independent budget, which is the budget done by a number of veteran organizations assessing what they believe the needs of the v.a. are. i support that budget. bottom line is, do you believe the v.a. needs more funding in order to deal with the access issue, make sure that people all over the country can get into

the system in a timely manner? >> i believe it is underfunded and there should be reallocation of funds within the system. >> good point. and others can speak to that. >> i think clearly the problem rests with a lot of the management efficiencies that the administrations have tried to put into the budget. a recent g.a.o. report of 2012 indicated v.a. reduced their budget by $2.5 billion which were not realized and which are impacting the resources. so this has gone on in previous administrations and that needs to be stopped. that's like gaming the system. >> the v.a. is underfunded but throwing money at the problem doesn't help, unless you have clear lines of accountability and reform for the things that are not working. >> i would agree with mr. tarantino. you can't throw money at the

problem if it's not done smartly. there were a lot of people hired and weren't hired where the need is. our own written testimony points out serious staffing shortages. clearly people are not being hired there where there is a demonstrated need. you could do reallocation of resources but there is even more need for additional resources. colleagues th two to my right that the v.a. is underfunded but first there should be infrastructure and systemic reviews and issues addresses -- addressed and after that, where the funds will be allocated, they should be funded. >> i would agree with our independent budget partners that we support the numbers and we believe the v.a. in its current form. >> you guys are part of the independent budget?

>> yes. and i would echo the concerns about resource utilization and proper distribution of resources. in my written testimony spoke about v.a.'s capacity. construction facilities. if we don't have the space, where are these clinicians supposed to practice? we have seen that with mental health hiring. where are they going to see their patients? >> allocation of resources but i would associate, particularly -- not the major construction but remodeling and adding to existing facilities. you have to have a place to actually deliver the care. but it is -- we are underfunded and don't have enough clinicians. that's how they game the system. they are under pressure not to admit there are not enough docs. >> i wanted to ask one brief

question, which is important. when you deal with the public system, like the v.a., every problem sometimes makes the front pages. there are studies that 200,000 people are dying out there in hospitals. on the other hand, the advantage of a public system is that citizens of the country and representing millions of veterans which you guys do, you have input into the process. let me ask you this question. my understanding is that the secretary kind of meets with representatives of the organizations fairly frequently, that he wants to hear your input. is that true? >> yes, it is. we have a sit-down breakfast with him once a month to discuss the issues. >> i assume everybody thinks that's a sensible idea? >> yes. input from the veterans'

organizations, of course. >> yes, our executive director meets with both the secretary and the under secretaries on a regular basis. >> that is not true for us. we had our first meeting with the secretary at v.a. headquarters last week. >> so you have not been meeting on a regular basis? >> no. >> our executive director meets with him on a monthly basis. >> yes, we met with the secretary on a regular basis. >> we meet with the secretary -- >> thank you, mr. chairman. the v.f.w. leadership meets with the secretary and his deputies. national level. not on progress attic things. only place in v.a. that is sticking to the president's executive order on consultation

of stakeholders before decisions are made is the under secretary for benefits, because it doesn't happen in many other areas, and if it did, the decisions would be better. >> i have gone way over my time. you will have equal time. >> that's the prerogative of the chair. >> following up on the tone of the discussion, i'm going to make a statement and i would like you to tell me whether you agree with the statement or not. the question before us today is not the quality of health care delivered to veterans by the v.a., the question is access to quality of care. would you agree with that, commander? >> we do agree with that, but there are pockets within it, like a skin cancer, if you get the small pockets out, the overall system will live. if you don't take care of that, the system will die.

>> yes. d.a.v. agrees with that and i would like to point out a task force back in 2003 that president bush established to look at health care pointed out at that time that there was a mismatch of funding and demand and if something wasn't done about that, access was going to be affected and that's what we're seeing now. >> we would agree with that statement. >> yes, definitely access. >> our concerns would be access especially in rural areas. >> we would agree with that, but access that can reach into care delivery, one of the concerns we received from a veteran in nevada, he was diagnosed with skin cancer. but because a doctor had left the v.a. medical center, they wouldn't be able to schedule him for a proper consultation until that person was replaced.

