who know they're going to be speaking and i think that will be for the >> we will take them all together first, your questions. >> thank you for having us and organizing this event and planning for it with much foresight. i have two quick questions. oft are the implications recent events in iraq for the status quo in syria? and turkey was mentioned as well during the discussion. what role has turkey played recently in iraq and in syria? part of secretary kerry's engagement strategy going forward? heres take this answer

first. >> anyone of you. so, isil's incursion expanded the conflict. a border that iraq does not recognize and has very little meaning given the fact that violence is spanning the border. it will take some pressure off of assad because the forces fighting in iraq are not fighting in syria. it could mean that the other jihadist groups in syria are going to make inroads into isil territory in syria, which, by some accounts they already have.

dynamics,ll have some but it won't change the fundamental dynamic of the syrian conflict, which is, you have a government under bashar assad who is trying to retain control. it is fighting in opposition that is largely. extreme. i would love to find that mythical moderate secular opposition in syria, but i am afraid one really does not exist, at least not in large numbers. itterms of turkey's role, will be very interesting to see what happens in the kurdish region. turkey and the pkk have come to some court of -- some sort of agreement recently, which is nice, given the amount of violence that the pkk uprising in southeastern turkey has created. it depends on this -- a great

deal on what kurdish leaders forward.d do going whether they are content with a orger stake in a larger iraq if they make a move towards independence to do that. they would need a buy-in from turkey. i don't see a kurdish state as without kurdish support. that is what i would look for going forward. >> it appears to me that what is shift inly at way is a people's thinking that jihad is our useful, and people feeling that jihad is are actually a genuine regional threat. turkey has been willing to acquiesce in jihad is organizing . it is possible that what this does, and it would be because of american diplomatic efforts and ofers, that the rise

dionysian in northern iraq would hin would be more of a problem than a problem solver. it could create greater solidarity to try to isolate the jihad groups, diminished of funding, and potentially affect the outcome, both in iraq and syria. to --r that would be done benefit thomas it does seem to me that there is an opportunity in this to get everybody on the is.e page on the jihad >> three questions in a row and then we will have answers. i was a military physician.

we are assuming that the action against baghdad is only military. what if it is not only military? a -- it mightol create a great crisis if they control the refinery. how can we react to quickly? if not, why not. ? how would you envision a consolation. what is the objective of the new government. ? >> i am originally from iraq.

there is consensus, i think, that the invasion of iraq was embedded with a lot of errors. there was a lot of bad will towards united states. want beforee now and turks to go to iraq all over again and use drones. ? will that not garner more hatred and produce more terrorists? we use drones. drones are a blind instrument despite all the technology. >> this is a question on the regional issue. how can united states attain partnerships with such questionable allies in the region, including saudi arabia, the gulf monarchies, who have been known to finance the very

groups that we are fighting against. in the event that there's is a scanner safe haven, can you state the direct threat to the united states homeland of having terrorist safe haven throughout this region? i know you have said in terms of the timing of diplomacy and those sort of things that there is time, so i would just like to question that. >> we have several questions here. each one of you take a card. as far as reconciliation is concerned, it is not a title. we're not going to bring a person in government because he is a sunni. we will not say here is a sunni token and here's a kurdish token. it is a true partnership based on the efficiency of the government and not based on their ethnic and religious backgrounds. we are bringing people together to form a unity government that represents iraqis.

to answer your question, we don't have an army. there was an ineffective army that did not shoot one bullet to sul. ct the fall of mozi a i was on a panel a week and half ago and somebody made the argument that there are more foreign fighters in syria now than in the entire history of the afghan conflict. up to 12,000. this problem of people transiting is a fundamental security issue, not just for the u.s., but for all of the region. i'm not sure there is direct help from governments in the gulf, there are differing levels of effort to cooperate to stop the financing. i think those efforts need to be enhanced. >> i know we are running out of

time, about u.s. military intervention creating backlash, i agree with you. i think it would if we did it today, because we would simply i, taking sides with malik the person who caused this problem in the first place. that is why i am saying diplomacy and politics first, get a government that is worth u.s.rting, and then military intervention could be conducted in a way that the iraqi people would actually support. >> i want to thank you all and hope you would thank me. i appreciate the panelists with their expert and professional contributions, thank you very much. >> on the next washington journal, u.s. options in iraq. as of violence there increases.

kenneth vogel talks about the creation of new super pac's. "washington journal" is live every morning. you can join the conversation on facebook and twitter. >> coming up on c-span, officials testify at a house hearing on veterans health care. then, the challenges facing working families. >> religion is a powerful identity forming mechanism. it is part of human society to figure out who is us and who is them, who is my group and who is the out group. if you eat like me, like me, if you go to the same churches i do, then you are us then you are them. you can see very easily how that them attitude can

lead to extremism and who margin of is him. it may be the most powerful form of identity formation, but just as powerful is violence. how do you know who is us and who is them? if you are fighting alongside me, you are us. if you're fighting against me, you are them. violencereligion and being used to things that are at odds, they have, as everyone knows throughout history, and much more aligned than we would like them to be. >> religious scholar and best-selling author, rexa aslan will take your calls and comments for three hours live on sunday, july 6. former texas congressman and republican candidate ron paul children'ser 7, rights advocate mary frances berry.

we're discussing the forgotten man, a new history of the great depression. join others to discuss the book in our chat room. go to the, television for serious readers. >> next, the house veterans affairs committee continuing its investigation into delays in the medical treatment of veterans. officials from the veterans administration testified at this hearing chaired by congressman jeff miller of florida.

ultimately, to improve access to care for veteran patients who have been facing unacceptably long wait times at v.a. facilities across the country. it important to those efforts is the status of v.a.'s accelerating access to health care initiative very was launched in late may in response to the department's current wait time crisis and information ,eleased last thursday suggests in court nation with the v.a.'s other efforts, have led to the scheduling of approximately from mayppointments 15-june 1. i'm glad to see the department seems to be taking its access failure seriously, is taking steps to improve the timeliness of care for veteran patients. i do have serious concerns about v.a.'s efforts to date. one of my concerns is the

continued lack of detailed information that congress has received about the initiative. this makes it another in a long and continually increasing list of examples of v.a. failing to act in an open and transparent manner. the committee requested a briefing from the department on the accelerating access to care initiative on june the second. i followed up this request with a formal letter to acting secretary gibson on june 5, requesting an immediate briefing on the initiative. sincenow been 19 days that request for an immediate briefing and no further information or knowledge meant of our request has been received. it baffles me as to why the department failed to provide this committee with the information we have requested on a program of this size and importance. has indeed's work led to 200,000 more appointments for veteran patients so far, what is there to hide? the lastrtantly, over

several weeks investigations by the inspector general general's office and the department itself have reuven that the v.a. health care system suffers from a systematic lack of integrity. data manipulation and patient waiting times have been found to be widespread. given that, how can congress, the american taxpayer, and our nations veterans and their families have any confidence in these latest numbers -- in these that the department has released. why were those actions not taken long before now? as part of the accelerating access to care initiative, the v.a. claims to be taking steps to, in the department's own words, systematically review clinical capacity, and sure panels are currently sized in achieving the desired level of productivity, extend or flex clinic hours on nights or weekends, increased use of care reach outmunity, and

to veterans to coordinate acceleration of their care. should these actions have been operational components of regular v.a. business long before now. v.a. has had the statutory authority to use these options previously. we know that at least 35 veterans in the phoenix area alone died while waiting to receive v.a. care, so i suspect that number may rise in the coming weeks and months. we know that 57,000 veterans nationwide have been waiting 90 days or more for their first v.a. appointment. 60 4000 veterans enrolled in the system over the last decade never received the appointment they requested. is too late for those 35 phoenix area veterans and it may be too late for other veterans who have ,een waiting for weeks, months and in some cases years. i ask again, if there were actions that v.a. could've taken to increase access to care for veteran patients, why were those actions not taken long before now? who yield to the ranking member

for his opening statement. >> thank you, mr. chairman, for once again having this hearing tonight, providing timely quality safe health care for veterans is commission. the gold to come pushing this mission is to successfully measure the capacity in capability of the organization. at this point in time, i do not have much confidence that v.a. has been able to do that analysis. i firmly believe that if you do not have good numbers on which to base calculations, and you cannot possibly begin to accurately measure the capacity or demand. anticipating capacity and demand essential to good strategic and. clearly, v.a. is struggling to get a handle on how many veterans are undergoing or waiting for treatment. it seems to me having a significant number of patients on the waiting list indicates a is overwhelmed and

under prepared. vha simply cannot handle the increasing number of veterans to whom we have a moral obligation to provide sound treatment. the v.a. oig reported that 14 specialty care services were studied. recommendation, one of the recommendations was to have the vha developed relative value unit productivity standards and staff and guides for the field. i recognize this is a complex process in v.a. health care -- and v.a. health care has continued to change over the years, but eight years to develop the system is too long and is unacceptable. while dr. lynch states and testimony that by the end of september 2014, all vha physicians will have productivity standards in place.

