[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
      AN EXAMINATION OF BUREAUCRATIC BARRIERS TO CARE FOR VETERANS 

=======================================================================

                                HEARING

                               before the


                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         Thursday June 12, 2014

                               __________

                           Serial No. 113-73

                               __________

       Printed for the use of the Committee on Veterans' Affairs

         Available via the World Wide Web: http://www.fdsys.gov
                      http://www.house.gov/reform

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                     COMMITTEE ON VETERANS' AFFAIRS

                         JEFF MILLER, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida Vice-      Member
Chairman                             CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O' ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida

                       Jon Towers, Staff Director

                 Nancy Dolan, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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                            C O N T E N T S

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                                                                   Page

                         Thursday June 12, 2014

An Examination Of Bureaucratic Barriers To Care For Veterans          1

                           OPENING STATEMENT

Hon. Jeff Miller, Chairman
    Statement....................................................     1
    Prepared Statement...........................................     3

Hon. Mike Michaud, Ranking Minority Member
    Statement....................................................     4
    Prepared Statement...........................................     6

                               WITNESSES

The Hon. Tim S. McClain, President Humana Government Business
    Statement....................................................     7
    Prepared Statement...........................................     8
Dan Collard, Chief Operationg Officer, The Studer Group
    Statement....................................................    14
    Prepared Statement...........................................    16
Betsy McCaughey Ph.D., Chairman Committee to Reduce Infection 
  Death
    Statement....................................................    18
    Prepared Statement...........................................    19
Robert L. Jesse M.D., Ph.D., Acting Under Secretary for Health, 
  Veterans Health Administration U.S. Department of Veterans 
  Affairs
    Statement....................................................    56
    Prepared Statement...........................................    58

                                APPENDIX

            STATEMENT FOR THE RECORD.............................    82

Letter From Robert Jesse to Chairman Miller                          82


      AN EXAMINATION OF BUREAUCRATIC BARRIERS TO CARE FOR VETERANS

                              ----------                              


                        Thursday, June 12, 2014

              U.S. House of Representatives
                     Committee on Veterans' Affairs
                                           Washington, D.C.
    The committee met, pursuant to notice, at 9:15 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    Present: Representatives Miller, Bilirakis, Roe, Flores, 
Runyan, Benishek, Huelskamp, Coffman, Wenstrup, Cook, Walorski, 
Jolly, Michaud, Brown, Takano, Brownley, Titus, Kirkpatrick, 
Ruiz, McLeod, Kuster, O'Rourke, and Walz.
    Also Present: Representative McNerney.
    The *Chairman.* The committee will come to order.
    Thank you, everybody, for coming to this hearing this 
morning. We have numerous Members that are on their way, but we 
want to respect the time of our witnesses, and we appreciate 
them being with us today.
    But before I begin, I want to ask unanimous consent to 
allow our colleague and former committee member, Congressman 
McNerney of California, to sit at the dais and participate in 
today's hearing. Without objection, so ordered.
    So welcome to today's full committee hearing on Examination 
of Bureaucratic Barriers to Care for our Veterans.
    As we all know very well now, during a committee oversight 
hearing in early April, we came forward with the results of a 
committee investigation that had uncovered evidence suggesting 
that dozens of veterans died while waiting for care at the 
Phoenix Department of Veterans' healthcare system.
    Just over two months later, we know now that in addition to 
23 veteran deaths at the department linked to delays in care 
earlier this spring, at least 35 more veterans died while 
awaiting care in the Phoenix area alone.
    What is more, a VA audit released earlier this week found 
that over 57,000 veterans have been waiting 90 days or more for 
their first VA medical appointment and 64,000 veterans who have 
enrolled in the healthcare system over the last decade never 
received the appointment that they requested.
    That is 121,000 veterans who have been waiting for care to 
be provided that they earned. That number exceeds the 
population of several mid-size U.S. cities like Athens, 
Georgia, Abilene, Texas, or Santa Clara, Texas, or even 
Evansville, Indiana, and I fear there is more yet to come.
    Yesterday I spoke to a group of VA providers from across 
the country at an event for the National Association of VA 
Physicians and Dentists speaking about the current crisis 
engulfing the department. They have said that VA's procedures 
and processes are inconsistent, inconsistently applied, and 
often prevent efficient use of personnel.
    The statement echos the serious calls for alarm that we 
have heard from others over recent weeks.
    During a recent committee hearing, Dr. Daigh, VA's 
assistant inspector general for VA's Healthcare Inspection, 
testified that VA suffers from, and I quote, ``a lack of focus 
on healthcare delivery as priority one,'' unquote.
    As a result, quote, ``several organizational issues that 
impede the efficient and effective operation of the VA 
healthcare system and place patients at risk of unexpected 
outcomes,'' end quote.
    In an article published last week in the New England 
Journal of Medicine, a former VA under secretary for Health, 
Dr. Ken Kaiser, and a current staff physician at a major VA 
medical center wrote that the systemic data manipulation and 
lack of integrity VA is experiencing are but, quote, ``symptoms 
of a deeper pathology because simply VA has lost sight of its 
primary mission of providing timely access to consistent high-
quality care,'' end quote.
    All of these remarks go to prove what we have already 
known. The VA healthcare system and the bureaucratic behemoth 
that accompanies it is complex and its problems are even more 
complex.
    I believe that the majority of VA's workforce, in 
particular the doctors and nurses who provide our veterans with 
the care they need, do, in fact, endeavor to provide high-
quality healthcare.
    Unfortunately, VA leadership has failed those employees 
almost as much as it has failed our veterans and correcting 
those failures is going to take a lot more than the band-aid 
fixes the department has proposed thus far.
    It is going to take wholesale systematic reform of the 
entire department starting with holding senior staff 
accountable.
    VA hasn't gotten where it is today due to just bloated and 
ineffective middle management or lack of training and 
professional development for administrative staff or 
inefficient or nonexistent productivity and staffing standards 
or cumbersome and outdated IT infrastructure.
    The department got where it is today due to a perfect storm 
of settling for the status quo. VA cannot continue business as 
usual. It is very clear the status quo is not acceptable and it 
is time for real change, again, beginning with accountability 
up to the highest levels of VA bureaucracy.
    And I hear repeatedly from the VA about its delivery of 
high-quality, patient-centered care, but this committee, 
republicans and democrats alike will not rest until we hear 
that same assessment from every single veteran seeking care. It 
is time for VA to tell us the bad news, not just the good news.

        STATEMENT OF THE HONORABLE JEFF MILLER, Chairman

    Welcome to today's Full Committee oversight hearing, ``An 
Examination of Bureaucratic Barriers to Care for Veterans.''
    As we all well know, during a Committee oversight hearing 
in early April, we came forward with the results of a Committee 
investigation that had uncovered evidence suggesting that 
dozens of veterans died while waiting for care at the Phoenix 
Department of Veterans Affairs (VA) health care system. Just 
over two months later, we know now that in addition to twenty-
three veteran deaths that the Department linked to delays in 
care earlier this spring, at least thirty-five more veterans 
died while awaiting VA care in the Phoenix, Arizona, area.
    What's more, a VA audit released earlier this week found 
that over fifty-seven thousand veterans have been waiting 
ninety days or more for their first VA medical appointment and 
sixty-four thousand veterans who have enrolled in the VA 
healthcare system over the last decade never received the 
appointment they requested. That is one-hundred and twenty-one 
thousand veterans who have not been provided the care they have 
earned.
    That number exceeds the population of several mid-sized 
U.S. cities like Athens, Georgia, or Abilene, Texas, or Santa 
Clara, Texas, or Evansville, Indiana. And, I fear that there is 
more yet to come.
    Yesterday I spoke to a group of VA providers from across 
the country at an event for the National Association of VA 
Physicians and Dentists (NAVAPD). Speaking about the current 
crisis engulfing the Department, NAVAPD has stated that VA's, 
``procedures and processes are inconsistent, inconsistently 
applied, and often prevent efficient use of personnel...'' This 
statement echoes the serious calls for alarm we have heard from 
many others in recent weeks.
    During a recent Committee hearing, Dr. Daigh [DAY], VA's 
Assistant Inspector General for Healthcare Inspections, 
testified that VA suffers from, `` . . . a lack of focus on 
health care delivery as priority one,'' as a result of, `` . . 
. several organizational issues that impede the efficient and 
effective operation of [the VA health care system] and place 
patients at risk of unexpected outcomes.''
    In an article published last week in the New England 
Journal of Medicine, a former VA Under Secretary for Health - 
Dr. Kenneth Kizer - and a current staff physician at a major VA 
medical center wrote that the systemic data manipulation and 
lack of integrity VA is experiencing are but, `` . . . symptoms 
of a deeper pathology,'' because, ``[q]uite simply, VA has lost 
sight of its primary mission of providing timely access to 
consistently high-quality care.''All of these remarks go to 
prove what we already know. The VA health care system and the 
bureaucratic behemoth that accompanies is complex and its 
problems are even more complex.
    I believe that the majority of VA's workforce - in 
particular, the doctors and nurses who provide our veterans 
with the care they need - endeavor to provide high-quality 
health care. Unfortunately, VA leadership has failed those 
employees almost as much as it has failed our veterans and 
correcting those failures is going to take a lot more than the 
band-aid fixes the Department has proposed thus far - it is 
going to take wholesale systematic reform of the entire 
Department, starting with holding senior staff accountable.
    VA hasn't gotten where it is today due to just bloated and 
ineffective middle management; or lack of training and 
professional development for administrative staff; or 
inefficient or nonexistent productivity and staffing standards; 
or cumbersome and outdated IT infrastructures. The Department 
got where it is today due to a perfect storm of settling for 
the status quo. VA cannot continue business as usual. The 
status quo is unacceptable. It is time for real change - again, 
beginning with accountability up to the highest levels of VA 
bureaucracy. I hear repeatedly from the VA about its delivery 
of high-quality, patient- centered care . . . but this 
Committee will not rest until we hear that same assessment from 
every veteran seeking care. It is time for VA to tell us the 
bad news, not just the good.
    With that, I yield to our ranking member, Mr. Michaud, for 
any opening statement he might have.

 OPENING STATEMENT OF THE HON. MIKE MICHAUD, Ranking Minority 
                             Member

    Mr. Michaud. Thank you very much, Mr. Chair, for having 
this very important hearing, Examining the Barriers to Care for 
our Veterans.
    This is a unique time in the history of the Department of 
Veterans Affairs. We as a committee have been responsible for 
bringing to light systematic problems, many dating back over a 
decade.
    But as we are shining the light on these problems, we must 
also begin to take steps to address them. I am proud that this 
committee has addressed these problems in a bipartisan fashion 
and I am hopeful that the spirit continues as we roll up our 
sleeves and begin the hard work of finding solutions.
    The VHA is a sprawling organization with over six million 
unique patients, facilities spread all over the country, and 
nearly 275,000 employees and a $56 billion budget. To put VA, 
the largest integrated healthcare system in the country, in 
perspective, VHA is roughly the equivalent of five Mayo Clinics 
combined.
    Recent admissions of wrongdoing are shameful and the 
practice will not be tolerated. The systematic lapse of 
integrity confirmed by the internal VHA access audit and the VA 
OIG reports points to a bureaucratic bureaucracy that has 
seemed to have lost its way and its focus.
    I think these problems, the time is right to begin 
discussing how best to address these challenges and the time 
might be now to effect big changes that will put the focus back 
on the veteran and away from the culture of complacency.
    In our discussion of reform, I want to make sure that we 
are not just rearranging the desk chairs. All the 
reorganization in the world will be futile without a strong 
base of values.
    I do not doubt the commitment of the vast majority of VA 
employees. However, sometimes we all know that we need to be 
reminded of who we are here to work for. We are here to work 
for the veteran, brave men and women who have sacrificed so 
much for our freedom, men and women who right now deserve 
better.
    I strongly suggest that VHA develop a code of conduct or a 
caregiver culture that will become ingrained throughout the 
organization regardless of whether there is one VISN or 50. 
Working in the VA requires the utmost integrity.
    As Dr. Roe pointed out the other night, all a VA employee 
needs to do without a doubt is they have to be reminded that 
they are working for the veteran, not a bureaucracy.
    As with most things, there are tradeoffs. We are looking at 
structural reform, centralization versus decentralization, 
standardization versus innovation. These discussions have been 
ongoing for years, if not decades.
    I would like to think VHA is an adaptable, learning 
organization that can make needed transformation, but let me be 
clear. The only way we are going to truly address the litany of 
problems is to look at the fundamental change within the 
department.
    And rightfully we are all looking at ways to address the 
problems as we see today, but I am also hopeful that our 
ambitious schedule of hearings in the weeks ahead will think 
anew about how best to provide the quality, comprehensive care 
to our veterans in a timely fashion.
    And I hope that they challenge us to think anew about how 
to refashion systems and infrastructure, management and 
personnel policy and procedures to address the access issues 
head on and to help the VA live up to its ideal.
    I believe it is essential that we look at structural and 
cultural root causes that got us in this position in the first 
place.
    We have heard that the leadership of the medical centers 
feels disenfranchised. We have real concerns over the effective 
level of accountability. We need to shorten the feedback loop 
from the front-line provider to VHA leadership.
    One of the discussions we must have is over the right 
administrative structure of the VHA, how to ensure that 
policies and procedures are followed nationally while making 
sure that the VA is not a one-size-fit-all system.
    We have heard many times about the excessive, intrusive 
administrative burden our providers experience which takes time 
away from caring for our veterans. We need to do what we can to 
eliminate this administrative work.
    Many are pointing to the IT infrastructure. There is no 
doubt that an outdated scheduling system contributes to the 
current problems and needs emergency upgrade. At the same time, 
we need more detail on what is happening to the millions of 
dollars Congress has appropriated for IT.
    Before we can look at investing even more money here, I 
want to know why the VA did not do a better job in planning 
strategically, anticipating the needs of a facility system 
population, and putting in place actions including things like 
IT upgrades to address these anticipated needs.
    The time is right to leverage outside expertise. There is 
no monopoly on good ideas. I look forward to hearing from the 
panels today and hope to continue this excellent discussion 
throughout the coming weeks.

         PREPARED STATEMENT OF THE HON. MICHAEL MICHAUD

    * Thank you Mr. Chairman.
    * This is a unique time in the history of the VA. We. As a 
Committee, have been responsible for bringing to light systemic 
problems, many dating back for over a decade. But as we are 
shining light on these problems, we must also begin to take 
steps to address them. I am proud that this Committee has 
addressed these problems in a bipartisan fashion, and I am 
hopeful that this spirit continues as we roll up our sleeves 
and begin the hard work of finding solutions.
    * The Veterans Health Administration is a sprawling 
organization, with over 6 million unique patients, facilities 
spread out all over the country, and nearly 275,000 employees 
and a $56 billion budget.
    * To put VA, the largest integrated health care system in 
the country in perspective, VHA is roughly the equivalent of 
five Mayo Clinics combined.
    * Recent admissions of wrongdoing are shameful and the 
practices will not be tolerated. The systemic lapses of 
integrity confirmed by the internal VHA access audit and VA 
Office of Inspector General reports point to a bureaucracy that 
has seemed to lose its way, and its focus.
    * I think with these problems, the time is right to begin 
discussing how best to address these challenges, and that the 
time might be now to effect big changes that will put the focus 
back on the veteran, and away from a culture of complacency.
    * In our discussions of reform, I want to make sure we are 
not just rearranging the deck chairs. All the reorganization in 
the world will be futile without a strong base of values.
    * I do not doubt the commitment of the vast majority of the 
VA employees. However, sometimes we all need a reminder of who 
we work for.
    * And we work for veterans - brave men and women who have 
sacrificed so much for our freedom. Men and women who, right 
now, deserve better.
    * I strongly suggest that VHA develop a code of conduct or 
a caregiver culture that will become engrained throughout the 
organization regardless of whether there is one VISN or fifty.
    * Working in the VA is a particularly special government 
service and requires the utmost integrity. As Dr. Roe pointed 
out the other night, all VA employees need to know without a 
doubt they are working for our veterans.
    * As with most things, there are tradeoffs when looking at 
structural reforms. Centralization versus decentralization, 
standardization versus innovation, these discussions have been 
ongoing for years if not decades.
    * I would like to think the VHA is an adaptable learning 
organization that can make needed transformations.
    * But let me be clear - the only way we are going to truly 
address the litany of problems is to look at fundamental 
change.
    * Rightfully, we are all looking at ways to address the 
problems we see today. But I am hopeful that our ambitious 
schedule of hearings in the weeks ahead challenge us to think 
anew about how best to provide quality comprehensive health 
care to our veterans, in a timely fashion. I hope that they 
challenge us to think anew about how to refashion systems and 
infrastructure, management and personnel, policy and procedures 
to address the access issue square-on, and to help the VA live 
up to its ideal.
    * I believe it is essential that we look at structural and 
cultural root causes that got us into this position.
    * We have heard that the leadership of the medical centers 
feels disenfranchised. We have real concerns over the effective 
level of accountability. We need to shorten the feedback loop 
from frontline providers to the VHA leadership.
    * One of the discussions we must have is over the right 
administrative structure of the VHA - how to ensure that 
policies and procedures are followed nationally, while making 
sure that VA is not a ``one-size-fits-all'' system.
    * We have heard many times about the excessive and 
intrusive administrative burden our providers experience, which 
takes away time from caring for veterans. We need to do what we 
can to eliminate this administrative work.
    * Many are pointing to the IT infrastructure. There is no 
doubt the outdated scheduling system contributed to the current 
problems and needs emergency upgrades. At the same time, we 
need more details on what happened to the millions of dollars 
Congress has appropriated for IT. Before we look at investing 
even more money here, I want to know why the VA did not do a 
better job at planning strategically - anticipating the needs 
of facility-specific populations, and putting in places actions 
- including things like IT upgrades - to address those 
anticipated needs.
    * The time is ripe to leverage outside expertise. There is 
no monopoly on good ideas. I look forward to hearing from our 
experts today and hope to continue an excellent discussion 
through the coming weeks.
    * Thank you Mr. Chairman, I yield back.
    Joining us today, we actually have two panels. On our first 
panel already seated at the table is the Honorable Tim McClain, 
president of Humana Government Business; Mr. Dan Collard, chief 
operating officer for The Studer Group; and Dr. Betsy 
McCaughey, chairman for the Committee to Reduce Infection 
Deaths.
    We do appreciate all of you being here with us today. And 
with that, Mr. McClain, you are recognized for five minutes.

                  STATEMENT OF TIM S. MCCLAIN

    Mr. McClain. Thank you, Mr. Chairman.
    And, Mr. Chairman, Ranking Member Michaud, and Members of 
the committee, thank you for holding today's hearing to Examine 
Bureaucratic Barriers to Healthcare for Veterans.
    I will focus my remarks on the very complex subject of 
organizational impediments in the Veterans Health 
Administration that are not conducive to the delivery of good 
healthcare to veterans.
    In my written statement, which I ask be made a part of the 
record----
    The *Chairman.* Without objection, all of your statements 
will be entered into the record.
    Mr. McClain. --I make four specific recommendations to 
improve organizational alignment in VHA. But in this oral 
statement, I want to address just one, and it is probably the 
one that is most disturbing to veterans and Congress, and that 
is a failure of ethics.
    There is a pervasive VA culture that puts personal gain and 
the system over the needs of the veterans and this is wrong. 
And I want to make two points to the committee. Let's not have 
Congress and VA just put band-aids on the current crisis 
without resolving the systemic causes and, two, I believe any 
long-term solution must include a culture and organizational 
assessment by a nationally recognized company.
    The current crisis differs from previous VA crises by the 
fact that it reflects a serious cultural deficit throughout VA 
at certain levels of management. This is to the culture of what 
should be at VA.
    Now, I want to emphasize and make it clear that from my 
experience at VA, I found the vast majority of VA employees to 
be competent, professional, and dedicated to the primary 
mission of serving veterans, but the culture at certain 
management levels reflects an attitude of personal gain over 
service to veterans.
    Some major changes are required. But before making any 
major changes, I proposed in my written statement that VA be 
directed to contract with a nationally recognized company to 
conduct a top to bottom assessment of the current culture. A 
gap analysis can then be performed to determine the current 
state and then what is needed to move the VA system to a 
veteran-centric 21st century system.
    The experience will be influenced by what I will call the 
voice of the veteran which essentially is direct veteran input 
into what this culture should look like going forward. If 
Congress or VA fails to seize the once-in-a-generation 
opportunity to deliver a modern VA healthcare and benefit 
system, we will all be back in this hearing room in the future 
lamenting the then current crisis.
    Mr. Chairman, this concludes my oral statement. I would be 
glad to answer any questions. Thank you.

