every budget since i been and dutch ruppersberger has been ranking member. that's unusual. but an important thing to have happen in a committee like ours. it can happen. it should happen. the questions at home shouldn't be, what are you doing to fill in the blank on this other major issue. it should be, on your committee, what are you doing on this particular problem. how are you going to make that problem better? if every member is a generalist, we will be in trouble. i spent my last four years not being a generalist. i looked at all members of national security, and i think it helps. i think members who serve on ag and energy and commerce and serve on those committees, what we should demand of them is more time in committee working through these issues and if in means staying in d.c. five days a week, okay, so be it. i think you can do it in less but you have to force people to , show up and do the work. that's a hard thing to do. and we have gotten away from it.

and i think that has caused huge problems in the ability to build coalitions to move things forward. tune in six months, and i'll lay out the whole thing. >> thanks for doing this, sir. >> thanks for having me. >> appreciate it. >> thanks everybody. [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute] >> we're learning today that one of the people suspected of laying a key role in the 2012 benghazi attacks is currently in the u.s. the suspect was captured by the military two weeks ago in a town does outside of benghazi, libya. the justice department has charged the suspect with recharges and in connection with attack thatsulate

killed four americans. he is being held in washington, d.c. according to government officials. an arraignment expected today, rarer admiral john kirby smoke about the suspect and the charges against him in yesterday's pentagon briefing. here is some of what he had to say. -- allegations from intelligence and special operators in the region that he was low on the list of about 20 or so suspects who were engaging in benghazi terror attacks. how do you respond to those allegations that this was sort of low hanging fruit? and gathered the evidence to supports the notion that he was a key figure in the benghazi attacks, based on that evidence and that information and a painstaking process of gathering the evidence and the intelligence necessary to get him, we got him

. now, he is off the streets. within one hour of us saying that we got him, the questions we were getting, how could this dangerous guy be sipping mango juice in a café and you can just pick him up? why does it matter? .e matters we believe we have a strong case and that case now needs to be taken into court. he needs to pace just this. ? >> you can find more of that pentagon briefing online at c-span.org. a sunday.august 15 on very much one of those -- it appeared on national television. a great cowboy show. not really my time.

many viewers for a member the show. he interpreted the show to say, we are not going to allow the it's one of the most significant events. to happen in the history of money. window whereold people could simply not come into fort knox and say here is $100, i want the gold value. that was the consequence of a the government had gotten into with its debt. they were trying to fight the vietnam war and it did not work out. there was a deficit, a trade deficit. talking about the history of money, its relationship to war and how the to impact worldwide free markets. afterwards.0:00 on

this month, we are discussing "the forgotten man." join others to discuss the book in our chat room. book tv. television for serious readers. for over 35 years, c-span brings public affairs offense from washington directly to. putting you in the room at congressional hearings, white house bends, briefings and conferences. and offering complete gavel to gavel coverage of the u.s. house , all as a public service of private industry. we are c-span. created by the cable tv industry 35 years ago and brought to as a public service by your local cable or satellite provider. watches hd, like this on watch us in hd, like us on facebook and follow us on twitter. >> the house veterans affairs committee held a conference. the witnesses including two

officials from the veterans health administration. their testimony came the same day that the u.s. office of special counsel sent a letter to president obama and congressional leaders saying they determined the v.a. was nonresponsive to whistleblower complaints on multiple occasions. this hearing is a little more than two hours. >> 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 released last thursday suggests, in court nation with the v.a.'s other efforts, have led to the scheduling of approximately 200,000 appointments from may 15-june 1. information suggesting that last thursday, in coordination tw the other efforts has leds to

200,000 point nous. i to have concerns about the effort to date. one of the con essentials is the continued lark of information that skong has received about the nishlgtive. >> making this in a long list of examples of va failing to act in an open and trarns parent matter. the committee asked for a recap on june 2nd. i followed up with a formal letter on june 5th: it has now been 19 days since that request for an immediate briefings and no further information or 5:00 nol o knowledge.

of our questioned to sooech. if va's work has, indeed, led to 200,000 more pay she says ths sense so far, what is left to ied. given that, how can the people have kftsds in thee larks.

>> va. claims to be taking sets in its own woshds. extend or flex clinic hours on nights and weekends. increase the use of care in the kmumpbty and riech old to vet ere rans. va has had the ongs to use these recently. sequel snow stlooes 350 vet ere rabbles died wild waiting to see i have isle skraer. we know that 50,000 it is too late for those 35 phoenix area veterans and it may be too late for other veterans

who have been 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? i 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. 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

is central to good strategic planning. 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 system that is overwhelmed and unprepared. 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. on the 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. with that, i yield back.