i'm skeptical of the usefulness of the standards due to the current crisis. they are unlikely to hear from the v.a. how they are capacity any time line so when this will be done. most importantly, any resources that may be needed to ensure that v.a. is fully fulfilling the primary mission of providing health care to our nation's veterans. mr. chairman, i know that the vast majority of apartment employees are hard-working and dedicated to caring for our veterans. for that, i applaud them. we still have a responsibility and duty to take care of all of our veterans. i look forward to hearing from the v.a. tonight. i want to thank you for coming. for that -- with that, i yield back. >> thank you very much. we are honored to be joined this evening by dr. thomas lynch, the assistant secretary -- deputy undersecretary for health. he is accompanied by dr. carolyn

clancy. we appreciate you both for being here tonight, and dr. lynch, we appreciate you coming for your return engagement. you are recognized for your opening statement. >> good evening, chairman miller, ranking member mich aud and the committee. thank you for the opportunity to these issues. at the outset, let me address the significant issue that has been the focus of the committee, the v.a. and the american public. that is the issue of weight times. no veteran should ever have to wait an unreasonable amount of time to receive the care that they have earned for their service and sacrifice. america's veterans should know they will receive the highest quality health care from v.a..

while we realize the timeliness of the services is in question, v.a. acknowledges and is committed to correcting the unacceptable practices in patient scheduling. as my colleague stated on june 9, this is a breach of trust. it is irresponsible, indefensible and unacceptable. i also apologize as he did to our veterans, their families and loved ones, members of congress, veteran service organization, our employees and the american people. his practices are not consistent with our values as a department, and we are working to fix the problem. v.a. has a physician workforce of more than 25,000 physicians representing over 30 specialties. v.a. now has comprehensive information about staffing asels at each medical center well as a productivity of our physician workforce utilizing a standard of care measure of 's.ative value units, or rvu

they consider the time and intensity of medical services delivered. optimizing productivity is critical to our ability to determine the nickel capacity and mobilize our clinical assets to rapidly address unacceptable delays in service. supporting a productive workforce requires appropriate ratios to ensure that the clinics run as efficiency -- as efficiently as possible. the difference between estimated capacity and a workload represents a amount of additional care we could provide to address veterans waiting for care. the has accelerated adoption of productivity standards because he are critical in determining vha's capacity in improving timely access to quality care for veterans. we are about a year ahead of -- will in completing help relatively standards in place by the end of this fiscal

year. like all of health care, v.a. has transitioned to a system in which outpatient care is increasingly important. v.a. has established a nation's largest medical home approach to primary care in which people ams. theyare for te receive advice and consultation which could be provided to technology, telephone calls, secure e-mails and telephone bills. investments in education, training and the ongoing evaluation to ensure that services are focused on the needs and preferences of individual veterans. since the majority of u.s. physicians receive some training in a v.a. facility, we have also invested in contemporary approaches to undergraduate and graduate training that reinforce the importance of teamwork and technological skills, and leverage research investments to modelsthat the new

achieve the goal of veteran centric care. the health and well-being of the men and women who will bravely and selflessly serve this nation remains v.a.'s highest writerly. work continues and we will not be finished until v.a. can assess capacity, productivity and staffing standards for all specialties and provide ready access to high-quality fishing care available to our nation's veterans. we must regain the trust of the veterans we serve. v.a. leadership and our dedicated workforce are fully engaged. this will conclude my testimony. i colleague and i will -- are prepared to answer any questions you and the committee may have. >> thank you, dr. lynch. how quickly can the v.a. higher staff under current authorities? >> i don't have the answer to that question. currenthat our processes, particularly in human resources, are slow. we are putting processes in place to speed this process is,

to speed the process so we can hire physicians more efficiently and more quickly. >> are there any impediments that we as a legislative body can do to assist in removing some of the barriers? moment, mr. chairman, i can't think of any. sorry about that. i would just add that some part of the reason it takes a bit of time is the credentialing and identifying process. i would think you'd want us to be rigorous about that. the human resources park is part one. >> what is the expected cost of access to careg initiative and how are you funding it correctly? >> right now, the expected cost we have invested is .pproximately $312 million it is being funded based on moneys that we have been able to recover from across vha.

tell me if any additional authorities have been granted to v.a. medical centers as a result of the initiative? >> what you mean by additional authorities? >> any authorities being granted to help speed the process along. other than asking the facilities to look at their processes and the efficiency of their processes, see if they can identify internal capacity and if they cannot, to let us know what resources they need to provide that care in the community. that process has occurred, the facilities have made the requests, and to date we have --tributed approximately 300 $312 million of which approximately 152 million have been obligated at this point. according to the physicians foundation 2012 survey of

american physicians, over 80% of the primary care physicians in the united states see between 11 and 61 patients per day. u.s. physicians in general see an average of over 20 patients per day. can you tell us what the average daily patient loads of a v.a. primary care physician is? >> right now, the average patient load is approximately 10 patients per day. if i could qualify that by saying that i think we need to whate that we understand support staff our physicians have and what capacity they have in the way of rooms to facilitate their ability to see patients, i think it is not just the physician's ability and willingness to see patients, it is also the support that we provide them and it is the rooms that we give them chile can see patients in an efficient fashion. the range, by the way, is from from six-22 is

patients a day. >> you would know, a rooms would be needed in order for patients to be seen. >> many of our facilities are 50 or 60 years old and were designed in an era when outpatient health care was not the predominant mode of health care delivery. the mid-1990's converted from an inpatient model to an outpatient model. we are still challenged by facilities that were not constructed for the outpatient model of care. >> if i went to a new facility, i should expect that the doctors there would be seeing more patients than those in the old facilities. been working to put in place templates that facilitate the delivery of care using the medical home model. we are redesigning new clinics in our outpatient facilities should optimize the ability of

our physicians to provide care and to see patients in that model. >> one other question, if you would. the office of special counsel wrote a letter to the president today. the osc cites the case of a veteran with 100% service-connected psychiatric condition that resided in a brockton, massachusetts mental health facility for eight years. are you familiar with that ticket incident? >> yes sir. person had only one psychiatric note in his chart. is that true? >> that is true. note in eight years? >> that is unacceptable. the sameo stated in letter, it had no impact on that patient's care. can you believe that? >> congressman, the office of the medical inspector is unique in health care. we don't see it in the private sector.