>> which is an access problem. >> yes. it reaches into quality of care. >> capacity is one of the problems for access. >> it is primarily access and an additional thing v.a. is not in the medical system addressing the wounds and injuries of war and taking a military history and using it in the diagnosis and treatment. >> the reason i'm taking this track, i don't want us to leave this hearing with a mixed message. if there is a problem in quality of health care, we need to talk about that. but if there's not except in isolated cases, we need to talk about what is the problem, which is capacity problem number one but it appears to be an attitude national problem where there is a motivation to make the numbers look good than to give health care to the veteran.

anybody disagree with that statement? >> i think there have been concerns raised that the performance accountability system promotes something like that. so access is controlled in order to make performance look better. >> and capacity is a function of appropriations, i understand that. but it's also a function of the management of the system internally within the v.a. i don't ever recall, and i could be wrong, mr. chairman, us receiving a report from the veterans administration on any study its done to improve its access to capacity or improve capacity so we improve access. we have talked about time to get a determination on a disability or how long it takes to get into a v.a. center when it seems like we ought to have a thorough, thorough examination of the capacity situation in terms of the v.a., and then you have to look at the issues you addressed, mr. blake. i know you are not for any

private delivery of service. you want veterans hospitals to operate. but the option of having that access could help solve the capacity problem, particularly on a specialty like determine tolling, melanoma. so is that an idea that is not replacing the v.a. health care system but having veterans having options to access in the private health care system? >> i think veterans have even now and they are improving on it. pccc is an example. if we are going to move in that direction, there needs to be coordinated care. that doesn't work for veterans with specialized care needs like blinded care or amputation because those types of services don't really exist in the private sector at least not in the way our members come to expect it. privatized where

care plays a role or contract for services plays a role. one thing i would suggest that, is that what veterans want? veterans want into the v.a. so why would we create an option where they would go somewhere else? they want into the v.a., they can't get into the v.a. we are not sure that allowing them to go outside is addressing what their immediate desire is. >> except wants and needs are two different things and the need is the most important and if it gets them the service they need in a timely fashion even though it may not be in a v.a. hospital because of the particular problem, better than having them wait so long and have a life-threatening situation come about. >> i agree with that. >> all of your testimony was outstanding. i appreciate it. and i'm going to leave this

hearing with a clear message for the veterans of georgia, we need to solve the access and scheduling problems and we need to do it now and we need -- the v.a. needs to go internally and have accountability mechanism all the way down because i think the senior leadership is disserving the american veteran. we know what the needs are and i hope we will take this hearing and move forward and solve this problem and hold everyone accountable accountable and have an attitude of solving problems rather than masking problems. >> senator begich. >> i'm going to follow up on the senator's questions. we have had a similar problem and i thank many of you because you had concerns about what i'm about to talk about, but you were good in helping figuring

this out. we have a large american native population in alaska. we have an indian health care system which was not very, very good. in alaska, the tribes took it over. and now deliver, we consider the best health care in this country, in my opinion and i think in many other's opinions. c.m.s. has had some of the best health care in the country and because we don't have a veterans hospital, we are trying to figure out a system to create better care, access is what it's about. if you are living in nome, alaska and come into anchorage into the clinics, you could spend lots of money. we have 800 veterans in nome, squea that are native and nonnative and built a new facility for indian health

services. it is given the check to the tribal consortium that then delivers health care because of the work you did with our office, we now have access to veterans. they have a choice. can get the health care in their home or village and tell you story after story that has become very valuable or go to the clinic or go to seattle to the hospital. there was an access issue. because the care that the v.a. offers, we have great professionals. they work hard. i think they are overworked for the amount of time they have and not enough staffing. but the issue was we found a solution protecting the importance of v.a. health care, which is veterans want to be part of the v.a. health care system. they earned it and fought for it, it's a benefit of theirs. but in alaska, we had an access

issue. we couldn't afford to have a veteran waiting to catch the next plane when there is a hospital next door. we figured this out. and we have a model, which when you walk into the indian health care service, the odds of you getting a same-day appointment is 75% or better. and the question you brought up the amount of ailments is different than the model. the model, same situation, problem, too many ailments, one individual. when you come in, seen by a health provider, doctor, dentist, they meet with you as a team and resolve issues collectively rather than individually and the care and quality is superb. we have been pushing on the v.a. to look at the model. and also same-day access to be able to schedule a routine

appointment and to wait weeks or months is outrageous. and so, maybe i'm -- it's more -- i know many of you -- i point carl out because he and i had good gates on this. veterans call me and tell me thank you, not that they are not going to go to the v.a., they are going to go to the v.a. they have a choice. so i guess i would like -- you have heard my comments, i would hearing your in comments. the model is all about access. any comments from folks? >> senator, thanks for that question because it happens i was in alaska last month and they they want to expand what they are doing in that area and in a strip mall. but they also are looking for

additional space. and v.a. spent three years trying to get a lease worked up and they are frustrated. they want to do additional things. but i agree with your assessment as far as accessibility. east coast is different. as i travel to the western states, i think it is something we should build upon. >> it has a brand new hospital that will partner, which is unbelievable care. any other comments on that? i know my time's almost up. >> the only thing i would like to say, right now we have 27 points of access that are on hold because we can't get the funding and that's important that we move forward on that. going back to the clinton administration when they put a lot of construction on hold to determine where they wanted to build, v.a. has been underfunded in construction since the clinton administration.

