>> we are glad to have become today. we will change the methodology little bit. we have two votes. when i 2:45 and one following that vote. we are going to run the hearing continuously. we going to waive opening statements. we will go straight to secretary mcdonell to make his full statement. then we will go into q and a. with your cooperation, will work with those two votes. if we do shutdown, it will only be for a couple minutes.

let me welcome everybody to this meeting of the center -- veterans affairs meeting. i think today's hearing will be equally as good as last week. the commission on care is a great project that examined the veteran administration's delivery system for our veterans and had a lot of recommendations. a lot of provoking recommendations. i appreciate the embrace that secretary mcdonell has given to ideas from others that have come in. we have talked a little bit about them. he will have a great testimony. ,et me welcome the secretary robert mcdonald to make his testimony. >> thank you. ranking members, members of the committee, thank you for this time to talk about the ongoing transformation and commission on care final report. let methe house had a the same opportunity last week. neither i nor the veteran service organizations were invited to testify in person.

i asked that my written statement be submitted for the record. >> without objection. chairing thisk commission. nancy didn't do an outstanding job keeping things together. -- did an outstanding job keeping things together. on the course we have been on for the past two years, there is not much we have not thought of or not already doing as part of our ongoing transformation efforts. we differ on some details as we wholeheartedly agree with the intent of almost all of the commission's recommendations. 15 as of 18. we certainly agree on how wrong it would be to privatize the health care. privatization would be a boon for some health care severalions but as leading pss told the commission, a good thread in the financial and clinical by abilities from the programs which would fall particularly hard on the

millions of veterans who rely on v.a. for almost or all of their care. the main thing it offers a known else offers can we have a unique lifetime relationship with an online patients. nobody else offers that. care isal health integrated with our primary care and specialty care. nobody else offers that. care is customized to meet veterans unique needs including care for many nonmedical determinants of health and well-being like education services, career, transition support, housing assistance, disability compensation and many others. nobody offers that. our research into innovation makes is a leader in many areas such as prosthetics, post-traumatic stress disorder, bring injury, and in several others. -- brain injury, and many others.

they would all lose the choice of integrated comprehensive care tailored for veterans. by people who know veterans and are dedicated to serving them. v.a. is tot nba -- veterans. the demand for that choice comes from elsewhere. it does not come from veterans. veterans know better. i've tested this during my time as secretary. when somebody tells me that veterans should only have the choice of a choice program, i asked them, are you a veteran dr. --veteran? they usually say no. the night after they talk to them and they say no. i probes more and i find that bonita banner choice or two things, interest and ideology. let's face it, privatization would put my money in the pockets of people running

corporation street is in their interest so it makes sense to them even if it is not what veterans want or need. then there is the ideologues. they only deal with the issue in the simplest, theoretical, laziest terms. bad, private sector good. that is the thinking. thankfully, most members of the commission for more understanding. on 1.i disagree with the commission agreed that the idea of an independent board of directors. don't need to say much about that since the constitution probably will not allow it. i will say that a governance board does not make any sense to me as a business executive. it would only make things worse by complicating the bureaucracy of the top and spreading the response ability for vha so that no one knows who is ultimately responsible. the fact is, we have the government support, congress is our support in the congress worked the way it should, no one would be talking about adding

another layer of bureaucracy. is not the hold on increasing access. we are doing that. we are not the holdup on expanding committee care. we are doing that. we submitted a plan to streamline our community care programs last october. what has happened to a? -- it? we not behold upon real estate professionals. majorrently have eight medical construction projects and 24 lisa's meeting authorization. they are funded but we need a green light from congress to move forward. even a hold up on holding people accountable for wrongdoing. a, the former employee in georgia recently conducted -- augustine, georgia recently convicted of falsifying records.

prison's.ng years in all told, we have terminated over 3755 employees in the past two years. we have made sustainable accountability as part of our ongoing leadership training. the veteran's first act would hold people accountable and we look forward to seeing it brought to the senate floor for passage. the senate appropriations committee has also approved a what it newly equal to the president's request. we need to see follow-through. the holdup in our transformation is the need for congressional action. we have submitted over 100 proposals for legislative changes that we have put in the president's budget. no results yet. i detailed are most urgent needs in the august 30 letter to the committee. they include approving the president's thousand 17 budget 2017st to keep up with --

budget request to keep up with modernization. improving services and transportation and location rehabilitation. fixing agreement to keep long-term care facilities. and entity our return world that will not let the dedicated concierge is preferential's -- professionals care for veterans more than 80 hours. we also need -- modernizing the care for times appeals process. under the current law with no significant changes in resources, the number of veterans are waiting a decision nearly -- they will triple in the next 10 years from 500,000 today to almost 1.3 million. we submitted a plan to reform the process in june. we developed a plan with help and other veterans advocates. they are on board. we just need comes to get on board. i'm only after what is best for

veterans. as you know, i'm not running for office, i'm not angling for promotion. i could have taken an easier job two years ago but i did not. i answered the call of duty thinking only of giving veterans the benefit of what i learned at west point, the army and 33 years the private sector running one of the most admired companies in the world. two years in the process, my only concern is to see it continue. i know nancy will tell you that transformation is a marathon, not a sprint. years toake several turn any large organization a round. to turn it around, we must maintain the momentum of change and we can't do that without the cooperation of congress. are all inion agreement on this. tourist must act or veterans will suffer. -- congress must act or veterans will suffer. what can we do to break this

impasse and get things moving? whatever it takes, i will do it. just let me know what it is. thank you, mr. chairman. >> thank you. we appreciate your testimony. are you here to testify or moral support? >> hard questions. justr the member that arrived, we will go through the boats. i will wait until the last minute to go on those one -- vote one. hopefully we can keep everything rolling throughout the hearing. we have three great panels. secretary mcdonald, if you would look at recommendation number one. i know you have read it. have you got any idea what you estimate the cost to implement number one? >> it is about establishing an

integrated high-performing community-based health care network. october, i can't for member the exact number, i'm sure david will remember, we had different levels of cost depending upon what we decide to take on. we are in the process of establishing that network. the secretary is referring to the plane we submitted at the end of october, 2015 where we currently spend about $13.5 billion a year and community n community care. in order to do the changes we suggested, we suggested we would need $17 billion because we wanted to fix the emergency medicine provision that so many veterans get stuck in the hole. we will investment in infrastructure to do that.

inneed the investment-- infrastructure to do that. we think that is the best used of money -- use of money for taxpayers. the commission on care plan was far more expensive than that. >> a contemplated putting thether a network of private sector as well. >> that is correct. they probably contemplated doing that without the contracts we have for the two gatekeepers for choice and issue a single seamless card. >> that is correct. we would integrate the network. departmentso include of defense partners and health service and other federal partners that we have. >> this is not a setup. is it not true in the veteran's first bill that this committee passed that unanimously by the provisions in their for provider agreements are expanding the opportunity to make that happen? >> yes or.