it is v.a.'s arm to evaluate objectively outside of the facility concerns about the quality of care. i understand that the office of special counsel has raised concerns. v.a. and our acting secretary have taken his concerns very seriously. we need to take them seriously because v.a. is in a position to reestablish our integrity. he has established a group, a commission who will evaluate this concerns. the report is due in 14 days. i think it is important we understand what that review shows before we draw any conclusions. >> once again, thank you dr. lynch and dr. clancy for coming here this evening. we understand that the to careted access initiative is designed to ensure access to care by enhancing resources within the a

facilities and also sending veterans promptly to community-based care in -- and care.a. care when needed is not readily available at the v.a. facility. what is the role of pc threes and v.a. accelerating access to care initiative? develops will it be another model that we can use to provide care in the community. c3 is just in the process of being stood up. some sites have greater availability ofpc3 services than others. it is, however, an option that we can use to identify community writers who are willing to provide care and to meet certain conditions of the contract would specify that care will be provided within 30 days, that we will receive reports in a timely fashion. 3 gives benefit to

the v.a. because it assures time ms and that we get records back in a timely fashion. >> i will just add that they assure some minimum level of quality, foundational level of quality in terms of contracting with hospitals that are accredited by the joint commission, that the plans your contact -- contracting with have standards of quality assurance and so forth. we will be working with them to figure out how we even make those standards a bit higher. >> the committee is aware that the v.a. had conducted several pilot projects such as project ship hero and project. before 3. it usedng pc lessons learned from these pilot programs to develop a solution, which is coordinated convenience

and consistency with v.a. quality standards. my question is, now the pc three is up and running across the country, are all v.a. medical centers using this program as part of a solution? >> i believe the answer is when it is available and when the services are available, it is being used, yes. >> so, it is not throughout all of the v.a. medical centers, then. >> in certain areas, the contractors are having to identify providers and are standing up their services. in other areas, services are is being used pc3 to the best of my knowledge. is notnderstand that pc3 a mandatory program. how could he have a v.a. medical center fully utilizing it and utilizing the potential of this program if it is not a mandatory program? >> it would be my hope, understanding the benefits of the pc3 process, that it would be advantageous to the medical

centers to use a program. as i mentioned, there are standards for timeliness of providing service and standards for the receipt of work product after the services have been provided. a v.a. distinguish between short-term and long-term howcity shortfalls, and does a v.a. respond different to the long-term and short-term shortfalls? data becomes our see reliable, and as we increasing use of electronic waitlist, which is now been mandated, we will have the option to see our demand handled in one of two ways. either as a completed appointment, or as a patient who ends up on the electronic waitlist. depending on whether this is a short-term increase in the requirement for services, in

which case the v.a. may find it very convenient to buy that in a community, there was also the possibility that this is part of a longer-term trend in which case the v.a. may want to consider how much it is going to cost me to buy this. ultimately, do we need to make a decision that will be more cost-effective for us to identify the providers and make the service in-house. i think short-term pc three non-v.a. care provides the opportunity for us to offer prompt services to veterans whom we don't have the capacity in the long-term. when we see trends, he gives us the option to make decisions about whether we should continue to buy this in the community because of its complexity or whether we think we can offer it in-house. >> inc. you, mr. chairman. dr. lynch, in the last two weeks, the number of veterans in my district in colorado springs

that contacted my office asking for help while trying to see a doctor has more than doubled. one veteran described how he was referred to get a biopsy done on his thyroid to determine whether or not he had cancer, only to be told he could not be seen for two months. i can't imagine having to wait for two months to even just get a test done when you have a possible cancerous growth. what options are available to the denver v.a. medical center to expedite a biopsy appointment in particular, especially based on medical necessity, and if there is the possibility of a life-threatening condition. whatngressman, based on you're telling me, if services cannot be provided in less than 30 days, that is an unacceptable waiting time. shouldver v.a. facility be able to identify a community provider to offer those

services. /basest would be the feed approach that we talked about. we talked about non-v.a. care or fee basis approach. yes. >> so, 55 days for that type of procedure is unacceptable, do you agree? >> that would certainly be my impression, congressman. >> the data included in the v.a.'s bimonthly axis data update makes me worry that this problem may be getting worse before it gets better. myself and representative mike coffman have had a lot of the same concerns. although the report shows a number of veterans on the -- on the electronic waitlist across a country dropping slightly, the waitlist at the denver v.a. centered doubled the last 15 days. it went from 1632 to 3331.

what could have caused that number to double in 15 days went around the country it was dropping slightly? >> don't have the specifics on denver, congressman. and getbe happy to try that information for you. i can tell you that at the moment, the electronic waitlist is going to be dynamic. there are two processes occurring. we are working down the near list, the new enrollee appointment request. those patients are either being given scheduled appointments, or they are being put on the electronic waitlist. it is possible that some of the patients that were on the near list have been moved to the electronic waitlist. exactly why they are accumulating in the electronic waitlist, i believe we have the capacity to find out. now, you stated in your

written statement that the average current number of patients assigned to each primary care provider is 1194. odd as that compare with the private sector? >> the private sector medical ary up tol can very wit panels of 2000. it depends on the resources available and the support for the physicians seeing this patients. ,.a. patients are often older patients in the private sector may be younger, healthier and may not require the intensity of care that v.a. patients require. dr. clancy, would you have any comment? >> i would agree with all of that. home in theedical primary care setting is also unique.

>> one less question i want to get in. the v.a. is adopting productivity standards that are modeled on industry accepted standards. .'m really glad to hear that what has been the standard up until now? sadly, there hasn't been a standard to this point. we're now using the relative her andit to evaluate her. determine, number one, a minimum productivity standards and, you're not, why not? support and available resources. it could be a matter that there are not enough patients for them to see. in that case, either we need to identify more patients, we need to figure out a way that we can move their capacity to another facility, perhaps using something like tele-health.

>> you're recognized for five minutes. i really have no questions. i yield back. >> thank you, mr. chairman. thank you for appearing before us today. i understand that from 2008-2013, non-v.a. outpatient visits grew from 8.9 million or million, a 72%.3 increase. aboute any way of knowing the comparison between non-v.a. care versus in-house care, its s? icacy and is cost >> i don't have the comparative data from the views -- from

those years. i can tell you have spent approximately $4.8 billion on non-v.a. care. i would have to try and get previous data to see how our use increased. care has or changed as we have seen increasing outpatient requirements. >> if we want to expand access care, it will be extremely important that there is a continuity of care and health records can be as far as you are checked and pc3. what can we do to ensure that this happens? >> i think that is a very good question, and it is a challenge. right now, our community providers do not have ready access to the v.a.'s electronic

health record. as we movel you forward and establish more permanent relationships, whether we can begin to give certain providers access to the v.a. health care system. when i was in omaha, we were able to do that for several of our community providers who gave regular service to the v.a.. know that as part of the aca and the high-tech act which ,as passed around the same time do you have any idea if this has been done with interoperability with health record systems? >> i'm going to refer to dr. clancy on that one, if i made. >> complying with the standards set out a meaningful use is a popular term for those sets of cms, althoughm

the v.a. does not get money from them. we are complying with all the standards, yes. >> but the private health care provider -- providers were given incentives to digitize the records, there is a standard set forth by cms. offer interoperability with this guy? >> it should. in some cases we are starting to explore this, for example, with some pilot projects on allowing veterans to get immunizations at health facility. we can exchange the kind of information. there is a difference between people meeting the same standards and being able to share freely across platforms. i would be the ultimate goal. >> you're saying it should, but theoretically, people have who have been incentivized to digitize, those standards set wash -- you said this

forwarded by cms? >> yes. >> they should provide the platform for interoperability with vista? >> yes, they should provide the first foundation for it. >> so part of being able to facilitate this ability to access care in the private arena, this would be to facilitate this interoperability. ,aybe part the answer would be if there were further incentives for our physicians to digitize, this would be one part of the solution? >> i guess i would say that this is a very strong priority for hhs right now, both cms and the office of the national coordinator. we are part of that strategic cunning effort in terms of how we accelerate the path to its inner operability.

right now, with community partners do now is, they sent a makes it easier because it is a condition of their getting paid. that is attached to their vista record as a portable, downloadable file. is helpfulentivizing . crexendo i can option down the road. >> thank you. >> you're recognized for five minutes. >> i appreciated very much. -- i appreciate it very much. first of all, how many were contacted and actually spoke to a person, a v.a. person? the contact was, did they have an actual conversation with them? >> we do not have that breakdown yet, congressman. there were attempts made to contact all veterans.