         PREPARED STATEMENT OF THE HON. TIM S. MCCLAIN

    Thank you for holding today's hearing to examine 
bureaucratic barriers to healthcare for Veterans. I will focus 
my remarks on the very complex subject of organizational 
impediments in the Veterans Health Administration (VHA) that 
are not conducive to the delivery of effective and efficient 
healthcare to our nation's most deserving citizens.
    The following recommendations are submitted for the 
Committee's consideration to drive VHA organizational alignment 
for improving healthcare delivery to Veterans:
    I. A cultural assessment is recommended and should be 
completed before any major organizational changes are 
implemented
    II. Develop and implement a national Integrated Care 
Delivery (ICD) Model pilot program in several Community Based 
Outpatient Clinics (CBOCs) with a focus on health outcomes, 
cost of care, and Veteran satisfaction
    III. Utilize existing commercially available technology, 
such as health IT and scheduling/ consult tracking tools, to 
improve care coordination for Veterans who utilize VHA's ``in-
network'' and ``out-of-network'' providers
    IV. For national or congressionally-directed programs, the 
program offices in VHA central office should be empowered to 
enforce policies and directives by providing organizational 
authority, centralized budgetary control, and meaningful 
outcomes-oriented performance metrics
    I. A cultural assessment is recommended and should be 
completed before any major organizational changes are 
implemented
    Recent articles have opined that many of the current 
problems in the Veterans Health Administration are the result 
of an organizational culture that does not put the Veteran at 
the center of care and looks inward rather than outward for 
ideas and innovation. The alleged actions of certain VA 
employees in Phoenix and other VA facilities support those 
assertions. I believe the vast majority of VA employees are 
professional and dedicated to their primary mission of serving 
Veterans. However, there is a pervasive attitude among some 
levels of management that preservation of the ``system'' takes 
precedence over all other considerations,
    including Veteran-centric healthcare. The result is an 
overall attitude that fears outside influence over VA 
healthcare. The paramount objective is to treat all Veterans 
within the walls of VHA, even if that means the patients must 
wait for care and even when some Veterans prefer to get care in 
the community. Sending a Veteran into the community for primary 
care is viewed as a potential weakness which might be exploited 
by those that want to provide Veterans an alternative to care 
closer to home. In many locations, VHA considers care delivered 
by a contracted community provider to be inferior to VHA care.
    In a recent article in the New England Journal of Medicine, 
Dr. Kenneth Kizer described VHA's current attitude as 
``insular.''
    This attitude is in direct contrast to how contracted care 
is viewed by a system such as Kaiser Permanente. Patients in 
the Kaiser system refer to the ``Kaiser Experience'', where 
care delivered anywhere within the Kaiser network, in a Kaiser 
hospital or a contract community provider, is considered Kaiser 
healthcare and part of the Kaiser Experience.
    VHA should embrace this concept and move toward a ``VA 
Experience'' which incorporates all available quality 
healthcare and services in a community, including a modern 
Integrated Healthcare Delivery Model.
    The cultural issues identified are most likely not 
restricted to VHA, but may be present throughout VA.
Recommendations:
    1. After addressing the most immediate access problems, 
Congress should direct VA to contract with a national company 
or organization experienced in conducting cultural and 
organizational assessments of large, complex healthcare and/or 
service organizations.
    2. VA should allow the voice of the Veterans to define the 
ideal ``VA Experience''. Then, VA should conduct a gap analysis 
and compare the results of the current cultural and 
organizational assessment to the desired Integrated Care 
Delivery Model of a 2020 and beyond world-class healthcare and 
services organization of choice.
    3. VA should review all Personnel evaluation metrics and 
ensure that all VHA employees - from clerks, to clinicians, to 
senior managers - are evaluated based on outcomes for Veterans 
who are seeking and receive care from VHA - within its walls or 
in the community.
    4. With the assistance of national experts, VA should 
develop and implement a plan to move from its current 
organizational culture to the desired 2020 and beyond world-
class organizational structure and culture.
    II. Develop and implement a national Integrated Care 
Delivery (ICD) Model pilot program in several Community Based 
Outpatient Clinics (CBOCs) with a focus on health outcomes, 
cost of care, and Veteran satisfaction
    The transformation of VHA in the 1990s from a hospital-
centric to a clinic-based system occurred, in part, as a 
reaction to a desire to provide accessible care to Veterans in 
the face of limited and dwindling budgetary resources. VISNs 
were established, there was a shift away from hospital-based 
inpatient care to outpatient care, and VHA became the 
decentralized system it is today. Over the past decade, VHA's 
budget has increased significantly and today budgetary 
restrictions are much less of a driving force. However, along 
with the growth of the budget came the growth of middle 
management positions at VA. The number of VA employees 
ballooned from 230,000 to over 320,000 in just five years. It 
appears that the vast majority of the additional employees are 
not engaged in direct healthcare. The bureaucracy is bloated. 
Also, Congress in appropriating the huge increases to the VA 
budget failed to require accountability for health and benefits 
outcomes for the taxpayers' dollars.
    Over the next ten years VHA must continue its focus on 
addressing the signature injuries of the wars in Iraq and 
Afghanistan. In addition, there must be an equal focus on 
wellness and prevention to drive improved population health 
outcomes. As VA's budget stays flat or diminishes, as it surely 
will as the wars wind down, focusing on Integrated Care and 
population health are two proven ways to control rising 
healthcare expenditures by keeping the Veteran population in 
good health as the Vietnam era Veterans age.
    There is abundant research that links wellness and 
preventive services to improved health outcomes. However, the 
way that VHA is currently organized does not integrate wellness 
and prevention into patient care plans and Veterans do not 
receive a consistent set of wellness services from one VAMC to 
the next. A pivot to Wellness is needed in VA.
Recommendations:
    5. To drive positive health outcomes, realize cost savings 
and improve Veteran satisfaction, VHA needs to focus on further 
developing a Veteran-centric, care coordinated delivery system 
that strongly promotes wellness and prevention. This requires 
policies and attitudes on these issues that are implemented 
consistently across the continuum of care as Veterans seek care 
within and outside of VHA. This will also assist VHA in making 
the VHA system the portal of choice for Veterans' healthcare.
    6. Congress can work with VHA to design a standardized, 
Veteran-centric healthcare delivery system, which is based on 
Integrated Care Delivery, care coordination and wellness.
    a. VHA budget allocations should be dependent on VHA 
incorporating the policies, procedures, and programs designed 
so that VHA is the healthcare system of choice for Veterans.
    b. Congress should direct VHA to establish a pilot program 
in several CBOCs, including contracted CBOCs, to determine the 
effectiveness of an Integrated Care Delivery model on health 
outcomes and cost of care.
    i. Today, both VA and contractor-run CBOCs provide much of 
the primary care to eligible Veterans. The CBOCs serve as a 
natural home for extending wellness services as a test bed for 
the proposed coordinated and Integrated Care Delivery Model.
    ii. To fully understand the impact of integrating wellness 
offerings through the CBOCs, VHA should implement a pilot 
program in select VISNs that captures metrics and outcomes in 
both VHA and contractor-operated CBOCs that are representative 
of the variety of CBOCs that VHA operates. The pilot program 
must include provisions that allow CBOCs to experiment with 
various health and wellness approaches to determine the most 
effective and efficient model.
    iii. To ensure VHA and Congress are provided actionable 
information on these pilots, there must be a rigorous, 
independent evaluation component to the pilot program that 
focuses on care quality, cost, and Veteran satisfaction.
    III. Utilize existing commercially available technology, 
such as health IT and scheduling/ consult tracking tools, to 
improve care coordination for Veterans who utilize VHA's ``in-
network'' and ``out-of-network'' providers
    The Electronic Health Record (EHR) is a critical component 
for robust care coordination. It is especially important for 
Veterans with co-morbid mental and physical health conditions 
that see multiple providers, both ``in-network'' providers 
within VHA and ``out-of-network'' providers outside of VHA.
    VHA does not maintain a complete Veterans Health Record 
because it fails to capture, aggregate, and evaluate a 
Veteran's care from all sources, both inside and outside VHA. A 
significant portion of VA patients do not receive their entire 
healthcare from VHA. Some only come to VA for the prescription 
drug benefit. Therefore, VA does not have a complete picture of 
a Veteran's overall healthcare needs and treatment. VistA is an 
effective EHR tool to be used within each VHA facility; 
however, it is not ideal for an Integrated Care Delivery Model 
because it fails to aggregate charts, labs, consults and 
reports from all sources of a Veteran's healthcare. The 
technology exists today in the Health IT space to accomplish 
this important aspect of total healthcare.
    Currently when a Veteran receives an authorization for care 
through the Purchased Care Program, VHA essentially loses track 
of that Veteran's healthcare because there is no tool to track 
the healthcare delivered by providers in the community. This 
may be one reason why care provided in the community is suspect 
to many in VHA. An EHR that presents the total healthcare 
picture of a Veteran could help to alleviate that attitude.
Recommendations:
    7. Complete clinical information exchange is a key element 
of care coordination. VHA should be directed to:
    a. Utilize off-the-shelf solutions that exist today in the 
commercial market that will provide immediate connectively 
between VistA and EHRs that are used in systems outside of VHA. 
VistA evolution plans should ensure VHA IT can easily be linked 
with other existing IT tools and products that will enhance 
health care delivery for Veterans.
    b. Leverage existing Health IT capabilities in the 
commercial sector to aggregate and evaluate health data from 
all healthcare delivery sources. This includes the power of big 
data and data analytics to study and positively impact 
population health outcomes.
    8. Implement a national, centralized appointment scheduling 
system in VHA with a centralized budget and location(s).
    a. A national scheduling system will provide the 
opportunity for any Veteran to be scheduled for any appointment 
in or out of Network anywhere Veterans are eligible to receive 
care. There are numerous commercially robust scheduling systems 
in use today that VHA could adopt.
    b. Project HERO (Healthcare Effectiveness through Resource 
Optimization), a care coordination pilot program, utilized a 
contractor-provided scheduling and consults tracking system, 
which allowed VHA to track a Veteran's total healthcare 
experience when referred to a community provider. Such a system 
could be used to schedule and monitor the appointments for all 
purchased care. This centralized appointment system for 
contract care would be a tool for VHA in managing the delivery 
of timely access to care for Veterans.
    c. VHA still lacks a nationwide state-of-the-art claims 
processing system. Each facility still has unique capabilities 
and approaches to paying for out of Network (Purchased Care/
Fee) claims. In addition, VHA still lacks an automated system 
for collecting first and third party payments, which should be 
an integral part of an in-Network and out-of-Network claims 
payment system.
    IV. For national or Congressionally-directed programs, the 
program offices in VHA Central Office should be empowered to 
enforce policies and directives by providing organizational 
authority, centralized budgetary control, and meaningful 
outcomes-oriented performance metrics
    Properly managed, the decentralized model of VHA 
implemented in the mid-1990s has been a very effective model. 
However, some programs have required a national implementation 
approach, as directed by Congress. For those programs, offices 
in VHA Central Office establish national policies and issue 
guidance, but they lack direct line and centralized budget 
authority for ensuring that the policies are implemented and 
guidance is followed consistently in the field.
    As mentioned above, Project HERO was a care coordination 
pilot program that yielded savings of $16 million according to 
VA's calculations, even with a very limited use of the pilot 
program in the field. VHA missed a major opportunity to realize 
savings. Significant additional savings could have been 
realized if the Project HERO program office had centralized 
authority to implement a standardized authorization and 
referral process, and the authority to require a facility's use 
of the contracted network of outside providers in the pilot 
program.
    Many existing VHA performance metrics are focused on 
process rather than outcomes, which hinders the ability to hold 
staff accountable to program success and improved Veterans' 
health outcomes.
Recommendations:
    9. VHA should establish clear performance metrics that 
focus on clinical results, quality, access, timeliness, and 
Veteran satisfaction. These metrics would guide the work of 
VHA's administrative and clinical staff in central office and 
in the field. In addition, it would be an effective lever to 
drive desired behavior if these metrics are used to inform the 
staff's annual performance reviews and decisions about bonus 
awards and promotions.
    10. The field staff - administrative and clinical - needs 
to have a clear reporting chain to eliminate the current 
confusion about the chain of command, authority and 
responsibilities. For example, there are VISN BIMs (Business 
Implementation Managers) with different organizational 
structures across the country. Some VISN BIMs have direct line 
authority over the Fee clerks at VAMCs and can direct their 
behavior, while other VISN BIMs lack that authority.
    Mr. Chairman, thank you once again for the opportunity to 
address these extremely important issues. Humana Government 
Business stands ready to assist VHA in finding solutions to the 
current issues so that Veterans can receive the timely care 
they deserve.
    Honorable Tim S. McClain
    Tim S. McClain was appointed President, Humana Government 
Business in February 2012 and has responsibility for business 
and administrative contracts with the federal government. 
Previously, Tim was President and CEO of Humana Veterans 
Healthcare Services. He is a recognized expert in Veterans 
health care law and policy.
    Mr. McClain has over thirty- five years of experience in 
executive leadership and management positions. He served as 
General Counsel for the U.S. Department of Veterans Affairs 
(VA) from 2001-2006, a Senate-confirmed Presidential 
appointment position, serving two Cabinet secretaries and 
managing an office comprised of nearly 400 attorneys.
    In 2005, Mr. McClain served concurrently as General Counsel 
and as Chief Management Officer for VA, with overall 
responsibility for the Cabinet department's budget formulation 
and execution, procurement policy, acquisitions management, and 
business process oversight.
    Tim is a graduate of the U.S. Naval Academy, Annapolis, 
Maryland, and California Western School of Law, San Diego, 
California. He is a retired Naval officer, having served as a 
Surface Warfare Officer and in the Navy's Judge Advocate 
General's (JAG) Corps.
    Statement:
    Humana Government Business currently provides 
administrative services to VHA under the Project ARCH (Access 
Received Closer to Home) contract, and also operates thirty-
four Community Based Outpatient Clinics (CBOC) through 
contracts with VHA. Humana Government Business previously 
provided services under the Project HERO contract.
    The *Chairman.* Thank you very much, sir. We appreciate 
your comments.
    Mr. Collard, you are recognized for five minutes.

                    STATEMENT OF DAN COLLARD

    Mr. Collard. Chairman Miller, Ranking Member Michaud, and 
committee Members, thank you for this hearing as well. Thank 
you for the opportunity to address the committee on the issues 
of veterans' health and the underlying elements of culture and 
leadership.
    I listened with interest Monday night when I heard Mr. 
Griffin from the Inspector General's Office talk about the fact 
that if you have seen one VISN, you have seen one VISN. And it 
seems that both the testimony of your witnesses and your 
questions centered around evidence and variance.
    In Studer Group's work with over 900 healthcare 
organizations across our country, it is clear that those that 
implement standardized approaches to care produce the very best 
outcomes. These organizations build culture of accountability, 
alignment, consistency, and sustainability.
    We also find that their evidence-based approaches extend 
beyond evidence-based care to a framework of evidence-based 
leadership. This approach ensures that leaders are not only 
held accountable for the right goals, but these leaders are 
given the skills and the tools and the knowledge to achieve 
those goals. These leaders ensure consistency in the workplace 
for their employees. They also ensure consistency in the care 
environment for their physician colleagues.
    And as the public has watched the VHA issues unfold over 
the past 60 days, it is clear that the tolerance for variance 
is chief among its ailments. The amount of variance and the 
lack of willingness to standardize leadership has created an 
unfortunately predictable outcome. As we would say, what you 
permit, you promote.
    The data that demonstrates these connections of evidence-
based care, quality outcomes, patience experience, and lower 
cost just continue to mount. When one reviews the publicly 
reported data, it is clear that better healthcare is less 
costly healthcare. Data also suggests a strong correlation 
between patients' perception of care and the actual clinical 
outcomes.
    Further, there is data that correlates the specific 
questions like preparation for at-home care with the likelihood 
of a readmission.
    A review of the VHA facilities that report show that only a 
handful appear in the top core tile, a few just above the 
national mean, and unfortunately way too many in the lower 
ranks of healthcare.
    You connect this proof with the fact of employee engagement 
and one begins to see definite trends. A study published 
recently by the University of Alabama at Birmingham showed 
clearly the correlation between the level of employee 
engagement and the likelihood of the creation of work-arounds 
which equals impact on safety.
    I was reminded of that as I read the various reports of 
what we now know from the whistle blowers about the veterans' 
wait lists and the related mortalities.
    Largest healthcare systems in the United States have driven 
improvements by harvesting and implementing best practices 
across their systems. When organizations like Community Health 
Systems identify a best practice, they move quickly to put the 
practice in place across all 205 facilities. This includes 
patient safety protocols, caregiver-to-patient interactions 
about medications, and a leader accountability platform.
    I was concerned when I heard the witnesses on Monday 
reference the amount of time they thought it would take to make 
change. As Harvard business professor John Kotter would have us 
remember that the biggest obstacle to achieving high 
performance is not achieving the needed urgency.
    And, Mr. Walz, I think this was actually part of the answer 
to your question about the big idea on Monday. No matter what 
is decided, the VA must embark upon change with a never-before-
seen sense of urgency with a proven outcomes-based solution.
    We observe at Studer Group that it can be as 
straightforward as transferring the rigor and discipline of 
where an organization already excels into an area where they 
are sub-par.
    For instance, imagine if the VHA electronic medical record, 
which is hailed as cutting edge, could be the impetus for 
creating the scheduling software, which is today archaic at 
best.
    Imagine if the high-performing facilities referenced in 
Monday's testimony that stand out as models could be those 
models and indeed replicated with what Mr. Matkovsky referred 
to as exceptional leadership and culture. We wouldn't have 
tolerated the operation of 21 different navies or armies, air 
forces, marines, or coast guards when these veterans were on 
active duty. Why do we tolerate 21 versions of veterans' health 
today in our VISNs?
    Our Armed Forces also ensure readiness by putting in place 
systems of verification and validation of skills for both 
front-line sailors and soldiers as well as those leaders. We 
find safe, effective, timely healthcare to be no different.
    And, finally, we have to make sure that the Veterans Health 
Administration doesn't continue to fall victim to this disease 
process known as terminal uniqueness. Many healthcare 
organizations work with an organized labor environment. Many 
have large geographic footprints with a corporate office 
thousands of miles from where the care is being delivered. Many 
organizations serve a large indigent or disadvantaged patient 
population and, yet, these organized organizations find a way 
to not only survive but thrive.
    I ask that this committee would compel the secretary and 
his leadership team to move forward with urgency, implement 
standardized evidence-based approaches across the enterprise, 
ensure methods of validation and verification, and make sure 
that this all supports outcomes, focus, leadership development 
to ensure the consistency.
    I ask this today not only as a healthcare professional but 
as the son of a deceased marine corps veteran whom I saw all 
too often let down by the VA. Thank you.

               PREPARED STATEMENT OF DAN COLLARD

    Mr. Chairman, Ranking Member Michaud and Committee Members:
    My name is Dan Collard. I am a former hospital operator and 
a senior leader at Studer Group, a healthcare consulting firm.
    Thank you for the opportunity to address this committee on 
the issue of Veterans' Health and the underlying elements of 
culture and leadership.
    I listened with interest Monday night, when I heard Mr. 
Griffin from the Inspector General's office make the statement, 
``If you've seen one VISN, you've seen one VISN. It seems both 
the testimony of the witnesses and your questions centered on 
evidence and variance.
    In Studer Group's work with over 900 healthcare 
organizations, it is clear that those that implement 
standardized approaches to care, produce the best outcomes. 
These organizations build cultures of accountability, 
alignment, consistency and sustainability. We also find that 
their evidence-based approaches extend beyond evidence-based 
care, to a framework of ``evidenced-based leadership''. This 
approach ensures that leaders are not only held accountable for 
the right goals, but have the skills, tools and knowledge to 
achieve those goals. These leaders ensure consistency in the 
workplace for their employees and consistency of the care 
environment for their physician colleagues. As the public has 
watched the VHA issues unfold in the past sixty days, it is 
clear that the tolerance for variance is chief among its 
ailments. As referenced repeatedly, the amount of variance and 
the lack of willingness to standardize leadership has created 
an unfortunately predictable outcome. As we would say, ``What 
you permit, you promote.''
    Evidence: The data that demonstrates the correlation 
between evidence-based care, quality outcomes, patient 
experience and lower costs continues to mount. When one reviews 
the publicly reported data, it is clear that better healthcare 
is less costly healthcare. Data also suggests a strong 
correlation between a patient's perception of care and actual 
clinical outcomes. Further, there is data that correlates 
specific questions like preparation for at-home care and the 
likelihood of readmission. A review of VHA facilities within 
publicly reportable readmission databases indicates only a 
handful that appear in the top quartile, a few more above the 
national mean, and unfortunately too many in the lower ranks of 
American healthcare.
    Connect this proof with employee engagement and one begins 
to see definite trends. A study published by the University 
Alabama at Birmingham shows the correlation between employee 
engagement and the likelihood of the creation of workarounds 
which increases safety issues. I was reminded of this study as 
I read the various reports of what we now know from 
whistleblowers about the veterans' wait lists and the related 
mortalities.
    On standardization: The largest healthcare systems in the 
United States have driven improvements by harvesting and 
implementing best practices across their systems. When 
organizations like Community Health Systems identify a best 
practice, they move with urgency to put the practice into place 
across their 205 facilities. This includes patient safety 
protocols, caregiver to patient interactions around medication 
instructions and a leader accountability platform. I was 
concerned when I heard the witnesses reference the amount of 
time they thought it would take to make changes. As John Kotter 
reminds us, the biggest obstacle to achieving high performance 
is not achieving the needed urgency for change. Mr. Walz, I 
think this is part of the answer to your question about the Big 
Idea. No matter what is decided, the VA must embark upon change 
with a never-before-seen sense of urgency and with a proven, 
outcome based solution.
    Studer Group observes that it can be as straightforward as 
transferring the rigor and discipline from areas in which an 
organization excels to areas that are sub-par. Imagine if the 
VHA electronic health record or benefits management systems 
that have been hailed as cutting edge could be the impetus to 
create scheduling software whose current version is archaic at 
best. Imagine if the high-performing facilities referenced in 
earlier testimony could be held out as models and indeed 
replicated with what Mr. Matkovsky refers to as ``exceptional 
leadership and culture.'' We wouldn't have tolerated the 
operation of 21 different navies or armies, air forces, marines 
or coast guards when these veterans were on active duty. Why 
would we tolerate 21 versions of Veteran's Health? Our armed 
forces ensure readiness, by putting in place systems of 
verification and validation of skills . . . of both front line 
soldiers and sailors as well as their leaders. We find safe, 
effective, timely healthcare to be no different.
    Finally, we must insist that the Veterans Health 
Administration does not continue to fall victim to the disease 
process known as ``terminal uniqueness''. Many health systems 
work with an organized labor environment. Many have a large 
geographic footprint with a corporate office thousands of miles 
from where care is being delivered. Many organizations serve a 
large indigent and disadvantaged patient population. And yet 
these organizations find a way to not only survive, but thrive.
    I ask that this Committee compel the secretary and his 
leadership team to move forward with urgency, standardize 
evidence-based approaches across the entire enterprise, ensure 
methods of validation and verification are put into place and 
support outcomes-focused leadership development to ensure 
consistency across what should be the greatest health system in 
the country. I ask this today, not only as a healthcare 
professional, but as the son of a deceased Marine Corp veteran, 
whom I saw all too often let down by the VA. Thank you.
    The *Chairman.* Thank you, Mr. Collard.
    Dr. McCaughey.

                  STATEMENT OF BETSY MCCAUGHEY

    Ms. McCaughey. Thank you.
    I am Betsy McCaughey, former lieutenant governor of New 
York State----
    The *Chairman.* If you could check your----
    Ms. McCaughey. --a huge advocate and chairman of the 
Committee to Reduce Infection Deaths.
    I have spent a good deal of my career in infection 
prevention in hospitals and I admire many of the achievements 
of the VA in that area. But I am here today to express my 
concern that this bill passed in the Senate yesterday, the 
McCain-Sanders bill, will not save the lives of vets stuck on 
the wait list.
    This bill as currently written is designed to protect union 
jobs, not ailing vets. In fact, the VA is run largely by unions 
and for unions. And one of the culprits is this 316 page union 
contract full of mind-numbing rules that prevent assigning an 
employee to a new task, a new work shift, a new building, or 
reprimanding someone on the staff for misdeeds or just poor 
performance.
    Nine months ago, the VA rolled out a $9.3 billion 
initiative to allow vets who were stuck on wait lists to access 
civilian care, but the unions fought it as hard as they could. 
The American Federation of Government Employees labeled it in 
their newsletter, The Worker, an attempt to dismantle the VA 
brick by brick. That is not true, but they vilified it that 
way.
    And this current bill sabotages the ability of vets to 
access civilian care in three ways. First of all, it requires, 
and I am referring to Section 301 starting on page 21 since I 
am sure you will be reading the bill, it requires that any vet 
wanting to access civilian care get a letter from the secretary 
of the VA confirming that the vet has waited an unacceptable 
amount of time for treatment or lives more than 40 miles from a 
VA medical center.
    Good luck getting that letter. I talk to vets all the time 
who have contacted the VA, called them, emailed them every day 
for six months and couldn't get a reply.
    Secondly, if the VA does manage to get the letter and get 
the choice card and get to a civilian doctor, then he has to 
hand the card to the doctor who is instructed to call the VA 
and get prior approval before treatment.
    Good luck getting somebody to answer that phone call.
    And, thirdly, most preposterously, this bill states that 
this choice program will end in two years. In other words, a 
few hours after the VA manages to finally get the hotline up 
and get the cards distributed to vets, it will be over.
    So there is a way to solve this problem and put the vets in 
the driver's seat. And I am going to credit the Rand 
researchers with this idea because the fact is that almost half 
of vets stuck in these waiting lists are seniors. They are 65 
or older and they are virtually all on Medicare.
    If they were encouraged to seek non-combat-related care, 
age-related care as such bypass surgery, angioplasty at 
civilian hospitals, particularly teaching hospitals, it would 
reduce the backlog by as much as half, solving this national 
crisis.
    And in many cases, vets would get better care because the 
mortality rates at the teaching hospitals associated with many 
of these VA medical centers are much lower. They are high-
volume hospitals and they do these age-related procedures all 
the time. What is holding the seniors back is lack of knowledge 
about that resource.
    And, secondly, the co-payments, the out-of-pocket expenses, 
we could give those vets who are already on Medicare a special 
VA Medigap card. It is budget neutral. You are already paying 
for the care and, yet, it would allow them to access better 
care. It would reduce the wait list and it would allow vets who 
have fought for our freedom, it would allow them the freedom to 
get the care they need.
    Thank you for this opportunity.