>> -- yes, sir. >> right answer. >> we would like veterans first to get to the floor and we are happy to help any way we can. >> we appreciate your support. >> and we appreciate the leadership. >> i last question is a common. recommendations on -- comments. i'm interested in hearing how much progress you have made on interoperability? you are under contract with georgia tech. the recent breakthrough that has helped? mentioned, in april of this year, we did certified interoperability with the department of defense. under the council's leadership, we have created the concept which is the digital help platform. -- health platform.

this is taking the industry to a new level. this will increase the ability to do interoperability with community partners. what you're referring to is, georgia tech has a fantastic technology center. we have developed a conceptual that we arer this looking forward to sharing with members of this committee that we think is a path forward to take us to a new level. >> we appreciate the progress you are making. senator blumenthal. >> thank you. mcdonald, i think your august 2015, you indicated you had concerns about the cost. 's reflectors options on the care system model. 65 billion to $106

billion in fiscal year 2019. that is dependent on enrollment and management and other factors. i would appreciate the i appreciate that they devoted themselves to improving the system and i appreciate the recommendation. i wonder if you could explain the concern with the commission estimates? >> this is the nub of the issue with in terms of the difference between the commission report and our point of view on the network. i'm sure nancy will comment more on it later. the question is, how much unfettered access to the private theor do you allow individual veteran and who takes responsibility for integrating the health care? we believe we need to take that responsibility that when a veteran goes up to the private

sector, we still have to own the response ability of the health care and the integrator tends to be the primary care doctor. if we don't do that, then it results in not very good care. also, dysfunctional care because it is not integrated. it also results in higher cost care because those doctors that they may go to may not be qualified by us as being capable of being in that network and may not follow the standards of cost that are necessary to be part of that network. >> i think the secretary has said it correctly, senator, which is we have differences here with the commission on care report on two accounts. one is the quality of care we believe will be better with v.a. maintaining care coronation. we believe that we understand the needs of veterans best and

we do support and embrace working with the private sector. that is correct. v.a. needs to be the care coordinator. on the cost side, this would be irresponsible just to turn deductibles,th no no cost control mechanisms. this would be returning us to the late 80's, early 90's where there was just runaway cost. we think the best thing for veterans and the best thing for the taxpayers is to do this carefully and an integrated network the way we proposes in october of 2015. -- proposed in october of 2015. >> 98 percent of all clinical supplies for required -- acquired using purchasing cards. it is made through this purchase.

only 30% of supply orders made through standing vendor contracts which would be more effective and efficient. this sametold that issue may arise with medical devices and other kinds of supplies. is a stark contrast to the private sector benchmark since90% supply pictures -- purchases with negotiated vaice discounts the ea -- -- can do unlike medicare. we are pushing for medicare to have the same options with negotiating. the bha fromnting using those contracts? >> nothing. a 12earing we have on break your priorities which you had in the senate, we do not do the same hearing in the house,

one of those breakthrough priorities is to set up a consolidated supply chain. everyone of our medical centers has its own supply chain. as you have suggested is nonsensical. what we can do, what we have seen from our consolidated pharmacy we do have a consolidated supply chain is our cost advantages are tremendous because of the scale we cap and the customer service is fantastic. the number one pharmacy in the country for six consecutive years by jd powers because of that scale advantage. what's we're in the process of doing is building a consolidated supply chain for all of our medical centers. so far, we have avoided about 35 going dollars of cost. our commitment to you -- $35 million of cost. that is our community by december. >> as a courtesy to everyone in

the audience, we're going to take a different order in terms of questions and testimony to pay senator brownback for giving us mercy by being on time. i will let him do the next question, senator bozeman and then we take everybody else as they arrive. we will keep the hearing moving as fast as we can. >> thank you. i will ask to brief questions. -- two brief questions. implementation of veterans went through some growing pains as we all expected. your meetings with veterans and providers and health experts and others, lay out the challenges and opportunities that you see veterans choice? >> we have made tremendous progress. dayst up a program in 90 that affected 9 million

veterans. we also made changes along the way. since the original bill, we have now changed the way we define distance, the 40 mile limit. we had changed it from geodesic distance to driving distance. that doubled the number of veterans of being able to be of veterans choice. originally the program was designed where would simply give a program -- phone number to a veteran and car at the party of minister to. my belief is you cannot outsource your customer service. we are pulling that responsibility back in. the integration coronation responsibly and we are not taking responsibility for customer service and we have taken third-party administrator employees and put them into our tolding as a test in order make that easier for the veteran. where are we headed?

about 22% of our appointment every day are in the community. there are about one million vitamins -- veterans that rely on the program. there are about 5000 veterans that only use the choice program which is a strikingly no number -- low lumbar -- number. it shows that most veterans want the hybrid. >> they want to know they have a choice. withare mostly satisfied cincinnati v.a. or cleveland and they want to know they have the choice. chronicle ora legislative hurdles that impede vha from routinely updating facilities? talk that through with us. if you asknk that most of our field hospital directors, they would say that there are challenges.

i think we have seen a strong direction towards be more responsible -- responsive to the hospital leaders. she is an established cap executives who work with the vha and we are working together to break down those barriers. and assecretary said, nancy said, this does take time because we are breaking down years and years of bears. i think we're headed in the right direction. -- barriers. i think we are headed in the right direction. >> thank you all for being here. we appreciate your hard work. over onee program has million people participating which is a good thing. list that as a legislative priority as far as reauthorization. priorityarity or not a -- priority or not priority?

>> it is part of our program to consolidate care. we believe we did request reauthorization in that package that we submitted on the consolidation of care. we do want reauthorization. ends august 7 of 2017. without reauthorization, we're going to see us go backwards. we have reached five going choice appointments. that is -- 5 million choice appointments. that is fantastic. we're getting it to work. if we can get veterans first past, it'll work better. reauthorization is a priority for us. >> august 7 is important but if a woman is pregnant, we need to know nine months in advance how

we're going to care for her. the sooner the better. >> that was my follow-up and it is good to know that you have cleared that up. it has been a momentous task. do you have any contingency plans in regard to august of 2017? it can help us by helping members understand not on this committee but throughout congress how important it is to get reauthorization. midst of in the renewing our strategies for 2017. most of our leaders are at the national training center right now. one of the things we have brought up is the importance of communicating that august 7 they do and also the nine month in advance of that. i think that is important.

>> to quantify this. .e spend about $13 billion 22% of our care goes to the community. were billion is the choice program. -- 4 billion is the choice program. we would have to reduce access of care by about a third that would hurt veterans. veteransre to help with the resources that you provide us. we going to continue that mission and we will do the very best job possible. there is no substitute for what you have provided. >> thank you. i do think that it is something we need to work on to make it clear how important it is. >> terrific question and i appreciate the answer and it gives us homework to do before the meeting. we will stand in recess for a moment. we will continue the hearing and we will be back as quick --

recess until senator moran get to. -- gets here.