>> thank you very much. we are honored to be joined this evening by dr. thomas lynch, the assistant 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 michaud and the committee. thank you for the opportunity to discuss 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. these 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 levels at each medical center as well as a productivity of our physician workforce utilizing a standard of care measure of relative value units, or rvu's. 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 support/staff ratios to ensure that the clinics run 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. v.a. has accelerated the 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 schedule in completing -- will 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 receive care for teams. they receive advice and consultation which could be provided to technology, telephone calls, secure e-mails and telephone bills. r which peemd pea v pail for dreenls. ledge iing.

since the majority of u.s. physicia physicians received some training in a va facility. we have also reinforced the importance of team work and technological skills. to ensure that the promise of these new models achieves the goal of personalized veteran nencrik care. the work koblts and we will not be dob until this's ready ax cess to high-rmgtsz envigsz pair. we are fully engaged. this concludes my testimony. my colleague and i are prepared to any any questions you and the

other mr. >> so that we can physicians more quickly. >> are there any impediments that we, as a. >> at the moment, mr. chairman u i tntty of i you willed. >> i think you would want us all to be rig.

>> what's the kmpted cost of the salary and access secure nationaltive. and how are you funding it currently? >> right now, the cost is becoming $300 million: >> other than asking if fa tillty to look at them, to let us know what resources we need to provide that deer in the kmubty.

to date, we have distributed 312 you won ways over 0% see between 11 and j i could qualify that by sayings i think we need to assure who capacity they have in the way of rooms. r i if you will it's knot

just@physician's antsd and willingness from them. >> so you would know how long roojs would be needed, i would shshs shd. >> congressman, themp designed in a time when heltcare was not the tom nant move. . we are still challenged by facilities not con strukted by the outpatient model of care. >> so if i went to the new that sill tid, u i can want that the

doctors. >> the va has beenworking to presumption of guilt in place testimony plaits. one other question, if you would. the office of special counsel wrote a letter to the president today. citing a case of a veteran with a 100% psychiatric condition block forted in a eight years. are you particular with that incident? >> yes, sir. had only onean psychiatric note in his truck. is that true? >> that is unacceptable, sir. despite the fact that the office of the medical and specter substantiated this

occurred, it also stated that it had no impact on that patient's care. can you believe that? >> the office of the medical inspector is unique in health care. we don't see it in the private sector. 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 those concerns very seriously. is in a position where we have to establish our integrity. established a group, a commission will evaluate those concerns. the report is due in 14 days. it is important we understand what that review shows before we draw any conclusions. >> thank you. >> thank you very much, mr. chairman.

thank you for coming here this evening. thenderstand that accelerated access to care initiative is designed to ensure access to care by enhancing resources within v.a. facilities . also sending veterans promptly to community-based care and non-v.a. care when needed. it is not readily available at the v.a. facility. what is the role of the exhilarating access care initiative -- access to care initiative? >> it will be another model we can use to provide care in the community. pc three is just in the process of being put up. some sites have greater availability of services than others. it is an option that we can use to identify community providers

were willing to provide care and to meet certain conditions of the contract which specified that care would be provided within 30 days. that we will receive reports in a timely fashion. 3 is an enhanced method of providing care in the community that gives benefit to the v.a. because it assures timeliness and insurers we get records back in a timely fashion. fisher some minimal level of quality. -- they ensure some minimal level of quality. the plans that they are contracting with have met standards for the national committee. we are going to be working with them to figure out how we make those standards a bit higher. >> thank you. the committee is aware that the v.a. had conducted several pc3ects before implementing

. they have also indicated that designing pc three used lessons learned from these pilot programs to develop a solution which is coordinating convenience and consistency with v.a. quality standards. 3 is up and running across the country, are all centers using this program as part of the solution? and whent is available the services are available, it is being used, yes. >> so it is not throughout all of the v.a. medical centers. >> in certain areas, the contractors are having to identify providers. in other areas, services are is being used.c3 >> we understand it is not a mandatory program. how can we have a v.a. medical

center for legalizing pc3 if it's not mandatory? hope would be my understanding the benefits of the process that it would be advantageous to the medical center's to use that program . if there are standards for timeliness of providing services and standards for the receipt of work rotted after the services have been provided. >> how does the v.a. distinguish between short-term and long-term capacity shortfalls and how does the v.a. respond different to the long-term and short-term shortfalls? >> as our data becomes more and as we see increasing use of the electronic waitlist, we will have the option to see our demand handled in one of two ways. either as a completed