the process is there were three attempts made. if we could not contact the veteran, they then received a certified letter. we will be developing the. as we collected, and we should be able to provide you with information that would tell you how my patients were directly contacted, how many were contacted by mail, how many could we not contact, and also the disposition of the patient's ontacted. >> if they receive something in the mail and they contacted the v.a., with the speak to someone immediately? >> that would be my expectation. >> but you don't have any data on that. >> i don't have the data right now, no. >> what about as far as the waiting time? let'sontacted somebody, say the contact was made, there was a conversation between a v.a. individual and the patient, the veteran. along with the have to wait for an appointment? we wouldation is that

explain to them how long they would have to wait for care in the v.a.. if they did not find that acceptable, we would provide care for them in the community. >> you don't have any information to give me so far, any results, let's say that i had to wait within -- how long would i have to wait to get a v.a. appointment? >> i don't have that information, but the expectation would be that if we get -- that if we could not see him within 30 days we would offer him care in the community. >> worded this is a. come from? day policyd this 30 come from? patients community, are waiting anywhere from 15-30 care.r longer to seek we chose that as a reasonable

number. the v.a. chose that. acuity ofpend on the the patient. if the patient needs care immediately, we would provide that. if there wasn't, we would provide it within 30 days or offer it within the community. i might turn to dr. clancy and find out if she has any further insight on the ability for the community to provide care any more fashion than 30 days. >> i would guess, congressman, that you and your colleagues have probably seen data from on howy released surveys long it takes to get appointments, which ranges from 10 days up to 45 or so in boston. obviously, it doesn't have a lot to do with the number of doctors boston has, because a lot of doctors. the problem is there is no industry standard. i would say that when veterans contact the facility and are given a wait time are expected wait time, if that is not

acceptable option, to go out of the community, they are also counseled that they have a more urgent need that they should come into an urgent care or emergency room for more immediate care. >> on the average, how long would it take, let's say it is decided to go outside the v.a. for care, how long would it take the appointment? >> a lot of that will depend on outguessnd he is >> and doubt and it would be much faster, given the data i just mentioned a moment ago wait times are shorter. i would expect it would be much tougher in the boston area, for example. >> however, i would just add contract, it pc3 is the contractual expectation that patients will be seen within 30 days. , mr.e last question

chairman. >> under the department of veterans affairs, it is the one, the v.a. established a nationwide staffing policy for all v.a. medical facilities. can you briefly describe what the policy is specifically. how does the medical center's no which positions are needed, the andrt that information to, what is done with that information to address the staffing shortage? >> i will have to take that for the record. i am not familiar with that policy or the data associated with the policy. i know that we currently have information through our office of productivity efficiency and staffing that is looking at the number of physicians that we have, the specialty of those physicians, and their ability to provide care in an efficient fashion using the rv you model. >> these report back to me because i feel you should have that information with you now and today.

thank you very much, mr. chairman. >> you are recognized for five minutes, mr. waltz. >> thank you for joining us once , ain and to start out and is lot of this stems from the inability to get information and for us to our constitutionally mandated job. >> over three weeks ago we sat in here, and after the audit several of our members mentioned that our facilities were flagged. nothing has been said. everyday i get calls asking, what so these facilities? why to take that back and let him know we are waiting? renew this issue is. >> is good for site for you thinking ahead. >> he and i agreed that it is important that we brief the committee, and that we are making arrangements to do that.

and also providing briefings to other congressional staff on a reason by reason basis. >> you've been coming down here a lot and i am appreciative of the work you do, but i think the time is come where you know you don't get the benefit of the doubt on anything right now. after today's os see, you mentioned that was unacceptable e. i guess for me, i'm trying to get at the heart of this. i still think we are floating around is getting to this. i want to get back to his leadership and structure issue. >> if i director medical center what our national strategy for veterans was, how would the hope they would answer that our strategy is to provide timely care to our care.ns is quality >> is that a strategy or goal? >> is probably a goal.

>> i will probably go back to this from a national security standpoint. dod and its forces come back to fulfill those requirements. do you do that at the v.a.? i am getting back to this that we've been trying this issue since 2005. we started in the 1980's. my question is, i'm not dallas orby minneapolis or st. paul's that i would get a strategy answer. >> i think, sir, i can offer that we are developing a strategy as it relates to access, and as it relates to scheduling. we have in place a seven ep process that we are developing. it will address the development of the demand capacity models, that will develop the policies and directives to drive scheduling and access that will

relook at our performance assessment measures so that we can develop the measures and goals appropriate to drive our the appropriate endpoint, which is quality timely care. we are developing the processes to put together program and integrity. to recruit people and train them and to integrate our care processes with the non-v.a. care model. when necessary to meet the dash cracks where does that kinds come from? >> this is an organizational plan that was developed within vha over the last 3-4 weeks in that we to the issues have faced regarding veteran access. >> is their white house input into any of this? >> not to mine knowledge, sir. knowledge, sir. >> there is a mayo clinic down

in phoenix. it was brought to my attention that they were doing some of the prostate surgeries, is that correct? >> that is my understanding. said we haven't come in, he can do surgery in 48 hours. we had it going out in the community, and we had a community partner ready to do it, and yet we went back in house again to delay that care. how will this be different? how will what you are doing now that now if than your prostate surgeries, meteorologist ready at mayo clinic, how will you speed up the prep before the surgery which is standard crappy arco >> part of our process would allow those providers to do certain basic studies that are essential to their clinical assessment or

preoperative evaluation. >> so the whole package will go. >> i would say we would look at very high class studies but routine studies should certainly be done in the community and not brought back to the v.a.. >> i yield back. >> i like your questions. >> a very much concerns me in that the whole structure of the needs to bes -- evaluated. i hope we can get to that, at least move in that direction, because what is happening here is just not right. that came updeas from her testimony, you mentioned the fact that you aren't sure how much of this community-based health care is

and should be kept in a a temporary basis. the extra expense associated with the private sector care, it occurs to me that i don't think you have any idea what it actually costs to take care of a patient within the v.a.. you have any idea if you're taking care veterans, at what rate it is costing us, do you? >> it does track the amount of cost that goes into the care of each patient. it has not been used extensively. >> if you'reilable doing a certain code, to have any idea how many rv you's you produced in a year? we have a pretty good idea how

many for medicare, for example, .ow many units we are getting i don't believe there's any comparison. you're not doing it within the v.a. cost more money or outside cost more money, do you? >> i do know that when i was own -- in omaha, we began to look at the cost of the specific operations. >> does that mean you have an idea or? ? there is no interoperability among the medical electronic records. you can't get someone's record from somewhere else just because you have it in electronic form. that would be the ideal, but it doesn't work that way. question, the expectations of having his rv your unit and how many

physicians you need and how much productivity they have, are you aware that the v.a. has been informed that there has been a pipeline problem with physicians in -- and productivity problems for years. the inspector general when i had my subcommittee last year, they told me it will be three years before they have some kind of a plan to develop physician staffing. iu talk about it a lot but don't know what you are -- >> that plan is in place. we will have productivity standards for all of our medical specialties by the end of this fiscal year. >> i would like to see that because when they testified, they said it would be three years. >> they are about a year ahead of schedule. >> can you provide that? in december 2012, there was a

report by the ig that said although five facilities the ig visited were operating contrary to v.a. policy which requires medical facilities to develop staffing plans that address performance measures and other care indicators. in december of 2012, they said all the facilities they visited did not operate according to be a policy -- to v.a. policy. what has been done to change that? >> that is what the office of productivity has been working on since the ig made his recommendations in late 2012. they have been developing the standards for each of our medical specialties. >> do you know who was in charge of that? >> it is run by dr. carter metcher. and eileen moran. i believe that been down and