>> i have a set of circumstances i want deal with. question you want to resolve the experiences we find ourselves in. we have the circumstance, just to set the background for my questions. we face one of the worst lack of in my view of

accountability at the v.a. with the case of a physician assistant who abused kansas veterans. potentially other veterans in our state. criminally charged with multiple counts of abuse on numerous veterans who sought his care and counsel. he had a criminal record. admitted on his license. the v.a. hired him anyway. clearly, he should never have been hired and retained as an employee. a physician assistant. nation i received they are not considered significant risks or lower risks than other health care professionals so that letting that should take place

did not. what he did was target veterans who were suffering from ptsd and used his position at the v.a. to add to the wounds of war of those who served our country instead of healing them. of witnesses,mber many of whom wished to remain anonymous. criminal proceedings have been filed. flavor, thereou a are two army veteran brothers who were patients of this individual who felt they had no choice but to go back to this physician assistant for their care and treatment. the quote was, the fear of learning -- losing what i earned versus the fear of sexually assaulted, i don't know which important.

>> i don't know whether to go back because i might not get the care i need if i don't. the victim who asked to remain chargess, when these were filed said, it violates veterans trust. we are dealing with a number of issues and we have to go back to the agency test to caring with our veterans which is adding further wounds. i want to focus on two aspects. again, i know your stuff has reached out to mine, i assume in response to a letter i wrote a few weeks ago. this goes to accountability. something you and i have had a conversation about for a very long time. i want to go to,'s how does somebody hired with his background? perhaps more importantly, it is

troublesome to me this individual was never fired. after the inspector general's thert, he voluntarily left v.a.. one of the conversations we have had for a long time is about the ability to fire people. of all the circumstances i can think of, i can't figure out why this would not be one in which a person was fired as compared to voluntarily retiring which i assume among other things, has a different connotation. a different or. i assume it also has different consequences with regard to benefits and his future. could, you had v.a. officials leadership in front of week.mmittee last i got what you would expect me to hear. i'm not discounting but they said that they want a zero

tolerance, the v.a. is committed to a zero-tolerance to sexual assault on veterans or staff. i know that is the case. we want zero-tolerance parents but we have instances in which the hiring process was faulty. the discharge process did not take place. mr. secretary? of sexualusation assault, sexual molestation, is unacceptable. heard about this, i went to leavenworth. i was there. i have different data then you have so we need to get together and compare our data. what i understand from my visit and the documents are reviewed, when this individual, and there was an accusation of this individual's potential of having done this, we immediately remove

him from caring from patients. we immediately started the procedure to do an investigation into fire him. he resigned. we went back and looked at our hiring process. what i was told at the time, you have different data so i've to find out why i didn't see the data you may have or where you got your data. there was nothing in his file this was a risk. this occurred. obviously, you have different data that i have. this is not something we would tolerate. showed up inthis the hiring process, we would not hire them to read you have? x know, i have the same information. , rsecretary mcdonald

information comes from the v.a. inspector general. a significant number of press accounts, i suppose, as well. criminal proceedings now in the district court. i have seen the application for he voluntarily indicated on the form he had a criminal history. folksunfortunately, the did not pick up on either. i assume that was reviewed when this individual was hired by the v.a.. that, are you telling me when someone resigns, you lose your ability to fire them? he beat you to the punch? >> if somebody resigns, they are .o longer an employee that is true in the private or public sector. have judicial options which is what is occurring right now with this individual.

>> i have no doubt that what the facts as i described them are accurate. would continue to ask you to use this as a learning experience. not only helped prosecute so we can send the message to veterans about how careful we are but again, in my view, it goes back to hiring practices and discharge procedure. i would ask you to respond to my letter in writing so we can see your response and then we can have a conversation. >> we will certainly respond to your letter writing. obviously. a learning organization. you have the best practices diffusion hearing this week.

we will get back to you. again, i want to be careful not as proof of reports accusation. let's let the judicial process play out. we will share what we know and we would appreciate seeing the documents you have. >> i met with the inspector general. we have had conversations, extensive, about this topic. i can assure you what i am reporting is not anything but what i was told in that setting. >> i have not met with him on this. >> i would ask you if you would ask the v.a. professionals, the leadership in kansas, would you instruct them to have a dialogue with me and fully lay out the scenario as they see it to me? >> that is their responsibility. we ask each one of our medical

center directors to work with members of congress. i want to thank both the secretary for being here today. is, has placed a priority on v.a. accountability as i know you have. when we hear stories, i know that hair on the back of my neck raises as it does on yours. we get the facts, i think it is important that the driftwood goes. that is probably, mentoring to that person. it is really important to them knowledge, there are millions of veterans in this country who rely on the v.a. and congress needs to be held accountable, too. you submit budgets, legislative ironies that allow you to do your job. it is our responsibility as members of this committee, and

the same thing on the house side, to consider those requests. to deal with them as elected representatives. when that doesn't happen, and it hurtsry -- frankly, the folks who are veterans. the system is called into question. mr. secretary, you are the front of the attack. thanin fact we share more our share of responsibility. do you believe accountability is a two-way street? >> i certainly do. i provided today one of the most hard-hitting, i think, opening statements i could. transforming in a saying we simply have to get a budget and we have to get

the legislation that we've been asking for for, you know, years. >> we passed the veterans first act out of this committee unanimously 125 days ago, we have to deal with it on the floor and it sounds to me like we're going to be leaving town next week, which is crazy. i will just tell you crazy that this is something we can get to the floor within two days, i would bet we would get a vote out of the united states senate on this bill, but we are where we are. i talked to veterans all the time, i know you talk to even more of them. some of them love the va, some of them not so much. would you agree that we have some work to do to get the faith and trust back of many of our veterans out there? secretary mcdonald: we do. in fact, we measure it, in fact, i just got the measure this morning. one of the things we measure, and this is very common in hospitals or people who provide customer service or veteran services, we measure the effectiveness of the experience, the ease of getting the experience and the emotion of having it and i have a chart here that shows that we've made progress.