             PREPARED STATEMENT OF BETSY MCCAUGHEY

    Chairman of the Committee to Reduce Infection Deaths
    Before the House Committee on Veterans' Affairs
    On ``An Examination of Bureaucratic Barriers to Care for 
Veterans''
    June 12, 2014
    PUBLIC EMPLOYEE UNIONS WILL SABOTAGE VETS SEEKING CIVILIAN 
CARE
    Chairman Miller, Ranking Member Michaud, and members of the 
Committee, thank you for inviting me to testify before you 
today. My name is Betsy McCaughey, Ph.D. I am a former Lt. 
Governor of New York State, a patient advocate, and Chairman of 
the Committee to Reduce Infection Deaths.
    I have concerns that even the recently passed legislation 
will not save the lives of vets currently stuck on wait lists 
for care.
    The unions that dominate the VA run it as a jobs program 
for the benefit of their own members, not vets. The union 
contracts are filled with mind-numbing rules that prevent 
workers from being given a new task, moved to a new shift, or 
disciplined for shoddy work or dishonesty. The VA is run for 
workers, not patients.
    The biggest culprit is the American Federation of 
Government Employees, or AFGE. The union wants more patients, 
bigger VA budgets, and more staff, never mind what ailing vets 
need.
    Nine months ago, the VA rolled out a $9.3 billion program 
to refer vets needing specialists to civilian medical centers, 
if the wait at their local VA facility is too long or they live 
too far away. That is exactly the same thing the Sanders/McCain 
bill purports to do. AFGE fought the program from day 1, even 
accusing VA executives of deliberately causing the backlog. 
``Create a Crisis and then outsource the work,'' the union's 
newsletter, The Worker, states.
    Vets have been discouraged from accessing civilian care 
even when they've desperately needed it and have insurance to 
pay for it. Here's the reason: The VA's healthcare budget is 
based on how many vets enroll and how much care they use. For 
unions, the bigger the budget the better. Even if it means 
letting vets with Medicare who could get timely civilian 
treatment for their cancer or heart disease die in a VA wait 
line instead.
    AFGE President J. David Cox insists the only remedy for the 
VA's wait lists is more VA staff. ``Chronic understaffing'' is 
the problem, he says. How can he know? VA hospitals have no 
clue how many staff they have or need. A 2012 audit by the VA 
Inspector General found that the agency's hospitals lacked any 
method for calculating staffing needs, in part because of 
resistance to measuring worker productivity.
    Shockingly, one million vets who seek care at the VA are 
covered by Medicare Advantage, the private plans the federal 
government purchases for seniors. Astoundingly, the VA spends 
10 percent of its medical care budget treating seniors who have 
Medicare Advantage. Yet the federal government also pays over 
$3 billion a year to Medicare Advantage insurers to cover the 
same people. Paying for the same care twice. What a waste. But 
as long as the unions dominate the VA, these inefficiencies and 
corruption will not be fixed.
    Even with legislatively directed non-VA care, mischief will 
continue. They are discouraging vets from actually accessing 
care outside of the VA system. And here are the roadblocks 
sabotaging vets getting outside care:
    The veteran needing care must receive a letter from the 
Secretary confirming that an appointment at the VA is not 
available. Good luck getting that letter. We know about Vets 
who have called and emailed their VA hospital daily for six 
months without getting any response at all.
    The civilian doctor must telephone a VA hotline to get 
prior permission before providing care. Good luck to the Doctor 
trying to get the VA on the line in a timely manner.
    Should the Sanders/McCain ''Choice Card'' come to fruition, 
after setting up all these new procedures, the choice card 
program will expire in two years--probably only a few hours 
after the VA finally gets the hotline set up and issues the 
cards.
    And the House version, H.R. 4810, passed unanimously 
Tuesday, still relies on the VA to spell out what Veterans 
really need. The bill stipulates that veterans will be covered 
for outside care ``including all specialty and ancillary 
services deemed necessary as part of the treatment recommended 
. . . '' Necessary according to whom? Recommended by whom?
    In short, VA staff cannot be trusted to deal honestly with 
vets needing care. The VA's own internal investigation revealed 
on Monday that 76% of VA facilities doctored appointments or 
kept dummy books.
    Remedies:
    There is a better way to solve this problem. Let's put the 
Vets themselves in the driver's seat. There are two age groups 
of veterans we're concerned about: seniors and those under 65.
    Almost half of Vets (45%) enrolled in the VA health care 
system are 65 or older. Virtually all of them are on Medicare, 
according to RAND researchers. Encouraging vets on Medicare to 
use civilian care instead of the VA could cut the VA's patient 
backlog by as much as half, solving a national crisis.
    Most VA hospitals have links to nearby teaching hospitals 
where older vets can get cardiovascular and cancer surgery with 
better survival rates than at most VA hospitals. These civilian 
hospitals, which perform higher volumes of these age-related 
procedures, have better outcomes. Sadly, the VA fails to tell 
seniors that.
    And the long waits in the VA system increase the risk of 
needless death. Boston VA researchers found patients aged 70 to 
74 who wait more than 31 days for treatment face a 9 percent 
increased risk of stroke.
    Low-income senior veterans are most likely to stick with 
the VA. One reason is that out-of-pocket costs are lower there 
than with Medicare. But that can be rectified easily, as RAND 
researchers recommend.
    Vets could be issued a special Medicare card that 
eliminates the Part B premium and reduces Part B copays and 
deductibles to the small fees the VA charges ($15 for a primary 
care visit, $9 for 30 days of medications, $50 for specialist 
visits.) This would be budget-neutral because either way 
federal tax dollars are picking up the excess cost.
    Thank you again for your time and the opportunity to appear 
before the Committee today, and I will be glad to answer any 
questions you may have.
    Betsy McCaughey, Ph.D.
    Betsy McCaughey is a patient advocate and former Lt. 
Governor of New York State. In 2004, she founded and is now 
Chairman of the Committee to Reduce Infection Deaths (also 
known as RID), a nationwide educational campaign to stop 
hospital-acquired infections. In five years, RID has made 
hospital infections a major public issue. It has provided 
compelling evidence that preventing infection improves hospital 
profitability as well as saving lives, and RID has won 
legislation in over 25 states for public reporting of infection 
rates. RID has become synonymous with patient safety and clean 
hospital care.
    Betsy McCaughey's research on how to prevent infection 
deaths has been featured by the Wall Street Journal, Good 
Morning America, the CBS Morning Show, ABC's 20/20, and many 
other national media outlets.
    Betsy McCaughey is the author of over three hundred 
scholarly and popular articles on health policy, infection, 
medical innovation, the economics of aging, and Medicare. Her 
writings have appeared in The New York Times, The Wall Street 
Journal, New Republic, Policy Review, Forbes Magazine, New York 
Law Journal, Los Angeles Times, U.S. News & World Report, and 
many other national publications. Her 1994 analysis of the 
dangers of the Clinton health plan in The New Republic won a 
National Magazine Award for the best article in the nation on 
public policy. She has been profiled in The New Yorker, The New 
York Times Magazine, New York Magazine, The Washington Post, 
and other publications. She writes a weekly column for 
Investors Business Daily and Creators Syndicate.
    Prior to entering the health policy field, Betsy McCaughey 
earned a Ph.D. in constitutional history from Columbia 
University. She is the author of two books on that subject. She 
has taught at Vassar College and Columbia University, and she 
produced prize-winning studies while at two think tanks, the 
Manhattan Institute and later the Hudson Institute.
    From 1995 to 1998, she served as Lt. Governor of New York 
State. She focused on health issues, and her bills became 
models for legislation in many states and in Congress.
    The *Chairman.* Thank you, Dr. McCaughey.
    Mr. Collard, I will start with you, but anybody that wants 
to answer this question, feel free. Each Member will have five 
minutes. And we also have a round of votes. That is why evening 
hearings on return nights are so good. We don't get interrupted 
with votes.
    But my staff recently obtained an email in the supervisory 
chain, how many levels there are between the scheduler and the 
secretary, and, of course, the scheduling clerk is called 
medical support assistant, shows 12 layers of bureaucrats and 
middle managers between those two people.
    Is that surprising?
    Mr. Collard. It is not surprising, but it is clearly an 
indicator of the issue. On the private sector, you wouldn't 
think about care could be rendered in a safe, timely fashion 
with 12 layers of leadership between someone in the trenches 
and someone making the decision.
    It also creates the greater opportunity for the variance in 
communication, the variance in setting expectations. The layers 
just create the permutations for communication within the VA.
    The *Chairman.* Anybody else want to comment?
    Ms. McCaughey. And how about the time it takes, all that 
communication? This is time. And, you know, one of the studies 
that just recently came out showed that when an older vet is 
forced to wait 90 days or more for treatment, it increases the 
risk of stroke by nine percent. That is a study right out of 
the Boston VA Medical Center. So this time is critical to 
saving the lives of these vets. That is why they are dying in 
these wait lines.
    The *Chairman.* Tell me, if you would, how does this 
structure compare to your experience in observing other medical 
centers or systems, Mr. McClain?
    Mr. McClain. I do not have a lot of experience in observing 
other medical centers. Humana for the most part is a health and 
wellness and Medicare Advantage company. We do a lot of 
business with VA and we have seen the difficulty that we have 
as a contractor in also getting certain answers and certain 
things changed or done for the betterment of the veteran.
    The *Chairman.* Mr. Collard.
    Mr. Collard. We would find traditionally no more than three 
or four layers. I was with an organization yesterday and it was 
the traditional structure of a senior leadership team, 
directors, managers, and right to the front line.
    The *Chairman.* And I think, Mr. Collard, you may have, but 
others of you may have also alluded to this as well. The number 
of healthcare networks that exist across this country,
    . You have a large system.
    How many networks should there be? I mean, surely it should 
be broken up somehow, but 21?
    Mr. Collard. Even if the number stayed 21, the ability to 
standardize across the 21 is really the key. You know, 
healthcare is always local no matter whether it is private 
sector or government. Healthcare is always local because we are 
serving local veterans.
    But the ability to say whether it needs to be 21 or six, 
really the underpinnings of that, when you lift up the hood on 
that is the ability to standardize across no matter how many 
regions or VISNs or divisions that you have.
    The *Chairman.* Dr. McCaughey.
    Ms. McCaughey. Yes. One of the problems is really quite 
simple and it has been pointed out in many of the reports that 
have been submitted to Congress over the last decade including 
the one that was presented on Monday and the one that was 
presented by the General Accountability Office in March of 
2013.
    And that is that vets are assigned an appointment and then 
months go by and nobody calls them to remind them a day or two 
before the appointment that they are supposed to come. That is 
a practice that is always done in private sector medicine. 
Every doctor's office, every clinic, every hospital calls 
patients and reminds them to show up for their appointment.
    The result of this failure is that in some departments like 
ophthalmology, according to the GAO report submitted to you 
last March, the no-show rate is 45 percent. So when you say you 
don't have enough appointments and enough doctors, almost half 
of them are going to waste and, yet, why every year does 
another report have to remind the VA to call the patients and 
nothing is done about it.
    The *Chairman.* My time is about to expire, but if you 
could, as succinctly as possible, what is the greatest single 
barrier that exists out there today within the VA to providing 
timely healthcare?
    Mr. McClain. And I am going to go off from what Mr. Collard 
said is standardization. You have all heard it. If you have 
seen one VA, you have seen one VA. And there is too much, I 
guess, flexibility or variability in how services are delivered 
and how veterans can access services at each of the VA 
facilities.
    Mr. Collard. When you standardize your practice, you create 
greater predictability and outcomes. Whether it is an attorney, 
a finance expert, a healthcare expert, they would all agree 
that when you standardize your mode of practice, you create 
greater predictability and outcomes. And it is the outcomes 
that I think ultimately this panel has to be able to address 
and not just the process of care measures that we are talking 
about.
    The *Chairman.* Thank you.
    Dr. McCaughey.
    Ms. McCaughey. Yes. I would like you to focus on the 
failings of this bill because pretty soon, you are going to be 
voting on it or compromising with the vote you took in the 
House to create a final bill. And that final bill that you 
create has to remove these impractical impediments.
    Otherwise, you are not passing a bill to give vets access 
to civilian care. It will be a charade if they have to get a 
letter from the secretary and if there has to be a call made to 
get prior approval for the treatment. Just remember that, 
please, as you compromise with the Senate.
    Thank you.
    The *Chairman.* Thank you.
    Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Mr. McClain, one of your recommendations is to review all 
personnel evaluation metrics and ensure that all VHA employees 
from clerk to clinician to senior managers are evaluated based 
on outcomes for veterans who are seeking and receiving care 
from VHA.
    Mr. Collard, you also urge the VA to support outcomes and 
focus on leadership.
    My question to you two is the over-reliance on metrics has 
been mentioned as one of the factors leading to the current 
wait time problems.
    How do you distinguish between metrics and outcomes, Mr. 
McClain?
    Mr. McClain. Thank you, Mr. Michaud.
    My short answer to that would be that most of the metrics 
that are reported today in VHA, and there are hundreds of them, 
are process oriented and simply checking a box or doing 
something versus actually measuring what that accomplishes or 
the outcome.
    And so my point in making that was that we should be 
rewarding and measuring outcomes for veterans, good health 
outcomes rather than simply checking the box and doing a 
process.
    Mr. Collard. I would add that it is just the sheer size of 
the numbers of metrics. I went the HR route and pulled a middle 
manager's evaluation within the VA today, you would see metrics 
scored by the dozens. And if you think about that many metrics, 
how can a leader give any proper attention and proper priority.
    When you have a weighted evaluation around those that are 
outcomes versus process, you have the ability to create focus 
and priority, and that is what I would say it is not just the 
metrics, but the sheer number of metrics that we are looking 
at.
    Mr. Michaud. Thank you.
    Is it valid to have a strategic metric, Mr. McClain?
    Mr. McClain. I think that it is valid to have a strategic 
goal as to what the outcomes might be and be measured against 
that goal. I think that is valid.
    Mr. Michaud. Mr. Collard.
    Mr. Collard. Look over on the----
    Ms. McCaughey. I wanted to point out----
    Mr. Michaud. Mr. Collard, would you answer?
    Mr. Collard. Go to the CMS Web site and you will see one of 
the metrics. What the private sector is really paying a lot of 
attention to right now is readmissions. We know the fact that a 
tactic like a post hospitalization phone call has the ability 
to reduce readmissions and, yet, what we don't do is we don't 
measure hospital operators on the number of post visit phone 
calls that they make because in the publicly reportable Web 
sites that you would find, you would find the actual 
readmission rates for folks within certain disease categories.
    Mr. Michaud. Okay. Thank you.
    Some within the VA has raised concern that there are 
inadequate numbers of extenders and this causes physicians to 
spend undue time with paperwork and routine clinical work.
    Mr. McClain, what does the private sector use as a 
benchmark for the physicians to physician extender ratio?
    Mr. McClain. Well, it varies depending on what type of 
clinic. Our involvement are with the community-based outpatient 
clinics. We operate 34 of those under a contract with the VA. 
And so we utilize VA's for the most part panel size of 1,200 
per physician and then the support, the medical and also 
administrative support for a single doctor would be somewhere 
four or five support personnel for that doctor.
    Mr. Michaud. Mr. Collard.
    Mr. Collard. I would defer to Mr. McClain.
    Mr. Michaud. Okay. Thank you.
    Doctor, my question for you would be, I am interested in 
your comments on the VA paying for care for patients already 
covered by Medicare Advantage and the potential for the 
government paying for care twice.
    What policy changes could remedy this situation?
    Ms. McCaughey. Well, it is very interesting that such a 
large percentage of vets actually have insurance. Only about 
ten percent of vets being treated at the VA are, quote, 
uninsured. And it is probably tragic that they weren't included 
in the Affordable Care Act.
    But nevertheless, many of these vets who are insured either 
with employer-based insurance or Medicare Advantage or regular 
Medicare or Medicaid resist going outside of the VA system 
because of the out-of-pocket expenses.
    And as I explained before, if we gave them the Medigap card 
for the seniors particularly, a Medigap card, a special VA 
Medigap card that absorbed those out-of-pocket expenses, they 
could seek a lot of care in civilian hospitals, particularly 
teaching hospitals that are high volume for angioplasty, bypass 
surgery, hips and knees, some of the things that seniors 
frequently need. So they would be getting in many cases better 
outcomes, not always better, but often better, and it is budget 
neutral for us. As a Nation, it is budget neutral.
    Mr. Michaud. Thank you.
    And, incidentally, under the Affordable Care Act, 3,000 
Mainers were denied access because our government refused to 
extend Medicaid to the 70,000 Mainers of which 3,000 were 
veterans. So thank you.
    Thank you, Mr. Chairman.
    The *Chairman.* Thank you.
    Mr. Bilirakis, you are recognized.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    I thank the panel.
    My first question is for the entire panel. Many have 
mentioned and stated the VA has lost its focus of their primary 
responsibility of caring for our veterans.
    Do you agree? Maybe let's start with Mr. McClain, please.
    Mr. McClain. Yes, Mr. Bilirakis, I do agree.
    Mr. Bilirakis. And also Mr. Collard.
    Mr. Collard. Yes.
    Mr. Bilirakis. Yes. Doctor.
    Ms. McCaughey. Yes.
    Mr. Bilirakis. All right. Now, tell me where you think 
their focus has been. We can start with Mr. McClain.
    Mr. McClain. The current focus, I think, has gone off the 
veteran and has gone on to preserving the current system. I 
think that there is a lot of if it is not invented here, we 
don't want to hear about it.
    So there is not a lot of invitation for innovation to come 
in and partner with VA in order to move it into a more modern 
healthcare system. So where I see it is it is, as Dr. Kaiser 
stated, a more insular system right now.
    Mr. Bilirakis. Mr. Collard.
    Mr. Collard. Two answers really. I spent time with a VA 
leadership group in one of the western regions last year and I 
heard for probably two hours more reasons about why we couldn't 
do something versus why we could do something.
    I also think that sometimes we feel that standardization 
stifles innovation and I don't think it could be any further 
from the truth. When you have a standardized platform in any 
industry, you actually have pretty fertile ground for 
innovation because once an innovation takes hold, you now have 
a platform by which you can harvest, distill, and disseminate 
those best practices through innovation across an enterprise.
    But I think what happens, as I would associate with Mr. 
McClain's comment, the ability to attach to the way we have 
always done things is really probably that barrier of focusing 
on veteran-centered care.
    Mr. Bilirakis. Doctor.
    Ms. McCaughey. Yes. I would like to point out two things. 
One is that, as I mentioned in my opening statement, in the 
1990s, the VA really took an admiral lead in patient safety and 
particularly in prevention of nosocomial or hospital acquired 
infections.
    Lately we have seen less and less of this. Dr. Jane who has 
now taken a bigger job at the VA has done some wonderful work 
in the prevention of methicillin-resistant staphylococcus 
aureus.
    But in general, that pioneering effort to protect patient 
safety that I saw in the 1990s has disappeared somewhat from 
the culture. That, and as I pointed to that before, how can you 
have a focus on the patient when you have 316 pages of rules 
about what employees can and cannot do just from one union, 
just from one.
    This contract governs the work rules for 200,000 people who 
work at the VA and it is preventing a focus on the patient.
    Mr. Bilirakis. Thank you.
    Next question, do you believe the VA's shortcomings and 
failed benchmarks was the result of inadequate funding or 
management of resources, Mr. McClain?
    Mr. McClain. I personally don't think it was the result of 
inadequate funding. The VA budget has really increased 
significantly in the past five or six years. But I think pretty 
obviously it is a mis-allocation of those resources.
    Mr. Bilirakis. Mr. Collard.
    Mr. Collard. Not only a mis-allocation, but perhaps just 
looking the other way when you have the resources. I think I 
heard on Monday night the fact, Chairman Miller, that you 
raised, a specific financial number that has been invested or 
been provided for IT and IT-related services and the question 
was raised, where is the money.
    And so whether it is a mis-allocation or just perhaps an 
ignoring of those funds available perhaps leads to the current 
state.
    Mr. Bilirakis. Dr. McCaughey.
    Ms. McCaughey. Yes. The VA budget has increased 173 percent 
from the year 2000 through 2012. That in inflation adjusted 
terms is 72 percent. The increase in total VA patients was 69 
percent. So the funding increased at a faster pace than the 
number of patients who had to be treated. And the number of 
acute care patients who need costly care increased only 49 
percent. So the VA funding should have been adequate to meet 
the increased demands on the system.
    Mr. Bilirakis. Okay. Last question, a very important 
question, how would you rate VA's urgency to change its culture 
and become more patient centered for the veteran? And we will 
start with Mr. McClain again.
    Mr. McClain. I don't see any urgency.
    Mr. Bilirakis. Mr. Collard.
    Mr. Collard. Could I have you restate the question again?
    Mr. Bilirakis. Okay. How would you rate VA's urgency to 
change its culture and become more patient centered for the 
veteran?
    Mr. Collard. On a numeric scale, very low if we are rating 
it in current state.
    Mr. Bilirakis. Dr. McCaughey.
    Ms. McCaughey. I agree with that.
    Mr. Bilirakis. Thank you very much. I yield back, Mr. 
Chairman.
    The *Chairman.* Thank you.
    Mr. Takano, you are recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. McClain, your testimony encourages the VHA to adopt a 
more inclusive approach to contract of the care along the lines 
of the Kaiser Permanente model and the, quote, ``Kaiser 
experience.''
    How do you respond to VHA concerns with the continuity of 
care and record transfers?
    Mr. McClain. Well, I respond to it, and we have some direct 
experience in this having done Project HERO and currently doing 
Project ARCH, is that VA doesn't favor outside care for the 
most part. In other words, they favor the biases to treat 
everything within the walls.
    The success of the Kaiser experience is that they view all 
care that is delivered in one of their networks as part of 
Kaiser care and that is part of the Kaiser experience. In other 
words, the people who are going outside into a community 
provider feel that that is just part of the Kaiser system.
    Part of the issue is that currently VA, although the VistA 
system is a terrific system for electronic health records, it 
does not have the ability to collect those consults and primary 
care charts that are on the outside. And that is one of the 
things in my written testimony that I proposed is there is IT 
currently available that will consolidate and aggregate all of 
the care of a veteran whether it is delivered inside of a VA 
medical center or outside so that the provider in the VAMC has 
a complete picture of the veteran's health.
    Mr. Takano. Could you comment on the capacity of the 
private sector care providers, what percentage of them are 
ramped up to be able to utilize the software?
    I have heard that, you know, a relatively small percentage 
of providers have the capacity or have updated to electronic 
records.
    Mr. McClain. I don't have that number in front of me. I 
couldn't testify to that, sir.
    Mr. Takano. Well, thank you.
    Mr. Collard, Mr. McClain, regarding cost management, would 
you find that the veterans, the VHA, and the way they deal with 
prescription drugs and pharmaceutical costs is a good thing?
    I have heard that they actually use their size to leverage 
down those costs.
    Mr. McClain. The answer is, yes, I think they do a pretty 
good job. By statute, VA actually purchases drugs in bulk for 
DoD and VA and the Indian Health and coast guard. And so by 
statute, the manufacturer is required to give them a discount 
off of commercial rates. And so actually VA does a very good 
job in purchasing drugs.
    Mr. Takano. Mr. Collard.
    Mr. Collard. I would concur.
    Mr. Takano. So does that same sort of approach exist with 
Medicare?
    Mr. McClain. Not to my knowledge.
    Mr. Takano. And would that contribute to out-of-pocket 
costs for senior citizens generally, do you think?
    Mr. McClain. You know, sir, I haven't looked at that. I 
don't have an opinion on that.
    Mr. Takano. Well, thank you.
    You know, Mr. Walz, I could yield my time to you if you 
have any questions. I am kind of done.
    Mr. Walz. I thank you all and come back to it.
    Mr. McClain, you are right and I really appreciate some of 
the ideas that are coming out of this. And this idea that is 
being brought up of how do we get the big idea, how do we get 
to the big idea.
    I guess one of my concerns is, and I would ask on a 
comparison, this is to you, Dr. McCaughey, you carried around 
this, I would just--this is the collective bargaining agreement 
between St. Mary's Hospital, the Mayo Clinic, and their 
healthcare provider. It doesn't make as good a theater as a big 
one, but it is still there.
    I would make the argument that the Mayo Clinic delivers 
good, quality healthcare. Your assertion is is it is totally 
based on the collective bargaining of the people there I don't 
believe in any way moves this argument forward.
    So my question to you is, when was the last time you 
personally were in a VA hospital and tell me about your 
experience there as you talked to the providers and talked to 
those nurses at the nursing station?
    Ms. McCaughey. Well, I actually just talked to some of the 
people at the VA hospital here in D.C. a few minutes ago. And 
