to talk with veterans in our communities one on one, and we have a commitment to make sure that we continue to stay the course. that to me is the most important thing that this committee can do, and i thank the chairman for not allowing us to move on to other matters that may be pressing, but what could be more pressing, than to make sure our veterans receive the care that they need and deserve. thank you, mr. chairman. >> other members will be iltering back, but i would like to hear from the acting secretary now, and we get five minutes, but you will have more time. this is a serious discussion, and we want you to have the time you need to make your case, and we want the members here to have the time they need o ask you the questions.

all right, senator burr suggests maybe we should make a -- wait a few minutes for other members to come back from recess. let's take a quick recess here.

>> it's create cal we continue to have these hearings to do everything we can to hold v.a.'s feet to the fire and make sure that accountability is there. we know some things now that we did not know at the last hearing. we know for a fact that v.a.'s wait list manipulation and access to care issues is, in fact, systemic. report after report has confirmed this. in fact, 77 facilities are currently under investigation by the v.a. inspector general. it's an astounding number. and i believe the scheduling problems are the tip of the iceberg. now we have allegations of whistle blower retaliation and

mproper payment of claims. the cancer doesn't seem to stop, but it must be stopped. while i appreciate your efforts , secretary gibson, i think you have done some things, and they are recognized and acknowledged. but i think we'd all acknowledge there's so much more to be done. there has to be accountability for wrongdoing or these issues will continue, and the senate will have more hearings, not only next week and the week after, but in five, 10, 20 years from now. there's a serious lack of leadership from the top. the white house needs to have a more visible role in addressing the crisis. we collectively have the ability to fix this agency, we just have to find the will and the common ground to do it. all of us have to be a part of the solution.

in may, during our last committee hearing, i encouraged the expanded use of non-v.a. care to get urgent treatment to those veterans that were languishing on both secret and official waiting lists. the bill recently passed by the senate gives greater flexibility and treatment options for veterans faced with long wait times or lengthy travel. the choice card injects much needed competition, in my opinion, into the process, and it demands of the v.a. that they get their act together. and the accountability and transparency pieces of the legislation are not only important, they're critical. the notion that employment should be tied to performance might seem elementary to most people, but this has not been happening at the v.a. there have been several instances in which senior v.a.

executives who were involved in mismanagement or negligence were not reprimanded, but instead receive bonuses and positive performance reviews, shameful. and while senior executive service employees can be disciplined and fired under current law, it's a very long and drawn-out process. again, that doesn't work. the secretary needs the authority this bill provides to cut through bureaucratic red tape, and most importantly, to hold individuals responsible. we have to root out the culture of corruption that is contributing to nearly all of v.a.'s most pressing issues. it's a huge challenge, but we can and must get the v.a. back on track and focused on their core mission of providing quality healthcare to our veterans. they deserve nothing less.

thank you, mr. senator. i yield back. >> now i want to take this opportunity to welcome mr. sloan gibson, acting secretary of the v.a. i thank you very much for to give us an update, and we look forward to hearing your testimony. secretary gibson is accompanied assistant lip, the deputy undersecretary for health for administrative operations, and your prepared remarks will be submitted for the record. senator begin son, you've already made your statement. secretary gibson, please begin. >> mr. chairman, forgive me if i dispense with the traditional niceties and get straight to business. as has been recounted this morning, we have serious problems. here's how i see the issues. first and foremost, veterans

are waiting too long for care. second, scheduling improprieties were wide spread, including deliberate acts to falsify scheduling data. third, an environment exists where many staff members are afraid to raise concerns or offer suggestions for fear of retaliation. fourth, in an attempt to manage performance, a vast number of metrics have become the focal point for staff instead of focusing on the veterans we are here to serve. fifth, v.a. has failed to hold people accountable for wrongdoing and negligence. and last, we lack sufficient clinicians, direct patient support staff, space, information technology resources and purchase care funding to meet the current demand for timely, high-quality healthcare. furthermore, we don't have the refined capacity to accurately quant few our staffing requirements, because historically we've not built our resource requirements from

the bottom up. we have instead managed to a budget number. as a consequence of all these failures, the trust that's the foundation of all we do, the trust of the veterans we serve and the trust of the american people and their elected representatives has eroded. we will have to earn that trust back through deliberate and decisive action and by creating an open, trance partner approach for dealing with our stakeholders to better serve veterans. to begin restoring trust, we focused on six key priorities. get veterans off wait lists and nto clinics, if i can systemic problems, address cultural issues, hold people accountable, where conduct or negligence are documented, establish regular and ongoing disdisclosures of information, and finally, quantify the resources needed to consistently deliver timely,

high-quality healthcare. here's what we're doing now. v.h.a. has reached out to over 160,000 veterans to get them off wait lists and into clinics and made over 543,000 referrals for veterans to receive care in the private sector. 91,000 more than in the comparable period a year ago. this is in the last two-month period, and i would point out here that for each of those referrals on average, they result in seven invests to a clinician. they're adding more hours, using temporary staffing are you sources and expanding use of private sector care. we're moving rapidly to augment and improve our existing scheduling system, while simultaneously pursuing the purchase of a commercial, off the shelf, state of the art scheduling system.

i've directed medical center and directors to conduct monthly inspections in person of their clinics to assess the state of scheduling practices and to identify any related obstacles to timely care for veterans. to date over 1,100 have been conducted. we're putting in place a comprehensive external audit of scheduling practices across the ntire v.h.a. system. worry building a system for measuring patient satisfaction, which i believe will be central to our measurement processes in the future. i've personally visited 10 v.a. medical centers in the last six weeks to hear directly from the field on the actions being taken to get veterans off wait list and into clinics. i leave later today for albuquerque and el paso. the inappropriate 14-day access measure has been removed from all performance plans to eliminate any motive for

inappropriate scheduling practices. in the course of completing this task, over 13,000 performance plans were amended. where negligence is documented, appropriate personnel actions will be taken. this also applies to whistle blower retaliation. i'm sure we'll talk about that further. i've frozen hiring as a first step to ensure that we're all working to support those delivering care directly to veterans. v.h.a. has dispatched teams to provide direct assistance to facilities requiring the most improvement, including a large team on the ground right now in phoenix. all v.h.a. senior executive performance awards for fiscal year 2014 have been suspended. v.h.a.'s expanding our use of private sector healthcare to improve access. i sent a message to all 341,000 v.a. employees and have

reiterated during every single visit to v.a. facilities that whistle blowers will be protected. we will not tolerate retaliation against whistle blowers. i've conducted over a dozen meetings and calls with senior representatives of other stakeholder groups to solicit their ideas for improving ccess and restoring trust. i've named an interim undersecretary for health. she will spear head our immediate efforts to restore the trust of veterans. dr. jonathan perlin, current on the leave absence from his dutieses as chief medical officer and president of clinical services for hospital corporation of america has begun his assignment as senior adviser to the secretary much his expertise, judgment, and professional advice will help gridge the gap until v.a. has a confirmed undersecretary for health. dr. jerry cox has agreed to

serve as interim director of the office of medical inspector, a navy officer for more than 30 years and former inspector of the navy. dr. cox will provide new leadership and a fresh perspective to help restructure o.m.i. and ensure strong internal audit function. as we complete reviews, fact finding and other investigations, we're beginning to initiate personnel actions to hold those account act who committed wrongdoing or were negligent in recharging their responsibilities. to support this critical work, iss lee bradley has begun an assignment. she's a former general counsel at v.a. and a member of the general counsel team at the department of defense, where she had direct responsibility for the ethics portfolio for d.o.d. before i conclude, let me briefly address the need for additional resources.

i believe that the greatest risk to veterans over the immediate -- over the intermediate to long term is that additional resources are provided only to support addressed purchase care in the community and not to materially remedy the historic shortfall and capacity. such an outcome would leave v.a. even more poorly positioned to meet future demand. we've been working close with the office of management and budget for several weeks to develop the request for funding. while the amounts under consideration are large and the context of v.a.'s size, scope, and existinging about the, they represent moderate percentage increases in annual expenditures. furthermore, a substantial portion of the funds required are not recuring in space and technology that would not be reflected in long-term rates. resources required to meet current demand covering the remainder of fiscal year 2014 rough fiscal year 2017 total