we're not -- obviously these are lower numbers than we would like but we've gone from 47% interest trust inst -- 47% december 2015 to 59% in the april through june quarter. we're measuring this every quarter. i'm not happy, nobody is happy with 59%. >> in terms of greatest concerns identified by the commission, things like leadership vacancies, staff shortages, a culture of risk aversion, really what are some of the ways that the va can improve those issue areas? secretary mcdonald: we are -- of our five transformation strategies the second strategy of improving the employee experience, training employees, giving them the tools they need. right now we have our top leaders off site in our national training facility where we're training them, we're training

them in tools like human center design, we're training them in leadership, we're moving to one consolidated leadership model across the enterprise which is what great organizations do, we're training them in lean six sigma. so we're providing them the training they need, then we give them training packets that they take back to their locations and they train their subordinates and we cascade that training through the organization. that is how you change a culture and that's what we are in the midst of right now. >> okay. so as you well know we've talked about staff shortages, leadership vacancies, in fact, right now montana has a temporary director, you don't call her temporary, something else, acting, that's it, acting va montana director who, by the way, i like very much, i think she's doing a marvelous job, but when i had a conversation with her, it's been two, three weeks ago, and she holds people

accountable very well, one of the things she talked about was is that if we're going to get good people into the va due process has to be withheld. and this is a management person that understands that if people look at the va and say i've got no due process rights somebody can make any accusation at me they want and i can be gone without any argument. that doesn't help us fill those -- not only the leadership positions but also the staffing positions where there is a nurse, a doc, administrative personnel, appeals person, whatever it is. could you talk a little bit about when we talk about accountability because i'm telling you you come from the private sector, you understand that if you have dead wood on your staff, it costs you twice as much money as you're paying for them. can you talk about how we hit that sweet spot so that people want to work for the va because it's a pretty good outfit but yet understand that if something -- if they make a call, if they go against that culture of risk

aversion and make a call somebody has got their back? secretary mcdonald: we're training the organization in what we call values-based leadership rather than rules-based readership and we're trying to inspire them and i think we're being somewhat successful given the quality of the people we're getting on board. i've changed 14 of my 17 leaders. so in two years 14 of 17 of the top leaders have changed and i think we've brought in better quality people. but part of this and i've done a lot of the recruiting myself, as you know you and i went to the university of montana recruiting and i've been to over two dozen medical schools recruiting, but our applications are down about 78% versus what they were before. so the kind of environment and context you are talking about does have a real impact on the quality of the people we get. go ahead. >> well, i mean, i think that's important to note because, like

i said, the issue that senator moran brought up is totally unacceptable. i mean, if that's the way it is it's totally unacceptable. on the same token i do know from past life experiences that when you've got somebody out there that's trying to make the right call and somebody can accuse them of something and they don't have any rights it just goes counter to the accountability issue. secretary mcdonald. in my opening statement i mentioned that we have terminated 3,755 people in the last two years. i also said 14 of my 17 direct reports are new. the only -- in my opinion the only issues we had around accountability have been the accountability in getting legislation which we need, which you mentioned, but also the interactions we have had with the merit system protection board which frankly we have all agreed that veterans first would fix. so the answer here, i think we already have the answer in front of us, it's how do we get veterans first on the floor and passed because we've all agreed

that that is a potential solution. >> i think -- thank you, mr. secretary. i think, mr. chairman, i appreciate your leadership on this committee a lot. as you know that. i've told you that and i've told you that publicly. you are a class guy, but, damn, we have to get veterans first act passed. we just do. >> since we are talking about that subject, let me just comment. outstandingee did work for 1.5 years on the veterans first bill. two questions have been asked is what happens with choice after august of next year and the other question is how you dial eal with the merit system protection board and accountability in the va. there are those people in the news media and some in my party and other places that have criticized our bill for not being strong enough on the merit system protection board and not

making choice permanent. first of all, we deal with the leadership of the va in terms of the ability to hire and fire and take them out from under the merit system protection board which is the right thing to do, number one. number two, the accountability because you have that accountability it will flow from the bottom up because the top is being held accountable. and we've been able to get the n necessary you need to do that. all of us want to make sure the choice endures and choice becomes permanent and none of us want it to run out of funds and go out of business next august, but not passing the veterans first bill today which provides for provider agreements in the states with the va would be a serious mistake. people are staying they don't want to do that, some people are saying they don't want to do that because they want to go ahead and get choice fixed first when they come up with the $51.4 billion to get choice fixed first i'm happy to do it. in the meantime let's expand the opportunities to make contract agreements and provider agreements and work at the beginning of next year to fix the choice program so it doesn't sunset in august but is perpetuated around the country and improved and perfected.

i apologize for horning in on that. when i heard my two favorite subjects come up i had to make a comment. senator moran. >> please consider me an ally in on veterans choice. particularly the legislation we would like to see past. this as anleave open-ended question. as i thought about your response, one of the things i think is true and you could look into is you indicated mr. we found outoon as about him, he was taken away from patient care. as i understand, he continued to be an employee. he was removed from patient care but continued to work at the v.a.. the day he was removed from patient care is the same day he

admitted the allegations. admitted he dealt with patients in the way he did. my point would be, that is a moment when somebody could be discharged. and yet the va just removed him from patient care and kept him on the payroll. so to me that, again, highlights this difficulty in getting rid of in this case not just bad actors but terrible actors. >> it sounds to me like, senator moran, like you have better information than i do and that you have met with the inspector general and he has not yet met with me on this issue. so i need to find out what he discovered in his investigation. obviously if you have the case you fire them. that's why we fired 3,755 people. you don't tolerate that kind of behavior. >> thank you, senator moran. i thank the members of the committee for being so cooperative to move the hearing forward. i think we will go to our second panel. before you leave, secretary mcdonnell i want to thank you and dr. scuhkin. for your appearance today and leadership over the last two

years. we have a lot of progress yet to attain but i appreciate your leadership by both of you and we are here ready to stand and help you whenever we can. >> we will call our second panel. i am going to keep it moving. our second panel are representatives from the commission on care and when i got the commission's report a few weeks ago and it was put on my desk i took it home for early reading for lots of reasons, but i know there was a lot of thoughtful input and progress made. i wanted to see what the

commission had to say and i want to commend the chairman and the commissioners and the other members on the work that you did. a lot a lot of people don't give those individuals the credit they deserve and we appreciate very much what you have done. we will hear from both of you today and our two witnesses to testify first is miss nancy m. schlicting, the chairman of the commission on care and honorable thomas e. harvey esquire who must be an attorney if he has esquire behind it. >> you nailed that one. >> we appreciate the work that you did and you will both be recognized for up to five minutes each. if you have any printed testimony you want to submit for the record it will be accepted and printed as-is. >> chairman isakson, ranking member blumenthal and members of the committee thank you for the invitation to discuss the report of the commission on care for your support of the commission and for the extension of time that you gave us to complete our work.

it has been a privilege and honor to serve as the commission chair charged with improving veterans healthcare over the next 20 years. for the last 35 years i have served in senior leadership roles in large hospitals and health systems and for the last 18 years i have been in detroit, michigan, at henry ford health system serving for 13 years as the president and ceo. my experience in leading henry ford which is a $5 billion, 27,000 employee health system through a major financial turnaround and navigating our organization through the years of massive job loss in michigan, population decline, the bankruptcies of our city and major employers while still growing substantially making major capital investments in our communities and winning the 2011 malcolm bald ridge national quality award have prepared me very well for the demands and complexity of the commission's work. our commission was composed of 15 talented and diverse leaders.