appointment or a patient who ends up on the electronic waitlist. depending upon whether this is a short-term increase in the requirement for services, in which case the v.a. might find -- 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. do we need to make a decision that would be more cost effective for us to identify the providers and make the service in-house? short-term, pc3 provides the opportunity for us to offer services to veterans who we don't have the capacity in the trendsrm, when we see come and gives us the option of making decisions about whether

we should continue to buy this in the community or if we think we can offer in-house. >> thank you, mr. chairman. in the last two weeks, the number of veterans in my district in colorado springs have contacted my office asking for help while try to receive a doctor has more than doubled. described how he was referred to get a biopsy done on his thyroid to determine whether only to bead cancer, told he could not be seen for two months. i can't imagine having to wait for two months to even get a test done when you have a roast.e cancerous tell me what options are available to the denver v.a. medical center to expedite a biopsy appointment. especially based on medical necessity and if there is a possibility of a life-threatening condition. you are telling

me, it services cannot be ,rovided in less than 30 days that is an unacceptable waiting time. the denver v.a. facility should be able to identify a community provider to offer those services. >> that would be the fee-based approach ear to the use of non-v.a. care or the fee basis approach. 55 days for that type of procedure is unacceptable. >> that would be my impression. >> thank you. the data included in the bas bimonthly access data update makes me worry that this problem might be getting worse before it gets better. especially in colorado. we have a lot of the same concerns. although the reports show the number of veterans on electronic waitlist across the country dropped slightly, the electronic

waitlist at the denver v.a. medical center where many of my constituents receive care doubled. 1632 two 3300. what could have caused that number to double in 15 days when it was dropping slightly around the country? >> i don't have the specifics on denver. i will be happy to try to get that information for you. i can tell you that, at the moment, the electronic waiting list is going to be dynamic. two processes that are occurring. we are working down the new appointment request. they are being put on electronic waitlist. it is possible that some of the patients have been moved to the electronic waitlist.

exactly why they are accumulating, i don't know. i think we have the capacity to find that out. >> if you could get back to me on that, i would appreciate it. thank you. you stated in your written statement that the average current number of patients assigned to each primary care provider is 1194. how does that compare with the private sector? >> the private sector model can vary with panels of anywhere from 1000-2000. it depends on the complexity of those patients worried it depends on resources available and the physician's sing those patients. v.a. patients are often older. patients in private sector may be younger, healthier and may not require the intensity of care that v.a. patients require. would you have any comment?

>> i would agree with all of that. home is alsodical unique for being integrated in many of our facilities with mental health providers were right there if those needs arise. >> one last question. in your written testimony, you said the pa is adopting y standards. i'm glad to hear that. what has been the standard up until now? sadly, there has not been a standard to this point. we are now using the relative to evaluate the productivity of our providers. using that information to determine, are they meeting in the productivity standards? if they are not, why not? it could be a matter of support

and available resources. it could be a matter that there are not enough patients for them to see. to identify more patience or we need to figure out a way that we can move their capacity to another facility. you have to using something like tele-health. >> thank you. >> you're recognized for five minutes. i really have no questions. i yield back. >> you're recognized for five minutes. >> thank you, mr. chairman. thank you for appearing before us today. i understand that from 2000 8-2013, non-v.a. patient visits 9 million to 15.3 million. knowingve any way of about the comparison between

non-v.a. care versus in-house care? its efficacy and its cost. >> i don't have the comparative data from those years. i can tell you, in the last fiscal year, we spent approximately $4.8 billion on onvia care. -- on non-v.a. care. i would have to try to get previous data to see how our use of non-v.a. care has increased or changed as we have seen increasing outpatient acquirements. -- requirements. if we want to expand access for veterans to non-v.a., it would be important if there was a continuity of care and health records that can be transferred seamlessly. that is part of what you are talking about. the quality check on the pc3.

what can we do twin sure that this happens -- to ensure that this happens? >> that is a very good question. it is a challenge. right now, our community providers do not have ready access to the v.a.'s electronic health record. i can't tell you as we move forward and establish more -- when i was in omaha, we were able to do that for several of our community providers. who gave regular service to v.a. that, as part of the aca and the high-tech act, congress created incentives for health care providers to make the transition to electronic health records. you have any idea this digitization has been done with electronic health record

systems? >> i will defer to dr. clancy. >> we are complying with the out by those incentives from cms. it v.a. does not get money from cms. we are compliant with all the standards. the private health-care providers who were given incentives to digitize their records -- as a standard set forward by cms, will that provide interoperability with vista? guest: it should. in some cases, we are starting to explore this. with some pilot projects on allowing veterans to get immunizations in a walgreens. we can exchange that kind of information. there is a difference between people meeting the same standards and being able to share freely across platforms.