testified or briefed some of the positions of this committee. >> it is one thing to have a plan and another to carry out the plan. the inspector general told us in he went to five facilities and none of them were carrying out the policies that were in place. you don't have any idea then if anybody -- any action was taken over the fact that these five places it did not comply with the rules, do you? >> i do not, sir. >> i am out of time. >> yes yo, you are. mr. bradley, you will recognize. >> thank you, mr. chairman. thank you to the panel for being here this weekend -- this evening. obviously, we now have some new

information that we have received from the audit. the v.a. taken this new information we have learned about the real way times -- wait times as opposed to the previously reported wait times? does the v.a. plan on updating the skip plan to reflect those new data points? >> the v.a., as we are beginning to look at the information, we andregarding our resources we are seriously discussing the space needed to address the delivery of that care. that has been under active discussion this week, in fact. if the v.a. is evaluating the capacity facing one of them, i would imagine as you about the evaluate theyou need for space and personnel, it

may be very extreme in some cases. you need much more space and many more personnel in other places. maybe he can be resolved by increasing hours at a particular facility. are you gathering that information and putting it in the matrix? by each location, we know exactly what the underlying issues are and how the v.a. will approach that? most specifically, timelines. space is something very concrete. personnel may not be as concrete but it is pretty a concrete -- pretty concrete. will you have the evaluation location by location and a timeline you believe? >> we are ready have most of that information location by location. we have physician information. we have staff support information. location. we have physician information. we have staff support

information. location by location. i cannot confirm whether we have space information. but it's critically important in making decisions regarding efficiency. and we are working and discussing the implications of space as we put our models together. >> so, you will have a model of space then and timelines location by location and you say you have -- you already have that for personnel. is that what exists currently or what exists currently and what is needed in the timeline? >> yes and yes. we have the information based on what we currently have and we have been looking aggressively over the last several weeks at what may be required to either increase the efficiency of our providers, or if they are functioning efficiently whether we they'd to consider adding additional physicians to meet that capacity. >> so, could you share that information with me then on the

personnel side? >> certainly. let me see if i can set up a briefing for with you the folks that put that together. >> what's your, i guess, timeline for space, what is your time line to put together a matrix so that, to identify what are the space needs throughout the country? >> i would have to get back to you on the space issue. that's still being discussed and i don't have a definite timeline for that. >> okay. the chair in his opening comments talked about asking the question how quickly can the va hire a doctor. so, you talked about the fact that you weren't really sure. but i'm wondering, you know it's too long. we all agree on that. can you just share with me just your, at least the va's initial thinking on what some of the barriers are and what might be some mechanisms for shortening

that period and expediting the process? >> i think we're clearly going to have to work at improving the efficiency of our human resource process for handling new recruits. you are absolutely right. it is clearly too long. oftentimes we lose people during the process. some of it is essential, the credentialing and privileging process is essential. but some of the other processes involved in human resources can clearly be improved in terms of their efficiency. i think interestingly some of the things that we're learning in phoenix as we're working with that facility to increase their capacity to add new physicians may help the rest of our system to function more efficiently in the hr process. >> thank you. i yield back. >> mr. huelskamp you're recognized for five minutes.

>> thank you. dr. lynch, you committed to shrinking care packages or sized to achieve a desire productivity. what are these desired productivity standards that you're using for primary care providers. >> right now the standards they are use are the number of patients per physician. they do have model, models that they can use to see whether we can increase that capacity based on staffing or based on room availability, or based on patient complexity. we are also beginning to implement the use of the productivity model to look at primary care and see if we can use that to take a look at not only the number of patients a physician is seeing, but the complexity of those patients and their productivity. so, for instance, perhaps a physician is seeing six patients a day.

perhaps they are new patients or complex patients that have a high relative value unit. that physician may be more productive than a physician seeing 15 established patients during the course of a day. >> do i follow that. how do you monitor that, though? >> right now we're monitoring that by looking at the rvu productivity of our physicians. >> monitored at the national level, the division level, the facility level? >> yes. at thele facility level. >> at the facility level. given the gaming strategies and other things that have suggested and have shown that the data is not valued or maybe reliable do we have potentially the same problems with what you're attempting to measure here? why would we not have similar problems with knowing exactly what's going on with productivity? >> dr. clancy? >> i think that's an incredibly important question and one that we share your concerns and also

recognize that since integrity of data has been a problem for us, we not only need to clean up our policies and stream line them but that we also need to have some independent valid addition thvalidation that it can be assured by a third-party. >> that has not been done? >> not yet because the scheduling new policies -- >> any of the data has not been independently confirmed >> the rvu data is independently validated. >> if we have falsified data and we've shown that va admitted to that, the gaming strategy four years ago admitted that was going on, i don't know how the data could be valid or reliable in either case based on what dr. clancy just said. i'm trying to find out how you can assure me the numbers you gave here match what's happening in the real world.

>> congressman, point well taken. va does need to establish the integrity of their data. i will take your comments back to the office of productivity efficiency and staffing. and ask them how we can validate the information we have so that we can establish the integrity of that data and assure you of the confidence that we have. >> the range you gave was six to 22 patients a day. that's your claim today? >> yes, sir. >> that's not valid? >> i think -- that information valid. i think it's very difficult to, to try -- >> i had a whistle blower has approached my office from a facility and i am and my congressional districts were lucky that way claims there are primary care physicians that see as few as five patients in an entire day. that would be definitely outside the range. do you have any other -- could

that be possible? >> i would have to look at the information and evaluate it. i, at this point, anything could be possible. and i'm certainly willing to look at any -- >> i agree. that's my problem. when you say anything can be possible, this is not independently confirmed. how do you make decisions when you don't know if your data is accurate. gaming strategies, we've heard actually the iffalsifying and wt i've heard from this whistle blower there are some that are working very, very hard and then physicians across the hallway to see five patient as day which basically is half the day they are sitting there waiting for something. and obviously when we're looking at ways to provide better access to care, ways we can do that by enhancing productivity, but we don't have the data i think to answer any of these questions and so i look forward to you showing us how the data is valid and reliable, but if this whistle blower identifies physicians not working as hard

as they should be, we got a serious problem in the system. >> congressman, we need to understand that further. >> okay. thank you mr. chairman. i yield back. >> dr. reese, you're recognized for five minutes. >> thank you, mr. chairman. the discussion on ways technology and innovation can increase the capacity of the va from provide timely accessible and high quality veteran centered care is very important. however, today this committee learned that the office of special counsel whose job it is to protect whistle blowers and investigate their claims found that the va has failed to use information from whistle blowers to correct troubling patterns of deficiencies of patient care that negatively impact the health and safety of our veterans and they failed to correct these troubling patterns of these deficient patient care practices. they describe, quote, a culture of nonresponsiveness.

the osc revealed the va's office of the medical inspector frequently refused to acknowledge the systematic problems in the va that exist or acknowledge how they negatively affect veteran care. in other words, it was an institution centered and not a veteran centered response. we need to create a veteran centered culture of responsiveness. the office of the medical inspector of the va needs to either come forward with a serious explanation, or get out of the way so solutions can be found and implemented and veterans can receive the care they need when they need it. today we're talking about accelerating access to care. what we need is an accelerated access to high quality care not inadequate care. my question is how are you ensuring that the care to veterans is high quality?

you know, as a physician in clinical practice we have quality review mechanisms. and some of these mechanisms begin with credentialing, board certification, risk management continuing medical education requirements, and evaluation of patient requests, and also chart audits. what systematic method are you ensuring from your health care providers or the system in order to ensure high quality care? >> congressman, i'm going to defer to dr. clancy to answer that question. >> so, you often hear it said that once veterans can get in, they often think that the quality of care is very good and, in fact, by the numbers, whether you're looking at information reported to hospital compare we use the same metrics or same metrics used to evaluate health plans as a system vha looks quite good. in addition to that, at a very

high level we have all of the regulation that the private-sector has plus additional investigations by the inspector general, the gao and other parties. so we have quite a bit of oversight in that regard. va before there was a famous institute of medicine report on not harming patients to err is human actually stood up a national center for patient safety. as a result of that and other efforts there's a very, very strong focus on psychological safety and encouraging all employees to step forward. if you see something say something, we actually have a video about this that has been shown widely up the line. and i think secretary gibson was very, very clear with respect to whistle blowers where you started out here today and in accepting the office of special counsel report. >> so, you know, i think that there are definitely good

practices. and loma linda hospital is one of the better hospitals and serve the veterans in my district. even amongst the best there's always issues we need to improve. and if there's a report saying that there is a culture of unresponsiveness to these grave scenarios, that is systematic, then i think that we need to get to the bottom of it and figure out where is that disconnect between the whistle blowers and the responsiveness of those responsible to make sure these practices don't happen. let me get to the next question. do we have a count of full time equivalent primary care physicians per veteran ratio within the visits? >> yes, i'm sure we do. >> do you know what it is? >> it would vary by visit.