we developed several principles to guide our work including creating consensus and being data driven, creating actionable and sustainable recommendations and most importantly our focus on veterans receiving healthcare that provides optimal quality, access and choice. the independent assessment report you commissioned was invaluable as a foundation for our work. it is a comprehensive systems focused detailed report that revealed significant and troubling weaknesses in vha's performance and capabilities. our work took place over ten months with 12 public meetings over 26 days and we sought the broadest input possible, had intense debate and dialogue but had a unified focus at all times, what is best for veterans. i believe we have produced a very good report that is strategic, comprehensive, actionable and transformative. 12 of the 15 commissioners signed the report, signaling bipartisan support. and the three who didn't sign had divergent views, one thought

we had done too much and two thought we had too little transformation. the vha requires transformation which is the focus of our recommendations. there are many glaring problems including staffing, facilities, i.t., operational processes, supply chain and health disparities that threaten the long-term viability of the system. perhaps even more importantly the lack of leadership continuity, strategic focus and a culture of fear and risk aversion threaten the ability to success flee make the transformation happen over the next 20 years. transformation is not simple or easy. it requires stable leadership, expert governance, major strategic investments and a capacity to reengineer and drive high-performance. some of our commissioners believed in moving va to a payer only model. they believe -- some believe that government simply can't run a complex health system and that veterans should have the same choice that medicare beneficiaries have.

yet we believe va and vha under current leadership secretary mcdonald and under secretary dr. david scuhkin are making progress and we believe that vha should be invested in for several reasons. one is the model of integrated care delivery, secondly the clinical quality which is comparable or better than the private sector in most metrics, third the veterans focused research, medical education and emergency capacity. fourth, the specialty programs. and fifth the role as a safety net provider for millions of complex and low income veterans that may not or could not be filled by the private sector in many markets. as we know each with the affordable care act access to primary care and mental health professionals across the country is still very challenging. our recommendations fall into four major categories, one, creating a vha care system which fully integrates vha, private sector and other federal

providers including the dod and other providers. and that vha continue to provide care coordination and vet all of the providers in the networks. secondly, is the leadership system and governance and a particular emphasis on continuity of leadership, leadership development and creating an oversight through a board of directors. third is the operational infrastructure focusing on i.t., facilities, performance or management, hr and workforce, supply chain and diversity in healthcare equity. finally eligibility, focusing on other than honorable discharge or eligibility for healthcare benefits and eligibility design. we clearly do not want this report to sit on a shelf. and we ask for your help to make our report come to life through enabling legislation which was included that does require your action. we are mindful that some of our recommendations have cost

implications and we worked with health economists in modeling different options. we do not suggest that congress has not already made very substantial investments in the system. rather we call for strategic investments in a much more streamlined system that aligns va care with the community. i would be very pleased to be a resource for the committee as you continue your work on this -- these issues rand i'd also look forward to your questions. thank you very much. >> chairman isakson and members of the committee, ranking member blumenthal, it's a pleasure for me to be here with you today to address the work of the commission on care. it's a particular pleasure because for five years i sat where tom bowman is sitting behind you as staff director of the committee under senator alan k. simpson. in my personal experience the vast majority of va staff at all levels are professional and highly committed to the veterans they serve. like many of us i was concerned to learn of the issues that came

to light regarding the manipulation of wait times for appointments at the phoenix va medical center. i'm happy to have been a part of the effort to better understand what had gone awry and to find solution no those problems for today and into the future. service on the commission has been an interesting experience. the commissioners brought their very back grountds to this venture with one characteristic in common. all of us were committed to assuring that this country's commitment to its veterans was well met. we may have differed on just how best to do that but the good faith of the commissioners was palpable. under the leadership of our very competent chair, nancy schlicti , each commissioner had an opportunity to express his or her priorities and to defend those should they be challenged. the final report contains 18 recommendations, some of these are good ideas. others strike me as unrealistic. some are included because one or more of the commissioners felt very strongly about them.

the white house made it clear to our chair that they would like a consensus report. i signed off on the report in deference to that expectation even though i had some reservations. i had had a full and fair opportunity to express my concerns in open session. among the many things i learned from senator simpson was that in negotiations on matters such as these after all of the give and take you have to be able to take what you can, hold your head high and declare victory one more time. and that is what i would like to do here. over nearly a year that the commission met we discussed a broad array of problems within the va, many of those were long standing. we discussed those with senior va leadership who themselves recognized that there were issues that were beyond their ability to address. i like to think that by shining the light of discussion on some of those we may have provided

the impetus to the professional staff of the va to raise such issues. some quick statistics regarding veterans and the va. in 2008 there were 26 million veterans. today there are about 21 million. in 2008 the budget of the va was $68 billion. today it is about $175 billion. in 2008 va had 240,000 employees, today about 368,000. the number of veterans is in precipitous decline. we lose about 5 million a decade. the total number of veterans , about a third use the va for some or all of their healthcare, many just for prescriptions. by written testimony i highlight some of the specific issues in the report that i had problems with. i would of course be pleased to discuss those with the committee. what i wish we had done, there are a number of basic questions

that i wish the commission had addressed, some of these are things that no one wants to touch such as why do we have a the a health care system at all. this is something that a number of people ask me. we need to do something for those who were injured in training or in combat, but the fact is most of those being treated in the va system are suffering the same illnesses most of us can expect to experience with the passage of time. there's nothing uniquely veteran about those injuries and diseases and in most communities there are ample surplus space to treat them in the community hospital. some say there are some veteran-specific medical seasons such as spinal cord injury, blind rehab, posttraumatic stress disorder and traumatic brain injury. in fact, annually automobile and diving accidents create more sci patients than the va treats. most of the veterans using the va system are medicare eligible. if they use the community hospital it can just bill medicare.

if we're committed to having the va healthcare system who should be eligible to use it? some people assume that once you -- an individual puts on a uniform, they are entitled to free healthcare for the rest of their lives. no need to worry about health insurance ever again. i don't think this is what we want. a system was established a few years ago which said that for those are service-connected disabilities treatment of those disabilities was the first priority of the va system. priorities also included veterans of very low income. is there a better way to articulate eligibility so that the veteran and as importantly the american taxpayer can better understand what the va healthcare system is trying to do? who it is obligated to provide care for. in reviewing the materials relating to patients scheduling i was struck by the fact that the gatekeeper for most va care is a primary care physician. the medical education

establishment is just not turning out a lot of primary care physicians so that is a bottleneck that is only going to get worse. over the past several years there have been significant changes in the way healthcare has been delivered in the united states. that, too, will continue over the next -- the next several years. was the commission a success? several of my colleagues believe that we could only count it as a success if the administration and the congress adopted the entire document as we presented it. i personally am willing to declare victory with the changes that va secretary mcdonald, deputy secretary gibson and under secretary for health dr. david scuhkin and their staffs are now making. thank you, martin luther king. -- thank you, mr. chairman. >> thank you, mr. harvey. in the light of the fact that the committee members have been so cooperative in shultling back and forth with votes i will

continue to deviate from my normal practice and go out of order by not recognizing myself but instead recognize senator manchin from west virginia. >> thank you, mr. chairman for being so kind. thank you all for being here. i'm so sorry i had to go and vote on the first and missed the secretary and assistant. to either one of you or both of you, if you would, it's my understanding that the commission on care's recommendation included allowing the primary provider to be outside the va. it's very clear. i understand the aimed improve act says it worries me that the veteran could receive medical care completely outside the va with little to no oversight. in west virginia we have quite a number of veterans as you know. doctors outside the va network can be trained in mitt tear and -- military and veteran culture. i'm concerned that many are not equipped with dealing with the unique needs of a veteran. is a non-va doctor aware to spot a veteran with ptsd? are they aware of symptoms of topic -- toxic exposure?