let me explain that they are----
    Mr. Walz. Have you been out there?
    Ms. McCaughey. Right. I haven't been to their hospital yet, 
but I have talked to them. And let me explain that they are 
also concerned about the mismanagement or mis-allocation of 
staff resources.
    It is so bad, for example, that at some of the VAs, and I 
know you will probably confirm this, the physician has to spend 
a lot of time going out to the waiting room, getting the 
patient, explaining how to disrobe, doing a lot of things that 
in another hospital or clinic would be done by ancillary staff 
so that doctors can see not two patients an hour or three but 
maybe six.
    Some of this is a problem with union rules. And to say that 
it isn't is just preposterous.
    Mr. Walz. So it is happening at Mayo?
    Ms. McCaughey. I haven't read their agreement. But to say 
that unions are not part of this problem is just--read the 
American Federation of Government--just let me finish. You 
asked me to come here.
    Mr. Walz. Didn't you answer?
    Ms. McCaughey. That is not true. In a democracy, we both 
get to talk.
    Mr. Walz. Mr. Chairman, I will yield back my time.
    The *Chairman.* Time is expired.
    Ms. McCaughey. Thank you.
    I would like to explain, sir----
    The *Chairman.* Dr. Roe.
    I apologize. We are very short on time.
    So, Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    Mr. McClain, I think you are 100 percent correct. The VA 
needs to go through a top-down look from an outside agency. It 
doesn't need to be evaluated within anymore. It needs to have 
an outside look.
    And what Mr. Michaud said is absolutely correct. The VA 
could do one thing today. I said this Monday night at the 
hearing. The years I spent in clinical practice in medicine, I 
knew who I worked for and that was the patient. That was the 
center of why I was there. If I didn't have patients to see, I 
had no reason to be in an office.
    And if you ask anybody on a VA campus who they work for, 
they will say the VA. The answer should be we work for 
veterans. That should be the answer and that is a simple change 
in philosophy to change. I don't have any reason to be at this 
VA if there are not veterans there for me to care for.
    So I think you could do that one thing and I think the top-
down approach, I think you are spot on. And I think several 
things were brought up.
    Just interestingly, Mr. McClain, you mentioned that a CBOC 
that you ran, that the VA had four to five personnel to help, 
ancillary people to help. In our office, and I practiced for 31 
years, it is about three people.
    And you can even get more efficient the bigger you get. You 
don't need another scheduler if you add another doctor. You 
need another medical assistant. You may need another lab 
person, whatever, but you get much more efficient. Typically it 
is three to one and sometimes even less if you are very good at 
it. And we were very good at it and very efficient.
    The incentives that the VA has, and, Doctor, you mentioned 
this about consults. I said this Monday night. This is really 
simple. We had almost 100 percent, 95 percent of our consults 
that we saw kept their appointment.
    Why? Because if I miss that appointment, that is a slot 
that wasn't filled. I didn't have any revenue. So we made sure 
that we contacted that patient over and over to be sure that 
they kept their appointment and came in. Almost all of them 
did.
    If you mail a letter out two months ahead or three months 
and August, your appointment is August the 7th and then you 
don't ever check up, you should expect a huge number. And for 
someone in the VA, if you don't have anybody show up, that is a 
snow day. I mean, it is just free time. You are not doing 
anything.
    And I have heard over and over and over again from my 
doctor friends who are at the VA that they do all kinds of 
things that ancillary people ought to be doing. And if you go 
to a private doctor's office, they are going to have those 
people calling to make the appointments, all of those things. 
Your time is focused on seeing patients and taking care of 
patients.
    I think also something that is mentioned in this bill that 
absolutely has to change, there is no way on this earth that a 
veteran can go get a letter and do all of this and then go to 
my office and me do 1-800 hold. That is what it is going to be. 
And you are going to spend an hour and a half trying to get 
somebody in the office. The doctors are not going to see them. 
We can't afford to waste our time doing that. I mean, if we're 
able to see the patient, we ought to be able to do the care.
    So that is something, Mr. Chairman, when we go to 
conference has to be changed or this will be a waste of time. I 
certainly don't mind the sunset. I think many laws ought to be 
sunsetted and re-looked at after that length of time. I 
certainly appreciate your all's frank testimony. It is 
refreshing to hear someone from the outside not tell us how 
great everything is on the inside and we find out it is really 
a disaster on the inside.
    And also, Mr. Collard, you mentioned something that I 
totally agree with. There are many hard-working, good, 
dedicated people working at VAs today. They are seeing 
veterans, taking great care of them. But there is a culture 
there that does need to be changed.
    And I am going to stop and let you make any comments you 
want to.
    Mr. McClain. Dr. Roe, I agree completely. I would like to 
make a comment regarding the no-show rate because Dr. McCaughey 
has mentioned it and you have mentioned it in a commercial 
setting as to how important that is.
    And our experience, for five and a half years, we provided 
services under Project HERO which was a contract with the VA 
where we provided administrative services and we set the 
appointments.
    We essentially would get the veteran on the line with the 
doctor's office and do a three-way conference call to set the 
appointment and then not only send a letter, but we would 
follow-up within 48 hours before the appointment to remind the 
veteran of the appointment plus the directions to the doctor's 
office. Our no-show rate in Project HERO was less than five 
percent.
    Mr. Roe. Same as ours. I think you show right there, but 
that is a metric in the private world that you use because, 
again, your incentives are different in the private sector 
versus where you have just a VA budget that you have this much 
money to spend at the end of the year and you spend it. If you 
don't, you send it back.
    Mr. McClain. And that is exactly right. We were not 
compensated at all for a no show. I mean, that was not part of 
the contract. We knew that. But we were very diligent in 
getting the veterans to their appointment.
    Mr. Roe. Thank you, Mr. Chairman. I yield back.
    The *Chairman.* Thank you, Dr. Roe.
    Ms. Brownley, you are recognized for five minutes.
    Ms. Brownley. Thank you, Mr. Chair.
    My first question is to Mr. McClain. I certainly agree with 
your assessment of the culture and, as you described it, 
personal gain over the veterans. And if we are really going to 
create a system that is truly veteran-centric, then I think 
certainly, I think we could all agree that we need to hear from 
the veterans.
    And so my question is, are there any specific 
recommendations made by the VSOs at this time that you would 
actually endorse?
    Mr. McClain. Ma'am, I am not familiar with all of the 
recommendations from the VSOs. I have not listened to all their 
testimony nor read their resolutions.
    Ms. Brownley. But in terms of, as you described, a great 
need for outside assessment of the organization before we begin 
to make any of the big changes that we need to make, you would 
include VSOs in that?
    Mr. McClain. Oh, that is part of the voice of the veteran. 
They are a huge stakeholder. There isn't any question about it.
    Ms. Brownley. Thank you.
    And, Mr. Collard, I certainly agree, I think we all 
probably agree of your assessment that the IT system for 
scheduling is archaic.
    Are there systems out there that you would recommend?
    Mr. Collard. Not a particular system, but just knowing that 
they are present and they are used. And if I could just extend 
upon an IT element or a pre-call or a post-call.
    What we are really talking about is not fundamentally the 
reimbursement around or the productivity that is impacted like 
a snow day for a no show. What we are really talking about is 
that quality outcome again.
    So if a pre-call is made and we know the veteran shows up 
fully prepared for the procedure or the treatment, they know 
where to come, they know when to come, that is going to drive 
quality.
    The post-call efforts that are in place also, again, not 
just a unit of a box checked, but the empirical evidence on the 
private sector side that reduces readmissions improves 
medication compliance rate.
    There was a study in the Annals of Internal Medicine about 
a year and a half ago that showed simply the proper education 
within the care setting and post-calls improved just the 
propensity to stop at Walgreens and CVS and fill the script.
    And now, again, private sector example, but I think we all 
have to eventually come--we are doing a really good job today 
talking about the what and the how and we have always got to 
return to the why. And I think each of us have recognized the 
why of these conversations.
    Ms. Brownley. Thank you.
    And, Mr. Collard, again, I mean, from your vantage point, I 
mean, how do you think we can better instill integrity into the 
VA management? And, I mean, how do we instill, you know, 
starting yesterday, starting today, how do we begin to instill 
a sense of urgency within the Veterans Health Administration?
    Mr. Collard. As with any organization, urgency begins at 
the top. Accountability begins at the top. What we have to be 
able to do is narrow the focus. The one big idea, again, I 
would come back to Monday, this doesn't have to leave a 
committee and take on 50 things, but the one big idea that 
could create momentum and confidence in our veterans provide 
clear expectations out of that sense of urgency, out of an 
assessment that could be done, make sure that the training is 
adequate for those asked perhaps to do something new or do 
something differently, and then make sure that we just utilized 
methods of verification and validation like any other industry 
would do to ensure in real time that things are happening so 
that we don't find the fire storms that exist when either 
whistle blowers make a call or finally data reaches its peak.
    Ms. Brownley. Thank you.
    And you, I think, in your testimony, you talked about, you 
know, big change with proven outcome solutions and that the VA 
is unique, but we can't be terminal about its uniqueness, that 
we have to look to better outcomes.
    Mr. Collard. Uh-huh.
    Ms. Brownley. So is there anything about the VA medical 
system--I am not quite sure how to ask this because I agree 
with your assessment--but that is unique, that we don't have 
another place to look to for best practices?
    Mr. Collard. I just think we have to get beyond that as the 
question that would be asked from internally. The single most 
improved hospital in the United States of America is Trinity 
Medical Center in Birmingham, Alabama. They are in a 40 to 50-
year-old physical plant. They don't have any private rooms. 
They are all semi private.
    They have a call light system. When it rings from the 
patient bed, it actually rings to the PBX operator of the 
hospital who has to then ring the nurses station and, yet, they 
decreased call light times in excess of 60 to 70 percent with 
the hand that is dealt them.
    Ms. Brownley. Thank you. I yield back.
    The *Chairman.* Thank you, Ms. Brownley.
    Mr. Flores, you are recognized for five minutes.
    Mr. Flores. Thank you, Mr. Chairman.
    I thank all the witnesses for being here today.
    Dr. McCaughey, thank you for the quick feedback on the 
Senate bill. That is very helpful.
    Mr. Collard, one of the things I would ask you to do in 
future testimony is when you use the word standardize, be sure 
to say that that doesn't mean centralized because I think one 
of the issues we have got is that centralization sometimes 
cannot be the solution.
    Mr. Collard. Uh-huh.
    Mr. Flores. Mr. McClain, you hit the nail on the head 
today. You said that we have a unique opportunity to reform the 
VA and that if we don't do it well that we will be here again. 
And with that in mind, that generates my question.
    I would like each of you to spend about 90 seconds telling 
me what the VA of the 21st century would look like and totally 
disregard what the VA is today. Disregard the people, the brick 
and mortar. Disregard everything. What does the VA of the 21st 
century look like? What does it have in terms of people, 
culture, systems, leadership, use of private sector resources? 
Is there a need for a union in the VA?
    And so let's touch on that and I am down to actually about 
a minute for each of you. And I would really appreciate if you 
would provide some feedback in writing afterwards. I know you 
are doing this as volunteers, but you have the best interest of 
our veterans at heart. So if you could follow-up in writing, 
that would be awesome, but just a minute from each of you, and 
let's start with you, Mr. McClain.
    Mr. McClain. Thank you, sir.
    To put it in as few words as possible, I would say it has 
to be veteran-centric. In other words, you put the veteran in 
the middle and you build the system around. So you have teams 
in an integrated fashion providing care coordination and 
integrated care to the veteran.
    And the metric is outcomes, health outcomes, how long did 
you extend the life of this particular veteran, how long did 
you extend the quality of life of this particular veteran, and 
right now we are not measuring any of that.
    Mr. Flores. Okay. Mr. Collard, you have about a minute.
    Mr. Collard. I think it is the Veterans Healthcare 
Administration that has as one of its chief focal points the 
ability to reduce variance in all practices or in as many 
practices as can be. And what that can mean is the practice of 
access for our veterans, the practice of care, the practice of 
care environment for our physicians.
    You know, in the private side, we joke that a physician 
typically works in four hospitals, the daytime hospital, the 
nighttime hospital, the weekend hospital, and the holiday 
hospital. And I can just imagine how many different versions 
there are in veterans' hospitals today.
    So the ability to reduce that variance, to standardize 
those practices, and when identified as a true vetted best 
practice, the ability to move very quickly across the system to 
implement those best practices.
    Mr. Flores. Okay. Dr. McCaughey.
    Ms. McCaughey. Yes. Let me point out, and I am very 
grateful to be here today, that your time is valuable, but time 
is also extremely valuable for these vets who are waiting, who 
are stuck in these waiting lists, 63,000 who waited a decade 
and never got a first appointment and now 57,000 who are 
currently waiting for their first appointment over 90 days.
    So I would point out that this bill that you will be 
considering establishes two commissions, one to study the issue 
of VA construction, what has gone wrong, the delays, the cost 
overruns, and where construction is needed.
    Mr. Flores. I don't want to talk about legacy. I would just 
like to talk about the path forward.
    Ms. McCaughey. I want to just make this point. Don't waste 
your time with another commission. In 2012, you had a 
commission do that. Read the report. I am sure that the new 
commission will find exactly what the commission found two 
years ago. They discussed Las Vegas, Denver, St. Louis, all the 
places that had those construction problems.
    And, secondly, this bill calls for another commission to 
discuss staffing and healthcare needs, particularly the need 
for physicians. You had a study like that done two years ago in 
2012. I urge you to read it. It will save you a lot of time if 
you want to fix this while the vets who are sick are waiting 
for care.
    Mr. Flores. Again, I would ask each of you to think about 
this, back out of the weeds a little bit and think about this 
from a 50,000 foot overview. What does the VA of the 21st 
century look like? If we could start all over again and not 
worry about any of the past sins or the postmortems or any of 
that crud, what does the VA of the 21st century look like?
    And, again, I agree it should be veteran-centric. So if 
that is the vision, I want you guys to tell me what the 
structure is. And I don't have time for that. So if you could 
follow-up in writing, that would be awesome.
    Thank you. I yield back.
    The *Chairman.* Thank you very much, Mr. Flores.
    Ms. Titus, you are recognized for five minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    Thank all of you for being here.
    Over the past week, we have had a lot of discussion about 
how to integrate metrics into evaluating the system. We keep 
hearing metrics this, metrics that. And then just recently the 
VA said they are dropping the metric of 14 days as a way to 
measure the scheduling appointments because that was 
unrealistic. Now they have changed it to 30 days.
    I know we can't abandon performance metrics. But when I 
talk to the people at the Las Vegas hospital and they go into 
all these details, then they tell me but this doesn't really 
measure what we are doing because it doesn't count the first 
appointment that they have when they come in on the very same 
day, so it is not an accurate reflection.
    I wonder if we are not suffering from the ecological 
fallacy. We just can't see the forest for the trees.
    Do you have some suggestion about how we better use metrics 
or we get rid of some metrics or how we can do evaluations 
better, anybody?
    Mr. Collard. Yeah. You know, in our industry, we tend to be 
gluttons for punishment when it comes to metrics and I think it 
is important that we create a stop doing list. If you look at 
the Medicare value-based purchasing formula even itself just in 
the last couple of rounds is that there has been a decreased 
focus on process measures and a very much increased focus on 
outcomes measures.
    So not that you give the aspirin with an acute MI in the ED 
because we have all gotten pretty good at that now.
    Ms. Titus. Uh-huh.
    Mr. Collard. But how about mortality index? How about 
mortality rates? How about surgical site improvement 
initiatives there? So, again, narrowing the focus in a much 
fervent ship from process to outcomes.
    Ms. McCaughey. I would like to second that. I fully agree 
with that. And, in fact, the article in the New England Journal 
of Medicine that the chairman referred to it in his opening 
remarks underscores how besieged, how suffocated doctors are by 
the requirements and there are so many metrics in the charts 
that you lose sight of the really important ones. And not only 
that, but you lose the doctor/patient relationship.
    I am sure you have experienced this recently. You go to see 
your cardiologist, your internist and instead of having a face-
to-face conversation, the doctor is there trying to get 
everything into the computer while you are in the office with 
him or her. So we need fewer metrics. We need outcomes measures 
instead of process measures.
    And I would like to applaud those involved in formulating 
this bill and working with the VA to make their metrics 
transparent because for a long time, they have not made 
available to the public their outcomes measures much to the 
distress of all of us who wanted to see them.
    Ms. Titus. Thank you.
    Mr. McClain. I think that the one thing I would say is that 
we have to obviously measure the right thing. There are a lot 
of things out there in Medicare that I think shows some quality 
outcomes, indicators of quality outcomes. And even though VA is 
a fairly unique system just by the way that it is structured, 
it is delivering healthcare just like a lot of other systems 
are delivering healthcare. And they shouldn't be afraid to take 
a look at those metrics from the outside.
    Ms. Titus. One other question. We keep feeling this push to 
send veterans out of the VA into the private sector for care 
wherever they can get doctors who may be available to them that 
aren't in the VA. And that is fine. But in areas like Las Vegas 
and some rural parts of the country, you have got a shortage of 
doctors. So pushing them out there on already overloaded 
doctors is not going to solve the problem.
    I have got a bill working with some Members of this 
committee to create more residencies at VA hospitals in areas 
where there aren't enough doctors.
    Do you think that is a good idea or do you have other ideas 
how we might address that?
    Mr. McClain. I think that is one thing that you can do. 
Certainly there are several other things that we are currently 
looking at to discuss with VA in order to provide some 
solutions, especially in the rural health areas. Tele-health is 
a big one. There are perhaps mobile facilities that might go 
around to service some veterans.
    There are a lot of different things. You can hire what are 
known as locums or locum doctors in a particular area to serve 
for a particular period of time. And there are some innovative 
solutions that I know VA is looking at, but they haven't pulled 
the trigger yet on some of it. And this may be the opportunity 
to do it.
    Ms. Titus. Doctor.
    Ms. McCaughey. Yes. I was just going to add to that that 
most M.D.s in training at a teaching hospital do rounds at a 
VA, do some of their training at a VA hospital. It is just 
standard practice. And, of course, in rural areas, it is a bit 
different.
    But I would change the use of one word you chose. We are 
not pushing them out of the VA. We are just allowing them out, 
giving them the choice if they wait so long or don't have 
another place, if they can't get an appointment at a convenient 
VA. So I don't think anybody in this room wants to push vets 
out of the VA or eliminate the VA.
    Ms. Titus. Well, my point is if they go out into the 
private sector, we need to have some doctors out there who are 
available to help them.
    Ms. McCaughey. You are so right.
    Ms. Titus. And there are shortages of doctors and you have 
VA hospitals that might be a place where you could do 
additional residencies.
    I yield back. Thank you, Mr. Chairman.
    The *Chairman.* Thank you very much, Ms. Titus.
    Mr. Runyan, you are recognized for five minutes.
    Mr. Runyan. Thank you, Mr. Chairman.
    Mr. McClain, it is some of your written testimony. Can you 
give me a couple metrics that the VA uses that are the most 
harmful?
    Mr. McClain. Well, I think the most obvious was the 14 
days. When you say harmful, I guess you are talking about 
harmful to healthcare delivery.
    Mr. Runyan. Yes.
    Mr. McClain. I would point to most of the metrics that just 
measure process and check a box rather than healthcare 
outcomes.
    Mr. Runyan. Okay. And this is really for all of you to 
touch on. And I know it has been touched on and I just want to 
confirm it and have it on the record because I think, and we 
will start with Mr. Collard, I think you have said it a couple 
times here.
    Some of the stuff, i.e healthcare record, the VA does very 
well. We have only scratched the surface on what this is. I 
chair the subcommittee on disability claims, so that is the 
next step. Okay?
    Now we are tying in the private sector, the VA, and another 
government agency, the DoD that don't communicate very well.
    Are there private sector platforms today that you could buy 
out of a box that could accomplish that?
    Mr. Collard. Not that I am aware. And I think what we have 
to be able to do is if you look at the VA electronic health 
record, which, again, is hailed as cutting edge, clearly there 
is an architecture there that even the private sector could 
look towards for some learning.
    The trouble in the private sector is you have a number of 
vendors that are positioning themselves as the most prolific 
electronic health record and what that does is that actually 
stifles the ability to communicate between private health 
systems.
    So, again, it is an opportunity for us to look to the VA 
where there could be some good things going on and perhaps move 
from there. But on the private sector, it is probably as 
fragmented as can be.
    Mr. Runyan. And, Chairman, I think it goes to what Mr. 
Johnson was saying the other night. They won't show us what 
their architecture is a lot of times, so no one could even 
build a system that could be even remotely compatible with it. 
It is part of the problem.
    And really I just want to make this point and I am going to 
yield back my time because I want to let some other people. And 
I think we came to the conclusion also that we do this in 
government all the time. Continuing to throw money at a system 
that is broken structurally is not going to solve the problem. 
And I know you all agree with that. I just wanted to make that 
statement. Until we fix it, throwing money at it is going to do 
nothing but cause us to throw more money at it.
    So with that, Chairman, I yield back.
    The *Chairman.* Thank you very much.
    Dr. Ruiz, you are recognized for five minutes.
    Mr. Ruiz. Thank you, Mr. Chairman. I thank all of you for 
being here and giving your input to this very important topic.
    There are some terminologies that have been said that are 
very important to me and the most important is to be veteran-
centered, so be patient-centered, and I appreciate Dr. Roe's 
comments on that because as a physician, it is our life blood; 
it is what we live for; it is the outcome that we seek; it is 
to make sure our patients, we reduce their suffering and 
promote their wellness in whatever we do, and at that moment, 
our patient is our world and you are universe, and I believe 
that is the sentiment that we should have here in Congress, as 
well, with our constituents, but also in the VA with the whole 
apparatus focusing on that. And I believe that the urgency is 
very much needed and I believe that with the working in 
collaborations with the VA, this committee can make sure that 
this urgency is highlighted.
    You mentioned also things that are very important, which is 
standardization, and I am familiar with that as an emergency 
medicine physician. You know, you come in with a patient and 
they don't know--you don't have any information. It is a multi-
organ trauma or emergency, medical emergency, and you just have 
to figure it out. And the way we do is we have clinical 
guidelines and training after training after training after 
training to help us with the framework to treat that patient. 
And I believe that in standardizing the care with the VAs 
throughout the system is very important, but when I did my 
veterans initiative back home in the Coachella Valley in 
California's 36th District, some of my veterans there said they 
have to re-register and they have difficulties going from one 
VA to another VA, even if they, you know, are here for the 
summer or the winter break or whatnot.
    So how do we create that interoperability within the VAs 
throughout the country?
    Mr. Collard. I guess that is more of an IT question. I know 
that that has been a goal of VAs, that they haven't 
accomplished yesterday. I think that several years ago there 
was the VLER, the veteran lifetime electronic record, which was 
a composition of all of the VA benefits that a VA veteran could 
get in one place; in other words, you could go for your 
healthcare, but if you had a disability claim, it would also be 
reflected, and if you had a VA home loan, it would be 
reflected.
    I think that is still a great goal. I don't know where VA 
is along the timeline for doing that, but in just getting a 
single medical record where you do not have to re-enroll every 
time you go north or south or wherever you are going in the VA, 
I think has to be a goal that would really assist veterans 
across the board.
    Mr. Ruiz. Wonderful. And the next question, Mr. Collard, is 
we talked just now about the difficulties of communication and 
sharing of that information have one VA hospital to another, 
but how about the communication structures with non-VA 
providers with the VA? And we know that there are some barriers 
to doing that, and what can we do to minimize the barriers so 
that the family doc in a rural area, if there aren't enough 
physicians, can receive the information from the VA that they 