so we need to do something about that also. more -- moran. >> i appreciate you being here. let me raise a topic about the assessment that's going on, face-to-face review across our country. one of my congressional colleagues had a conversation with v.a. personnel in jackson, mississippi after the assessment presumably took place and this is a bit of a paraphrase of his or her report back from what they heard about this assessment. we asked about their face-to-face review. the team came in on monday and interviewed some clerks and superviseors and didn't find any evidence of scheduling issues. no veterans were interviewed. what struck this person was the this nt superficiality of

so-called audit. it did not come through the electronic reports and is not indicative of a thorough review. we are going to have one more review that is to be completed within two weeks, with 1700 facilities across the country. so in part my concern is the quality of the review. it appears to me this is more of damage control to what people do when there are allegations of mismanagement, improper conduct, you have another review. and so my concern is how credible will the review be based upon the amount of time and resources that's being devoted to itment but perhaps more troubling to me is how many more reports, allegations, i.g., g.a.o., congressional hearings do we have to have before there is a different approach or attitude at the v.a. to solve the problem? and so i guess i don't disagree

with an audit across the country, but what is this really going to accomplish? will we be here six months from now which the v.a. has a plan in place to transform itself so the access issues that you all described are not the same ones that we heard today, we heard last week, we heard last month, we heard last year? the phoenix situation seems to have brought national attention to this problem, but i can't imagine that there is anyone at the table who believes that the phoenix situation is really what is the problem. it's a symptom of a much broader problem that has been ignored for a long time. let mander, -- and here, me add this, i understand that the testimony of the secretary this morning in response to the senator from north carolina in which he outlined, he, the senator, outlined a long list of audits and reviews, g.a.o.

reports, inspector general audits and the secretary indicated that he was unaware of those audits and reports and hadn't -- and therefore hadn't been used in any conclusions that i assume would be made at the v.a. there was an i.g. report included in that list that said the unexpected death report could be avoided if the v.a. focused on its core mission to deliver quality health care. it is difficult to implement v.h.a. directives when there are no standard descriptions or organizational structures. the i.g. believes it's time to review the organizational structure and business rules of v.h.a. how can that be an i.g. report that a secretary of veterans affairs would be unaware of? it's directly related to the management, organization of the department of veterans affairs. if there is one in here in my

commentary and what is what assurance do you have that when this face-to-face review is done that something will be different in the direction that the v.a. is taking in regard to creating higher quality of care for veterans and making certain that they have access? commander. >> senator, that's quite a task. with the i.g. audit, yes. in the findings, once they come out, i think this committee needs to establish a along with v.a., milestones so as to rectify these issues as they go through. but as you noted in your report, each hospital is different. and even when a director changes, a hospital doing excellent, then could possibly slip below the standard. so it's going to be an ongoing challenge and we would hope that the secretary and the v.a. would move forward as soon as possible

with the changes necessary to give us the quality health care that all veterans deserve. >> my time is soon to expire. i don't know if the chairman is allowing you to answer my question. you have indicated that you have or senior staff have ongoing conversations with the secretary or high level individuals at the department ofsecretary or high-l individuals at the department of veterans affairs. the question i would ask, does that result in a change in approach style management attitude at the v.a. that results in higher quality care for our veterans. iq for the opportunity to issue a statement and to ask the question. >> thank you. panel forthank the their testimony, their vision.ive and their i want to thank you for staying for this part of the hearing and express my apologies. i got tied up in a committee.

i will follow-up with you in private. it is good to be asking questions about this. we agree access is the issue. it is the issue. we have had everything talked about from dollars to construction to milestones to all sorts of stuff. helpful. i'm going to ask you, each one of you, because you represent veterans in this country that are being served by the v.a., i think you have an understanding of what the challenges are out there. you tell me what you would do first to fix the v.a. and what you would do second. i am assuming there will be 3,