do they know veterans may not disclose certain symptoms if they are uncomfortable? these are all valid concerns. i'm speaking because i go around to my clinics and the hospitals. i speak to a lot of the veterans. what had been done in the past to the veterans is unconscionable, the wait time and all the stress. i think everybody recognized that. but when i talk to the veterans they still want veteran care. they demand -- i've asked them, i said, you know, if you can't get it we will -- he said, no, no, they take care of me here. they know what i need. they know how to treat me. that's my concern. in the future how do you see va striking a balance between making sure veterans receive access to the care in the community and the care received is high quality. how can you see that will happen in the private sector? >> one of the things that is very important about our recommendationes is we are not proposing the current system of having a separation between the private sector and the va. what we are proposing is a more integrated model. >> who is going to coordinate that? >> v.a. is going to coordinate

that. va has to vet the network, select the providers that meet very strict criteria and in the report we include several elements of that including not only their education and their experience, but also their military competency and of course about 70% of physicians in this country train in va medical centers. so it's possible that we can create a very well-equipped set of primary care physicians when needed. we also suggested that every market should be carefully evaluated in terms of access needs. so more primary care physicians in the community might be needed in some markets versus others. where va has adequate numbers to provide that for veterans, perhaps they would have none. so the control of this va care system that we are proposing is the va. and that includes vetting the networks, it includes having high criteria for participation and it could be different in different markets based on needs.

>> senator, let me just add one other thing to address a different part of your question. can people be trained to be sensitive to the veteran peer pressure experience? -- the veteran experience? and the answer is yes. i just turned around to rick wideman from the vietnam veterans of america and i know they have a card, a fold out card that has a number of questions they encourage doctors to ask a person who is a veteran, you know, about the experience to elicit some of that. so there is training available. >> so sorry to hurry up. our clock is running here. the commission on care's proposal that you have categorized ask a path that have move va into being more like tri-care. i had spoken to a lot of my veterans and they amp that when -- argue that when champ is and tri-care started offering more low cost insurance to military retirees we started seeing the copayments starting to rise. they are saying that it's a

gotcha. they pull you in and get you on the other end. i understand many of our veterans are concerned that shifting care to outside the va will lead to less money going to the va and less services offered and more coming out of their pockets to what we have committed to them. 10 or 15 years down the roid i -- road, i want you to be able to keep the promise we made to those veterans especially those with unique injuries like poly trauma, spinal injury, ptsd. my question, do you think the character dbhags that the commission on care wants va to be like tri-care is true and what would you suggest congress to consider when thinking about the future of the va healthcare? >> actually, senator, one of our commission members dissented from the commission report largely for that -- these concerns, that if we do this is it going to be draining money away from the va, from the va facilities that are needed?

i don't frankly have an answer to that, you know, would it be likely that copayments would increase. >> so if that's the case i would say, yes, our veterans have really reason for concern. they truly should have reason for concern because it's very well we would go down that path. >> if i could comment on that. i do think it's important to see the balance in the report. while we are suggesting primary care choice when needed within that va care network, we are also suggesting significant improvements in the operations of the veterans health system. >> my biggest problem is opioids . if you have a doctor suggesting one kind and one doctor trying to wean them off, who is going to coordinate that? i'm concerned about that. it's the biggest problem i have in my state and the biggest problem we have with our veterans right now. you need a single source to take

care of and cure them. if you have a doctor that thinks they should be treated with pain , with a pill versus alternative care you have serious problems. >> well, the va needs to have clinical standards for the providers that are part of that va care network that are consistent. >> mr. chairman, i'm so sorry to take a little bit more time than i should have, but i thank you. >> you're always timely and to the point. i'm going to just ask one question and make one observation. recommendation number 18, establish an expert body to develop recommendations for va care, eligibility and benefit design. tell me what that means. >> i think the feeling on the part of members of our commission was we did not have the time or the focus on eligibility, but many people felt that it was time to do a comprehensive review to really evaluate it as a whole and take a look at eligibility standards today and there were members of the commission that felt, for example, that some of the lower

priority categories were not necessary, that the focus should be on service connected injury, on lower income veterans. so it was felt that that would be something that a separate body could take a look at. bifurcate the veteran population? >> there are several priority categories. >> any discussion of expanding eligibility beyond veterans? >> there was some discussion about that about making some of the facilities more efficient. one of the example is that with some of the very specialty programs that exist within va the volumes are very low and there is potentially a challenge of maintaining those programs and potentially they could become a resource within community. so i think there were a number of thoughts about how to best utilize the capacity within va

facilities and maintain it and at the same time really look at the total eligibility program. >> lastly and very quickly was the eligibility for va healthcare for a non-honorably discharged veteran a part of that discussion? of the that was one issues we were raised. >> did you make a definitive recommendation? >> well, it's included in our findings and it basically outlines that for other than honorable they would be put in sort of a tentative category until it could be evaluated but the idea was to provide the care for veterans that often have reasons for being put in that category that have nothing to do with their service and the honorable service they provided while in the military. >> it would be a case-by-case basis. >> mr. chairman, the concern was that if you had a veteran who has had multiple deployments, has served honorably for an extended period of time, comes back to the states and decides he has just had it and acts up

and is given and other than honorable discharge, not a dishonorable discharge but one of the other categories, perhaps that was in part caused by his multiple deployments, maybe ptsd, maybe traumatic brain injury and it would be unfair to leave him out of the va care system. >> thank you very much. >> thank you, mr. chairman. and i want to thank the panel and all the great work that you -- you've done and everybody who contributed to the report. i want to begin which thanking senator manchin for his passion on this issue with regard to opioids. we're having a similar challenge in alaska and i actually want to thank dr. sculkin and secretary mcdonald. we had a big summit in alaska on opioid challenges and heroin

challenges this summer and we had some very top, top doctors from the va come out to alaska for that. dr. lee and dr. drexler so i want to thank both of you. i want to he can to us on an area that i didn't see in a lot of recommendations but i know it's in there because it's a really important topic and when you talk about the delivery of care the issue that of course i'm very focused on in alaska is delivery of care in a rural community, extreme rural communities. and, mr. chairman, i apologize, i know this is a little unorthodox, i'm really sorry i missed having the secretary and dr. sculkin here, i know they are still here but i would love, gentlemen, to be able to chat at one of the breaks on the tribal sharing agreements that are a concern right now but it relates to this issue. but i was back home in my state,

of course, over the summer like all of us and in a lot of the communities there just seemed to be a very different approach to delivery of healthcare in some of the real far reaching communities in alaska that are -- you know, we don't have roads, we have real unique challenges given the size and distance. and some of it relates to how the va interacts with other health organizations, clinics, tribal organizations in the far reaching communities, but one of the things that i saw because i asked everywhere i went, i went to a number of my communities is there seems to be a very different standard depending on the community, even depending on like veterans sitting next to each other. so i always meet with veterans no matter where i go in the state, try to. some of them said, hey, no, i can go right down the road to the local clinic or the local native health organization.