>> you are saying it should. , physicians who have been incentivized under the aca to digitize, the standards by cms should provide the platform for interoperability with vista? >> it provides the foundation for it. >> part of being able to facilitate this ability to arena care in the private would be to facilitate interoperability. maybe part of the answer would be that, if there were further incentives for our physicians to part of, this would be the solution. >> this is a very strong

priority for hhs right now. both cms and the national coordinator. we are part of that strategic fighting effort. that would make it much easier. would our community partners do is, they send a report. makes it easier because it's a condition that they're getting paid. tickets attached into the vista record as a portable downloadable file. >> would this incentive is nation be helpful -- with this incentive be helpful? >> down the road, for sure. >> thank you. >> thank you, mr. chairman. of the 70,000 veterans who were contacted and were on the waiting list -- how many were contacted and they actually spoke to a person?

tell me what the contact was. if they had an actual conversation with them. >> we don't have that breakdown yet. we will. there were attempts made to contact all veterans. there were three attempts made. if we could not contact the veteran, they would then receive a certified letter. we will be developing the data as we collect it. we should be able to provide you with information that would tell you how many patients were directly contacted and how many patients were contacted by mail and how many we could not contact. disposition of the patient's contacted. >> if they received something in the mail and they contacted the v.a., would they speak to someone immediately? >> that would be my expectation. i don't have the data right now. time --r as the waiting

they contacted somebody, contact was made, there was a conversation between aba --ividual and the patient how long would they have to wait for an appointment? >> the expectation is that we would explain to them how long we would have to wait for care -- they would have to wait for care in v.a. if they did not find it acceptable, we would provide cure the community. >> you have any information to give me so far. any results as far as, let's say they had to wait -- how long would they have to wait to get aba appointment -- ava appointment? >> the expectation would be, if we cannot see that within 30 days, we would offer them care within the community. >> where did the 30 day expectation come from? >> at the moment, there is not

science behind it. there is evidence that, in the patients are waiting anywhere from 15-30 days or longer. i believe we chose that as a reasonable number. >> who chose that? >> v.a. chose that. depends on the patient. if the patient needs care immediately, we will provide that. if there is urgency, we will provide it within 30 days. to dr. clancy and ask if she has any further insight. i would guess that you and your colleagues have probably seen data for how long it takes to get a new patient appointment which ranges from somewhere 10 in dallas 245 or so in boston.

it does not have a lot to do with the number of doctors in the area because boston has a lot of doctors. there is no industry standard. when veterans contact a facility and are given a wait if that's not acceptable, they go out to the community and they are counseled if they have a more urgent need, they should come in to an urgent care or emergency room for more immediate care. ifhow long would it take it's decided they have to go outside for care? how long would it take for the patient to get the appointment? >> a lot of that will depend on what existing capacities in that community. >> on average. >> we don't have a number for that yet. i would guess in the dallas area it would be much faster given the data i just mentioned. we times there are shorter. i would expect it would be much tougher in the boston area, for example. pc3 contract, it is

the expectation that patients will be seen within 30 days. >> one last question. health care programs enhancement act of 2001, the establishdate to staffing policy -- can you describe what that policy is? know which physicians are needed, who they report that information to and what is done with that information to address a staffing shortage? >> i will have to take that for the record. i'm not familiar with that policy or the data associated. i know we currently have information through our office of productivity and efficiency and staffing that is looking at the number of physicians we have

, the specialty of those physicians and their ability to provide care in an efficient fashion. me.'s report back to i feel you should have been information with you today. -- please report back to me. thank you, mr. chairman. thank you both for joining us ken. i will start off by asking the this comesf from the inability for us to do our job. we said our facilities were flagged and we were guaranteed we would be told why that was. nothing has been said. everyday, i get calls asking what's wrong with these facilities. i will ask you. i actually had a discussion before i came down here tonight. we knew this issue would be