need to provide the continuity of care that the veterans need, 
but also provide those same standards of reporting to the VA so 
that they can enter that information into their outcomes 
measurements that they need for the patient?
    Mr. Collard. So being as far from an IT expert on the panel 
today, I would say that what Mr. McClain has referenced before 
in terms of a more open-source environment within the VA's 
system itself.
    Let me go off the answer for just a little bit because a 
lot of this also has to do with the manner with which a veteran 
is received at a different facility, and let us just call it 
first impressions. If I go from the veteran to the person on 
the other side of the desk as well, I think many of us have, 
whether it is at an airline counter, whether it is at a 
hospital, an emergency room, sometimes, we get an impression 
that the person on the other side of the counter doesn't have 
quite the empathy that they would need to project to a veteran. 
I think we have to even be able to--this is a little bit of a 
hearts and minds conversation here, as well, and, again, it is 
off the IT perspective, but I think the ability to create a 
sense of openness and welcome and first impressions for those 
veterans is also key.
    Mr. Ruiz. Thank you. I have run out of time.
    I yield back whatever I had.
    The *Chairman.* Thank you very much.
    Dr. Benishek, you are recognized.
    Mr. Benishek. Thank you, Mr. Chairman.
    Well, I really appreciate your testimony this morning, and 
I completely agree with you that we cannot waste this 
opportunity to revamp the entire VA system, because as I think 
you said, Mr. McClain, we will be back here once again. You 
know, I was just looking at the VA Health Administration 
organizational chart and what is it going to take? I mean do we 
have to get a--arrange for a bidding for some off-site 
consultants to tell the VA how to reorganize itself because, 
obviously, I don't believe that they can reorganize themselves.
    Mr. Matkovsky, the assistant deputy undersecretary was here 
on Monday. She seemed to think that a few fixes here and there 
in the system is going to make everything hunky dory, and I 
completely agree with, I think all of you, as far as the whole 
system needs to be re-evaluated and a structure of management 
put in place that allows more communication between the 
management and the people that actually deliver care.
    You know, as a physician, I worked at the VA. I, by the 
way, don't think that the health record is all that great, but 
it is often better than many other health records. We need to 
have better communication between, I feel, like the physicians 
who actually take care of patients and the top management 
because often, physicians are put in circumstances that waste 
their time, are bad for patients and don't get things done in 
an efficient manner.
    So how do we make that happen? Can you maybe give me some 
more ideas that expand upon what you said before? Maybe each of 
you could take a minute of this and tell me how, as Congress, 
how can we make this happen to the VA to change the entire 
structure so it is much more efficient?
    Mr. McClain. Doctor, I would start off with contracting 
with people who are expert in organizational design. There are 
companies out there that that is exactly what they do. It is a 
skill; it is an expertise. And I really wouldn't expect VA to 
be able to determine exactly what that next organization should 
be because that is not their expertise. But there are companies 
that that is all they do, and they do it very well, so that is 
where I would start to look.
    Mr. Benishek. All right.
    Mr. Collard?
    Mr. Collard. If I could extend Mr. McClain's comments. We 
can assess all day along, but the real question is once the 
assessment is completed and recommendations are given, is will 
there be execution on those recommendations? And with the 
number of physicians we have on the panel, let's just use two 
glaring examples. We used aspirin with acute MI earlier. It is 
probably a pretty successful metric across the United States, 
but then let's talk about hand washing.
    We have been talking about hand washing for as many 
centuries as there are medicine, essentially, out there and for 
some reason, we have not gotten good at hand washing. The 
difference between one metric like aspirin with an acute MI and 
hand washing is we just tend to continue to talk about it, and 
those organizations that find a way to put the structure in 
place for clear expectations, execution, verification, and 
validation of those organizations that find themselves the 
ability to reduce infections by just improving something as 
common sense, uncommonly practiced as hand washing.
    Ms. McCaughey. Now you are really close to my heart. But I 
would say in addition to looking at the top-down structure, and 
we know that leadership is important from the top, spend more 
time listening to what the doctors in the VA say. Here is what 
I hear: They are very frustrated when they see a patient and 
they said, I would like to see this patient again in 30 days, 
right, and then all that malarkey goes on and they never see 
that patient again. The patient never gets an appointment with 
that doctor again. There is not enough continuity of care with 
the same physician.
    And when Dr. Ruiz said before this has to be patient-
centered, it really has got to be patient-centered. It really 
has got to be the doctor-patient relationship. That is what is 
being lost in this huge bureaucracy and we really have to make 
sure that that is protected because that is, in essence, what 
is going to make these vets better; that is what is going to 
save their lives.
    So, in addition to looking at the top-down structure, I 
would really make sure that you are talking to the physicians 
who are working inside the organization.
    Mr. Benishek. Oh, I don't disagree with you at all. I mean 
as a physician that worked there, I was very frustrated with 
the fact that ideas that I had, you know, just weren't taken up 
or dismissed because they were my ideas and they weren't coming 
from the management, and that would just need to be fixed by 
this basic restructuring of the entire system.
    I am out of time. Thank you.
    The *Chairman.* Thank you, Doctor.
    Ms. Negrete McLeod, you are recognized for five minutes. 
Ms. *Negrete McLeod.* Okay. Thank you, Mr. Chair.
    I have found out that the VA audit of Loma Linda which is, 
we actually have three members on this committee that, while it 
is not directly--four--okay, four, Mr. Cook. We have four 
members that it doesn't sit right in our district, but all of 
our people around it is where they focused their care at. It 
has--right now, current patients only have to wait four days 
for rescheduling of an appointment. New patients have to wait 
an average of 43 days for primary care, and appointments, 50 
days for specialty care, and only 28 days for mental health 
care. Loma Linda has the lowest wait time for mental health 
care in Southern California.
    And coming as a Kaiser member for 42 years myself, I 
remember when I first joined Kaiser people used to say, Oh, you 
are a Kaiser member. Now people say, Oh, you are a Kaiser 
member. So, you know, being there, I have seen the evolvement 
of Kaiser from those kinds of negative remarks to those kinds 
of really favorable remarks because Kaiser has evolved--in 
California at least, I don't know about other states--but that 
is the plan that everybody wants to emulate because they have 
got all of their stuff together. Their medical records are on-
time. Their everything--I have had the same physician for 30 
years, so I get to see my own physician. So I don't know why 
the VA couldn't emulate something like Kaiser.
    And while now we have had tons of hearings of what is wrong 
with the system, we as a policy committee--and there are a 
whole lot of physicians on here--we are the policy committee; 
we should find out how we fix it and then all of our focus 
should be on how we fix it and no more about incrimination. But 
let's move forward as the Nation's policy committee on this 
particular issue. Thank you.
    The *Chairman.* Thank you very much.
    Mr. Huelskamp, you are recognized for five minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    A couple follow-up questions on some of the comments that 
were made. In particular, Mr. McClain, and Mr. Collard, your 
companies have apparently either operated multiple facilities 
or oversaw those or looked closely at those in reports. Have 
you found any other health system in this country that is 
similarly situated--so poorly situated as the VA is today? I 
guess, start with Mr. Collard whose company has done many, 
many, many of those examinations.
    Mr. Collard. Sure. You know, the first ones that come to 
mind would be organizations that might even look a lot like the 
VA, the safety net hospitals, so organizations that are 
typically, perhaps inner-city, serve a particularly 
disadvantaged patient population, they typically tend to be 
trauma centers. They tend to have all the right reasons not to 
succeed, and yet those are the organizations that we can show 
time and time and time again, when decisions are made, when 
strong leadership leading with good cultures around alignment 
and accountability succeed, which, again, just causes the 
question, why couldn't we emulate that within----
    Mr. Huelskamp. Well, I am looking for--I am trying to 
determine how bad off the system is. But when you say that if 
we just did a good review and look closely, we would have a 
whole culture of non-accountability. And so if you make a bunch 
of recommendations and we have got stacks and stacks and stacks 
of them, the doctor mentioned those, I mean tell me how you 
would implement those. So what is another study if you have 
leadership or if that is not a very descriptive term in my 
opinion of what is going on. How do you actually handle that?
    We know what the answers are; the doctor mentioned that. We 
need to put the veterans back in the driver's seat. Get the 
administrators out of the way, let them see their doctors, 
whether they want to do it in a clinic, in a hospital, or 
elsewhere. So how would you implement that?
    Mr. McClain, how would you implement in suggested reforms? 
I think we know what we need to do, but nobody's done it.
    Mr. McClain. Well, it is very difficult. Anyone that has 
done any sort of change management realizes that trying to do 
it from the inside is very difficult. So I would think that 
some company that specializes in this to assist VA in making 
the change to the veteran-centric system, I think, would be a 
good investment for VA.
    Mr. Huelskamp. And, Mr. McClain, I understand your company, 
if I read it correctly, operates a number of TRICARE 
facilities?
    Mr. McClain. We are, in my segment of VA, we have the 
TRICARE south region, and so we are the manage care support 
contractor for TRICARE. We have 3.2 million beneficiaries in 
the south.
    Mr. Huelskamp. If a TRICARE subscriber, customer, whatever 
you call them, doesn't like the care that they are getting, 
what do they do?
    Mr. McClain. Well, we are an administrative services 
organization for TRICARE; in other words, we maintain a network 
of providers and specialists for the TRICARE beneficiaries and 
we also have a patient advocate. And if they don't like the 
care that they are providing, they can come back to us and we 
can try and resolve the issue for them.
    Mr. Huelskamp. Do they have to get permission from the 
facility you have assigned them to?
    Mr. McClain. No.
    Mr. Huelskamp. So they actually have a choice?
    Mr. McClain. Yes, they can----
    Mr. Huelskamp. Well, very good. I think the VA might learn 
from that, as well.
    One thing, Doctor, I would like to hear from--one question 
on the union rules that she would provide to us. I had heard 
some stories about that. I would like to look at those later, 
but a follow-up comment----
    Ms. McCaughey. They make good reading.
    Let me just point out your very interesting question, 
however. Competition usually provision improvement, and if we 
develop some avenue that provides broader choice for vets on 
where they receive care, not dismantling the VA by any means, 
but whether it is a Medigap card just for VAs or for older 
vets, whatever it is to give more vets a choice, right. You 
hear on the radio and on the television, you see the hospitals 
advertising, come to our hospital, we have the best care, 
right? The cleanest rooms, whatever it is.
    The VA doesn't have to do that. But their budget every year 
is dependent on how many vets are enrolled in that system. It 
is absolutely, by statute, dependent on that. So they don't 
want to see their vets going other places for care. Competition 
will improve the system.
    Mr. Huelskamp. Yeah, that would be great to see the VA 
having to advertise and actually--I would argue that their 
budget is not dependent on their standard of care. What I think 
we have determined here in the last few months is that there is 
a standard of care, it is just ridiculously low.
    Ms. McCaughey. Although some VA hospitals are quite good. 
There are some that are really good; they have great leaders 
and----
    Mr. Huelskamp. But the veterans, and I could believe that, 
but we have 70 criminal investigations going on right now. So 
as a member of Congress and awaiting data, the data has been 
tampered with. It is hard to accept anything from the VA 
because the data has been falsified and we are hearing that 
again and again.
    Thank you, Mr. Chairman. I yield back.
    The *Chairman.* Thank you, Mr. Huelskamp.
    Ms. Kuster, you are recognized for five minutes.
    Ms. Kuster. Thank you, Mr. Chairman. Thank you for all 
being here with us today.
    And I share your concerns that came out of the VA OIG 
report. It does seem that the VHA has lost its focus on the 
primary mission of safe, quality care for our veterans.
    I want to focus in on this discussion about competition and 
get at the notion of veterans having choice because in my 
district, I have--I meet with veterans every time I go home, 
and just recently around these issues we had a veterans round 
table to talk about the quality of care in New Hampshire. My 
veterans go to Manchester to our veterans health center and 
also to White River Junction on the border have Vermont.
    And the question that came up was the one that you raised 
about going outside of the network. I was presuming that that 
was a logical conclusion, but the veterans that I actually 
spoke with want to have their care at the veterans facility. 
They feel more comfortable there. They feel that they are going 
to be better understood there.
    So my question is how--and I like this idea of the Medigap 
card, I am interested in that. Beyond that, how can you use--
and let's just start with you, Mr. McClain--about the TRICARE 
when you are working with that network, what are the wait times 
there for someone who seeks an additional appointment?
    Mr. McClain. Depending on what the specialty is or what the 
follow-up is, we can get them in within 30 days.
    Ms. Kuster. And that is actually very similar to what it is 
in New Hampshire in the veterans system. I guess my question 
is: Are there things that we could be doing with the facilities 
in terms of one of the issues was about residencies brought up 
with Representative Titus. Are there other ancillary care 
providers? Is there something that you do in the private sector 
that we could be doing with nurse practitioners or people--
other--because I agree with you that we need to focus on that 
relationship with the patient and their healthcare provider.
    Can you give us examples of what we could be doing from the 
private sector, and maybe, Mr. Collard, you have a suggestion 
on that?
    Mr. Collard. Sure. A couple of quick fixes that have been 
mentioned in numerous testimonies is just the ability to 
recruit at a more rapid pace, mid-level providers. If you take 
a look at the private sector folks whose names typically make 
the headlines, every single one of those folks today are 
talking about access to care. It is not a different issue. And 
one of the ways they accomplish improved access to care is 
through the provision of mid-level providers is that first wave 
of patient interaction and it just, again, seems to work. The 
outcomes tend to be there.
    Ms. Kuster. Do you think it would makes a difference to 
have a policy of alleviating debt for people who come out of 
medical school or other schools for healthcare providers that 
they serve within the veterans system and we would alleviate 
that debt, do you think that that would make a difference?
    Mr. Collard. It has already been proven to work. Having 
operated hospitals in some of the most medically underserved 
counties in the United States, mostly the southeast United 
States, you know, we already have programs when residents will 
come and agree to practice in rural or underserved areas; that 
is a proven program. And I think this is no more--no less noble 
of a cause, than for these veterans.
    Ms. Kuster. And would certainly describe my district in the 
rural parts of the north country. I am very pleased by the way 
that we were working hard to get increased access to 
telemedicine for vets who have to travel in bad weather, 
mountains, such. But we were also successful in--we will be 
opening two health clinics in Berlin and Colebrook in the 
northern parts of my district.
    I want to focus in on this issue about hiring because one 
of the most troublesome things I have heard about the VHA has 
to do with how positions are filled and there is not a priority 
to clinic positions. I was shocked by that, that the leadership 
can make a decision about filling administrative position. How 
can a surgery team operate and function at a high, efficient 
level if they lose a nurse and that position isn't filled?
    What is your comment, for any on the panel, about the way 
positions are filled within the VHA and how can we do better 
and what is a policy that--and this is the most bipartisan 
committee in the entire Congress, and trust me, we know a lot 
about substitutions that do not function well--but we can 
function together. Help us understand the policy that we could 
change about putting a priority on those clinical positions 
that are on the front line in filling those first.
    Mr. Collard. So two quick things. I think it indicates the 
danger of levels of bureaucracy. The second point is behavior 
follows incentive, and so I bet if we look at how folks are 
driven for performance reviews, et cetera, you would find, 
perhaps, not a disconnect between the ability to fill an 
administrative position versus the ability to fill a clinical 
position.
    Ms. Kuster. And if we focus on those outcome measures, 
rather than these process measures?
    Mr. Collard. Well, the outcome is getting the physicians 
the mid-levels and the frontline caregivers in place is the 
outcome.
    Ms. Kuster. Right. Well, I mean if the outcome is good 
results, you are going to need to have those positions filled.
    Mr. Collard. Yeah.
    Ms. McCaughey. I just wanted to point out that the report 
that was presented in 2012 deals specifically with this issue 
of assessing how many physicians are needed and who makes the 
decisions to hire them. I have it in my purse and I am going to 
give it to you at the end of the session because I think you 
will find a lot of the answers in there.
    Ms. Kuster. And the other point I wanted to make is that 
there is no other state that has been shortchanged more about 
VA facilities than New Hampshire and there are so many vets in 
New Hampshire who ride way over a hundred miles to go to a VA 
hospital in Boston or in White River because there is really no 
acute care hospital for VAs in the state and that needs to 
change. Whatever positions you make about constructing another 
hospital, New Hampshire should be near the top of the list.
    Well, I am pleased to report to you that the surgery is 
going to be resumed in Manchester, and I used to think that a 
hundred miles was a long way until I met my colleague, Beto 
O'Rourke, who told me that his veterans travel ten hours to get 
to any type of facility. So we--although we have a great deal 
of discussion about being the only state in the country that 
does not have a full-service hospital, we are very, very 
fortunate that the two hospitals that serves our veterans are 
very high-quality.
    Ms. McCaughey. Yes.
    Ms. Kuster. We do have an issue about people going to 
Boston, but I am well past my time.
    The *Chairman.* Thank you very much.
    Mr. Coffman, she just ate half your time.
    You are recognized.
    Mr. Coffman. Thank you, Mr. Chairman, and thank you for 
yielding to me.
    I have got a question. I am intrigued by this notion of 
this Medigap policy. First of all, refresh me, I become 
eligible for TRICARE next year when I reach age 60, and I think 
for--as a reserve military retiree, and I think when I will be 
65 then, I go on to Medicare, and then does TRICARE then pay 
for a supplemental? How does it work for military retirees?
    Mr. McClain. TRICARE for Life, that is the program when a 
military retiree reaches age 65, becomes a Medicare fee-for-
service patient. So there is no more TRICARE Prime, TRICARE 
Extra or whatever; it is a--you are a Medicare fee-for-service 
patient, but you do have a TRICARE wraparound. So, really, it 
is one of the richest programs out there for Medicare.
    Ms. McCaughey. But, of course, most vets aren't eligible 
for TRICARE.
    Mr. Coffman. So tell me about how your--the system that you 
are advocating here today----
    Ms. McCaughey. Yes.
    Mr. Coffman. --and then, Mr. Collard, I would also like for 
you to reflect on it. So tell me how----
    Ms. McCaughey. So this is a simple proposal. As I pointed 
out, almost half of the vets using the VA are on Medicare; they 
have 65 and older. They are virtually all covered by Medicare, 
but the out-of-pocket expenses under Medicare are too much for 
many of them, and so they continue to get care at the VA, even 
when they have an age-related problem like they need a bypass 
surgery and there is a teaching hospital down the street where 
they could be getting the care, but they are worried about not 
so much the anyone patient deductible, but the outpatient 
deductibles and copays. And so if we gave them a Medigap card 
just for vets, a special red, white and blue one to pick up 
those out-of-pocket expenses, then they would have the choice 
of going to another type of hospital for that care.
    If you look at the outcomes measures, particularly for 
these age-related procedures, with the exception of just a 
couple of the VA hospitals, other teaching hospitals are 
producing better survival rates, so we would get a twofer. We 
would get the care for the vet. It is budget-neural, because it 
is all coming out of federal dollars, and they would have a 
better chance of surviving their procedure.
    Mr. Coffman. Mr. Collard, my two colleagues at the table 
are much more resident experts on the notion of payor sources 
and what the structure looks like. I want to come back to the 
choice issue a while ago. There is a demonstration project 
underway as a structure for those of you who would be familiar 
with the Captain James Lovell Federal Health Center in Chicago 
which is one of the first demonstrations of the ability to 
combine veterans health with active military health.
    And I remember one of the very first conversations that I 
was part of two years ago, and interestingly enough, the 
leaders of the Lovell Federal Health Care Center were less 
worried about the veterans being forced to come there and more 
about the veterans having the choice to go to Advocate Health 
Care, at the time, Provena Health Care, et cetera. So I think 
there is another opportunity for us to look within the industry 
and, perhaps, I couldn't say what their results are today, but 
this was a conversation two years ago where federal health care 
leaders were already focused on this notion of patient choices.
    Mr. Collard. Well, I just want to say that I want to 
preserve the system right now until we fix the VA by whatever 
means. We, right now, are keeping our wounded coming back from 
Afghanistan out of the VA system by virtue that they do the 
rehabilitation on active duty, unlike those who came home from 
Vietnam who were stabilized from the military system and then 
sent home to the VA, and our morale of our wounded is much 
higher, particularly on the military system.
    Mr. Coffman. Mr. McClain, can you comment on this notion of 
providing this supplemental--to paying for a supplemental to 
Social Security to where there are not any copayments, so 
whereby veterans, 65 and older, who meet the income 
qualifications for care for have service-connected issues would 
qualify?
    Mr. McClain. I think that it could be a part of the 
solution. You are really talking about funding here. You are 
talking about appropriations, as to what bucket it comes out 
of. There have been a lot of discussions over the years about 
Medicare--as to whether VA can be reimbursed by Medicare, and, 
you know, the answer so far has been no. So it would take some 
significant legislation for that to occur.
    Mr. Coffman. I do want to make a point--I know that we are 
short on time--but one of the things that baffles me about some 
of the waiting lists--now, I certainly get the fact that if the 
veteran wants to go to the VA for care, we need to honor that, 
as long as he or she understands that this is going to be a 
little bit of a wait, that is great. But there were so many 
other means that some of these waiting lists could be taken 
care of by sending it out to fee-based care; sending it out 
under a contract; sending it out to an affiliate; sending it to 
a CBOC. I mean there are a lot of different ways that this 
could have been handled, and for some reason, which I haven't 
heard anybody talk about yet, is I'm not sure why those other 
sources of care were not used.
    Thank you, Mr. Chairman. I yield back.
    The *Chairman.* I can tell you why they didn't want to use 
it, because the VA thinks it is their money and they don't want 
to relinquish it. The problem with that is that money belongs 
to the veteran, and instead of saying we took an $8-million 
dollar hit for non-VA care to their budget, they need to say we 
took and gave $8 million dollars to the veteran.
    Mr. O'Rourke, you are recognized for five minutes.
    Mr. *O'Rourke.* Thank you, Mr. Chairman.
    And to add to the point that Dr. Roe had made earlier and 
Mr. McClain had made about the success that hospitals and 
health organizations have in reminding patients of their 
visits, in the midst of this hearing, I got a text telling me 
that my appointment on Monday, June 16th with Dr. Rizik is at 
9:00 a.m. to confirm. Hit C and reply on the text or hit C, 
confirm the appointment. It gave me a phone number to call up 
if I had any questions. So we know that those systems are out 
there, and not to beat the horse any more, but let's get that 
done. It works.
    And Mr. Chairman, I would like to thank you and the ranking 
member who is currently not here, but you all on this committee 
have done such a great job in responding to this crisis, and I 
just think showing excellent leadership. We have heard from the 
VA directly. We have heard from the GAO, the Office of the 
Inspector General. We are hearing from the private sector. I 
think each of us in our individual capacities are listening to 
the veterans in our communities, but I would just ask that we 
have a panel of veterans in veteran service organizations. If 
we are talking about veteran-centric care and basing this on 
the needs of the veterans that we serve, I think we need to 
hear from them. And add to Mr. McClain's excellent suggestion 
of having a management organization identify structural and 
organizational weakness, and complement that with the veterans 
and what they are missing in their care right now. And I think 
that one of the issues that has to be included in that review 
is the issue of accountability, and we have talked about it and 
described our frustrations with the amount of money that has 
been authorized and appropriated and virtually lost within that 
system and not making its way to those veterans, and I think 
that really is an issue of accountability, and we see it 
throughout the performance of the VA.
    An issue that I would like to get your thoughts on, and I 