others say, no, i have to fly to anchorage or i have to fly to seattle and, you know, that can cost thousands of dollars just to get to these, you know, from some of the different communities in alaska. some of them say, then, the va pays for all that and puts us up at a hospital others say, no, you are on your own, literally in the same community. so i'm just wondering on this issue how much you looked at it and what recommendations you have and then more broadly with regard to consistency on delivery because it does seem very different even in the same communities, different veterans have very different experiences. >> well, first of all, i think that what you're describing is the challenge of veterans healthcare system that is so diverse and covers the entire country. to be able to provide meaningful access in every single part of in every single part of where veterans live and work. and so we felt that that was one of the major driving forces for

a more integrated model so that in communities where va facilities may not be available, that there is easier access to integrate with existing providers within that community. we also felt that there was a need for better integration with other federal providers which could apply certainly within the native american community across the country. but the consistency of care frankly in this country applies -- that challenge that you describe is true with veterans and nonveterans. in northern michigan we have access issues. in some areas, we have no ob services within 200 miles for women who might be trying to deliver. and that ishallenge why we feel it is important to take a local look to provide better access. the question of why some has the v.a. pay for it and others

don't, that might be an eligibility determination, which i can't respond to. really looking at the diversity of markets and how to best provide the care. and particularly when veterans are moving, it's not as if the veteran population is stable. and the facilities available in each market are quite variable as well. some may have outpatient facilities that can accommodate a lot of needs. some may not. the need to move from more inpatient to out-patient care is something we're seeing across health care today. it's a challenge. but certainly something we had conversations about. >> and are there recommendations that relate to this in the commission report? >> the concept of the v.a. care system incorporate some of the questions you asked. >> does it focus on the extreme rural communities? >> yes. are you ok on time? you are ok on time?

senator blumenthal. >> thanks, mr. chairman. and i want to thank you for all the time and energy that you voted to this very, very important work to both of you. mr. harvey i think you've raised in passing one of the central questions that faces us, why have a separate pa health care system. and i think you have heard some answers here, which we see in our daily -- literally our daily lives when we visit va health care facilities. not only do veterans want to be with fellow veterans, but there are ways that veterans care is tremendously enhanced by professionals who see them literally daily, hourly for the

same kinds of wounds, injuries, and so forth. and i might just add in an area that is receiving more research, there was an article i think yesterday or the day before in the "new york times" about studies being done on hospitals and measures of their quality and how when consumers are better informed, not only about the metrics of outcomes but also about how they are cared for. actually the outcomes are better when the emotional or social factor is part of the measurement. so i think in all kinds of ways, i see the va health care system as not, and i think you share this point of view, why should you we have it, but it offers the immense opportunity and potential to actually lead the

nation in terms of quality because it provides that opportunity to really attract the best and the brightest as it has at certain va facilities. and the challenges it faces as i think one of you stated in your testimony is the same challenge the rest of our health care system does. we need more primary care doctors, under chriss, more -- more psychiatrists, more equipment at affordable prices, more pharmaceutical drugs. but still, rising health care costs are a challenge. what i have not seen so far and maybe madam chairman you can talk a little bit about it, consumer protection, making sure

that the -- there are policies and procedures designed to monitor the quality of care that veterans receive outside the va health care system. the metrics and the evaluations can be applied in va health care facilities. but what about the health care outside the va walls when there are choices offered, when the choice program comes to play in whatever form it may? >> well, a couple comments in response to that. one is the more unified and integrated the so-called outside providers are within the va system, i think the greater the opportunity is to really evaluate performance, set clinical standards, and apply the same approach that is within va to the care that is received in the community. so that's a very important and different concept than

the choice program or the traditional ways va has paid for care in the community. within our recommendations, we suggested that performance metrics need to be very comparable. that we should have the same metrics of performance in the community as within va. and that those metrics should be a requirement of participation really as a vetted provider within the va care system. so i think the more that that becomes the model i think it begins to allay some of the fears. whether it's pain management, opioid use. orkut is other elements of care that are provided. >> did you want to add anything? thank you for your service. >> the only thing i would add, senator, you mentioned -- and we addressed this in part of our report -- the competent of the health care provider understanding this veteran has had a particular type of experience and being sensitive to that.

and as i said, perhaps when you were out, i i know the vva has a little card that they suggest using with various questions to ask the veteran patient to elicit some of the experience so that as you are factoring this into the diagnosis and the analysis, you're giving as a doctor you have that as part of that. so that cultural competency and understanding the military backgrounds is an important thing. you get through a system like the va. you will not get it at washington hospital center. >> thank you so much. >> tell us about senator bozeman and then we will go to panel three. >> thank you for your work on the commission. before i get started i want to thank senator mcdonald and his team. mr. chair, we had meetings last week, senator mcdonald and a lot of the people here were in my

office on giving me an update on the transformation on the break through priorities. i think it's great work. i have a lot of confidence in what they're doing. i have to give special thanks to senator mcdonald coming back to my office the following day to give me a report on toxic substances program. i think we're making progress. and i appreciate the continued work. thank you both for being here. i've got -- i'm going to jump to three of the recommendations where i think the va may have some concern. i may understand why. i'm sorry. is it ms. schlicting? good. i notice in my notes they had one note on discussion about privatization. when i see privatization ever privatization. i mentioned that i do not believe that the v.a. should be completely privatized and i do

not know any senator who thinks is a good idea valuee is a therapeutic to the v.a.. on the other hand, i think there are opportunities. that is what we are getting at. i think the v.a. has concerns that have less to do with the end result and more to do with

process. visited and done a surprise visit. this was one of two programs around the state and i would be less interested in creating other organizations and would oft to create a web expertise. do with aess to withpt and more to do implementations. do you have any comments? this component we recommended be the center of this there is a focus

and there is a business process improvement. done is a great project and i see the emerging number of best practices that we need to execute and proliferate in an orderly way. want to move to the board likerectors one and i feel this committee will have another a monthly is

flogging from two different groups. i like ours and would not want to share it. in all seriousness, it is something to be looked at. if we have this layer down to memberslevel, it may be moved from the details. i have invested a lot of time we will be better off. areill have to make sure we there isfollow up and

no doubt that veterans should receive care. ms. short may be a temporary or permanent injury. show shock, or whatever we called it, it is a matter of and we want to work towards the same goal. it is more of a means, rather than an end. flogging now.the i think this is very helpful and

of talked about a kosher isk aversion and trust and like to get your thoughts on how you can get after the risk aversion and distrust issues. it is a difficult problem and about thear a lot there are the competitions. it is very important.