4, 5 more down the line. is it money? is it the resources they have the need to be allocated different? do we need to put a focus on hiring professionals? you cannot say do all of them. we want to hold folks accountable. if you can give me your priorities of what we need to do, it could be helpful. assessment is the first thing that needs to happen. speakhave heard the v.a. , they have enough money. they do not have the accurate numbers. system,are gaming the how many actual visits are they going to have a year? instead of having 85 million, will of the 150 million? you cannot assess a money value to that until you make an assessment as to what the problem is. >> want to get the assessment, you follow that assessment as a blueprint to fixing the v.a.

does anyone else have anything to add? >> i have a list of four things i would like to talk about. first is resources. as our budget partners have talked about, it may not be a numbers game, it may be an allocation of resources. >> what are you telling us to do? recommend taking the recommendations on how to properly fund v.a., things like capital infrastructure. andnd would be training outreach for your gatekeepers. the people that mandy call maners -- the people who the call centers. consistency across the board. your experience at one center is very similar to your experience at another center. finally, another i want to talk about his accountability. we have had a lot of talk about accountability.

the secretary said 3000 employees were sanctioned in some way, whether that was termination, retirement, or transfer or devotion, what have you. there is a problem -- and having conversation over recent weeks, their art two things that we know. reprimanding or firing an employee is a difficult process. has significant eeo and other legal protections. it can take a long time to take punitive action. second, when there is a vacancy in the federal government, not v.a. exclusive, it can take between six months to a year to fill that. when you have an underperforming employee, you have to make -- do you make the trade-off decision -- i have an underperforming employee. is it better to serve -- have them on the books serving some veterans or terminate them and have a vacuum of care for six

months or possibly longer? bring us around to another discussion about how we can work with the department. this could apply to all agencies and government. reduce the red tape for hiring. it takes too long to get that done. thent to ask about accountability portion. myountability is, from perspective, really easy to talk about. sometimes, it is very difficult to put your finger on where the problem is, who is the problem, and quite frankly, how you deal with it. example --n -- for the argument could be made that because we have hired all of these middle management folks, you made a good point on that -- we should not be doing that. these should be on the ground folks. we have hired these middle-management folks to make sure the folks on the ground are

doing the job. how do you deal with accountability? do you contract it out? what do you do? secretary orw the is everybody else held harmless? introduced by mr. miller on the house side is a good start. people said do you favor the bill that strips people at the the a of protections, but there is a reasonable point in between mr. miller's bill as it currently is and what we have now. they cannot fire people. they say they can't, but they cannot. the lady from kansas city, they removed her as a director, but kept monday morning, we her here at government expense and flew her back every three years, paying her $180,000. they need flexibility. >> thank you. thank you, mr. chairman.

to everybody who is here, this has been extremely helpful. i think we are going to find that the access issue which you consistently say is the problem, is going to be easier to identify than resolve. i think about a va hospital needs five specialists. they are probably going to recruit from the area around and compete with private doctors, hospitals, and that is true, whether it is a doctor, a nurse, or the medical technician, whatever it is. building that capacity, even would be af money challenge. i think we agree to that. let me ask you a question. i also agree, we are waiting for

a hospital in omaha. i am beginning to wonder if it will happen in my lifetime. i am a fairly young man. i am not too old. the moneyd get all of all at once, which would be hard to accomplish, how much construction can you get up and going on and on? let me ask you a question about access. let's say we're thinking about this and we have all of this population that is needing more access, not less. be a non-arab people, a whole group of people and we are aging. we are the baby boomers and we need more access, not less. open to anmembers be idea that said something like they say iy call, need to see a health care professional because i have a spot on my leg that does not

look right. i think it might be cancer. want to see you just as quick as we can, but that will be four months or six months or whatever. would your members be open to an idea that says, if you cannot or in within two weeks, three weeks, or whatever the appropriate timeline is, you can seek private care. you can go to your local doctor or specialist or whatever. the government will pay the cost we will cover that because we do not want you to wait. we believe that is the best way be the with access to quickest and most effective way. the other thing i mentioned is in states like mine, we are a

western state, the state of nebraska. rural veterans is difficult and especially difficult in some areas like mental health and specialized care. >> what is your thought about that? --the v.a. utilizes medicine. even though there is only a utilizingy can -- by -- >> i appreciate that, how would your members react if i said look, we are not going to make you wait anymore. if the v.a. cannot meet your needs within a certain period of time, we will allow you, if you choose, to seek private care. if you want to wait, you can. >> we would not be opposed to that because we want the best health care fast as possible, ve to put ao hal