really loved Ms. Titus' idea about getting more residencies in 
rural or hard-to-serve communities like ours, is this question 
of where are we going to get the doctors in the capacity that 
we need? Already in El Paso, which as my colleague mentioned, 
is about a ten-hour roundtrip drive from the nearest VHA 
hospital--we do have a VA clinic, but we do not have a 
hospital--our patient-to-doctor ratio is on par with Syria or 
Panama. It is a developing country's doctor-to-patient ratio. 
We are having a hard time already throughout the country, 
especially in areas like El Paso. So I like the idea of more 
incentives and ways to attract doctors and providers to our 
community.
    But when I meet with doctors, to your excellent suggestion 
of listening to the providers, they complain of having to 
perform functions that could much better be done by clerical 
staff. One provider, one doctor told me that he actually had to 
write out a prescription for a veteran to be picked up by a 
van, taken to the Greyhound station where he then boards a bus 
to go to Albuquerque, New Mexico, five hours upstream on the 
Rio Grande, and then to return. He said, Why can't somebody 
else do that? Why am I having to perform that? So I would love 
to get each of your comments and thoughts about how we do more 
to support the current providers we already have, who, by the 
way, I think are doing an excellent job.
    I do spot inspections in the parking lot of our VHA clinic 
and talk to veterans leaving. I have not heard from a veteran 
yet who told me that they had a bad experience. They feel like 
they are treated like kings and queens, princes and princesses 
by the providers there. They have nothing but good things to 
say. What can we do to better support those providers and maybe 
20 seconds down the line starting with Mr. McClain?
    Mr. McClain. I think, once again, you could bring in some 
people that really understand process re-engineering and re-
engineer that process. There are a lot of things that a doctor 
does not have to do and it is still within the standard of 
care, that could easily be done by a physician's assistant or 
an RN or an LPN.
    Mr. Collard. You begin by that voice of the provider. 
Because you have to make sure that none of this testimony 
sounds like we demonize the providers and those folks that are 
right there on the front lines. Secondly, the ability to remove 
the non-value added work steps that those providers are going 
through today, and this is not unique to any industry.
    Ms. McCaughey. And thirdly, in section 301 of this bill 
there are two provisions that will make it more difficult for 
doctors, civilian doctors to provide the care that a vet is 
asking for with the choice card. So I would hope that you read 
those two passages--it is about like page 24--read those two 
passages and see if you can alleviate some of that paperwork 
burden that the civilian doctor would face if he agreed to 
treat that veteran.
    Mr. *O'Rourke.* Thank you. Thank you.
    Mr. Chair, I yield back.
    The *Chairman.* Thank you very much.
    For the Committee's knowledge, our intent is to have a 
single hearing in a couple of weeks with just the VSOs, to not 
have them in these hearings, but to give them the entire 
hearing to be able to look at all of the testimony that has 
been provided. They obviously are the stakeholders in all of 
this.
    Dr. Wenstrup, you are recommended for five minutes.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    I can't tell you how grateful I am for this day to have 
arrived, and unfortunately it took disastrous findings within 
the VA to get to this point and it is a step in the right 
direction. I can tell you as a physician I am face-to-face 
asked Secretary Shinseki three times if I could go in with a 
team into the VAs and into the ORs and discuss where the 
inefficiencies are and how we could do things better and every 
time I was told, Yeah, we will do that. It never happened.
    But I am encouraged because right before all this broke, we 
set up a meeting with the four doctors who are on this 
committee, bipartisan, with several of the administrators with 
the VA to talk about efficiency and access to care and quality 
of care. And, you know, there is a difference in different 
systems, right, if you have a system where many people that 
work there are saying, It is not my job; that is a problem.
    And what you have mentioned many times today, I couldn't 
agree with me, and that is the physician input. If they can 
have the input of how things can be better, you have got to go 
that route.
    And the other difference is the difference in 
responsibility in private practice and in other settings, which 
sometimes the VA, if I had a patient that missed an 
appointment, I want to know why, and also if they were post-op 
or whatever, I would tell them, they have got to be here. I 
have got to see them; it is my responsibility. And that tends 
to be missed if you don't know who is coming or going.
    And measures such as standard of care are great. Obviously 
we need to do that, but if you are seeing one patient a day and 
giving outstanding care, it doesn't mean very much. And you 
also have to look at the access to care and the efficiency of 
operations. And so what you are saying today, I think is spot 
on.
    The problem I have found within the VA system is you had 
too many people who don't know what they don't know because 
they have always been in that system. So they have never seen 
anything different, so they think that they are doing something 
great, but they don't know that others are doing it much 
better, and that is where we need the outside input and the 
best practices.
    We are hearing a lot of the same things here today, and I 
think that is great. Ronald Reagan once said if you have a 
message that is important, tell it over and over again, and to 
me, the best practices and efficiencies are driven by choice, 
which we have heard so many times today. When a patient is a 
liability, rather than an asset, we have a problem.
    And patients need to have choice because for me, my level 
of success and how well I was doing is by how many wanted to 
see me when they know they have a choice, and that is really 
where we need to be driven.
    It was mentioned before, too, you know, the ACA and 
throughout, we are really not addressing the doctor shortage. 
Because if you don't have providers--and not just doctors, it 
could be nurses, PAs, et cetera--you need to address those 
shortages in our country, and often times in the rural areas 
especially. So those are the other things that we needed to 
focus on.
    I am pleased right now that the door is open for change and 
everybody here is open for change because I didn't know this 
day would come, and again, I am sorry that it took what it took 
to get to this day, but we have got to drive on. I like what 
Mr. Walz says, let's get the big idea out there and we can do 
that.
    One thing I found interesting several months ago is I asked 
Dr. Petzel, I said, If the VA system were reimbursed at 105 
percent of Medicare rates, would you be in the black? And he 
said yes. Some of the doctors on this committee politely 
disagreed that they would be able to pay their bills and be in 
the black with the system that they are running.
    From your observations, what is your opinion on that?
    Mr. McClain. I really don't have any data. I have not 
looked at that. I have no idea.
    Mr. Collard. Lift up the hood on the question. When you 
compare yourself to yourself there is probably not a lot of 
accuracy that you can get. So when you take a look at those 
organizations in the VA that actually do submit data to the 
publicly reported databases, you have a way of measuring 
against others, and it is not a private sector versus public 
sector conversation. But when we continue to, whether it is 
patient perception--they use a tool called SHEP versus HCAHPS 
that you would see in the private sector--when you see that 
those two simply don't submit the data, the outcomes data that 
we talk about, we are actually stuck in this vicious cycle of, 
as you said, you don't know what you don't know, because you 
are comparing yourself only to yourself. It would be like 
taking a blood pressure of a patient without any gradations on 
the blood pressure cuff; you are just kind of guessing, well, 
it is that high.
    Ms. McCaughey. I would like to address that question, too. 
According to MedPAC, Medicare used to pay ninety two cents for 
every dollar delivered. After the Affordable Care Act, they are 
now paying less than that.
    And the reason that I raise that is one provision of the 
bill that you are going to be considering this week says that 
civilian doctors who take the choice card will be paying not 
more than the Medicare rate. So it is important to alert 
everyone to what you are probably heard from your constituents 
back home, that finding a doctor who takes Medicare is getting 
harder and harder.
    The *Chairman.* Thank you very much, Doctor.
    Thank you, Mr. Walz. You are recognized for five minutes.
    Mr. Walz. Thank you, Mr. Chairman, and thank you for being 
here today. And I think Dr. Wenstrup, and you heard it again, 
are hitting on this and getting there, and the care for our 
veterans is our top priority.
    Mr. Collard, I thought you brought up some really great 
points, and I see the books you have there, and I always think 
in our office we--every new employee reads good to great and we 
talk about this idea of organizational design and system 
performance and trying to get there. And I--this was a 
description of a high-performing medical institution, multi-
disciplinary teamwork, physician-led governments, and patient-
centered culture. Is it about that simple?
    Now, they followed up--this is Commonwealth--they followed 
up--I don't want to bait you on this. They followed up like 
this, information continuity, care coordination and transition, 
system accountability, peer review and teamwork for high-value 
care, continuous innovation, easy access to appropriate care, 
with multiple entrances into the system. That is where they 
went on with.
    Mr. Collard. The data that I have shared with you today 
comes 100 percent from the Commonwealth fund site, 
whynotthebest.org, so I would consider it, and at the risk of 
being oversimplified, yes.
    Mr. Walz. Very good.
    Mr. McClain, do you agree that you see that?
    Mr. McClain. I don't have any comments.
    Mr. Walz. And I bring this up because we have got to 
believe that we see this, and it is not as if Jim Collins is 
all of a sudden the VA just--they have read it. They have seen 
it and everything, and what I am trying to get at is how do we 
incentivize that? Dr. Wenstrup brings it up. I think we all 
agree with that on how we try to get there. There is, first and 
foremost, the care of veterans, but there is a cost factor that 
figures into this and how, when we do this big idea--because I 
do believe this, I believe if we get this wrong now, we are 
going to set the care for veterans to the next two decades 
going to be very, very difficult to change. So this is an 
opportunity, but it must be thought out and it must be right. 
It must not be driven by ideology.
    And Mr. Collard, your position on it, this is not the 
issue--if you simplify this into the public versus the private 
sector, we are going to go down a road that is going to look 
just like this. I would guarantee that.
    So I thought about this: Why do you think this never went 
into the scheduling because is, again, Commonwealth, and we 
have seen it in practice in hospitals. Patient scheduling 
system uses algorithms to assign new patients to physicians and 
orchestrate a patient's time at the clinic. It takes into 
account the patient's availability, the specific time and 
sequencing requirements of office consultation, laboratory test 
procedures, and the travel time between appointments.
    If you have ever been in a medical institution that does 
this, you leave with a sense of wonder that they were there to 
move you from place to place. Is this a cultural barrier of why 
this wasn't implemented at the beginning?
    Mr. Collard. Yeah, one of the issues we haven't spoken 
about is just that, the notion of patient flow. So the whether 
it is flowing a patient through a site facility or through a 
series of recommendations and consults through different 
facilities, part of this is, again, the efficiency of patient 
flow, which, again, is probably a whole other hearing.
    Mr. Walz. When we do this, and we are going to have to get 
human nature in this, incentivized and disincentivized 
behavior, oversight and everything else that goes into this, 
Dr. McCaughey, this goes back to you and the work, and I see 
this, of course, representing the district that the Mayo Clinic 
is in. Hospital acquired infections are a huge issue, a hundred 
thousand Americans die by these every year; they are huge.
    Now, it is incentivized on this that hospitals who don't 
get a handle on this and bring it down are going to be 
penalized in reimbursements from Medicare. Does that makes 
sense?
    Mr. Collard. Well, it makes absolute sense, and the data 
beneath those incentives and outcomes with which are just 
irrefutable. If you take a look at a patient's perception of a 
hospital's responsiveness while the patient is in the hospital, 
there is almost a linear correlation between the patient's 
perception--we get hung up on that sometimes, well, it is just 
perception, how does the patient know how really good we are? 
And yet when you pull the data from the CMS Web site across 
3900 facilities you see a linear correlation between patient's 
perception and the actual cases per thousand patient days of 
vascular catheter associated infections, Stage III, Stage IV 
pressure ulcers and poor glycemic controls.
    Mr. Walz. I was just on that site today. Why do you think 
it took us so long for the private sector to be willing to put 
that information up?
    Mr. Collard. Well, actually, it is our own kind of 
perversion to the data. When you go to the CMS Web site you 
take a fork in the road. You either go to the experience or you 
go to the quality, and, in fact, it is the very same dataset. 
So when you pull the entire dataset and begin looking at those 
correlations, it is actually right there in front of our eyes.
    Mr. Walz. How do we meld VA's experiences into that because 
it does seem like we are on two parallel realities here on 
reporting and experiences and things like that. What would be 
your suggestion on how those two are melded?
    Mr. Collard. Well, we won't suffer from a shortage of data, 
that is for sure. It is a matter of how we bring the data 
together. So it is the ability to bring some organizations--if 
you go on the Commonwealth funds site today, you'll actually be 
able to pull 83 or 84 VA hospitals that actually submit that 
data.
    Mr. Walz. That's right. That is what I was just able to do.
    Mr. Collard. And I just ran the custom report prior to the 
hearing to make sure that we had a good current sense, but that 
is only 83 or 84 of the VA hospitals. Where are the others and 
how could we then get away from this comparing ourselves to 
ourselves?
    Mr. Walz. So the solution is out there. The will of the 
American people to get it, and now it is a matter of getting it 
in place, is that your----
    Mr. Collard. You bet. And we have the guiding coalition 
around this table and the VA and with folks who have MD and DO 
on their name badges, physicians or scientists, and the 
scientists, they are driven by good, credible data, not 
anecdote. So we have to work both on this committee, as well as 
our physicians within the VA that could lead to these kinds of 
answers.
    Mr. Walz. Very good.
    I yield back. Thank you.
    The *Chairman.* Thank you very much.
    Ms. Walorski, you are recognized for five minutes.
    Mrs. Walorski. Thank you, Mr. Chairman, and Ranking Member 
Michaud.
    I am grateful, as well as most of the members here--that 
you have heard from that have been here today--because I really 
feel like we have a copilot now and the solution is there and 
we can see light at the end of the tunnel, and it has been a 
very, very dark story. And I don't have questions, I just 
wanted to thank you for being here.
    I wanted to echo what Mr. Walz just said that I think you 
can see the relief in this room around most of this place today 
that the solutions are there, and I would agree with Mr. Walz, 
the attention of the American people is on this, and the 
continuing drive by the American people to continue to seek out 
the absolute best solution, the big idea, the step forward, and 
I think that many of us today see light at the end of the 
tunnel. And I am grateful, you know, when we saw the story 
getting darker and darker and 69 criminal investigations and 
the kinds of things that are happening, I think most of us--
because we talk about it outside of this committee--knew that 
there are solutions there. There are best practices there. 
There are private sector and private industry folks that 
certainly are here to come alongside and guide this into the 
kind of success that we know the VA can be.
    So I just wanted to add my comments that you coming today 
and just broadening the light here for us to be able to see how 
it can work and give us something to shoot for as a 
jurisdiction of oversight continues is the most welcome news, I 
think, that I have seen since we got into this whole situation. 
So on behalf of the veterans in my district, we are grateful, 
because I do see light at the end of the tunnel.
    Mr. Chairman, I want to thank you for your leadership and 
Mr. Michaud, as well. I will yield back my time.
    The *Chairman.* Thank you very much.
    Ms. Brown, you are recognized for five minutes.
    Ms. Brown. Thank you, Mr. Chairman.
    First of all, let me say that I want to thank the veterans 
that work in the VA hospitals for their service because 
basically the veterans at that tell us over and over again, 
once they get in the system, they are very satisfied with the 
service. So that is not a misnomer.
    Ms. McCaughey, I have a question for you because we are 
looking at the different systems and advantage care as opposed 
to VA system and TRICARE. Advantage care costs us more money.
    Ms. McCaughey. I think you are referring to Medicare 
Advantage?
    Ms. Brown. Yes, exactly.
    Ms. McCaughey. Okay.
    Ms. Brown. But in your testimony, it seems as if you are 
recommending that as----
    Ms. McCaughey. No, I was pointing out that a large number 
of vets have enrolled in Medicare Advantage and yet they are 
going to the VA hospital for their care. So, in fact, we are 
paying for it twice. I was pointing out that literally ten 
percent of the VA health care budget is going to vets who have 
another kind of coverage. It is just a tragic inefficiency when 
you look at we are discussing money and where to get enough 
money to care for our vets and then you find something like 
that which was documented recently in the New England Journal 
of Medicine--I am happy to show you the article--and we think 
why aren't people figuring out that such a large number of vets 
are paying for care--we are paying for their care twice? We are 
paying to the insurance companies that run Medicare Advantage 
plans and we are paying again to the VA system. Let's, at 
least, sort it out and get it straight; that is what I was 
suggesting.
    Ms. Brown. But I am just trying to be clear that the VA 
system is a system that the veterans prefer. Part of the 
challenges that we experience, for example, people who don't 
have hospitals in their area, all of this is formula-driven, 
and so therefore we might need to come up with some additional 
ways that we are going to serve veterans. In fact, until 
recently we have not built a VA hospital in 15 years until we 
appropriated for six new hospitals.
    So the question is are we going to continue to build 
additional hospitals based on the number of veterans or are we 
going to come up with some partnerships that the veterans and 
the VA--because in the testimony that we had last week, when we 
sent a veteran outside of the system, we have got to make sure 
that it is a certain quality of care.
    Ms. McCaughey. Of course.
    Ms. Brown. And if that continuity is not there, then you 
still going to have the exact same problem we are experiencing 
today.
    In addition to that, I am a Mayo person, and if I have an 
appointment and all of the bells and whistles, and if I don't 
keep that appointment, there is a charge if I don't to make an 
appointment. We don't do that to veterans. So if they have an 
appointment and if they don't make that appointment, it is no 
penalty to them.
    Ms. McCaughey. Well, in fact, there is a terrible penalty 
to them. It is not a monetary penalty, but it means that they 
are waiting longer and longer for care. And when vets don't 
show up for their appointments, I am not blaming the vets. If 
many cases, they have waited as long as six months for that 
appointment. The fact is that the VA hospitals and clinics 
should be calling the vets 24 to 48 hours or e-mailing them 
ahead of time to remind them of their appointments. It is 
unrealistic to think that a vet is going to remember their 
appointment----
    Ms. Brown. Absolutely. I agree with you, but still, I am 
saying in the other side of the world, if you don't make that 
appointment, there is a financial penalty that you receive.
    Ms. McCaughey. Uh-huh. And what is your point, Madam?
    Ms. Brown. I made my point.
    Ms. McCaughey. Thank you.
    Ms. Brown. The point is that we have additional veterans in 
the system because we opened the VA system up to the Vietnam 
veterans. Each one of them did not have to prove that they had 
a certain disability. So we got thousands of additional 
veterans into the system and the Secretary did it and I am very 
grateful that he did it. Now we have to figure out how to serve 
them, and I am saying that the VA system is one of the best 
systems in the United States; that is what I am saying. And I 
read your expertise. Your expertise is in the area of 
infectious diseases which is a problem, but the bill that we 
have before us, I am hoping and the Chairman's recommendation 
and his bill and the Senate Bill, I hope we can work out what 
is the best way to move forward with the VA system.
    And thank you for your kindness and your time, Mr. 
Chairman.
    The *Chairman.* Thank you very much, Ms. Brown.
    Mr. Jolly, you are recognized for five minutes.
    Mr. Jolly. No questions, Mr. Chairman.
    The *Chairman.* Thank you very much.
    Mr. McNerney, you are recognized for five minutes.
    Mr. McNerney. First I want to thank the Chairman and the 
Committee for allowing me to participate in the hearing.
    You know, I heard some really excellent ideas here and I 
have seen a real bipartisan spirit in finding real solutions, 
so I think it is a great morning and we have accomplished a 
lot.
    I, first of all, have a hypothetical question for Mr. 
McClain and Mr. Collard. If the no-show rate were reduced to 
five percent, which we heard is attainable, and physicians were 
relieved of the non-value added requirements, which is a phrase 
that Mr. Collard used, would there be enough physicians to 
provide health care that is needed to our veterans?
    Mr. McClain. I haven't actually done the math or done the 
analysis on this, but it certainly would help. There isn't any 
question about it, and that would certainly bring it closer to 
what the commercial expectation would be in health care 
delivery.
    Mr. Collard. It is a question that is answerable. We 
probably don't know this. None of us at the table have the 
math, but it is a question that is answerable because the 
variables are real variables.
    Ms. McCaughey. I will give you the 2012 report that was 
provided to Congress on just this issue, assessing the--how to 
assess the need for additional physicians at each location.
    Mr. McNerney. Please be brief.
    Ms. McCaughey. I am just going to give you the report after 
the----
    Mr. McNerney. Okay, thank you.
    Mr. McClain, would you talk about the current state of 
affairs regarding transfer of patient data between private 
sector and the VA and if there are barriers, how could we 
reduce those barriers?
    Mr. McClain. We had a problem when we started out in 
Project HERO, we were not able to immediately input any data 
into the VA's medical records. In other words, we maintained a 
network of specialists, so a veteran would be referred out to a 
specialist and you would get a consult and you would get a 
written consult report that we ended up faxing back to the VA 
and apparently then it was attached in a PDF form and then 
attached to the CPRS, to the veteran's record.
    In the CBOCs, it is a different thing. I mean we are 
essentially part of the VHA Health Care System and we have 
access to VistA and to CPRS, but it is very, very difficult--I 
understand the firewalls. I understand the privacy issues. I 
understand the IT issues that come up, but there has been a lot 
of work done in the commercial and civilian sector on exchange 
of information. I think the answer to your question is DoD and 
VA have been trying for over ten years to exchange information 
and they have been very successful.
    Mr. McNerney. Thank you.
    Mr. Collard, in your testimony, you used a new term I 
haven't heard before ``evidence-based leadership''; are there 
models for identifying evidence-based leadership? Is there some 
way we can move forward in helping to identify that?
    Mr. Collard. Yeah, I think what you would find is that as 
you look at the models and the structures, the parallels to the 
other side of our evidence-based world, and that is evidence-
based care. One, you begin with the diagnosis before a 
prescription, and so the notion of an assessment prior to just 
jumping into the fray becomes key.
    Then the alignment towards an eventual outcome, which is 
really where evidence-based care goes, so alignment of goals or 
those desired outcomes, which also includes the proper training 
as a physician would receive that provides evidence-based care, 
the aligning of behaviors. So the agreed upon behaviors to 
produce the outcome and then a topic that we have not even come 
close to talking about today, but shown in some of the latest 
bills, the ability to manage the performance gap much better. 
Whether it is--and we will push the organized labor issue aside 
for a second because we have organizations that are highly 
organized that are very successful in managing performance. 
They don't let the presence of a union stand in the way. But 
the ability first and foremost, we recruit the highest 
performers in the enterprise. That the ability to look for 
those that seek and can benefit from development and in our 
industry-wide, the ability to quit hanging on to the low 
performers that drag the rest of the industry down. And we can 
argue the ends, if it is an end of one or an end of two, but if 
it is my grandmother in the bed, that low performer is probably 
causal to a lack of good care.
    What that brings us, then, to, much like evidence-based 
care, is through research, through vetting of the data and the 
outcomes, the ability to standardize, the ability to then 
accelerate that standardization. That is kind of a quick model 
of evidence-based leadership.
    Mr. McNerney. Thank you.
    And, again, I thank the Committee for allowing me to 
participate.
    The *Chairman.* Thank you, and welcome back. It is great to 
have you with us.
    Members we now have a series of votes that have been 
called. What we are going to do is thank our panelists who are 
here with us today. We look forward to communicating with you 
off-mic as well. You have helped bring some information to us 
today that I think is very worthy of consideration and we 
cannot fail. As we have already talked about, we do have an 
opportunity that does only come about once in a lifetime to be 
able to fix this for the veterans.
    Dr. Jesse, I apologize. I would rather us go vote. I don't 
want any members to miss a vote, and we will reconvene at the 
end of the last vote and we will probably be an hour.
    [Recess.]
    The *Chairman.* Joining us on our second panel from the 
Department of Veterans Affairs is Dr. Robert Jesse, Acting 
Under Secretary for Health. Dr. Jesse, thanks for being with us 
today. Thank you also for indulging the committee members while 
they went to vote. And with that, you are now recognized for 
your opening statement for five minutes.