$17.6 billion. these funds address shortfall and information technology and purchase care necessary to provide timely, high-quality are. the president, congress, the american people and v.a. staff all understand the need for change. we must, all of us, seize this opportunity. we can turn these challenges into the greatest opportunity for improvement in the history of this department. i believe that in as little as two years the conversation can change. but this can be the trusted provider for healthcare and benefits. if we are successful, who wins? the growing number of veterans

that turn to v.a. for healthcare each year, the 700,000 veterans who are currently diagnosed with post traumatic stress order, the million iraq and afghanistan veterans that have turned to v.a. for healthcare since 2002. and the average veteran who turns to v.a. who is older, sicker and than average patients, these are the veterans who will win when v.a. becomes the trusted provider of care and benefits. our ability to get there depends on our will to seize the opportunity, to challenge the status quo, and to drive positive change. i appreciate the hard work and dedication of v.a. employees, the vast majority of whom i continue to believe care deeply about the mission, want to do the right thing, and work hard every day to take care of

veterans. as well, i appreciate our partners from the veterans service organizations, our community stakeholders and dedicated v.a. volunteers. lastly, i deeply respect the important role that congress and the members of this committee play in serving veterans, and i am grateful to you for your long-term support. i'm prepared to take your questions. >> thank you very much for not dealing with niceties, but dealing with realities. as i understand it, we're talk nag broad sense about two very serious problem areas. number one, i trust that we have an immediate crisis, that we have hundreds of thousands of veterans on wait lists that those folks must get the medical care they need in a timely manner, and i'm pleased to see the acting secretary has moved aggressively in that area. but if understand you

correctly, the second point you made is that while it's important we put out the current fire, unless we effectively deal with the long-term capacity issues facing the v.a., we're going to be back here year after year with similar-type problems. you mentioned the number, and want to you get into some detail. what are we talking about? how many -- in phoenix, other areas of this country, there are long waiting periods, and the goal of this committee is to understand those waiting periods to make sure that veterans get quality care in a timely manner, so let's just start off with personnel, all right? how many doctors, how many urses, how many other types of medical personnel do you need to achieve the goal, be as specific as you possibly can, and how much is that going to ost? >> mr. chairman, of the $17.6

billion, approximately $10 billion is allocated for a combination of purchase care and hiring additional clinical staff. the blend of that will change over time, as we ramp up that capacity, as we are success informal hiring people. >> sir, is it fair to say that the degree to which we strengthen the v.a., we become less dependent on expensive contract care, is that a fair statement? >> it is absolutely a fair statement. >> ok. i interrupted. >> and over the three-plus year period of time that $10 billion gets allocated, probably more on the front end than the back end, as we're successful in hiring. as i mentioned in my opening statement, our ability to develop highly refined, bottom up stments of specific reerments is pretty limited. our best estimate at this time is that this would, closing

this gap would require hiring approximately 10,000 additional clinical staff. those are divided among primary care, specialty care, and ental healthcare, and of the 10,000 roughly 1,500 of those are actually physicians. others are nurses and nurse practitioners and other direct patient support staff. >> you talk about space. >> yes, sir. >> i trust you're not talking about building some las vegas type expensive buildings. what is the relationship between space and the emergency that we currently have in terms of waiting periods? >> i will tell you, mr. chairman, in every medical center i visited except one, and that's in augusta, the number one constraint that they're operating under right now is space.

fayetteville, north carolina, for example, is growing their patient population at a 7% annual rate. and when it takes us five or more years to get a building out of the ground, it doesn't take long to fall behind. so where we are today as a department is we are behind in terms of the space required today to serve patients. there's $6 billion included in the $17.6 billion total that's designed for infrastructure. >> and can you give us -- what are those projects? do you have them? >> there are, and i'm going ask phillip to go into some of the details, there are eight major projects there. there are 77 lease projects for outpatient clinics that would add about two million square feet and roughly four million appointment slots. and there's minor reconstruction and maintenance

that would add several million, roughly four million in round numbers, additional outpatient visit slots there. >> we have heard time and time functional in terms of appointments at the v.a. has to do with significantly outdated program, a computer situation. can you say a word on that, how you intend to prove that? >> there are four underway tracks dealing with the scheduling system. there are 11 existing defects in the system that are being patched as we speak. ere are four different interfaces that are in the process of being developed to make it easier for schedulers to access and to actually provide the opportunity for veterans to be able to directly access their schedule. on the 11th of july, we let a contract for major enhancements to the existing scheduling

system that will remedy many of the most egregious problems that we have right now that make it hard to deal with, and in parallel with all of that, as i mentioned in my statement, we are pursuing the acquisition of a commercial, off the shelf, state-of-the-art system that's probably two years down the road in terms of actually having that functionality in place, which is why we're pursuing these other tracks. >> let me conclude over my time f. we don't have the resources t the v.a. to address issues like hundreds of thousands of folks coming home, what happens in years to come? >> the wait times just get longer. we don't -- we don't meet any acceptable standard of timely and consistent quality healthcare. you know, i have committed to the president, i've committed to veterans, i've committed to the staff at v.a., i will not hold back for asking for

resources, because we have not been managing requirements a a department. this would never happen in a private sector. it never -- you'd fail as a usiness if you did this. i've told these folks that have worked on these numbers, i don't want a pen nye there we can't justify, not one cent. >> ok, i've gone over my time. >> mr. chairman, thank you. secretary sloan, secretary gibson, again, i commend you. you've sort of made all of us go back and sort of ask about numbers, because it hasn't been that long ago that we wrote off the money for the new software program to do scheduling, and i think that was the second time and the $14 billion plus we've got currently in the construction and maintenance account that means that projects are on a seven, eight,

10-year timeline. so it's good to see one that v.a. has sent and that o.m.b. is recognizing the realities of what the needs are. and i've got a set of questions for you, but i'm going to -- i'm going send those to you and ask to you respond to them and ask unanimous consent that all members have an opportunity to do that. >> without objection. >> i want to focus for just a few moments on data integrity. the inspector general made this statement, and i quote all of these, we have concerns that the performance goals are not realistic and comprised by data integrity issues. we're receiving numbers of serious allegations regarding male mismanagement, manipulation of dates of claims and other data integrity issues

in the baltimore, philadelphia, los angeles, oakland, and houston v.a. regional offices, and today we received an additional allegation regarding the little rock v.a. regional office. we are concerned at how quickly the number of regional offices with allegations is growing. we removed all provisional claims from its pending inventory. v.b.a.'s process misrepresented the actual workload of pending claims in its progress towards eliminating the overall claims backlog. the office of inspector team sent to philadelphia regional office on june 19, 2014, determined that there were significant opportunities for regional offices to manipulate and input incorrect dates of claims in the electronic record . incorrect application of date of claim comprises data integrity related to timeliness. then there's some exchange that

took place between the congressman and the assistant i.g.. you remarked in your opening statement that v.b.a. itself reported a decrease in the national back log by more than 50% since march 2013. do you trust those numbers? at this point, i would say no, i can't trust those numbers. i think we have a lot of work ahead of us to address the allegations we've just received. they all seem to focus on data integrity, and they need to be looked at very carefully, so i don't want to say i trust them. near the end of the hearing, congressman oh courage asked miss halladay, and i quote, one of the things you said in your opening comment that struck me was that some of the success may be comprised by data integrity issues, anything that the secretary has said tonight that alleviates those concerns, miss halladay, simply responded, no. also on the issue of whether

v.b.a.'s quality metrics are reliable, the general accounting office provided this testimony, and i quote, in prior work, we documented shortcomings in v.a.'s quality assurance activities, and more recently concerns have been raised about the lack of trance pearns a related to the changes in the national accuracy rate. in several basic areas there are not followings, they're not following general statistical procedures. that looseness in their methodology translates to numbers that aren't accurate and aren't very helpful in terms of looking at trends over time, in terms of performance, accuracy rates, and/or in terms of relative performance. that's not good metrics. the office testified that they continue to identify a high rate of areas, processing of claims decisions.