feett on that because they -- the fee-based will be higher. >> i get that, but we are saying we want the best care. >> that is the point. if you are not willing to give the a the resources it needs to allow for access in the facility, you're going to need to give them more resources i sending veterans out to the community. ba has the authority, i do not think they use it enough, for purchase care. out, if a veteran cannot be seen in a certain timeframe, they should be able to get that care by a private doctor that needs to coordinate the care, but we need to be careful that we do not start increasing the money going out to private doctors and taking away the v.a. possibility to hire internally because all we

are doing is robbing peter to pay paul. we will have less money to do it on the private sector. >> i am out of time. here's my point. if it results in better care, isn't that what we are trying to achieve? i hope i can have a discussion. >> can i address that? it is my understanding that the is envisioned to address part of the problem that you outlined specifically. that is what we want. we want coordinated care. the key is the continuity of care and ensuring that the v.a. is ultimately responsible for that veteran so they know what the veteran his roots -- is receiving. in the it is moving direction of addressing the concerns you are raising. >> senator blumenthal. >> i want to thank all of the

leaders who are here today for your presence today, but also relentlessss and work on behalf of the veterans of america. your leadership has made a big not only in the performance and outcomes in the veteran's administration, but in countless communities and other areas across the country. my thanks to you. my questions are simple. me,of you would agree with i believe, that the asestigation should hard-hitting, aggressive, thorough, and prompt as possible. the resourceses ive agencies,stigat they ought to be called on as well. would you agree?

>> i do, senator. >> we not only agree, but our national president road to the eternal -- attorney general of arizona last week and the u.s. attorney for the district of arizona, asking them to launch criminal investigations into reckless endangerment, possibly resulting in loss of life. earlier, were not here let me just tell you that i urge that the secretary of the v.a. shockingly -- strongly consider and recommend he involved the department of justice because there is ample evidence and i emphasize evidence, not just allegations of criminal tongdoing to warrant the fbi review this situation, as they

do, my. the reason is simple. not only the evidence, but also the inspector general lacks the jurisdiction authority, the resources, and the expertise to do a prompt and effective criminal investigation. only the fbi can provide the resources, expertise, and and the department of justice includes the attorney in everya and the ones in state that may be affected here. we share a determination. i believe the secretary of the v.a. shares this as well, to get to the bottom, to provide relief to anyone denied access. i think that is a determination that unites us in this room and

accountability means changing the team if necessary. there may, at some point, be a need to consider those changes as well. my thanks for being here. my time is limited. i think the chairman. >> thank you, senator blumenthal. i apologize if this question has been asked, but senator murray asked earlier as to what a face to face audit should involve. i would like to ask you and perhaps we can start with mr. bellinger, what needs to happen in a face to face audit to elicit the kind of information we need to address the challenges and problems that v.a. hospitals and clinics? i.t. has to start with first. they have to look at the process

of the books as far as what actually occurs and they have to go through the administration and the employees and also get input from the stakeholders and the veterans. >> did that happened the last time? there have been audits before. when those audits were conducted, where the stakeholders included? >> i do not have that information. >> to the rest of you have any do the rest of you have any information that will help us? >> often, we are not included. if you ask the veterans, they say, we got hurt, we got wounded. the veterans will tell you how to fix the facility.

>> would you agree that any face to face audit should include -- this is probably a rhetorical question. input from the veterans organizations as well as veterans at the particular facility. and iould agree with that would also, as we pointed out, recommend there be an independent third-party expert involved. it would alleviate a lot of the questions that were raised about the audit. i think it would help everyone be assured that these audits were being done properly and everything was being looked at. >> what do you mean by an independent third-party? >> i do not have the expertise to determine are the people cooking the books, are veterans theyng timely care, are spending sufficient time or too much time with the doctors?

there needs to be someone who is an expert in time management and accessing medical care that can be there to make a determination , are they asking the right questions and are the answers sufficient to address this problem. suggest also, if they are going to do a thorough audit, it would take more than a couple of weeks. a thorough audit would be an examination of the entire system. that might involve clinicians, nurses, whatever that may be. audit that is going on right now is what senator moran suggest happens, that is disheartening. that is not going to solve any problems as far as we are concerned. it might get to the bottom of a problem, a shallow depth problem

at a local facility, but i don't know if it will solve the deeper rooted problems. >> i would envision that an assessment of the entire v.a. health care system was involved not just in this process that has been described to us, but it would be an ongoing kind of assessment. i hope that will be the case. the secretary is still here and to heart he is taking the suggestions and comments you are providing. secretary, ine regards to all that we have been discussing, whether you think this is taking away from the v.a.'s core mission of providing health care for the veterans. does anybody care to respond? >> there is no such thing