raised. >> good foresight. i appreciate that you are thinking ahead. >> he and i agreed that it's important that we brief the committee and make arrangements to do that. and provide greetings to other congressional staffs. you have been coming down her a lot and i'm appreciative of the work you do. i think the time has come when you know you don't get the benefit of the doubt on anything right now. after today's osce, you mentioned it was an acceptable situation. if we had a veteran for eight years that we warehouse. that's a national tragedy. i'm trying to get at the heart of this. i think we are flirting around the edges here. a director of a medical center what our national strategy on veterans was, how would the answer? would hope they would

answer that our strategy is to provide timely care to our --erans that is quality care >> is that a strategy or goal? >> probably a goal. >> we have a national security strategy. it identifies requirements. forces come back to fill those requirements. you do that at v.a.? we have been trying this issue since 2005. we started in 1980. about gettingced a strategy answer. offer that we are developing a strategy as it relates to access and scheduling. seven stepplace a

process we are developing. that will address the issue of accelerating care. that will address the development of demand capacity models. develop the policies and directives to drive scheduling and access. that will relook at our performance assessment measures so we can develop the measures and goals appropriate to drive our system to the appropriate endpoint. which is quality, timely care. we are developing the processes to put together program oversight and integrity. to recruit people and to train them. and to integrate our care processes with the non-v.a. care model. >> where does that guidance come from? >> this is an organizational plan that was developed within bha over the last re-four weeks in response to the issues we have faced regarding veteran

access. >> is there white house input into any of this? >> not to my knowledge. >> i want to get to a specific one on this. i want to give you an example. there is a mayo clinic in phoenix. it was brought to my attention that they were doing some of the prostate surgeries. is that correct? >> that is my understanding. >> when they would have them come in, they would say they can do the surgery and 48 hours. v.a. would say, we have to do the ecgs and that will take 6-8 weeks. we had it going out into the community and a community partner ready to do it and yet, we went back in house again to delay that care. how will this be different? nowwill what you are doing be different from that if you have prostate surgeons ready and

? part of our non-v.a. care process would allow those providers to do certain basic studies that are essential to their lyrical assessment or preoperative evaluation. >> the whole package will go. >> i wouldn't say that we would look at very high class studies in routine studies done in the community. >> i yield back. thank you, mr. chairman. i liked your questions. it very much concerns me -- the whole management system at the me, needs to be reevaluated. i hope we can get to that and move in that direction. what's happening here is not right.

a couple of ideas that came up in your testimony today -- you mentioned the fact that you weren't sure how much of this community-based health care is proper. it should be a temporary or full thing or should be kept in the v.a. because of the extra spent -- extra expense. have any ideayou what it actually costs to take care of a patient within the v.a. , talkingte sector about paying them a medicare rate. you don't have any idea if you are actually caring for veterans -- what it's costing us. >> the v.a. does have v.a. dss model that tracks the amount that goes into the care of each patient. it has not been used extensively. rvus. don't do it for

you are doing a certain code, you don't have any idea of company rvus you produced in a year. we have a pretty good idea of how many units we are getting for the billions of dollars being spent. i don't believe there is any comparison like that at the v.a. i do know that when i was in omaha, we were able to, in our facility, to begin looking at the costs of specific operations. another thing that i want to bring up -- there is no interoperability in the electronic medical records. that does not exist. you can get somebody's medical record from somewhere else.

it does not happen. it's impossible. that would be ideal, but it does not work that way. the expectations of having this are you aware that the v.a. has been informed that there is a pipeline problem with positions and the productivity problems for the last 30 years and expectorant general has said that the v.a. needs to develop a plan and it has not been done? they told me it would be three years before tha there would be a common plan. you talk about it a lot. place. wean is in will have productivity standards for all of our medical specialties by the end of this fiscal year. >> i would like to see that.

they said it would be three years when they testified. >> they are one year ahead of schedule. >> can you provide that? in december of 2012, there was a report that said all five facilities that they visited were operating contrary to v.a. which declares medical facilities to develop staffing plans that address performance measures, patient outcomes and other care indicators. december 2012, they said that the opposite as they visited did not operate according to v.a. policy. what has been done to change that? >> that is what the office of productivity and efficiency and staffing has been working on. since they made those 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? metcher.arter and eileen moran. i believe they have been down and have testified or briefed some of the physicians in this committee. it is one thing to have a plan. it is another thing to carry out the plan. the inspector general told us back in this report that none of e facilities were carrying out the policies in place. you have no idea if any action was taken over the fact that these five places did not comply with the rules. >> i do not, sir. >> i'm out of time. >> yes, you are.

thank you, mr. chairman. thank you to the panel for being here this evening. --anted to talk a bit about we now have some new information that we have from the audit. when will the v.a. taken this new information that we have learned about the real way times as opposed to the previously reported way times and the increased demand thereof th?is of? v.a. is also seriously discussing the space needed to address the delivery of that care. discussion this

week, in fact. >> if the v.a. is evaluating the imagine space, i would you're looking at space, the need for more personnel and it may be very extreme. he you may need much more space and many more personnel and other places maybe it can be resolved a increasing hours at a particular facility. you gathering all of that information and putting it in a that you can, by each location, know exactly what the underlying issues are? and how the v.a. will approach that? space is something very concrete. personnel might not be as concrete, but it's pretty concrete. will you have that evaluation location by location in a timeline?