now, undersecretary hickey was the one that testified for the v.a. and despite her testimony, which was refuted by the spector general, the g.a.o., v.a. put out a press release entitled v.a. takes action to ensure claims in which the v.a. touts that it reduced the back log by 55%, has reduced the number of days it takes to process claims and has improved their accuracy rate to over 90%. now, listen, you've said that you've got to gain the trust of the committee, of the veteran, of the country, and i think weigh gree with you. let me ask you, how smart was that press release? did you sign off on that press release? and how can numbers that were refuted by the people that are actually doing the investigations of v.a. facilities, how can they refute

the numbers and the next day v.a. come out with the same numbers and tout them? >> i think you noted, trust is the foundation of everything we do, and where there are questions about data integrity, knowing we've got to go into those very deeply. there are a number of issues that have been raised there. i can sit and go through and pick at an item or two, but the fundamental issue remains, that there is -- there are questions about whether or not we've got good data integrity there, and just as we are undertaking independent reviews in the v.h.a. side, we will undertake those in the v.b.a. side. >> mr. secretary, they've been underway. much of it initiated by members of this committee with the inspector general, with the general accounting office, and you've acknowledged the shortcomings on the v.h.a. side

. this is fresh. this is this week, and still that press release stresses that the v.a. will continue to post these performance data on its website. how does publicizing suspect data increase the integrity and the trust -- >> senator burr, i would tell you, i come into this organization from the private sector, and i lock at the transformation that's been wrought over the last two to three years, and i defy anybody to show me any major part of the federal government anywhere that has transformed that much in that period of time. i think it's amazing looking at it from a private sector perspective, much less doing it in the context of a federal government agency. there is room to improve there. i got it. we've got to -- we got to restore trust there. i got it. they pulled the 100% provisional ratings out, and those didn't get counted in the back log. i got it.

my recollection, round numbers, it was about 12,000. i may not have that exactly right. the back log is down 350,000, round numbers. so i get it. we need to make sure that the data integrity is there, but i'm not going to pull back from standing by that department and the good work that's been done. you know, we can't have back and forth between -- i.g. has findings and we've got to embrace those findings. >> well, i appreciate the chairman's leniency here. i'm not sure you're embracing those findings, especial until comparison to how you've embraced the v.h.a. findings. it concerns me, because these are veterans that are waiting for their determinations to be made, in some cases, as the i.g. has pointed out, it involves overpayments. overpafments that are due to the american taxpayers. they are due back to the v.a. to help fund other things.

and it just strikes me, and i realize this was a v.h.a. hearing, it strikes me that you could have testify like we had on monday night and yet turn around and put out a press release still stating the same numbers the next day when every one of the investigators found that those numbers couldn't be trusted. so i'll work with you. it's an area of great concern. it's as big, if not bigger problem than the v.h.a. because the budget is the biggest budget at the v.a. i thank the chair. >> thank you, mr. chairman. the v.a. has removed the wait time criteria from the performance contracts of network and medical center directors, and i do understand the need to be wary of creating incentives for people to gain the numbers, but we also have a serious accountability problem. how will you still hold a network and medical center directors accountable for wait times, if it's not in their performance contract? >> i think the first step that

we've got to do is get to integrity and the data. and so the idea behind pulling that out at this stage of the game was to eliminate any questionable motivation. i think as we move forward, what we're going to find is that average weight times are a very poor gauge for timeliness of care for a large, integrated health system. you don't really find that out in the private sector. that's one of the reasons we're boosting our patient satisfaction measurement activities, because i think patient satisfaction is going to become central, even at a 14-day standard, if the veteran needs to be seen today, we've failed that veteran. >> so you're looking for different ways. >> i think we're going to be looking at different ways to evaluate timeliness of care. it will be a combination of atient satisfaction. it will be a number coming down steadily, and then as we have he capable to do things like

the sector, it gives you some gauge of the capacity of the system to handle that. today at least we're able to look at same-day appointments, roughly in the primary care area, we see about 100,000 veterans on a same-day basis every single month in primary care. that to me suggests that there is capacity that's being maintained to take care of that veteran who can't wait 14 days or 21 days or 30 days. >> healthcare from the private sector plays a critical role in making sure veterans get the timely care, but there are some drawbacks that v.a. has been trying overcome, like not being able to get medical records returned to the department and very little ability to see the quality of care that's provided.

if congress were to expand the authority for non-v.a. healthcare, what steps would be necessary to address those kinds of problems? >> i'm going to ask fill type jump in here in a moment. one of the biggest challenges we have with purchase care in the community is maintaining continuity of care for the veteran. the ability to get information, medical information, medical record information back and forth is a vital part of this. ensuring that the quality of care, i would tell you if the floodgates open, it will present the department with challenges. but the fact remains, we are right now referring out roughly a quarter of a million referrals every month to purchase care, and as i mentioned before, every one of those referrals on average will result in roughly seven appointments. that's an awful lot of activity. last year, 15 million visits to non-v.a. providers over the course of the year added to the

outpatient visits, and we have 100 million that we're managing, so it's already a very large number and a challenge for us, but it would be, if we open the floodgates, it would be an even bigger challenge. anything to add there? >> no, sir. senator murray, the one thing i would add is purchasing care in the community does not absolve us of the requirement, the responsibility to coordinate that care. in addition to the assurance that we can send, both send and receive clinical data, there's just -- the hands-on coordination required to make sure that an appointment has occurred, the veteran knows where to go, the families involved, all the rest of that, if we just look at the cost of the care alone, we're missing a big responsibility. >> when we look at how we do this and expand that, we have to look at all those issues as well and get them right or we're just going to create a bigger problem for the future, right, ok. finally, v.a. has had a lot of difficulty hiring providers for a number of reasons, including the pay that's lower than the

private sector and a very long, as you mentioned, cumbersome hiring practice, and the challenge he was of just hiring and healthcare anyway. because we know there's national shortages as well. now v.a. does a lot of training for doctors and nurses and work very closely with a lot of our universities. what more can the v.a. do to help build the workforce that's necessary to meet the needs of the department and our country. >> that's a great question, ma'am. i think one of the significant opportunities, and the chairman and i have talked about this before, are opportunities where we can work collaboratively there, maybe tuition, payment programs or tuition reimbursement programs, ways that we can encourage that. we rely very hivel on our affiliations as a source for new clinicians, and we are doing some things from a compensation standpoint as well, where we've got some flexibility to be able to meet local market. >> i'm very interested in that,

because i think that's part of the reason for a back log as well. there's a variety of reasons, but we can't ignore that side of that. thank you very much. >> thank you. >> following one senator murray's question about referrals, particularly the private sector, you wrote this down from your statement. you said y'all made recently referrals for private veterans for private carry. what percentage of those would you guess were mental health referrals? >> i'm sorry. could hasten a guess, but i would take that one for the record. >> reason ski that question is, i got into the atlanta v.a. starting in august of last year when we had two suicides and a drug overdose. when we dug down, they were using a community-based provider for mental health, v.a. would see the patient, refer them to the community-based provider with no followup between the referral and the appointment,

and in that period of time when the person was determined to be at risk for themselves and their own life, in two cases, they took their own life because they didn't get timely services on the referral. i think there was an interesting observation about coordinated care. as we expand private options and private healthcare, which i hope we do in terms of legislation going forward, care coordination is going to be one of the secrets to making that work, not just in reducing wait times, but in reducing the quality of care, or increasing the quality of care to the veterans, particularly with the number, as chairman sanders said, the number of people coming forward. that's going to be an ongoing process. it's going to be one that's going to have to be cord made and monitored. my question, did you ever see he memorandum? in may, when secretary shinseki was here, i asked if they had