         STATEMENT OF DR. ROBERT L. JESSE, M.D., Ph.D.

    Dr. Jesse. Thank you, sir. Thank the Ranking Member Michaud 
and the committee. I am actually really pleased to be here. And 
I sincerely mean that. I thought this morning's session was 
fantastic. There were a lot of incredible topics that were 
discussed.
    As you know, I have a prepared statement. I am not going to 
read that because I want to respond to some things from this 
morning. But I do want to say a couple of things up front.
    The *Chairman.* And your statement will be entered into the 
record.
    Dr. Jesse. Yes, thank you. I would be remiss if I did not 
start by just saying we know that we have left veterans down, 
but we are going to make it right. There has been a breach of 
trust. Many patients have been waiting too long. We need to fix 
that. It is unacceptable. It is unacceptable to the veterans. 
It is unacceptable to the American people. And it is 
unacceptable to you. And we need to apologize for that and we 
will do so. We apologize to the veterans; to the VSOs; to 
Congress; to the American people. You all deserve better from 
us and we will do that. We own this. We are going to fix it.
    We will do it with diligence. We will do it with haste. We 
will do it with integrity. And we will do it with unparalleled 
transparency. And I think from several of the hearings we have 
had in moving forward you will begin to hear certainly how VA 
is moving now to provide care for patients. We believe we have 
identified patients who are still waiting through the process 
you have. We are bringing them in. If we cannot get them in to 
get care in 30 days if they choose we will find care for them 
in the outside. That is our job one. That is the most important 
thing that we have to do. It is our most important focus.
    You have mentioned several, you mentioned that there are 
ongoing investigations. People will be held accountable. I want 
to say one thing that I am very concerned. I care deeply about 
the other employees in this organization that have been doing 
it right. There are 270,000 employees in VHA and the majority 
of them come to work every day driven on a mission, a sacred 
mission they have to do the right thing for veterans. They do 
work for veterans and close to 40 percent of themselves are 
veterans. And I think we have to acknowledge them, and their 
health, and their well-being are very important.
    We need to know how this organization failed and I think 
and I hope that is the topic for the discussion today. You 
know, how did the VA bureaucracy, you are not going to like 
that word, how did the VA organization structure become what it 
is today? And how is that impacted on what is happening in the 
VA?
    And we are going to need help. We are not going to fix this 
by being a little bit better ourselves. We are going to fix it 
by the kind of very robust discussions that were held here this 
morning and through, you know, learning from the Mayo Clinics, 
learning from the Kaisers, and others. And we frankly are 
having some of those discussions going on now.
    So this really is a time to reset. This is I think a 
crucial moving forward moment. And if we do not take the 
opportunity to do that, we have been remiss. There was a lot of 
talk this morning about patient centered care. Our plan moving 
forward, which we have been inculcating across the organization 
for the past year, is that we are going to have patient 
proactive, proactive, personalized, not just patient centered 
care, patient driven care. I think that is a very important 
distinction. We need to move from being the model of finding it 
faster and fixing it better to one that treats the front end of 
disease prevention and wellness.
    Standardization is incredibly important. I agree absolutely 
with Mr. Collard, that, you know, people say well if you 
standardize you cannot innovate. In fact you cannot innovate if 
you do not standardize. And this is as we have rebuilt our 
sterile processing around an ISO 9001 structure that provides a 
level of standardization that allows disciplined improvement.
    Centralization is important. It is best when it is 
standardized. It is not an equivalent to standardization. If 
you standardize business practices, that is great. You get 
efficiencies of scale and you get an operational consistency 
that is important. But there are other ways that are important. 
And for example, our CMOPs, our mail order pharmacies. You 
know, the seven mail order pharmacies have for the third year I 
think now in a row won the J.D. Power Award for pharmacies. 
They mail out 120 million prescriptions a year. Why is that 
important? What it did is it freed up the pharmacists, it got 
them from out behind the counter to out in the clinics and 
sitting with patients, doing medicine reconciliations, 
improving adherence to their regimens which in the end is 
really what improves outcomes.
    And then there was a lot of talk about competition. And 
competition this days in healthcare is actually choice. And if 
we are not the healthcare agency, if we are not the healthcare 
delivery system that veterans choose, then we will have lost. 
And coordination of care is important. And in talking about a 
big idea, one of the things we have learned is that to 
relentlessly drive an organization on performance measures that 
are process measures will not get us where we need to be. We 
want to relentlessly drive this organization on value. Value is 
quality over cost. Quality is in the eye of the beholder, so 
there are multiple dimensions to it. And cost is not always in 
dollars. It is the opportunity cost, it is the emotional cost 
of getting care. But we need to make that equation right for 
the veteran, for you all as our oversight board, and for the 
American public. Because if we are not a value to all of you, 
again, we will not have met our mission.
    So thank you, sir. I again thank you for the first panel. I 
thought it was excellent. And I am prepared to have a further 
discussion.

       PREPARED STATEMENT OF ROBERT L. JESSE, M.D., Ph.D.