i would have to get the specific information for visitor for a facility. >> are they used to determine where your resources are spent? >> they are certainly used in association with information regarding demand to make resource decisions, yes, sir. >> the national recommendation is one full time equivalent physician per 2,000 americans. to be considered medically underserved it's one full time equivalent physician per 3500. so it would be important to determine whether a physician per veteran ratio reveals an underserved va system per area so we can start addressing these underserved areas with priority. thank you. i believe that's the end of my time and i yield back my time. >> thank you very much, dock are the. >> mr. kaufman. dr. lynch, how long have you

been with the va system >> about 30 years. >> how long have you been in senior leadership? >> about a year and a half. >> you know, what surprises me and i certainly commend the va for having this access to care initiative. i think the problem is that, and i think we need to be convinced because what we're asking is the same people that drove us into this ditch, to figure out how to get us out of this ditch, and what amazes me is the fact that in the leadership with the va, all of the issues that have come forward through whistle blowers. and i know that you went -- when the story -- i think it was a catalyst for this, which was the phoenix va scandal, i think you personally went down there to look at it. i mean you didn't -- >> i've been to phoenix four times. >> when you testified before

this committee you went there, you came back, you didn't talk to the schedulers that were actually doing the work, you didn't talk to dr. foote the key whistle blower. you made no outreach to him. you didn't talk to any of us. you testified to that effect here. and so we're counting on you to get us out of a ditch. i just don't think it's going to happen. i just don't think you can do it. i think what we need, is we need a new secretary of the veterans affairs that's going to come in and going to clean house. because you have been in the system for a long time. and you're not outraged. the reality is you're not outraged. you have testified before this committee a number of times, always been defensive. always been defensive. covering concealment, escape and evasion. those are terms i learned in the military as a ground combat officer and you have -- you've used those brilliantly i think before this committee. and the va has not been

transparent. has not been -- you know, has admitted a lack of integrity. so tell us how we can count on you and the leadership team that exists there now to get us out of this ditch and to be honest with this cheat and with the american people with the veterans that you're here to serve? >> congressman, i value the va system greatly. i think it is a good system. i think -- >> it's not a good system. how can you say -- >> i think it's a good system. >> really? >> yes i do. it's good quality care. i die dr. clancy -- >> doctor here's the problem. >> our system compares favorable with the private-sector in terms of quality of care and patient satisfaction. we're challenged right now. we're challenged because of data integrity and we need to re-earn the confidence of the public, of the congress, and of your veterans.

we're working to do that, sir. >> you're just glossing this sufficient over. >> i'm not glossing over. >> you ought to be outraged. >> i take this very seriously. >> you're part of the problem. i just don't see you as part of the solution. i don't see you able to get us out of this ditch and we're in a ditch and you're in denial that we're in the ditch. >> congressman, i'm not denying at all we have a significant problem. if you want to call it a ditch i will not disagree with you. we do have a way forward. i think we do have plans. i think we do need to re-establish our integrity. i think we can do that. we can salvage a system that does provide good care and make that system provide timely access. >> i'm stunned you would call this, with all the information that's come out, and i don't think we're at the bottom of all this yet, that you would call this a good system. i think it's absolutely stunning. and i just -- i think that the veterans administration is the

most mismanaged agency of the federal government. i think that it has not been there to serve those that have served our country but the leadership of the va has been there to serve themselves. and with had testimony before this committee about all the bonuses, all the bonuses, despite the incredible bureaucratic incompetence and culture of corruption, that's the only thing you are effective in is writing checks to each other. mr. chairman, i yield back. >> miss kirkpatrick, you're recognized for five minutes. >> thank you, mr. chairman. i want thank you and ranking member michaud for continuing to have these hearings. i feel like we're not getting to the bottom of this. and dr. lynch, we've had a number of hearings. you've been hear a number of times. and we've heard that -- i just

want to focus on the scheduling delays. that's the problem that we're trying to get to the bottom of. this committee has heard there's five reasons for this scheduling delays, that there was an unexpected surge of new patients. there was not enough funding. obsolete facilities. obsolete technology. a lack of patient extenders and personnel. a lack of consistent policy across the system. but that just further describes a problem, and my question is, why? why did the va not anticipate a surge in new patients? we know we have an ageing population. why did the va not have enough funding when we've given them all the funding that they've requested. so, you know, we're starting to think as a committee that this is a systemic problem, but we're still just not getting to the bottom of the why. can you answer that for me?

>> i think part of the reason may be relatively self-evident. we were not getting good data from the system. we didn't have a good measure of those patients that were waiting. >> but why? why? >> i think we know why. i think we've acknowledged that the system was not honest. we were not getting the information we needed. we had performance measures that were misguided. and we need to reform that. so we have accurate information and we can resource or system appropriately based on demand and capacity. i think we have the tools to do that. i think we have the information to do that. we need to assure that our data is accurate. we are working very hard to do that. we are making demands on both our visit directors and division directors to make sure the practices in their clinic are

according foil. we acknowledge we'll probably have to have an independent third-party confirm that that information is accurate. because at the moment we have to verify to you, we have to justify to the american public that our information is real and accurate and we can provide timely care and we can give the information that we need to assess demand and capacity. >> well, i appreciate your answer, but i feel like we're still not getting to the bottom of this. and leapt me just say, why is the va so slow? why are they so slow in responding to mr. waltz's office. why have they end so slow in responding to this committee? just why, why, why. is it because there aren't enough incentives? >> it is not correct. i think we do have to work with this committee and we do have network with congress if we're going to build a better va system and we do need to give you the information that you need.

>> dr. lynch, let me just ask it is a system that can innovate? >> yes it's a system that can innovate and we've shown we can innovate in the past particularly in response to crisis. if you look back in the mid-1980s there were concerns about surgical care in the va. the va developed a risk adjusted model of outcomes assessment that has now become the model for the private sector. in the 1990s va was criticized. the va innovated with the electronic health record. that has now become a standard for the private-sector. i think we can innovate and i think we have an opportunity here in va to respond to this crisis with an innovative model of staffing, of assessing demand and capacity that can become a standard for the industry as well. >> please do it. i yield back my time. >> if i could just add one thing to what dr. lunch just said. i think all of your questions

are critically important and tearing us up as well but right now we're focused 100% on trying to get veterans into the system and using all the tools available at our disposal. there will be time for the why questions and the much tougher analytical questions that all of you are asking about how do we fine tune capacity and demand but right now the number of veterans wait cigarette an emergency and that gets the highest priority. that does not mean anything else is off the radar screen. and i just have to say in response to the innovation question i did have the pleasure and opportunity of visiting division one which encompasses the state of maine and some of the innovations they have tested and deployed up there are really terrific. i think our challenge is out how to spread to it achieve the same successes as we've seen in surgery and in other areas. >> thank you. thank you, dr. clancy. >> thank you, mr. chairman. you know, as we sit here and