seen it. dr. peters said yes. secretary shinseki said he had not. i think both told the truth. i don't think he ever saw it, because i think the senior leadership of the v.a. didn't et him see it. my experience is it lies at the problems of the services that insulated the leadership of the v.a. from the problems that they had. yells would a memorandum written four years ago describing what we're discovering now in 2014 not have been acted on? the last sentence of the third paragraph says these practices will not be tolerated. it doesn't say look at this when you get a chance, and it delin ates each of the programs just like the whistle blowers did the other night. you're an interim director or interim secretary. you're going to hand off to mr. mcdonald, who is a well qualified individual. what are you doing to put in place the type of information

transfer that will see to it mr. mcdonald doesn't become a rookie victim behalf a distinguished general was in terms of mr. shinseki? >> i'm not going to let him. i'm going to let my old friend become a rookie victim of anything. more fundamentally -- >> let me interrupt. i'm not being trite when i ask this question. >> no, i understand. >> for four years, the v.a. has insulated its leader, in the case of secretary shinseki. >> i will tell you from my own personal perspective, i've learned to never have all my information filtered through a couple of people. from the first day i got to v.a., i started reaching down in the organization to get additional information. i think your sense is a very accurate one. i think historically v.h.a. has operated a fairly insular organization, not fairly, but a very insular organization, and i think part behalf we've been doing is dismeagetsing a lot of those barriers. since my first day as acting

secretary, ever single morning, we have something called access standup. we have senior leaders from across v.h.a., as well as senior leaders from across the department. we're up in our integrated operation center, and we're boring into data around access to care. what's the status, what are we doing, how many contacts, how many appointments, what are the wait times, what's the status on many of these different nshtives that iva luded to in my opening statement? it's just part of what we're putting in place. i would have to say, this young guy right here, i've said before, if i was half as smart as phillip, i'd be darn smart. he's been doing an awful lot of the work to put in place the kind of management information that you're talking about so at we're not just relying on the chance that information filters up, that we've got dash boards in place that will help s identify where there's a

scheduling malpractice that's n place, there was a particular clinic that we're able to identify those things. and in tandem, requiring medical directors to get out in the clinics so that they take direct ownership for the consequences. the first sentence in the memo that provided that direction was medical center directors and vision drktors are directly accountability for the quality of care and the timeliness of care. that was the first sentence, and it was in there because i wrote it. that's part of ensuring that we've got that kind of accountability, and frankly, it's part of the culture change for the organization. v.h.a. is not used to operating that way. >> my time subpoena, but with that endorsement of phillip, i have to ask this question. you're not leaving when secretary sloan leaves, sflu >> i'm not going anywhere either. i'm going to stick around. >> i'm talking about in leadership. make sure he's at the right hand of mr. mcdonald. >> there are a lot of good people. there are a lot of good people building a lot of good tools.

one of the things that we have a too many working on right now is actually take that memo and actually develop tools that allow us to mine data, to look or those patterns. secretary gibson has directed us to go look at an integrity score against it u.s. and rate it. are there certain questions, and if it persists, have an udit look at it and manage it. >> thank you bope very much. there are a lot of good people in the v.a. building tools, and there's a lot of damn good healthcare on the ground, and we need more of them and we need to get rid of the bad apples in that bunch. mr. sloan, you said that you have a concern about purchase care trumping v.a. capacity. i assume that's during the conference committee and other times where we'll put more emphasis on purchase care and not enough on v.a. capacity.

have you been able to do any sort of cost analysis on providing care for veterans outside the v.a.? is it more expensive, less spnssive about, the same? you can kick it over to matkos ky if you like. >> we would be serving veteran patients and the type of services we provide, and we compare them to a private sector model. sometimes we do it for a community-based outpatient clinic, sometimes larger. the general rule tends to be more expensive, and there are two different types of contract actions that we've used, models, they both have their problem. >> ok. i come from a state where, quite frankly, it's a frontier in a lot of areas in the private care, it may or may not solve the problems, but it looks pretty attractive. if it breaks the budget of the v.a., and we don't get better healthcare, which i think both of those are up for debate, it can be a problem. that's why i agree with your capacity issue with the v.a.

in the meantime, i want to talk about an issue that senator moran worked on, and that's project arch. i think it has worked well. it has not been perfect, but it has worked well. could i get an assurance from you that arch will not be prematurely shut down before it's reauthorized? >> the discussion that senator more an and i had the other day was exactly to that issue. my commitment is we will not -- the extent i've got the authority, there's some question there, but we will not end a program that is providing access to veterans until we have the robust replacement in place so that there is no lapse in care for the veterans that are being served in project arch. that's my commitment to senator moran, and it's my commment to you. >> that's good. i think the project arch definitely works, and it definitely allows you to have control of those medical records as you move forward, which is a big concern when we start going to the private sector. could i ask you, what do you say to folks that say that v.a.'s work shortages are a

myth and that the real problem is the medical personnel is just not working hard enough or fast enough? >> i'll start, and then i'll probably pass it over here to phillip for a wrapup. i think when you look, i mentioned earlier in my opening remarks, older, sicker, and poorer, when you look at the typical v.a. patient, so that the first, when you start talking panel sizes or r.v.u.'s, when you're looking at specialty care, you have to take into account the very different patient population that v.a. is dealing with. the number of primary care patients that a clinician sees is in all likelihood going to be different than what you see in the private sector. secondly, there are oftentimes factors that bear on their ability to see, for example, space. we talked about that earlier. i think the average in the private sector for primary care is 2 1/2 treatment rooms for a

primary care provider. i don't know that we've got good data on what that looks like across v.a., but i strongly suspect we don't have those resources. in the case of specialty care one of the places we're specifically underleveraged is on average we have one support person for every specialty care provider. that compares to a goal or target of 3-1/2 to one to primary care. we are underleveraging our specialty care providers and as a result they are not seeing as many patients as they ought to be able to see. if we get that i'm convinced we'll see product tivity enhancements. >> that productivity enhancement, will it meet the needs of the veterans that don't have access to the v.a.? another in other words what i'm saying is i was told for instance v.a. montana has 22 slots short on docs, nurses are

significantly higher than that. productivity can probably take care of some of those docs maybe, maybe not. but my point is that if we're 22 short on docs maybe it makes the work on the doctors harder. are they going to be as happy with the v.a.? nine out of ten say they're happy now. the ones who get through the door. >> let me take a moment and sum rise the process that we've een going through through. >> i may touch on panel size a little bit because i think there's some criticism there but we sometimes miss the comparative populations when we do that.

in our points that we have availability. some of that can be covered internally. some will require additional resources. so when we push out accelerating care we ask every facility to look at their numbers as well as whether or not they could increase them if they could not to give us requirement for nonv.a. care resources and we use that as the basis to accelerate care. >> thank you very much. >> senator moran. >> chairman thank you very much. again secretary sloan thank you for your presence today. senator burr and others have used, including you, have use the word trust. when -- i've never asked for a cabinet secretary's resignation, this is the first time i've ever done that in my ime in congress. we were indicating a problem with the culture, systemic problems, lack of leadership. it was my sense that all that was true or i would not have

taken the steps that i took. i was i don't know somewhat comforted in the position but very concerned by what i heard secretary shinseki say on the day that he announced his departure, which was something to the point that he had been surrounded by people whose views he trusted that he should not have trusted. the reason that there was some assurance to me was that it seems to me that we were right there is a culture and systemic problem if the secretary can't trust the people that he or she must deal with on a day-to-day base to provide information i want my comments here today to be broad and not just to kansas. i appreciate the senator from montana raising the issue of arch. but i want to use that as an example of why i as a member of congress have had difficulty in trusting the department of

veterans affairs. i don't mean this in a personal way to suggest that i'm personally offended by the circumstances that have developed over a period of time. what i mean is that my ability to assess what you're doing, to make decisions as a member of the appropriations can he but most importantly my ability to care for the veterans back home in kansas is handicapped by the sense that i've had that the department of veterans affairs doesn't trust us, doesn't share information with us, is not honest with us and perhaps most importantly has rarely responded to issues that we've raised, again this isn't a personal concern of mine it's not like i'm personally aucheded. but when a veteran in kansas brings an issue to me and i raise it with the secretary or anyone else at the department of veterans affairs, i think we should be able to expect an honest, fair, and timely response. and it hasn't occurred. so my ability to trust the department of veterans affairs s been significantly han