>> we already have most of that information location by location. we have physician information location by location. i cannot confirm whether we have space information. it is critically important in making decisions regarding efficiency. we are working and discussing the implications of space as we put our models together. >> you will have a model of space and time lines location by location. you say you already have that for personnel. what exists currently? what is needed? >> yes and yes. we have the information based on what we currently have. we have been looking aggressively over the last several weeks at what may be required to either increase the efficiency of our providers or

whether we need to consider adding additional physicians to meet that capacity. >> could you share that information with me? on the personal side. >> i can set up a briefing with you. timeline forur space. what is your timeline to put together a matrix to identify what the space needs are? >> i would have to get back to you on the space issue. that is still being discussed. i don't have a definite timeline for that. >> ok. the chair in his opening comments talked about asking the question, how quickly can the v.a. higher a doctor. you talked about the fact that you were not sure. you know it is too long. we all agree on that. theyou just share with me

v.a.'s initial thinking on what some of the barriers are. mechanismsbe some for shortening that period. guest: we are clearly going to have to work at improving the efficiency of our human resource process. for handling new recruits. you're absolutely right. it is clearly too long. often times we lose people during the process. some of it is essential. some of the other processes involved in human resources can clearly be improved in terms of their efficiency. interestingly, some of the things we're learning in phoenix as we are working with that facility to increase their a physicians may help the rest of our system. thank you.

i yield back. >> thank you, mr. chairman. as part of ea's excel running access to care initiative, you have committed to ensuring primary care clinic panels are sized to achieve the desired productivity. what are the desired productivity standards that you are using for primary care providers? >> right now, the standards they are using are the number of -- they per physician tohave a model they can use see whether we can increase that capacity based on staffing or based on room availability or patient complexity. we are also beginning to implement the use of the relativity model to look at primary care and see if we can use that to take a look at the number of patients a physician

is saying and the complexity of those patients and their productivity. 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. the physician may be more productive than a physician who is saying 15 established patients during the course of the day. that? do you monitor >> we are monitoring that by looking at the activity of our physicians. >> at the national level? >> yes. facility level. >> yes, at the facility level. >> now, given the gaming strategies and what has shown that the data may be not valid or not reliable, do we potentially have the same

problems with what you are attempting to measure here? why would we not have similar problems with knowing exactly what is going on with productivity? incrediblythat is an important question and one that we share your concerns and one that we recognize cents integrity of data has been a problem for us, we not only need to clean up our policies and streamline them but that we also need independent validation that these processes are both effective ad that the integrity can be assured by an independent third party we will be doing just that. 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 you send them out into the community and then you don't track their results out in the private sector or if you send them out and there are no providers in the private sector, we really have just kind of traded the devil for the witch. we haven't solved the problem. >> i very much appreciate that, congress woman. i want to be clear about one thing. i wasn't suggesting we would send primary care providers to camp for three weeks and then they would be oggyns by any stretch of the imagination. this was more to be in the coordinating role and to be able to provide some basic services but also to make shoo your that people got the services that they needed in a timely fashion and i would just say that our top consultants in women's health of urgent sit would be her middle name, but i will be

happy to get back to you about the mammography issue specifically. >> thank you. i yield backing >> wrxt rope, you're recognized for five minutes. >> i thank the chairman. i'm glad it's not three weeks, it took me 30 years of experience to get to the ob-gyn camp. i'm glad to hear you can't do it in three weeks. we want to as a group here and i think you hear from both sides of the aisle, to be able to go from good to great. to be able to do that though, we have to have information that's accurate and timely. and i looked at the memo today we were sent on the rdus. i know this is not a big thing. i think it's a symptom of what goes on in the va. if you look at a law that was passed in 19, in, 2002 it appears to me when you look at the '68iation the ig did with these five medical centers in boston, houston, indianapolis,

philadelphia, that and looked at the staffing levels we're talking about for specialty care services, it's taken 12 years and we still don't know what they are. i mean, this is law was passed in 2002. and it's 2014 and we're still talking about we don't know what our staffing feeds are. well, that's not complicated. having spent 30 years doing what i did, it's not hard to figure out what your staffing feeds are. if you can't get somebody in to see a cardiologist, you need a cardiologist. you don't need another study or anything to figure that out. i don't understand again did the accountability when this didn't happen for 12 years, and then last week, last friday, we found out that the 80% of the people in senior levels at the va got rewarded for doing a great job. and yet, we completely ignored this metric. it doesn't appear there's any penalty whatsoever for not following the law.