talk about all this i think a lot of times as people are watching, it almost seems like we're talking about patients as they are monopoly pieces. when mr. waltz brings up the point of the possibility of getting surgery within 48 hours but it's six weeks until they can get their pre-open work done teva it's disappointing the surgeon can't make something happen sooner or nowhere to go, these types of things aren't corrected and i'm sure these have gone on for years. you know, there's a lot of things that we're hearing tonight and you share our concerns. when did you start? when i got here i went to gener gener gener general senseki three times. why are so few patients being seen opinion you talk about rvus

and for our fans watching at home. rela receive value units. new patient has a higher value than an established patient. a short procedure has fewer value units than longer type procedures. when did you start looking at the rvus? >> the rvus, i believe, became part of our evaluation process after the report in 2012. >> that's been around for a while. it's some type of measure. but my question senior you measuring how many rvus per patient per day per month per p? >> yes, sir, we are. >> if you could pick one and give me all that information tomorrow, i would appreciate seeing how you're going about doing that, i would be very curious. dr. benechecck brought up a very

good point when he said how much are you spending per rvu. if you take all the money you're spending on these patients and tally up the rvus built, medicare knows how much you spend per rvu. you're measuring rvu but not how much you're spending per rvu. it's key. i think you look at how many patients or a facility is seeing is each day. there's more than one way to measure these types of things. in our practice, if one doctor is seeing 60 patients and a similar doctor seeing 30, we're talking to the one with 30 and see if they can get that up and continue the quality they have to have. when you're comparing to yourself, i don't think you're getting anywhere. that's part of the problem. my next question is, when you talk about doing these evaluations of efficiency, who's doing this? because if it's somebody that's

been in the va system their whole life, they're don't know what they're measuring and don't compare to successful healthy health care systems. so who is doing this currently? >> right now, it's being done by dr. carter mecher and eileen moran. >> and are they from the private sector? have they been in academia? >> i don't know dr. metra's history. i note he has met with the physicians on this committee. i think you have talked with him. >> yes. >> i think he does have a good handle and a good understanding of the rvu system and productivity. i think he has very innovative concepts of how we can use that to resource or system and to look at right sizing the number of physicians and the capacity that we have. >> and that's helpful. i would definitely look at someone who's had great success in thesers and they exist

throughout our country without a doubt. >> the we are speaking to kaiser and a number of leaders from private sector systems. if you had other suggestions, we'd be all ears. >> those are good suggestions. i would also suggest that you encourage account president and the senate to confirm someone who that is some administrative experience in the private sector in these areas. i think it would be a great benefit to our veterans and to our country. lastly, i do want to point out that the cincinnati va, who i represent that area, has been flagged. i have asked for why they were flagged and have not received my notification yet as to why. and certainly somebody knows why. so i hope we get that the very quickly, as well. i look forward to seeing one of those reports on the rvus, as well. >> yes, sir. >> i yield back. >> mr. custer, you're recognized for five minutes. >> thank you very much, mr. chairman. thank you dr. lynch and dr. clancy for being with us this evening. i think what all of us are

trying to do is to be helpful. i think our chair opened the hearing asking how can congress help you, and our challenge is that this whole process feels like a rubick's cube. every time we think we've got a piece in order and we think we understand what the problem is, is it not enough physicians, then we offer to help on that, but maybe that's not the problem. it's the space problem. if it's not a space problem, it's the support staff and the list goes on and on. i'm very fortunate to have experience with the va in new hampshire. my father-in-law got very excellent care within that system. buff obviously, the concern that we have is that that be replicated for every veteran around the country. so the focus of my comments is, how do we ensure access to high quality karat a cost that the taxpayers can afford for every veteran? and i've spent 25 years in the

private sector on policy issues. i know this isn't easy this conundrum of high quality care access and cost. it's sometimes a wobbly three-legged stool. but in your case, it seems that the problems of scheduling and wait time data has called into question the whole basis for your staffing and capacity calculations. and i think dr. lynch, you just mentioned this. you're trying to match supply and demand, but you don't have an accurate picture on the demand side and so trying to determine what the staffing model would be is of limited use. and when you tell us the average is a physician seeing ten patients a day, does that include the data that we've heard in this committee of 50% no shows? so is that actually a physician that has 20 slots per day but

only ten patients walk through the door? and we want to help you with this. we want to get the policy right. we very legislation that we're offering this week. it will be bipartisan that's about getting residents involved. give you greater capacity. we would be happy to help talk about what the space issues, but how can you help us with where to start helping you? >> congress woman, i think we can start by trying to give you the information that you asked for. and a apologize if you have not seen that. we have provided a briefing to members of this committee on the productivity model that we have. i acknowledge that until we can assure the accuracy of our scheduling data, that information is going to be flawed. although i can -- i am confident

at this point that i think beat do have reasonable information on productivity and we can begin to use the productivity information to begin to look at what we need in the way of additional staffing to increase the efficiency of physicians or in those practices that are very efficient, who we may need in the way of additional physicians. so i think we have a start. but i think we need to gather more data. i think we need told have accurate data on access before we can come to a fine answer. >> and then if we could add, ben benecheck's analysis about the cost in house and outside the va because it's difficult for us to make that recommendation as to how to you make these adjustments. you know, we want veterans to be seen in a timely way, but it's not unlimited, you know, the funds that can be put toward this. it is less expensive within the

va, then let's expand your capacity. if it's less expensive outside the va, then let's use private facilities but we're not able to measure this at this point. >> no, but i think that all of the information that you've heard and we look forward to briefing you more on on the productivity and staffing will be a huge puzzle piece here that will be foundational to getting to this second order question. after the emergency of addressing people waiting in line right now about what kinds of resources do we need, and the issue that dr. lynch brought up a couple of times about make or buy decision at the very local level because that's where it needs to happen, the answer to that is not going to be thumbs up thumbs down all the way. it's probably going to be make in some areas primary care, for example, and buy in some other specialty areas and so forth. and a lot of that will be a very dynamic relationship with community capacity and so forth. >> my time is up, but i do have

a specific question i'd like to get to later about women being served in the va because i think that's a unique situation, as well, and problematic at best. so thank you, mr. chair. i yield back. >> miss hoa lo ski. >> dr. lynch, i'd like to ask a question about the va staffing and productivity standards. had the ig that was here a coup weeks ago made an interesting kind of an assessment. he pretty much said be careful what you wish for to our committee on this issue of fee basis care versus va care. i did investigation in my state. i learned there are a number of va hospitals including in the one in fort wayne, indiana that are not functioning at full capacity, turning patients away, sending them to nonva hospitals due to lack of appropriate staffing or facilities. in this case, the va, their icu is closed. the er is now using criteria

over what he patients they'll accept and those they'll turn away based on their faults. by paying for nonva care in addition to operating half empty hospitals va appears to be paying for two systems of care. do you know how many va hospitals fit this description? >> i don't. >> can you give me that number? i found the fort wayne one quickly. >> i think there are facilities that are struggling. they're older facilities not always in fort wayne where they're in larger communities. sometimes they're in smaller communities. the population they support is small and oftentimes difficult for them to support an icu. those are difficult decisions but we need to look at our facilities where they are and we need to assure that we're using them optimally. >> i guess my follow-up question would be what the ig warned us about which is who is looking at those numbers to figure out, for example in, fort wayne, those

numbers for fee basis care are skyrocketing every year. once i found out there's no icu and there's using criteria who they can take and can't take, they may have to send somebody to cross the street for a risk basis procedure because there's no icu. who looks at those numbers? is that regional or statewide or that specific hospital looks at the skyrocketing numbers? who makes the assessment are we pay reggie for two facilities or are we paying for one. >> part of the challenge is based on the volume in some of our facilities, we cannot support an icu, not because we can't afford it, because we don't have the patient volume to maintain competence. and so there's a balance. and oftentimes it's felt that because of the volume and because of the competence,ing it is better to send these patients into the private sector. i understand your concern and we do need to look at where our costs are going and how we're using our facilities.