handicapped. a part of that is this arch program that narrowed down to be a pilot program that says if you live long distances from v.a. hospital outpatient facility you can access that at home by the veterans department giving you the ability to do that paying for the service. that's a pilot program five of them across the country in rural areas created in 2011. i kept continually asking questions of the v.a. how is it going? some pride of authorship but mostly is it working. are they liking it? is it cost effective? does the technology work? we got no answers over a long period of time. finally at the hearing with secretary shinseki this program is about to end. it's a three-year pilot program coming to conclusion although we are pleased to know you can extend it. and secretary shinseki in march

of this year indicated to me that i would have an answer to my question by sunset. those were his words by sunset. never had an answer yet. then in march of -- and incidently, one of the things i've learned since then is that in the spring of 2012, a year after the pilot program gets started, the wichita v.a. is interested in promoting this program to rural veterans and they were instructed by folks in washington, d.c. that you cannot recruit veterans for arch and you cannot quote market arch. my concern is that we have created a program that somebody doesn't like so they're out and about trying to make sure they prove it doesn't work. for somebody at the v.a. to tell folks in kansas don't market this, don't encourage veterans to participate suggestings that they want a failure. so then i become more suspicious as you learn this, as i learned this, on march 26

of this year the national program director directed the five pilot programs to notify veterans the program was coming to a conclusion. at the same time, in fact in april, a week or so later, senior staff at the v.a. assures my staff and committee staff that we are continuing to assess the program but subsequently we have learned that already the memo has gone out telling them those five pilot programs to notify veterans the program will no longer exist but ten days later two weeks later we're assured we're continuing to assess. that makes me suspicious about the inability to get the report promise bid the secretary of veterans affairs by sunset that i will know what's going on in arch. then in june we discovered that june of this year we discovered that there was an email ready to be sent terminating the program.

i and several other senators including some on this committee asked that not to be the case and we are told just in time the send button was never pushed. so a series of things that cause us to have great doubts about who is telling us what, what the truth is, and i guess in a more fundamental way are programs authorized by congress are they always -- can they be easily undermined by personnel at the department of veterans affairs who don't apparently like the suggestions that we have made? it's not a suggestion. the law that we passed. and finally then our telephone conversation of june 27, i appreciate you reiterating what you just said to senator tester. but that's the circumstance that i find myself in as somebody who is a supporter of veterans and therefore a supporter of the department of veterans affairs whose mission it is to take care of veterans across our country and our state.

>> that is important to reestablishing trust, this is one of the central cultural issues that we have to deal with as an organization. i would tell you that there is -- i used the word insular earlier to describe particularly vha as i find it coming into the department. i think that's the case. and what i've been doing over the last six weeks is pushing information out the door as fast and as hard as i can push it out i prod behind the scenes for responses to congress and we've got a lot of work to do in that regard. we have to earn the trust back. >> senator hirno. >> thank you. we know there are capacity issues at the v.a. and i just

would like some clarification on some comments or statements that you made. did you say that based on your assessment of the capacity issues that you would need 10,000 additional staff? i think you were talking about you 7.6 billion that would be requesting. >> that is correct. yes, ma'am. i know that sounds like a huge number. there are 300,000 people in vha alone. >> so is that 10,000 additional staff -- and i know you broke it down to how many doctors et cetera. so is that both for the emergency situation we have now or is this an assessment that reflects your long term staffing needs? >> there was a reference made in one of the opening statements earlier about the findings of the field audit and e number one cause for

scheduling difficulties was that there weren't sufficient provider slots to be able to schedule patients into. so what we're talking about here my comment earlier that we have not historicically managed requirements. we've managed to a budget number. so basically we took a budget number and then we did what folks thought they could do and the veterans wound up being the shock absorber in that process. >> so meanwhile what your needs are, you would need to hire 10,000 additional staff. >> yes, ma'am. >> and that would of course depend on the appropriation that is we provide. >> yes, ma'am. >> so if you were to have the appropriations to hire 10,000 people, what would -- how long do you think it would take for 10,000 people to be hired? because one of the things that i did here about the hiring in v.a. is that it takes a long time to hire a doctor. so i hope that in your review you're also looking at your

hiring processes. because it shouldn't take a long time whatever that means. so that's one question. so then to hire 10,000 do you have any sense of how long this would take should you get the money from us? >> a couple of comments. one, at every single medical center i visit i lear from rank and file staff that it takes too long to hire. so staffing practices is one of our areas of concentration. my guess is there are some of those thing that is we are going to find just a function of being in the federal government and that's the regulation and statute that we've got to follow but my guess is we're going to find a lot of that is self-inflicted and we've to clear that away so we can be more expeditious. second round numbers we probably hire 30,000 people every year anyway. so i know 10,000 sounds like a huge number it's about 3% of

staff maybe a little less than that. so but recognize that some of these are in places like primary care if a stigses, and mental health providers. and we know and you all know that those are tough to find. and so it will take time for us to be able to hire them. quite frankly the other problem we have, even if we could hire them tomorrow, we don't have a place to put them all. so in some instances what we're going to have to do is deal with some of the space issues in tandem with this. we may be able to do there are actually some provisions in here for what are called emergency leaseses. i actually authorized some of these when i go out to the field where somebody has found some clinic space that is local that can be occupied quickly, 10,000 square feet something like that they can put three patient line care teams in there. >> i don't mean to interrupt you but my time is running out. my concern is mainly that you are addressing the length of time it takes.

and if you are hiring 3,000 people every year there are probably some retention issues that you are also probably addressing. >> 10% turnover. that's not -- >> in fact, it's relatively low issue for a health care organization. >> you had mentioned that in response to a question that when the i.g. has findings, you re embracing those findings, since the problems and challenges that the v. have been longstanding, i wonder whether you have a process or someone in the v.a. who provides a response to the i.g.'s findings should be providing a report to congress to respond to the i.g.'s findings so that we also can provide the kind of oversight that congress should provide adds to what is happening in v.a.? >> there are responses to those. unless i'm mistaken i believe those are shared. is that correct? yes. >> so there are responses.

what i would tell you is that i don't believe that those have always gotten the visibility and attention. some of the examples surrounding the office of the medical inspector and some of those reports quite frankly i don't think were getting the attention they deserve. so as we look at overhauling certain of our processes part of what we've got to do is make sure that the issues that need to be elevated all the way to the office of the secretary are in fact being elevated and that where somebody says we've taken care of this issue that we know what's been done and we have confirmed that. >> i just have one more item. i was told by the veterans that i've been talking with many of them live on neighbor islands so these are rural issues. and i was told that even if they got vouchers to go out to get private care, that the doctors on the big island mowie, they wouldn't take veterans so it wouldn't help them. have you heard that concern? >> i would tell you that there are issues around pc 3 primary

care closest community contract that we've got with two different national providers for specialty care and we do find instances where i think we've got room for improvement that's a new program just launched earlier this year. and i don't think we're excuting as well as it needs to be excuted and there are discussions going on this week today with the leadership of those two programs to make sure that we address those issues. i get that feedback from staff and veterans as well when we're out in the field. >> you're addressing the issue. >> yes, ma'am. >> thank you. >> thank you. senator jo hans. >> mr. chairman, thank you. mr. secretary, in your request for more money, a lot more money, one of the things that you mentioned was new facilities and the idea behind that is that new facilities may improve productivity and

hopefully that results in better services to veterans that sort of thing. you mentioned that there were eight facilities that would be construction projkt -- projects houfment did you pick those eight? i know of a list out there that if you have a need for a facility new hospital say it makes its way up the list. did you just pick the top eight? and if you want to toss it over to phillip, that's fine, too. >> i am going to toss this one to phillip, if i could, please. >> sure. >> so we have a backlog of major construction projects. this is the major construction items, not the minor construction or nonrecurring maintenance. and there's a prioritized ranking system that typically -- not typically. has rated safety and security as the highest. so seismic corrections where we've got seismic deficiencies, where the building would

crumble those have to get fixed. there are a number of those. we have longstanding space shortages. every facility has a space shortage in terms of meeting patient care needs. we need to understand that. these aren't abstract numbers. there's not enough space. but the vast majority of these, the eight projectses are st. louis, louisville, american lake, san francisco, palo alto, west l.a., long beach. for the most part are safety and security high prioritized items because of structural deficiencies. some of them do have patient care for additional space. >> would this top eight be the same top eight as the list of 20-some projects out there waiting to make their way? >> it's from that list. yes, sir. >> would they patch? if i took that list and matched it with what you've just described for me? >> are you talking about the 26 or 27 major leases? >> no it's not lease.