am i wrong? why wasn't this done? >> congress man, i can't speak to what happened before i got here. i can speak to the fact that following the ig report, that was taken, the recommendations were taken seriously. we are a year ahead of time. meeting those recommendations. by the end of had year, we will have productivity standards for all specialties in va. and we will be able to use those moving forward to make decisions about where we need to supplement support for physicians or to provide additional physicians. >> let me just ask the question again. is there any accountability at all? i mean because this is 12 years went by, this information should have been able to you all where you could use it to help prevent what just happened. anyway, i want to also go on to a couple of other things. mr. o'rourke brought up. i totally agree with this. is that really, there are two issues at stake. the backlog is not going to be a big deal. we can fix that one very quickly i think. and today, be i got a call from

memphis, tennessee, a physician down there put together in three days with a university of tennessee system with the methodist hospital, they'll see any veteran, primary care or specialty care including oncology in 72 hours. they can do that. our group can do that. it can be done across the country. so the backlog is very simple to solve. a much more difficult decision is the culture of the va where we go 12 years, we don't follow what the law is, where we reward people at senior levels for doing i don't know what. maybe some of them did a really good job but others clearly did not because we see the failings right now. let me just give you a brief example. i went to my eye doctor today right here in the washington. i had a little retina problem. the doctor said he had been trying to get to the va here the ret nat specialist to the help out. he had a patient that was supposed to see a doctor in january this year with a retina

problem. it snowed that day. so they made the next appointment in june, that's this month. well, when the guy finally saw when the doctor saw him at the va, they rushed him over to the ret nat specialist because the guy had a detached retina for five months he didn't get treated. another call today, this physician i talked to in memphis had a fellow to took eight months to get to an oncologist outside of the va. recommended a biopsy, that took four months. the man has cancer. they probably can't treat it now. that's not -- we cannot have a system ta treats our veterans this way. and we have a system out there, a private physicians who want to help. they want their veterans like me and dr. win strup and others like this young man here, i should show you when we get through today. i want you to see this because they want to help. i think they're there to help. i think their intentions are right. i think your intentions are right. you want to make things better

for veterans but we have the second one. the first one, the backlog we can take care of that. i have no doubt in less six months we can get fixed. that second one, the culture in the va is going to take a lot of work and honesty and transparency from the va senior people so we can help you go from good to great. i yield back, mr. chairman. >> mpg that you very much, doctor. >> >> thank you. >> when you figure the cost as far as putting out services from the va, do yous are consider the savings ie we heard from chris datay in charge confident arts program, actually we're able to save the va about $600,000 during that pilot program for mile and. so do you consider the cost savings, as well or just the cost comparedtively? >> i think when we look at how

we manage excess -- excess demand, we need to determine whether we can provide that will service more economically within the va or whether it's better for us to buy that in the community. i think that's an important decision. we do know the community costs. we can calculate. beat do have the information to determine what it would cost us to hire those physicians and to provide care a. i think if we can do it more economically and at less cost in the community, then that would be an appropriate thing to do. >> but you can considering all the factors, it might cost x for within the va for a certain specialty care, it might seem cost more outside for that same specialty care but when you look at the savings, are with reimbursement, it's more cost efficient to do it outside versus inside. so do you look at the whole cost? >> yes, sir, i think beat do and we will. >> okay. my second question is, of the

three key elements of capacity, supply for clinical providers, amount of services providers can deliver, are modern i.t. infrastructure, out of these three, which one poses the greatest challenges to the va? >> i would say based on our aging infrastructure, our greatest challenges are providing the physicians adequate space to epatients and giving them the support they need to see patients efficiently. it's hard to separate i think i.t. is a challenge, as well. but i think we do have an electronic medical record. it's not a perfect record. it's in the process of evolution and improve. but i think our greatest chals are in support for our physicians and in the space for them to provide care in an efficient fashion. >> and my last question is, when you look at the wait list, i know some facilities have automated system where they call in, it's automated depending on how long it takes them to get