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

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

this is new? >> congress woman, i don't know the details of the accusation. >> could you provide that to us when we're probably going to get -- i think the details out. could you provide the answer to that in a timely manner? >> i will certainly try as i understand it. >> thank you. i yield back my time. >> mr. o'rourke, five minutes. >> thank you, mr. chairman. dr. lynch, you mentioned earlier that $312 million has been made available to be accelerate access to care for veteran who have been unable to receive it thus far. where did that money come from? >> the money was recovered from funds that were not being used across va. i believe that there was some activation monies that was repurposed to cover the accelerated care initiative. >> what are activation moneys? >> sometimes monies that are used for new projects. i don't know the details but i

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

va to say to get to the level of care that we have promised to our veterans,ing we need x. you know, you say that you have provided $312 million. is there more to be found among those funds from which you've taken so far? will there be more needed in the coming days? we're only weeks out from the revelations and as miss wolarski pointed out, myself included in our districts, we're still finding new gaps and short faus that need to be met so i'm think and you may not have a number in mind. wouldn't you say that you're likely going to come back to congress to requests additional funds? >> i can't answer that question right now. i can tell you that we are beginning to look at the resources, particularly personnel resources that we need to increase our capacity and we'll be working with the

congress to develop a proposal that would allow us to hire more personnel to provide that care. i know that we're looking carefully at the money we're spending on fee basis services. we have been able to find some central money to send those patients out. facilities and networks have also been able to identify monies, as well. it's anticipated that we will probably increase va funding on fee basis care from about $4.8 billion to about $5.4 billion this year. >> and i'd also ask you to, and you essentially committed to this earlier in previous answers but pay special attention to the providers that we have within the va system today in retaining them there. when i met with providers in e pass so a couple of months ago, morale could not have been lower and a lot of it had to do with the amount that they were being

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

to you in between these hearings and at these hearings to follow up we we don't get an answer. i appreciate your responsiveness so far. i do ask dr. clancy and dr. lynch and the leadership as we get through the this immediate crisis, if we lose this opportunititon address the real systemic structural cultural problems within the va, you know, i think that we will be right back here again in another couple years, five years, ten years having this very same discussion. so while addressing care and connecting veterans to care is important, let's make sure we don't stop there. we need to address the culture, the operations and the system. anyhow, i thank you for your answers and your work on this. i yield back. >> thank you very much, mr. jolly, recognized for five minutes. >> thank you, mr. chairman. dr. lynch, i want to give credit where it's due. i recently hosted in my kong griggs.district what i called a va intake day, invited the community to come in and talk about their care, their concerns

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

ability to get outside the system. it was a self-selected group. i recognize that. those were some quick metrics we got. mr. o'rourke mentioned mental health and behavioral health over memorial day. was a approached by a mom whose son committed suicide while he was waiting for mental health services. the fy 14 mill con va bill directed the department to competitively contract with nonva providers in certain communities where there was a need for additional mental and behavioral health capacity as well as where there was also a nonva infrastructure that could absolutely provide that. are you aware of that direction and can you update us on whether or not that has been pursued or is in the process of being implementeded? >> i know that the va has been actively working with the community. they have been holding it almost on a yearly basis mental health care summits to inform the

community of opportunities to participate in the care of veterans. so i think we are moving aggressively to involve the community where they are available in the care of veterans if it's necessary. >> i understand that reflects a spirit. but the department was directed by the congress, congress derps can the budget. congress makes directions when it comes to how that money is to be spent. and in the 14 bill, congress directed the department, did an they didn't ask, be directed the department to have a demonstration project to competitively contract out in certain communities at the choosing of the va mental and behavioral health non-va care to do a demonstration project to relieve capacity in certain areas. i guess particularly given the position you have, are you aware of that in the '14 budget? >> yes, i am aware of that. >> and has anything been done to implement that? >> yes, it has.

>> what has been done? >> we have developed demonstration projects i believe at five or six of our facilities to involve the community in veteran care. and we are evaluating the results. that is in process, yes. >> okay. i would very parochially tell you how wonderful the bay pines and haley system and the fact that stone claw system starts in october and we have the best beaches in the world. to the extent that tampa fits that profile, i would encourage you to look at it. two last questions. one, for nonva care right now, those hose ask to go outside, i understand that folks who need a specialty care service that's not available from within the va are likely the most candidates. what about for the va patients who simply aren't satisfied with the quality of care and ask to see a different primary physician outside the system? is that ever accommodated through non-va care? >> i think the va would attempt

to find the patient in over provider withinv a if he was unsatisfieded with his current provider. >> is there any -- and i understand there's some statutory guidance, any fees be the of going outside of the va? >> in rare instances if the patient is very unhappy and i'm speaking for personal experience, as chief of staff, i had authorized patients to receive care outside the va. >> and my last question, miss would he lore ski just shared the story that's breaking and i understand it's breaking. you haven't had an opportunity to review it but i do have a very specific question because the ig talked about criminal investigations or investigating allegations that rose to criminal level. we've had several hearings thus far. were you, dr. lynch, personally aware that this was a matter being investigated that the word deceased or the label deceased had been or was being removed

from files? did you have actually awareness that that was being investigated? >> this is the first i've heard of it. >> so you weren't aware it was being investigated? >> no, i was not. >> okay. thank you very much. i appreciate it. yield back. >> miss titus, you're recognized for five minutes. >> thank you, mr. chairman. i'd like to go back to a point that miss custer was making at the end of her comments. we're talking about evaluating the capacity of the va to care for veteran patients. i want to look specifically at the va's capacity to serve our fee may veterans. they're often referred to as the hidden veterans or the silent veterans because they're less likely to seek service because it's not very accommodating and the sticks that have just come out in an a.p. story certainly show that. with regard to capacity last year, the va served 390,000 female vets and yet, a quarter of the va hospitals do not have the a fulltime gynecologist on

staff. a quarter. with regard to quality, half of the women veterans received medication through the va health care system that could cause birth defects. despite the fact that many are of child bearing age and the majority were not on contraception. this is much higher than would occur in the private practice. with regarded to care coordination, the vaoig said that 60% of female veterans at community clinics didn't receive the results of their normal breast cancer exam within the required two weeks which is your own policy and even more disturbingly, 45% of those results never made it into the electronic health records data system. i mean, i find this these statistics are as bad if not worse than some of the others that we've been talking about just generally speaking. and they indicate that the issues of access to quality care and proper coordination of care may be even worse for our female

veterans than they are for the general population. now, i understand you have some plan to ensure that there's a designated female provider, women's provider in each facility. so idaho like to ask you, what's your time line for achieving that goal? when are you going to start doing some training of va providers on health care concerns like drugs that can cause birth defects and just what is your plan for looking at the female population because that's a group of veterans that is going to increase in number. >> you're absolutely right, congress woman. and i thank you for your questions. we were concerned by some of the findings reported in the story, as well. about 80% of our facilities do have a designated women's health provider. and in some of the other facilities there's been a challenge identifying someone to do that. so we are looking into training some existing staff, for example, some of the current

primary care clinicians to be able to meet that role. i should point out, this is not something that we just came up with on the spur of the moment for women. i mean, this is an area where we've had other similar sorts of training of experience training people with specialized expertise, for example, when there's a particular problem that's much more common in one facility. we figured out how to bring specialist expertise to the primary care facility. we're going to be trying to do the same thing so that we can get up to 100% as soon as possible. the issue on mammograms as i understand it in terms of the timely follow-up particularly for abnormal findings has been the focus of some substantial improvement efforts and we can get you more details on that. the other thing i would just point out in terms of women's health is that obviously, women have issues that relate to their unique needs and issues as women

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

and it says that they are typically informed within three days and typically is in quotation marks said that you don't really show how widely the improvements have been adopted or what specific progress has been made in this area. it's kind of hit or miss like so many of the things that we've been hearing about. so i am concerned that you are just going to train primary caregivers to be experts on women's health, maybe that's an interim measure, but it's certainly not the same as having somebody who is qualified in that field. and again, i go back to these clinics that exist say in rural nevada where it's very hard to find somebody who's an expert or even in our urban centers like las vegas where we lack providers. and this is something that we need to address even if youen