>> i think you're talking about the historical projects that were ranked and prioritized. >> yeah. >> it would match and it would match against that list for the most part. yes. >> for the most part. what's the most part missing here? >> so for the most part just to give you a direct answer might be the ability to complete a project given the size of the required funding it would fit in where somewhere else that might only be 20% of that project. that's what i mean. >> ok. >> at the can he's hearing in may, one of the things i talked about and other members did, too, is the expanded use of nonv.a. care to deal with the urgent treatment issues. this isn't an academic issue. it never was. it very definitely isn't today because we know people died on the v.a. waiting list and we know that throughout the system

the list was gamed intentionally and dishonestly to the detriment of veterans. now, there's a lot of ways of handling that. and mr. secretary, let me be just candid with you. i've sat on this committee now nearly 6 years. other members have sat on the can he a lot longer. -- committee a lot longer. this committee has been i think very, very generous to the v.a. . and i kind of find it remarkable. republicans, democrats, liberals, conservatives, it's kind of, when shinseki would come in, general shinseki, it was kind of like, what do you need, general? and it was almost like we would salute when he said what he needed and out the door he would go with more money and always the promise that we were

doing better. here's my concern. this sounds so similar to what we've heard over the years, i need more money. i need to be bigger faster grander. i need a bigger bureaucracy. i need to hire more people. and on and on and on. i think what you need personally is competition. i think if somebody were biting at your back side because they were providing better care faster care honest waiting lists et cetera, people would go, holy smokes. if we don't put our act together, we're going to lose out on this. if we don't see more patients during the day we're going to lose out on this. just let me ask you. hat am i missing here? >> i think -- i don't know what you're missing. i know that millions of veterans turn to v.a. for their health care. and as a number of folks have

mentioned, at various points this morning, an awful lot of veterans continue to believe they get great care. access to care is a challenge. for many. particularly for new patients. but there's a lot of great care that's being delivered every single day. >> i'm out of time. i hear this. but at the end of the day, these veterans fight for our freedoms. why don't they have the freedom to make their own choice about their health care? and maybe they say by golly i love the v.a. i'll stay with the v.a. until the day i die. but maybe they say that hospital 20 minutes down the road from where i'm at is simply a better situation for me than the hospital that's 250 miles from where i'm at with a long waiting list. and i'm totally out of time and i don't want to impose upon the chairman's patience, but i just think you guys need

competition. i feel very, very strongly about that. and if you can't clean up your act then guess what you lose out. that's what i think you need. i don't think you need more billions and billions of dollars. so thank you. >> thank you senator. senator begich did not make an opening remark so we will give you a modest amount of additional entitlement. >> thank you very much. i like the way you say that. let me -- i thank you both for being here. i appreciate it. but it's amazing to me, i've been here now just about six years but i'm looking at a 2003 report improve health care delivery for our national veterans. you're familiar with this report? ok. if not you should all read it but i'm really doing it for my colleagues because when i turn to one page here, what i'm saying is to make part of your point and says although enrollment have access to v.a.

health care system long waiting times for appointments continue to be problematic. for significant number of veterans. as a january 2003 at least 236,000 veterans were on a waiting list. six months or more for their first appointment. a clear indication of lack of sufficient capacity or at a minimum a lack of adequate resources to provide the required care. this is not new. just they didn't get the funding years ago and now we're playing catch-up. 1.4 se you've also had a million net new v.a. patients. we didn't do it. i wasn't here. somehow people missed this report. i don't know. for the record mr. chairman i think it's like somehow suddenly it's all a new problem. it just occurred yesterday. no. it's right here in this report. and because they were not funded properly, it built up.

new patients were added to the list. from afghanistan and iraq wars. maybe people missed that. i don't know. pretty simple, third page of the report, not complicated. done under a different administration. so i want to put that to the record because of the issues you're bringing up are relevant. do i think it's a lot of money? yes. is there money well deserved for our veterans? absolutely. because if they would have had it here we might have been recruiting doctors back then because the problem we're going to have is to senator hirno's question is hiring 10,000 people i agree you've got a hiring system that's great but to get mental health providers and primary care doctors you don't just turn a switch. every private hospital in this country is behind the curve getting doctors. nurses are backed up. we don't have the capacity to fill it. so i want to make this clear because i think there's a lot of good bumper stickers being talked about today.

i get it. but this is a systemic problem that's been around for a decade or more and yet it is now suddenly -- and thanks to the v.s.o.s and other whose have been coming forward, and they've been fighting for this for years and now we're figuring this out. i know my chairman knows i will bring it up all the time and that is what we're doing in alaska. we've talked about this. we saw this problem when i came into office in 2009 i said what are we doing? we have 1,000 people on the waiting list, 120 day wait periods. we didn't go to the private sector, all of us it's hard nouf get our appointments. think we're going to add veterans to the system and clog it up some more? we looked at our current system of federal tax dollars and how they're being used. indian health services delivered by our tribes in alaska. the federally qualified clinics. federally funded. so what did we do? we maximized the resources we have at our fingertips today.

what's our wait time in alaska in the northwest region? it's one of the lowest in the country. because we now have access. as a matter of fact in anchorage when you used a qualified federal clinic there and or the south central clinic -- and again you've got to be on the list, you sign up get through the system and get on the list for nonmajor medical same-day care. that's pretty significant. that's competition that actually works with the tax dollars we're all paying. but if we shove it out only to the private sector something magic will happen. and i agree we use closer to care program but that doesn't mean that's the panacea that every veteran is going to get care overnight. we have to look at the systemic problems here that i know you and i have talked about this idea and what we're doing in alaska and i think -- we have some problems still. we have some logistics problems, building problems still. scheduling issues and how to

make sure the records are transferred properly between federal agencies and i know we're going to figure the out. but doesn't that seem something we should be expanding and looking at around the country? federally qualified clinics, the one reason you have certain pay levels for doctors so you have a controlled cost unit. the private sector, you're not going to have a controlled cost. now, it does mean still we'll use private sector resources as we're doing in alaska along with federally qualified clinics and our indian health services otherwise known as the newcome model, a very impressive model. don't you think this is a model that we could actually go after some of this? again, i didn't mean to get so aggravated about this it just aggravates me when people tell me it's a new-found problem. people should have read this report. not you two. congressional people. go ahead. sorry. there's my rant.

there was a question there i know. >> i'll try to address it sir very quickly. the model in anchorage, the director then who actually was a trail blazer actually established a number of the tribal agreements with local alaska tribes. >> 26 of them now. >> phenomenal work that he did. he earned the trust. he literally extend it had network of community providers into a teamless integrated system up there and allowed us to avoid folks having to travel long distances the norm before used to be folks flying down to washington state. so remarkable work by the director. some of that has actually become sort of a pattern that we've used elsewhere in the country with local tribes and with ihs signing the agreement to extend health care services. but most importantly as well with the tribes in the dakotas in oklahoma across the country we have tribal agreements in place where we can reimburse for care.