it is making significant progress. it having continuity at the top for more than a couple of years our concern was how we have more stable leadership and oversight behind the governing board. we see the leadership in place and this is how the culture could happen in a positive way. a little moreake

we try to move forward in our recommendation. i think it is fantastic and they are working in this class. what has been done to engage the fantastic.ink it is >> you have added the long-term and as it with i.t. relates to schedules. can you talk about it? money.s lots of what is your sense, regarding and -- re willingness

and i was very impressed. brings a lot to this. my concern is that the v.a. seems to have had a terrible right.tting it should doing that you doctors andnts with

coordinate with the veterans administration. the proof of concept is something i would want to see. i honestly do not think they would be able to do all of these and they haveow not gotten the schedule right. the system of electronic health is an old system and has transferred and it will cost but in lots of money. quest they do for your testimony this is hard work and

thought-provoking and it revealed results in the changes we need to bring to the v.a.. we welcome our third panel. are you leaving? thank you for your help. you are the best. >> don't worry about it.

>> on behalf of all the members of their committee, or time about how invaluable your work has been added we have never had a situation where they are not ready to come forward. we appreciate your input.

think youel, you may are an afterthought. there are many things you should do differently. andant to thank all of you we're going to hear from the following individuals. the president was here. the iraqi and afghanistan veterans of america, the military officers association of america. weidman.rd we are up to five minutes.

schmidt and the members of the legion, we thank you for conducting this. this report contains a fundamental flaw that must be recognized and addressed. legion is closely aligned with a commissioner who said that the adoption of this proposal threatens the choice for the veterans who rely on this. the american legion believes in and we recognize that there are situations where we cannot keep up with the weeran population and

support the creation of the integrated health networks for this and they must be developed and structured in a way that preserves the capacity. providing unfettered choice jeopardizes this critical mass proposesmerican legion and the commission supports this with medicare rates. the commission gave no consideration to how the medicare rules would apply to the veterans through the primary

care physicians. they are not restricted to the amount for each patient and medicare provides based on 10 or 15 minute consultations, denying and this cost would be theye, if not more than making choices and best providers in the community and resting on the principle of unity -- of

using resources and expanding access to health care. competitors, more it becomes orton. if a veteran is injured, they beginle a claim to either or -- exists fortection this and it is essential to treat the that they malpractice claims the same, regardless. finally, the plan was presented in 2015. some balked at these costs and we believe that this must be

met. this is at the utmost and blumenthal has just came from a press conference where he introduced a reform bill. bipartisande bicameral consensus that the status quo is not acceptable. we have worked with this committee. what can be done? i'm happy to answer any questions. >> thank you. a vigorous debate is going to

take place. there have been numerous investigations. there is a report on the commission of care. to inform the nation's veterans. ultimately, they rejected the radical ideas and had a strong consensus on the comprehensive set of recommendations for the long-term transformation of the v.a.. they support the recommendations and i will focus if you in my oral remarks.

with the v.a. acting as the coordinator of care, the v.a. and the independent budget community put forth , how they would manage the care and reaching consensus. there was a compromise option to .et the veterans

this could result in the and you of the system are likely to end up with two parallel systems. it is more likely to provide high-quality care to the veteran increase it will spending annually. likewise, they noted there is no impactvaluation of the on this and the ability to develop comprehensive care and services impacts research and other critical missions. additionally, the commission could shift the medical care currently provided in the private sector. this reduction in work volume

would force them to close the facilities and deprive many disabled veterans with most or all of the care. access, theynsure must have the resources to address the independent assessment with the infrastructure needs and the flexibility with the networks and the care provided. establish a to board of directors and support greater continuity to create a separate governing board and hindering the ability to create the interrelated investments and

there is the budgeting purposes reportconclusion of care and we appreciate the commissioners finding workable solutions to complex problems. we are pleased that a number of recommendations are underway in this initiative. path the date, there is a forward and we are working towards creating a health care system veterans need. >> thank you. on behalf of the iraq and america,an veterans of thank you for this opportunity to share our views.

there are few issues that are veteransrtant to our than ensuring a veteran-centric dhs they are turning to the v.a. for health care. thisembers reported using and we are up six percentage points. those who use this the a are currently up five percentage points. more veterans return and face challenges. we need to know that that the pa will deliver for us and we must -- the v.a. will deliver for us. we agree that we must reform the v.a. we have submitted to the record and we must focus on the general analysis of the reports and the recommendations.

we have six general comments on this report. was presented as a series of independent recommendations and fails to acknowledge that this depends on the execution of others and requires time and resources. the report failed to consider how this will impact the ability to coordinate and the report failed to analyze the impact of and that it does not misalignment of the demand. this report failed to take into account the reforms planned or implemented. broadrecommendations are and can be left to

implementation. we oppose the creation of this recommendatione with thetegrated care primary care providers managing veteran care and the recommendation is to broad with a fatal flaw of external primary care. on recommendation nine, understanding the reason behind the establishment of the board of directors and understanding

this. we do not read -- we do not support this recommendation. we agree with the path to eligibility for the honorable h.is charges and those with ot is important to stress that this requires congress to support the increased resources. i would like to reiterate several key points. getting this requires betweenant coordination this and the veterans we serve.

this also requires a significant investment and it should not come at the expense of benefits. these must be part of a comprehensive plan to be implemented. thank you. isaacson, this gives us a chance to give our views on this report and we are grateful for the open and collaborative process established for the information and feedback from whoinvestors and those represent this constituency. we support most of the findings and we are pleased to see many recommendations incorporate the changes that have been advocated in since the implementation the choice act.

i would like to put up front that we want to see the adjusted work of the commission be enacted this year. we have discussed the appeals and the modernizations. let me go to specific recommendations. there are high-performing and integrated networks. needsnot meet all of the and the system does provide a isndational platform that stated up front in this report. they need to preserve the well-known programs in the areas of clinical education and response. these are related.

that said, we must retain responsibility with the patient outcomes to ensure the care services. creating an integrated in and leadersculture at all levels of the organization that are responsible for improving the organizational health. this transformation requires acrosszing leadership the enterprise. the improvements require making this happen.

most support a longer-term appointment for the under secretary of health and we are not in favor of the board of directors. congress must continue to be the rongest advocate. we agree to establish an expert body to develop recommendations for v.a. care, eligibility, and benefit design. the commission recommends that v.a. revised its regulations to provide health care eligibility for those other than honorable discharge. the commission believes that the adjudication assess in determining characterization of discharges takes far too long and is very strictly interpreted, preventing veterans from getting the care they need sooner rather than later. instead, moa recommends congress direct the