through the menu, they might hang up. say the heck with it, they're not going to bother. are they counted into that wait list and if so, how do you -- how can you track them? >> people call in to the va for a number of reasons. so it's going to be difficult to know what they're calling in for. we do measure, are however, abandonment rates and we do measure time to answer our telephone system. we're working to improve those so that that won't be a problem. >> thank you, mr. chairman. >> dr. win strop? >> mr. chicano. yes, sir. >> so i'm a little confused by interoperability of records. can you help me explain about there is no inner operability? >> well, this is a case where you're both right. the second stage of the

so-called meaningful use, this is the series of stepped incentives, right,ing that cms has put in place incentivizing is private sector providers to adopt electronic health records and the like not just to buy the stuff but to the actually use it in such a way as to improve quality of care. that second stage of meaningful use actually requires the providers be able to share some information with other providers. so you're right that meaningful use is actually a path to getting us to a place where we can share all the information. i think it's fair to say that many providers are finding this challenging. so dr. ban i check is also correct when he says give me a break because if you're thinking about actually just uploading all information from one to another, that's actually much, much steeper and likely a bit far off. i think your original an sherrion that in fact the incentives put in place by the hi-tech act are setting us in the right direction. i wanted to make the point vha

is complying with all of those. >> my understanding having spoken to some physicians who do work at va hospitals that they do appreciate the vista medical record. quote and i'm quoting him, the information is all there. and it seems common sense to me that if the records are integrated, nthat that enhances the integrated care within the system. so within the system doctors can pass this information around. so the concern that was raised in many hearings was the lack of interop ratability with dod and their medical record systems and the billions of dollars that we've not been able to spend in a way that we have interoperability. if you listen to situations and cases where service members and veterans their health care was greatly compromised. and so i've been listening in

these hearings and understanding that the challenge with being able to move into opening greater opportunities for our veterans to use access nonva care is this interoperability challenge, but so that's why i was raising the question. so the it would seem to me that if he woo want to move more in this direction that we're going to have to encourage private physicians and care groups to be able to communicate with the va's record system. >> yes, and so i think your other question or statement was that if this were written into the p c3 contracts, that providers who had met the meaningful use requirements and so forth would get preference or to the extent that they could contract with such providers that would be a good thing. in terms of coordinating care is a very fabulous idea.

so we'll take that back, as well. >> thank you. i yield back. >> mr. brown lee. miss titus. mr. jolly? >> sure. >> mr. chairman, just have a very quick follow-up. dr. lynch, i want to go back to the fy 149 appropriations question i asked you for a point of clarity. i understand you mentioned the va is in the process process of working with outside providers. is that just a general statement or are you suggesting that the demonstration project kong depressionally directed in the fy '149 budget is currently being implemented? >> it is being implemented, congressman. can i get you information on the sites where that is being provided at this time? >> yeah, you certainly could. there are about six or seven of us that wrote a letter to the secretary on may 7th asking for an update on the implementation. i know you've got a lot of letters coming your way right now. but it is a matter of concern because it was done with such

specificity. even the criteria were put in the congressional report as to how the centers were to be evaluated. so i just want to make sure we're talking apples and apples here that this is the fy 14. >> let me work with our was office of mental health operations. >> that would be great. >> get you the information that you need and make sure that we are talking ands and apples. >> sure. i'll leave a copy of the letter. it was may 7th. seven of us signed it. i'll put it in your hand when we leave tonight. appreciate a response. thank you very much. >> miss kirk patrick, five minutes. >> thank you. dr. lynch i just have the two questions. is there a complaint system within the vha something like a hot line that a veteran can call and someone get back to them about their complaint? >> dr. clancy, do you want to take that? >> yes, every facility has a patient advocate. and in fact, they get complaints. they get all kinds of calls, and that is actually tracked in

terms of time to resolution and so forth. that -- that all of the patient advocates now come under an office of patient centered care and cultural transformation. so we have begun working with them a bit from the quality and safety side to try to figure out how could we learn more from what they're hearing because we're noticing that i an number of private sector organizations are taking to heart just how important and useful it can be to learn from the patients themselves. so. >> so is that information looked at at nationally nationwide not just, it doesn't just stay at the local facility? >> yes, there is a national database. >> okay. then my second question is, are you consulting with the vsos on how to engage innovation in the system when it comes to scheduling these appointments? >> we have not been communicating directly with the vsos. i think we certainly have been