it is not perfectly seamless but it is something that has really taken root for us. >> and you do need new -- >> no we used our sharing agreement authority. we have certain agreement authorities in title 38 that we use. >> and you can do that with qualified plans. >> we can. >> and alaska we're doing that with a couple which one just went from a private to federally qualified clinic to deliver care because there's no veteran care down there which is a great example of how you can do this with your existing rules. et me ask you on -- having the v.a. utilize and we talked letter to on -- sent general shinseki on this regarding position that is indian health services uses which are some of the core there to use for their medical delivery system and seeing if the v.a. can do the same thing. it's actually in the bill of how to fund some of these folks in other words the health care

corps. can you tell me if your regulations allow you -- i know we talked briefly, i think this is a resource of over 5,000 professionals sitting there ready to go. >> talking about the national health services? >> yes. >> i think we would have to look at some credentialing and privilege issues that would allow us to share those authorities to treat in our system as well. i would have to take that back and look at it. >> can you do that for me? >> i will. >> the last thing, i have a bill on -- i know senator murray talked about and that is reimbursements for doctors in the sense of serving our v.a. system. and i have a bill on mental health providers sirke trick care which is a huge gack in doing agreements. can you give us some feedback on that at an appropriate time? >> if you will yield to me. the issue that senator begich is racing are very important and that has to do with how we not raid other facilities and

steal doctors and psychiatrists but develop more. and the issues are that you guys have a health education assistance program which a needs to be reauthorized and b needs to be significantly increased. right now the maximum you can provide is only 6,000 which doesn't do anything -- 60,000 which doesn't do anybody -- anything for anybody with 200,000. >> for others it's up to 100,000. so the question is have you had a chance to look at that bill and do you support this concept? >> i think we support the concept. we just have to look at the funding requirements associated with it. but the practice is something that would allow us to recruit and retain highly qualified staff. >> i have other questions i will submit for the record. it's just very frustrating when i see a report like this and people think it's a new-found problem and it's been around for ten years and we just need to get after it and deal with it. and it's going to take years to

change it. thank you. >> thank you. senator he willer you will have additional time as well because you didn't make opening remarks. >> what i may want to do is just submit my opening remarks for the record. that way i will go back to my 5 minutes and keep this timely on a timely. >> one of the few senators who wants less time than offered. >> having said that if i go over please don't cut me off. >> thank you for holding this hearing both the chairman and the ranking member and at risk of irritating you like senator begich claimed you know i will be talking about backlog stats sticks and i would certainly appreciate a rescheduling of the hearing of the backlog information and i will talk about that in just a minute. but i am looking at the latest statistics. secretary, the smartest guy in the room phillip here. taking some time. but i'm looking at the latest average days of completion of the reno and i bring this up because reno has the worst v.a.

regional office in the country and i've been hitting on this and i think it's a management problem. i don't think the rank and file in that office are at fault here. i truly do believe it's a management problem and i'm certainly hoping and have called for changes in that particular office. but the average days to complete now a pending claim is about 340 days. i have been harping on this for five years and they are making progress. in five years they've reduced it ten days. we've gone from 350 down to 340 days over five years. and you've got to imagine it's pretty frustrating. and i'm not frustrated for myself, i'm frustrated for every veteran in the state of nevada that truly needs the help and benefits of health care that they deserve. on top of that, we had an inspector general report found that 51% of the claims that were reviewed in this were

inaccurate. i have to tell you i appreciate your opening statement, your openness, and concern for openness. i think that's important transparency is important. bob casey, senator casey and i because he had similar problems in pennsylvania worked together our staff worked very, very hard we came up with this v.a. claims backlog working group submitted legislation. are you familiar with the information in this? >> i would tell you that i'm aware of it. it would be a stretch for me to say i'm familiar with it. >> fortunately i'll be able to meet with the nominee tomorrow. and get an opportunity for him to also address or take a look at it. because i think it's very clear the concerns, the problems that we have, and i think it does address some of those problems, the legislation is available. what's good news is senator moran and senator tester from this can he also are

cosponsors. i think it would go a long way so we don't in five years have a ten-day improvement that hopefully in less than a year we could see perhaps a much greater improvement. i want to get on another topic quickly and that is an issue that we have in the state of nevada. they're a small city in southern city called per on. it has about 6,000 veterans down there and you're shaking your head. i'm glad to see that. they have been waiting for a v.a. clinic for several years now. the director in las vegas approved it. they're now waiting for the national v.a. officials here in d.c. to get this done. what is the status? >> i have to get back on the detailed status. we've had some issues with our if i may our lease authorities that we've been trying to work through. i think some folks here may be

familiar with that, that have resulted in some delays in getting leases enacted. we had some challenges on the procurement side of that as i think your staff has been briefed over the years. and right now we're working through trying to make sure that we can exercise our lease authority in the current environment. that is the challenge we have, sir. >> do you have any time line for approval of this clinic? >> i don't right now. it's not an issue of approval. it's an issue of actually effecting a lease agreement. >> can we get an answer perhaps by this fall? >> i will get it to you sooner than fall. i will personally go in and look at it. >> i want to talk about, just a few another minute here, about the face-to-face audits and the problems we have scheduling. we had an audit first phase was released on june 9 with the las vegas v.a. hospital southwest v.a. clinic in nevada. they said it needs further

review. do you know if those reviews have been completed? >> we have referred all of those cases to the inspector general. and we have prepared a detailed set of briefings. i think we're trying to schedule it now with the committees and with delegations to walk through the audit findings as well as why someone would have wound up on a further review list. i know it's taken us a while to do that. i want to apologize for the amount of time. >> i want to make sure we don't miss the follow-up. i wouldn't anticipate that you would. but do we have any timeline into when those -- >> i would tell you the question there somebody mentioned earlier that the i.g.'s in over 70 different locations >> any location where they're in we're not able to go in and do any additional review. we've created accountability audit teams to go into all of those where the i.g. isn't and those are scheduled to be completed i think by mid august is the completion time.

but in the meantime we're going to provide some briefings on what the findings were and what we know. >> thank you very much. >> i'm going to be in reno in awing i'll get you the dates when i'm going to be there and i will go visitwhile i'm there. >> thank you. >> and lastly we appreciate the opportunity to provide technical input on the leasing issue. i think we've furnished some of that information to the staff that would help us be very helpful for us to be able to move forward. >> thank you. senator blum that will you have eight minutes and i alert the members that there will be a vote as i understand it at 12:20. >> thank you very much mr. chairman. i really appreciate your holding this hearing and your leadership along with ranking member bur. and thank you mr. gibson and matkofski for your situation.

i think you're in a difficult if not impossible position because you are temporarily before us without the head of an agency and my hope is that there will soon be a secretary of the v.a. but right now in effect there's an empty desk where the buck should stop. and i think that situation has to be recommendied as soon as possible and that is on us not on you. leadership has to include an overhaul top to bottom of the people who run the agency, very simply my view is that there has to be accountability for what's done in the past but also a change in leadership which you are commendably seeking as well. top to bottom across the country. and my experience over the last w months has been that the failure of the agency to be

more responsive and accurate and some of what it is saying to the public is actually aggravating its credibility and trust problems. senator burr raised one instance earlier with the press release that he mentioned. i have found that there simply have been no answers to some of the questions that i posed in letters to the agency. letters asking for site specific information about the audit that were performed. the v.a. officials locally and the audits seem to confirm that there have been no problems in connecticut with the delays and destruction of documents and manipulation of waiting lists and yet we found in recent data released by the v.a. that in fact wait times have increased over the may to july period in fact those wait times have

tripled. what's the meaning of that data? so i've asked not only for the site specific information resulting from the audit that was performed as a result of general shinseki's order but also for an explanation of those wait times. and i have yet to receive responses from the agencies complete and satisfactory in writing to the questions that i have posed. now, i understand you have a lot going on. but i would suggest that that kind of responsiveness in providing information is part of the mission that is all the more important. it's always existed but it's all the more important now. so i would like a commitment from you that the agency will respond to my inquiries in

writing as soon as you are able do so and that you will respond in the future to the inquiries that i posed. >> two quick comments. first of all, the answer is we absolutely will. it might even be more effective for us to come in and deliver a briefing. the way time data as flip lip just mentioned, briefing material around the access audits being provided. you haven't had the opportunity to hear other comments but we've been pushing information out the door as fast and as hard as we can over the last 6 weeks. that openness and transparency to your very point is an essential part of earning back trust. the last thing i told the president of the united states when he tapped me to be the acting secretary i said don't expect me to behave like the word acting is in front of my title.

so if anybody has seen behavior that looks like i was acting as a care taker please describe it for me. >> i welcome that comment and support it. can you tell us anything about inquiry i want nally, what its status is, when you expect it to be completed? and second, about the department of justice investigation? i called for a criminal investigation by the department of justice with great reluctance and regret but i do think that criminal responsibility has to be applied if there was obstruction of justice destruction of documents fraud in reporting, because those crimes even with an agency as important as the v.a. or perhaps especially because of its very important mission has to be implemented where necessary.

>> there was a mention earlier to the fact that the i.g. has reviews under way at 70-some locations across the organization. i should explain here before the i.g. goes into any location to do anything kind of review for any purpose they inform the f.b.i. and at any point during the course of their review of activities they uncover evidence of criminal wrong doing those routinely get referred to the department of justice. in fact, there is a criminal investigation division of v.a.'s i.g. so routinely there are criminal investigations undertaken and completed and prosecutions that occur as a result of i.g. investigation. so it's a routine matter. i would tell you of the 70-some odd location that is the i.g. has been reviewing at the end of june i got the first set of reports on the first location.

and so we have been working more than a thousand pages of transscripts of sworn testimony , turned out that we actually needed some additional information so we dispatched an official fact-finding group to go to that particular location. we've reviewed hundreds if not thousands of email traffic. and i expect by the end of this week to have proposed personnel actions on my desk for that for a number of individuals at that one particular location. there is nobody that wants to see this process move faster -- move forward faster than i do. it is pains taking. i would say the other general category here of issues have to do with the referrals coming from the office of special counsel. i've met directly with carolyn learner, we're expecting a substantial number of those to come to us very quickly and we've agreed on some expedited processes that we will work

through to ensure that the whistleblowers are properly protected and then to launch the appropriate personnel actions in the wake of that. >> and my time is about to expire. i apologize i'm not going do have more questions in this setting. i would like to follow up on the department of justice investigation. i know you can't really comment in this setting about it. most important about protection for whistleblowers i think one of the unexplored areas here has been the potential for retaliation against whistleblowers. i would like to know from you in the course of a future briefing what has been done to protect them but just one last comment. there is nothing routine about what happened here. you said that routinely the f.b.i. is involved. there's nothing routine about what happened here and i think the f.b.i. should be fully engaged and the department of justice involved. thank you.

thank you mr. chairman. >> senator bozeman you will also have additional time. >> thank you for having this very, very important meeting. i want to thank you all for being here. i know that you're working very, very hard to try and resolve these things. i also want to commend you mr. gibson for getting out to the places that are really struggling. and that also the places that are doing well in trying to figure out best practices and then again why others are struggling so much. the doctor i think it is important in the situation of bringing him on as an adviser. i think that was really a very good move. in regard to the your request as far as additional peshnel and things like that, is that based on current practice or is that based on reforms in the future that are going to significantly change things hopefully? >> the methodology we use is largely framed in the current

context senator bozeman. so what we looked at is looking at our current volume, looking at current delays in care forecasting those through the years and trying to atten wut them year on year. so it's not any subsequent reform that's in our current context. >> right. >> i had the opportunity to serve with tom osborne over in the house the great coach from nebraska and people used to talk to him about winning. and he would say we didn't ever talk about winning what we talked about was doing the little things. and one of the little thing that is has to be done -- and i'm a little concerned because you said it would take two years and probably in v.a. lingo that's probably more like four or five, is a schedule. that is one of the little things that if you don't get that done, tomorrow, my understanding is that they don't call people the day before and tell them they've got an appointment. you could catch your no show rate significantly just by doing that and then taking somebody that's on a backlog

and sticking them into the slots. that's just common sense practices done throughout the country with anybody in the private sector. so you have to get the scheduling under control. and there's no reason not to do that in a rapid situation particularly targeting the areas that are having problems. your facilities that are doing ok right now by whatever standards you're measuring, but it does seem like you would put that in place right away. >> you may have mentioned -- miss it had comments earlier. there are actually four different major initiatives under way on skedsyulling one has to do with fixing existing issues. there are 11 of those fixes that are in the process right now. there are four separate applications under development to make it easier for schedulers to interface with the system as well as to give veterans the ability to directly request schedules. there is a contract that's already been let that will make

major modifications to the existing scheduling system was let on the 11th of july. and we expect that to bear fruit in the may through august time period of next year to deal with some of the toughest, some of the most difficult issues associated with the existing scheduling system. of of that is in parallel while we are working -- >> good over the counter systems right now in place that major medical centers are using without any problem at all that are being -- that's the basis of medical practice. >> i would agree with you, sir. i think that you have two comments one of them is the underlying system and i think there was a reference made to a prior system effort. i don't think we're looking to go build something from scratch this time. >> i would hope not. >> we're not. that's something that people have been doing for years and i'm an opt tom tryst by

training and again that is the basis of your practice is scheduling. you mentioned that one assistant per specialist. and i would right now in the v.a. system i think you said 2-1/2 or whatever. that might even be a little bit low. but what is the what i would like to know is what the relationship between if you take a manger v.a. medical center -- major center and look at total staffing you look at the staffing that it takes to support that medical center, ok, what is the comparison with a major private entity as far as numbers? >> i don't have the exact percentages but if you look at the overhead rate in the v.a. or the indirect rate in the v.a. for support staff it's considerably lower and meets one of the areas i don't have the specific account >> i'm talking about the administration the whole bit. >> i'm looking just at the field costs not looking at

everything else for a blended overhead rate. i think we could come up with something like that that would look at a blended rate and see where the charges come in but in terms of what we have in our facility it is labor share is lower in the v.a. for support than in the private. >> not as dollars but people. >> in terms of people is lower in the v.a. than it is in the private sector. what you may be asking as well would be could we construct a blended rate that looked at the overall costs factors. we could. we have not done that. >> i think that would be interesting. the other thing is that right now if you go to to your medicare doctor if you're a veteran and you get -- you have a physical and the medicare doctor decides that you need high blood pressure medicine and then you go to the v.a. instead of filling that prescription which is a pretty good deal for the veteran, they have to have a physical in

order for that to be done, why is that? i mean is there any logical reason for that at all? how many slots would that free up if you made that one change? how much money would that save? >> i am not a clinician so i can't -- in a learned way describe that is the case but there are certain reasons why that would be appropriate and why that does make sense. but i will tell you that we are looking at things like referrals to audiology and where that could obvate and where we could bypass the primary care steps as an additional item but we need to look at that carefully and i think folks are looking at that now. maybe some pharmacy not all pharmacy we need to be careful but we are looking at that. >> i can see the scheduled drugs and things like that but to me it makes no sense at all that if a guy that is licensed and taking medicare dollars

another entity that is licensed by the government, why a prescription can't be filled for diabetes, high blood pressure, the vast joisht of stuff that actually comes across. could you look and see how many slots that would save? >> we will look at that. but the one thing one point of caution would be not to overcorrect in that direction. but we do have folks looking at the pattern between primary care and certainly specialties of patterns between primary and -- >> what do you mean overcorrect? >> to not be vigilant for pharmacy filled requests that would be coming in from the private sect of. just to make sure that we're determining the appropriateness of certain prescription fills. in the examples you've given seem pretty straightforward but we need to make sure those are the -- >> thrrs a large percentage served by v.a. and medicare so

part of this is understanding what the second and third order effects are of the kind of change that you're talking about. clearly one of the impacts would be that free up primary care slots. got it. that's a good thing. what are the second and third order effects and i think that's the point >> probably would decrease the acklog if you had primaries -- thank you. >> we have reached the end of what i think has been an important and productive hearing. mr. acting secretary i want to thank you very much for stepping in clearly unexpectedly and in a very important position and very difficult moment in the history of the v.a. thank you very much for the work you're doing. and thank you for what you're

doing. we look forward to working with you in the days weeks and months to come. thank you very much. the hearing is adjourned.