    Good morning, Chairman Miller, Ranking Member Michaud, and 
Members of the Committee. Thank you for the opportunity to 
discuss the current organizational structures of the Veterans 
Health Administration (VHA). At the outset, let me address the 
significant issues that have been the focus of this Committee, 
the VA, and the American public the last many weeks. That is 
the issue of wait times. No Veteran should ever have to wait an 
unreasonable time to receive the care they have earned through 
their service and sacrifice. America's Veterans expect and 
deserve the highest quality, timely health care.
    As former Secretary Shinseki and Acting Secretary Gibson 
have stated, we now know that within some of our Veterans 
Health Administration facilities, VA has a systemic, totally 
unacceptable lack of integrity. That breach of trust--which 
involved the tracking of patient wait times for appointments--
is irresponsible, indefensible, and unacceptable to the 
Department. Let me apologize to our Veterans, their families 
and loved ones, Members of Congress, Veterans Service 
Organizations, and to the American people. You all deserve 
better from us.
    Earlier this week, Acting Secretary Gibson announced a 
number of immediate actions to address the issues identified in 
our audit. Specifically, and of relevance to this hearing, on 
June 9, 2014, Acting Secretary of Veterans Affairs Sloan Gibson 
ordered an immediate hiring freeze at VHA Central Office in 
Washington, D.C. and all 21 Veterans Integrated Service Network 
(VISN) headquarters, except for critical positions, which will 
be approved by the Acting Secretary on an individual basis. 
This action will begin to remove bureaucratic obstacles and 
establish responsive, forward leaning leadership to accomplish 
VHA's mission of providing exceptional health care that 
improves Veterans' health and well-being.
    External independent organizations have stated very clearly 
that VHA delivers high quality care across the nation to 6.3 
million Veterans and other beneficiaries living in urban, 
rural, and highly rural areas. Today, our care delivery 
includes: 150 medical centers, 820 community-based outpatient 
clinics, 300 Vet Centers, 135 community living centers, 104 
domiciliary rehabilitation treatment programs, and 70 mobile 
Vet Centers.
    We collaborate with Federal partners, such as the 
Department of Health and Human Services to establish pilot 
projects with community-based providers, the Department of 
Defense (DoD) to improve access to care for Servicemembers and 
Veterans through sharing agreements, and the Department of 
Housing and Urban Development (HUD) on the HUD-VA Supportive 
Housing (HUD-VASH) program. Other responsibilities include the 
training and development of a workforce of over 300,000, 
coordination of a nation-wide volunteer program, and a range of 
special program offices, to include Rural Health, Telehealth, 
Informatics, Mental Health, and Procurement and Logistics. 
Directing and supporting this organization - the largest 
integrated healthcare system in the Nation, requires an 
Administration-level headquarters, an intermediate level of 
oversight (Veterans Integrated Service Networks), and a 
hospital-based network of front-line decision makers.
    VHA is committed to consistent and efficient use of 
staffing resources across its health care system. Since the 
1990s, VHA has used VISNs to direct and oversee health care 
delivery. Each VISN oversees a grouping of hospitals and other 
specialty facilities, such as community living centers, 
domiciliaries, community-based outpatient clinics, and Vet 
Centers. VISNs also share innovations at regional level and 
collaborate with other networks to elevate validated strong 
practices to the national level; integrate health care services 
within markets; monitor and assess the delivery of health care 
to Veterans; and reduce or eliminate duplicative functions in 
clinical, administrative and operational processes.
    In 2013, VHA evaluated each VISN's functions and staffing 
levels, and established a smaller and more uniform core size 
and set of functions. We believe the organizational structure 
of VISN offices and local health care systems supports our 
mission with a level of consistency that assures the efficient 
and safe delivery of health care to Veterans. However, in light 
of recent events, we also intend to take a fresh look at our 
Central Office configuration and endstrength, as well as VISN 
functions and staffing levels.
    Additionally, in order to help provide timely access to 
quality healthcare, the Department has announced other 
initiatives VA will apply at the facility level, including the 
hiring of additional clinical and patient support staff as well 
as other temporary staff. VA's priority is to ensure all 
Veterans receive timely access to high quality care, and we are 
prepared to make those organizational changes that will achieve 
this end.
    Mr. Chairman, the health and well-being of the men and 
women who have bravely and selflessly served this Nation 
remains VA's highest priority. VA recognizes the critical role 
that VHA Central Office and VISNs have in providing quality, 
integration and value in the delivery of health care to 
Veterans. The recent VISN staffing review and standardization 
strengthened the role that VISNs have in delivering high-
quality, patient-centered care to Veterans through our medical 
centers and their staff. As we have recently learned, continued 
review of this and other areas of VHA organizational structure 
must remain a priority. Mr. Chairman, this concludes my 
testimony. I am prepared to answer questions you or the other 
Members of the Committee may have.
    The *Chairman.* Thank you very much for being here, Dr. 
Jesse. My staff asked the office, and I know this is not under 
your purview, but what I asked for is, I asked the Office of 
Congressional and Legislative Affairs to provide an 
organizational chart for VA's Office of Mental Health Services 
to include accompanied names and titles on the 18th of April. 
On May 7th my staff was informed that this deliverable request 
would require either a letter from me, as the Chairman, or to 
go through, now get this. Members, a Freedom of Information Act 
Request.
    I sent a letter requesting the organizational chart in 
writing that same day. However, I still do not have it. So 
either a chart does not exist, or VA does not want to share it 
with the committee. What do you think about that?
    Dr. Jesse. Well, first of all I apologize. There is no 
reason why you or anyone else should not have an organizational 
chart. I am actually surprised they are not available on the 
web. But I apologize you are being put through that amount of 
effort to get it and I will get it to you.
    The *Chairman.* By close of business tomorrow would be 
appreciated. Can I have your personal assurances it will 
happen?
    Dr. Jesse. I will certainly try, sir.
    The *Chairman.* Thank you very much. I heard you put a try 
in there, but there is no reason that we cannot have it by 
tomorrow.
    Dr. Jesse. Well----
    The *Chairman.* And if not I am, yes, or if it does not 
exist, you are correct. During a recent visit to the Columbus, 
Mississippi CBOC I was told that many veterans choose to 
utilize the Tuscaloosa, Alabama VA Medical Center rather than 
the Jackson VA Medical Center because it is a closer proximity.
    Dr. Jesse. Mm-hmm.
    The *Chairman.* It was mentioned that there is a memorandum 
of understanding in place to allow this choice for veterans. So 
I guess my question is in a supposedly integrated system, why 
is there a need for this type of bureaucracy in order to cross 
a VISN line?
    Dr. Jesse. I do not know the answer to that. Particularly 
if there is a memorandum of understanding that the people can 
go back and forth. We have since I think the days of Dr. Kaiser 
have said it is one VA. The veteran should be able to choose 
which VA he goes to. So I do not have the explanation for that.
    The *Chairman.* If you could also for the record----
    Dr. Jesse. Yes.
    The *Chairman.* --get that. The other thing is, why are 
veterans who cross VISN lines categorized as new rather than an 
established patient?
    Dr. Jesse. Yes, that I know they are not supposed to. And I 
know this because I looked into it a little while back. I had 
been up at a clinic up in South Dakota and I was walking past a 
waiting room and there were gentlemen sitting there and they 
said, a guy says, ``Guys in suits, they must be from 
Washington. Get in here.'' So I went and talked to them and 
their comment was that they loved the care they were getting in 
South Dakota. But no one stayed in South Dakota. You know, 
retired people tended to go to warmer places in the winter. And 
their only complaint was that if they went somewhere else that 
they were not recognized even though they were going to the 
same place over and over again. So I came back and looked into 
that. There is a process that people are supposed to follow to 
do that. And you know, apparently we do not have that message 
out as clearly as it needs to be. It should not happen. Once 
you are in the VA, you should be in the VA. You can be found.
    But I will also say that there is an initiative going on 
now to actually not just do that across VHA but across all of 
VA. So that if, whether you change an address in the benefits 
side that gets pulled over into a master index so that the 
whole entire agency sees each individual as one person and not 
having multiple different iterations across. And we need to do 
that in order to make this seamless.
    The *Chairman.* When VHA issues a policy letter or a 
directive, how does that instruction flow from the central 
office to the field?
    Dr. Jesse. So the technical process is that as the 
directives get signed off by the Under Secretary then the 
distribution route goes through the networks. So it goes 
through network operations down to the network directors, and 
then from there it tiers down to the facilities and into the 
field. And at the same time the bottom, the last line of 
virtually every directive, well at least the ones, the clinical 
ones that I have been involved with, will have who your point 
of contact is if there are questions. So there are ways to move 
clarity and technical expertise back to the folks who are 
trying to implement that directive.
    The *Chairman.* And my final question, and I am running out 
of time, but the committee has been told repeatedly that the VA 
central office policy is often transmitted outside of any 
authority chain and often viewed by many VA medical centers as 
voluntary. Is that true?
    Dr. Jesse. I certainly hope not. No, a directive is a 
directive. And they are very explicit statements about what is 
required. If there are options and opt outs, they will be 
placed in that directives. You know, I think the key principle 
needs to be that directives are not ambiguous, that their 
intent is clearly defined, that the metrics by which they are 
going to be measured are clearly articulated, and that there is 
a solid and defined methodology for ensuring that they are in 
fact being met, and the intent of the directive has been met.
    The *Chairman.* Thank you. Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman. And thank 
you very much, Dr. Jesse, for being here. My question is, you 
heard earlier Dr. McCaughey and, for the record, I mean, Dr. 
McCaughey is not a medical doctor so----
    Dr. Jesse. Yes.
    Mr. Michaud. --raised a number of concerns with the choice 
card provision in the Sanders-McCain bill. Do you see any 
problems with VA's ability to provide veterans with eligibility 
verification such as choice cards to see non-VA doctors?
    Dr. Jesse. You know, I do not know explicitly. But we have 
been doing this, there are several different methodologies for 
non-purchase non-VA care, one of which is fee although that 
term tends to be used an encompassing. And when we give 
somebody a fee card it is equivalent to that. It is the 
authorization for you to go out and get your care. And there 
are some limits around that. It is not a preauthorization but 
there are bounds about what care can be provided and if it has 
to exceed that then they get authorization. I believe that is 
the way it works. So it should not be an inhibiting factor and 
I think you heard from Philip Matkovsky the other night that, 
you know, he really is putting rigor and discipline around our 
business processes. And I think if that were the type of case 
it would not be a phone call to a random number somewhere. We 
would have one of the business, the health resource centers run 
by the business office would be managing that I would presume. 
Until, you know, until we have a law and we have the 
regulations around it it is a little bit difficult to 
speculate. But we have the capability to do that.
    Mr. Michaud. Okay. So when the VA does it today do you have 
any problems with verification?
    Dr. Jesse. Well I am not going to say it is perfect. But I 
think, you know, for most cases it is effective. You know, we 
have been looking at, always looking at better ways to do it, 
Project HERO and Project ARCH. We are set up for that as 
pilots, to see if there is a better way to get that distributed 
care out there.
    Mr. Michaud. And Project ARCH is in Maine.
    Dr. Jesse. Yes, I know.
    Mr. Michaud. It is, veterans and everyone, they love the 
way that has been working, so.
    Dr. Jesse. Yes.
    Mr. Michaud. The VISN structure has been under scrutiny for 
a few years now and I understand that VHA has reduced the 
number of headquarters staff through a realignment effort. Is 
that process finished?
    Dr. Jesse. Well I would rather think of it as a work in 
progress. So there was a task force, a group that looked at 
this. And clearly there was wide variation in the size of each 
of the VISNs that could not be explained on either the size of 
the VISNs themselves, meaning their total number of unique 
veterans, or their purpose because their purpose is inherently 
the same. So what this group did was they came back and clearly 
defined the core roles that needed to be in each VISN office. 
And on some limited amount of flexibility around that, which 
was fundamentally driven around the size of the VISN. And so we 
went from a variation of I think at the low end just under 40 
people in a VISN office to a high end of 160, to that they are 
all male between I think about 55 and 65. Clearly defined 
roles, that this is what you must have in there. A little bit 
of flexibility. But there is not an ability to continue to flex 
up that staffing without coming in for further review. And I 
say it is a work in progress because it has been pushed out 
this year. We will see how it works. I am constantly looking at 
it, and if it needs to be smaller we will make it smaller. If 
it needs to be bigger, we will make it bigger, or if we need to 
rethink the process entirely. But that is what we did. So we 
tried to standardize at the VISN level.
    Mr. Michaud. Thank you. And just to follow up on the 
chairman's comments about getting a directive from central 
office and having the VISNs carry through with that directive. 
And these are, you know, I have heard comments that the folks 
at the VISN level are more concerned about the VISN director's 
interests in how things are run versus the Secretary's because 
the Secretary comes and goes. And I have also heard it on the 
VBA side as well when the American Legion came out to do their 
System Worth Saving brought note to the fact to VA employees 
that is not what central office said you should be doing for 
the benefits. And the response, and this is the Baltimore, 
Maryland VBA, was, well, there is the VA way of doing things, 
and then there is the Baltimore way of doing things. And we are 
doing it the Baltimore way. So I think there really is a 
problem in some of the areas and I would encourage you to make 
sure that when the directive does come that it is followed 
through.
    And the other note I want to say, since my time is running 
out, when you look at Department of Defense they have the world 
divided in seven different regions. And I question whether or 
not we need 21 VISNs throughout the country. So I will end on 
that note and yield back, Mr. Chairman.
    The *Chairman.* Thank you very much. Dr. Benishek, you are 
recognized for five minutes.
    Mr. Benishek. Thank you, Mr. Chairman. Dr. Jesse, good 
afternoon. I am looking at this organizational chart of the VA. 
I guess it is the Veterans Health Administration. And I am 
wondering, if a physician within the VA wants to lodge a 
complaint or make a suggestion, where on this chart does that 
occur? I mean, I do not see a place really that has physicians.
    Dr. Jesse. So there are two places, actually. On that chart 
there is Dr. Madhulika Agarwal who is the Deputy Under 
Secretary for Policy and Programs. And in that is Patient Care 
Services. And rolled up under Patient Care Services are much of 
the physician based and other clinical services. So----
    Mr. Benishek. Well I guess I, the reason I am bringing this 
up is, you know, I worked at the VA, and I talk to many VA 
physicians, and they complain that they have very little 
recourse when they have suggestions for changes or complaints 
within the system. I notice here on the chart here that the 
Office of Nursing is right here on the, reports directly to the 
Principal Deputy Under Secretary.
    Dr. Jesse. Yes, sir.
    Mr. Benishek. Well why is there not a similar place for 
doctors?
    Dr. Jesse. Well so the physicians work through programs. So 
the Office of Surgery----
    Mr. Benishek. Well what I am trying to get to----
    Dr. Jesse. Okay.
    Mr. Benishek. --is that it seems like the nurses have more 
input to leadership than the doctors do. And you know, the 
doctors often have suggestions that may improve the quality of 
patient care. And I do not, the physicians I talk to, I just 
talked to a group of VA physicians yesterday and they are 
frankly telling me that they get reprimanded and they have this 
retribution if they try to change the system. And have you ever 
heard about that?
    Dr. Jesse. So----
    Mr. Benishek. I mean, I have had VA physicians tell me that 
they were not allowed to talk to me by their superiors. They 
were told not to speak to me.
    Dr. Jesse. So let me if I may----
    Mr. Benishek. Is it the policy of the VA to not allow 
physicians to speak to members of Congress?
    Dr. Jesse. Absolutely not. Absolutely not.
    Mr. Benishek. Well I am glad to hear that.
    Dr. Jesse. So, no. And remember that, if I may remind you--
--
    Mr. Benishek. Well I ----
    Dr. Jesse. --that I come to this as a clinician who was 
going to----
    Mr. Benishek. --why would it be that physicians have been 
told not to speak to me?
    Dr. Jesse. I have no idea, sir. It is not right. Physicians 
have the right to speak to anybody.
    Mr. Benishek. Well that is what I would think.
    Dr. Jesse. And there is a mechanism through, surgeons have 
the Office of Surgery. Dr. Gunnar has been a stellar leader in 
that, that they can work directly up through.
    Mr. Benishek. Well what I am telling you is that this stuff 
occurs.
    Dr. Jesse. Emergency medicine has the Emergency Medicine--
--
    Mr. Benishek. This stuff occurs. This stuff occurs, okay? 
This is occurring now, today, yesterday.
    Dr. Jesse. Well I----
    Mr. Benishek. This pattern of veteran, or physicians within 
the VA being told not to speak to Congress, being told not to 
rock the boat because if you try to make it more productive it 
is going to make somebody else look bad. I mean, these are 
direct quotes from physicians that work within your system.
    Dr. Jesse. So I also work with those physicians. And you 
know, much of the improvement that physicians want to execute 
occurs at the local level and we identify best practices at 
those levels at those levels and we use or, leverage our 
network capability to distribute them. There is no reason that 
physicians should not and cannot communicate freely. How can we 
have improvement if people do not feel that they can exercise--
--
    Mr. Benishek. Well that is the situation as it is today.
    Dr. Jesse. So I would, I would like----
    Mr. Benishek. I mean, I was at a VA physician meeting where 
there were perhaps 50 VA physicians. And the common theme of 
the discussion was that they were afraid to talk to me and what 
can be done, I am afraid to tell you what is going on at the 
VA, doctor. Because everyone has told us that we will be 
punished and that they were put through like onerous peer 
review situations that were obviously punitive. And so that 
they were afraid they would not be able to practice outside the 
VA.
    Dr. Jesse. Well----
    Mr. Benishek. I am just telling you what is occurring.
    Dr. Jesse. --that is inexcusable. And I will, I will 
personally----
    Mr. Benishek. So can you pledge to me that if I speak to a 
VA physician and he complains to me that he was reprimanded, 
you will help me make sure that this whistleblower guy does not 
get punished?
    Dr. Jesse. Well we do not tolerate punishment of 
whistleblowers. We absolutely do not----
    Mr. Benishek. Well but I am saying it is occurring today, 
Dr. Jesse. So if I have a physician who talks to me, because 
they were asking how can, they were asking me yesterday, 
doctor, how can you assure me that if I tell you what is going 
on that you can stop me from getting fired? And I had a little 
bit of trouble telling him that I could promise him that he 
could not get fired.
    Dr. Jesse. Well I----
    Mr. Benishek. Do you understand what I am saying? So what I 
am asking you is that if someone comes to me with that 
complaint, can you promise me they will not be fired?
    Dr. Jesse. I can, sir, I will promise you that they will 
not get fired for complaining to you. I can do that much. I 
cannot speak to individual situations.
    Mr. Benishek. All right. Thank you.
    Dr. Jesse. All right? Sorry.
    The *Chairman.* But also understand that if we do find that 
somebody has directed people not to talk to members of 
Congress, it is a crime.
    Dr. Jesse. It is inexcusable. We do not accept that.
    The *Chairman.* Okay. It is criminal.
    Dr. Jesse. Yes. I think the voice of the veterans who we 
serve, the voice of the line of people working with veterans of 
every day is crucial if we are going to improve this 
organization. We have to be listening.
    The *Chairman.* Ms. Brown, you are recognized for five 
minutes.
    Ms. Brown. Thank you. Sir, in Florida we serve almost 
600,000 veterans. We are the third largest population of 
veterans in the country. And my question goes to, I personally 
think the VA system is an `A' or a ten. But when I, the first 
year I was teaching the principal said if you are an `A' or a 
ten, where is your room for improvement? So I am starting out 
saying I think the system is very good. What are the 
recommendations would you have for some improvement? Because I 
do not think the entire system is damaged, as I hear. And I do 
think there are things that we could do. I remember when 
Secretary Brown, Jesse Brown, when the veterans from the 
Northeast came to Florida, we serviced them, and we did not get 
reimbursement. The reimbursement stayed in the North. So I 
mean, I know a lot about the institution, probably more than 
anybody on the committee.
    Dr. Jesse. So how can we improve? Well the first thing we 
can do, as you heard earlier today, there are many VA 
facilities that are top achievers----
    Ms. Brown. Mm-hmm.
    Dr. Jesse. --incredible performance. But not everybody is 
there. And the first thing we need to prove is to get everybody 
up to that same level. The second is, we say we are a quality 
organization. But I constantly remind our staff that there are 
multiple domains to quality. One of them is access and one of 
them is timeliness. So if you cannot have access you cannot 
even have quality. So fixing this access problem and doing it 
immediately is key. Third is equity. You know, if there are 
inequities in the delivery system we have got to identify them, 
we have got to figure them out, and we have got to make them go 
away quickly. So as we improve the standards of all hospitals, 
raising all boats up to what we know we can achieve, but also 
ensuring that access, quality, equity are uniform principles of 
how we do that work.
    Ms. Brown. We had a hearing, the Florida delegation, on VA 
this morning and one of the recommendations, at one time the VA 
could just I guess hire a doctor and now they have to go 
through a different system?
    Dr. Jesse. I am not sure what you mean. We have a process 
for credentialing and privileging physicians.
    Ms. Brown. Mm-hmm.
    Dr. Jesse. It is not unique to the VA. Every hospital in 
this country will do the same thing.
    Ms. Brown. Mm-hmm.
    Dr. Jesse. Our process is actually, the credentialing 
process is pretty good. But one of the things we are doing is 
we are working with DOD because they have got one too, but it 
is different from ours, and trying to establish a federal wide 
credentialing process. So if somebody came from DOD over to the 
VA, they would not have to do it again. And even more important 
in the conversations around telehealth where you have now got 
people practicing across state lines----
    Ms. Brown. Mm-hmm.
    Dr. Jesse. --you can have a uniform set of credentialing, 
that takes time. The one thing that is unique to VA is that 
physicians especially, but I think almost all employees have to 
go through security and background checks----
    Ms. Brown. Mm-hmm.
    Dr. Jesse. --and that takes some time. What we are trying 
to do, and in fact we learned a lot of lessons if you remember 
last year when we had the hiring initiative to plus up the 
mental health workforce, we learned a lot about the speed of 
hiring. And the challenge but simple solution is do not wait 
for Step A to fix, before you start Step B, before the start 
Step C. Parallel process, you can cut down that time. If we do 
not do that, we lose people while they are waiting to get their 
job.
    Ms. Brown. And nursing is another example that it takes so 
long for us to process a nurse.
    Dr. Jesse. Yes----
    Ms. Brown. And how do we advertise? Do we advertise just in 
the VA system? Or I mean, how do we do it?
    Dr. Jesse. Well so there is a requirement, I believe, that 
all federal jobs have to be posted in, you know, at a federal 
website so everybody can see them. But I do know, you know, for 
instance when I am reading the Richmond paper there is, you 
know, on Sunday morning there are always ads for the VA looking 
for nurses there. So, you know, everything goes into a, you 
know, a website. But in fact you use local resources. We also 
have executive and physician recruiters as part of Workforce 
Services that go out and reach out and try and find these 
people. And we leverage them in the metal health initiatives, 
they were very effective.
    Ms. Brown. One last thing. We have had lots of discussions 
of how we get additional VA doctors into the system and what 
can we do as far as, I guess, the medical, what is it? The 
medical so that they can get I guess forgiveness on their 
loans----
    Dr. Jesse. Yes.
    Ms. Brown. --when they work for the VA. Or whether, in 
Florida, for example, a lot of our interns go out of the state 
because we do not have the--what is the word? So they go out of 
the state. Residency, yes. And so we do not have those slots. 
What can we do?
    Dr. Jesse. And so there are two things that you are asking 
about. One is can, for people who have large medical school 
debt, and the average is pushing upwards to a couple of hundred 
thousand now----
    Ms. Brown. Mm-hmm.
    Dr. Jesse. --if you do not have help somewhere along the 
line is can we do debt forgiveness. We do have some limited 
authority. It is insufficient.
    Ms. Brown. It is insufficient?
    Dr. Jesse. We have been talking to, and particularly where 
we want to place physicians in underserved areas, which is the 
real challenge. It is less of a challenge, people want to stay 
around where they did their residencies, so in urban areas with 
bit medical schools it is much less hard. So we have been 
working with HERSA, who has the program where they pay 
scholarships and loan reimbursements to people who work in 
designated underserved areas, many rural but not all. And it 
does not make sense for us to build another organization within 
VA to replicate that process if we are going to go that route, 
which I, you know, I think we should if we can. There is, you 
know, we have got to make sure. But to tag onto them. They have 
already got the infrastructure in place. They can move out 
immediately.
    And then the, you know, the other piece is increasing 
residency slots. VA is highly supportive of the residency 
training programs in the U.S. I think you heard earlier about 
70 percent of physicians get some of their training in the VA 
system. We have expanded that in certain areas. There is still 
not sufficient, well for mental health it is not that there is 
not sufficient residencies, in fact some of them have closed 
because there is not sufficient people going into them. So how 
does not incentivize that mental health community, that more 
physicians would want to go in there. And that is not a 
question that VA can answer, but we can support the slots when 
we need to.
    I think there is, the other piece of this, and it was also 
mentioned earlier, is how does one leverage the use of both 
nurse practitioners and physicians assistants, and the like. 
And it is our intent within the organization that people 
practice to the top of their license. And so I think supporting 
PA schools, supporting nurse practitioner programs, we have got 
the VA nursing academies which are very useful for bringing 
people in nursing into the VA systems. And we are also now 
training people in interprofessional training so that doctors 
and nurses train side by side and learn to work as teams. And 
people who go through that find that is a very satisfying 
career move. But we have got to start that early in the 
training programs and not wait till they graduate and then try 
to retrain them to a different way of practice.
    Ms. Brown. Thank you so much, and my time is up. And you 
have been very gracious, Mr. Chairman.
    The *Chairman.* Yes, ma'am. Thank you. Mr. Huelskamp, you 
are recognized for five minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman. Dr. Jesse, earlier 
you made some comments about responding to congressional 
requests and stuff. Could you restate what you said about that? 
Something about criminality or criminal if you did not----
    Dr. Jesse. Oh, I do not think I used the word criminal. But 
I do not think that it is excusable that a physician thinks he 
cannot talk to his member of Congress.
    Mr. Huelskamp. Okay.
    Dr. Jesse. That is, and nor do I think anybody in VA should 
be telling----
    The *Chairman.* Would the gentleman yield?
    Mr. Huelskamp. Yes.
    The *Chairman.* Very quickly, if you can hold the clock? 
What I am referring to is them being directed, not that the 
physician or whoever the clerk may be. Obviously it is in the 
investigation that a committee is trying to do as it relates to 
its oversight responsibility in Congress. So I was not implying 
that the physician was. But it is our understanding at the 
committee that there have been people who have been instructed 
not to talk----
    Dr. Jesse. Yes. So, well, do you want to, I can maybe put 
some context around that? Because----
    The *Chairman.* If you just hold the clock, and go ahead.
    Dr. Jesse. Okay. So right now, yesterday, today, this past 
week, as you know, VA has been putting out a lot of the wait 
time data as part of being very transparent about this. There 
has been concern that at the facility level they may not be 
looking at exactly the same data that we were releasing. We 
wanted to be very careful that we did not have facility or 
network directors appear to be misleading their congressionals 
by saying well this is where we are, and then having this 
national data release say something different. So there was a 
caution put out to wait until we had distributed the data to 
them that was going to be released. And I will say it was an 
ill-worded document that it was followed immediately by a 
statement of clarity that said it was not intended that they 
could not talk to congressionals, to just hold off until they 
had the data that they could talk to them about and ensure they 
were getting the right data. You know, we get terribly 
compromised if we do not, if we have got one person saying one 
thing and another saying another. And we want to make sure as 
we move forward especially, and understanding what we put out 
this week is only the first, the first drill at this, we will 
be repeating that on two-week intervals. So anyway----
    The *Chairman.* Thank you very much for that clarity. It 
does add some light onto the issue.
    Dr. Jesse. Yes.
    The *Chairman.* But I will also tell you this. We were told 
by Dr. Lynch two weeks ago, because every member of this 
committee has been asking for the data from their facilities. 
And we were told that we would receive it once the report was 
final. The report is final. I got a call today that my local 
media got it before I did. I just do not understand why people 
in the VA will not follow through with their commitment. Now 
you do not need to respond to that. But that is a statement. I 
yield back to Mr. Huelskamp.
    Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate that. 
I did want to read from an email that was handed to me by I 
guess an Acting Director, and for members of the committee I 
did not know this. If the Director and the Assistant Director 
are on vacation, or on a management conference at least in the 
Wichita VA facility, the Acting Director is the Chief Nurse. 
But handed me an email that said please immediately stand down 
on any further communications with stakeholders, delegation 
members, and others regarding the access audit, wait lists, and 
accelerating care initiatives. And I did not take that very 
well.
    Dr. Jesse. No, I, and----
    Mr. Huelskamp. Can you explain----
    Dr. Jesse. Well so actually I probably----
    Mr. Huelskamp. --so this was approved at the highest 
levels? Who approved this stand down message?
    Dr. Jesse. No, no. I saw that memo, and I personally saw 
that memo probably five minutes after it went out and I said 
this is not acceptable. If that cannot be pulled back then you 
need to put a clarification memo immediately to explain the 
intent is not to have you not talk to your congressionals, the 
intent is to wait until you have the data from us to share with 
them. Because we, frankly----
    Mr. Huelskamp. And I appreciate that explanation. The 
follow up email was five hours later, actually five and a half 
hours later, after I had sat there trying to get answers to 
questions. And let me describe, and you might have missed this 
the other night. Because I requested this email. The facility 
eventually provided it to me. Your office did not. The VA 
administration did not. I requested that at our last hearing 
and had to get that from the facility, so I appreciated that. 
But here is what occurred in one facility, and again there are 
numerous examples across the country and so I am trying to draw 
attention to one facility in Kansas that is not in my district, 
I do not have a hospital in my district, so we are always 
leaving the district for that. But here is what occurred.
    May 30th, the facility announced, or actually had a U.S. 
Senator visit the facility about noon and was told by, I think, 
if the Director was there that day, I do not know. He seems to 
be taking a lot of time off. But I think it was the Acting 
Director for the day said we have no problem here. Three hours 
later a fax went out that said we had discovered nine veterans 
on a secret waiting list, maybe unauthorized. And that was sent 
out to the delegation and the public at 3:00 Friday afternoon. 
I began calling once I landed in an airport, calling, sent 
emails, had no response for five days, no answers. Hey, we will 
get together with you but would not answer questions. Then 
there was a leak to the media of 385, rumored. And so I jumped 
in a vehicle, drove to the facility, and was handed this email, 
and said go away. Go away.
    And I did not. We stood there, and I finally got the 
Director on the phone who was in Denver at a management 
conference. But since then, this is what is concerning as well, 
since then they have discovered another 636. So there is over 
1,000 veterans on the waiting list. And doctor, here is what 
they told me. We did not know we even had a near list. We did 
not know that was in the system. The system that has apparently 
been around for twenty-some years, this facility did not even 
know. And I am not asking you to explain this. But I am asking, 
maybe this is why we need some more investigation, more people 
should show up and ask those questions. Because either they are 
misleading or worse, or frankly incompetent if you did not know 
you had these veterans sitting on a list. And as I understand 
the numbers that were released in the audit do not include 
other unauthorized lists. That is still yet to be known, is 
that correct?
    Dr. Jesse. Well if we do not know where unauthorized lists 
are, we cannot include them. The----
    Mr. Huelskamp. Tell me how you are going to find them.
    Dr. Jesse. It does include----
    Mr. Huelskamp. How are you going to find them then?
    Dr. Jesse. Well----
    Mr. Huelskamp. I understand that you do not know.
    Dr. Jesse. Right. So----
    Mr. Huelskamp. But you did not make any reference to other 
unauthorized lists that were found in Phoenix, the types found 
in Phoenix. You did not make any reference to those at all.
    Dr. Jesse. So the near list everybody should know about. 
And I do not say this as an apology, but there is a software 
defect that gives a different number if it is pulled locally 
than if it is pulled nationally. So all of the near data is 
being pulled nationally and the sites have been directed to go 
to the VSSE, the national center, to pull their data down. 
But----
    Mr. Huelskamp. How long did you know about this glitch in 
the data?
    Dr. Jesse. As we were trying to pull this data together. 
That is, because this is the problem. We had facilities saying 
we do not have----
    Mr. Huelskamp. Okay. We have had two weeks of hearings and 
this is the first time you have said the near list is a data 
glitch.
    Dr. Jesse. The near list is part of the process of 
scheduling.
    Mr. Huelskamp. It is not in the Dole VA facility. That is 
not accurate. Or else they are lying to me.
    Dr. Jesse. Well I----
    Mr. Huelskamp. And my question is, it is not about just the 
one center, or one hospital. This is systemic, nationwide, 
where basically what you are telling me is the near list is 
everywhere, that is what they told us two weeks ago. Then I go 
to a facility and what they say is we did not even know there 
was such a thing as the near list.
    Dr. Jesse. Well I cannot speak for a single----
    Mr. Huelskamp. Well how about finding an answer to that?
    Dr. Jesse. I will ask them.
    Mr. Huelskamp. Can we do that?
    Dr. Jesse. Sure, I will ask them.
    Mr. Huelskamp. And in the future when I request documents, 
I would appreciate you provide them. Especially ones that had 
gagged employees. I want to give them credit. They went ahead 
and answered despite Janet Murphy's direct instructions to not 
talk to me.
    Dr. Jesse. Well as I said, that was not the appropriate 
statement. And I hope we did get that corrected.
    Mr. Huelskamp. Who did approve that statement?
    Dr. Jesse. Nobody, it was Jan Murphy, well it was put out. 
Not every email gets approved by----
    Mr. Huelskamp. Well a gag order email, I just want to know 
who approved it. Janet Murphy?
    Dr. Jesse. Jan Murphy sent it out.
    Mr. Huelskamp. But who approved it?
    Dr. Jesse. Well I do not know. I saw it after it was out 
and I am the one----
    Mr. Huelskamp. Can you tell me who approved that? Was it at 
a higher level?
    Dr. Jesse. I do not, no, I cannot.
    Mr. Huelskamp. You cannot find that out?
    Dr. Jesse. Oh, I could find it out----
    Mr. Huelskamp. Please find out. Thank you.
    Dr. Jesse. But I will say we tried to correct that because 
it was not intended to be a gag order. I thought it was a poor 
choice of wording. No question, it sounds like that. It was not 
the intent. The intent was to ensure you saw the right data and 
you did not get in the conflict of where they were saying one 
data, and then you would see another piece. We want to make 
sure we are speaking on the same page.
    The *Chairman.* Thank you, Dr. Jesse. Ms. Brown? Ms. 
Brownley?
    Dr. Jesse. Brownley?
    The *Chairman.* All right. Oh, that is right, I let you go 
way over. Ms. Brownley, five minutes.
    Ms. Brownley. Thank you, Mr. Chairman. And thank you, Dr. 
Jesse. I wanted to agree with our opening comments regarding 
our veterans who work within the VA. And I do believe that most 
of those veterans are working hard every single day and are 
doing a good job. And I believe that these men and women who 
served in uniform were dedicated and I believe these men and 
women who are no longer in uniform are equally as dedicated.
    I certainly do not want the men and women working within 
the VA to be discouraged. But they do need to understand that 
they have been working in a system that has lost its way and a 
structure that has lost its way and as a consequence was, 
particularly in this wait list issue, doomed to failure. And so 
I do not want them to miss, I do not want them to misunderstand 
in these discussions that this is not a criticism of them 
individually but it is a criticism of the system in which they 
were working.
    Dr. Jesse. Thank you for that.
    Ms. Brownley. And to that end I was also curious to know 
from you what the VA is currently doing. We are all trying to 
get our arms around the problem and to fully define the 
problem, and how you have used the VSOs to help in that 
process, and how you intend to use the VSOs to come up with 
solutions?
    Dr. Jesse. The VSOs I think are incredibly important to use 
moving forward. They have been incredibly important to us all 
along, but today, yesterday, tomorrow, moving forward, they are 
going to be critical. As I said, if we are going to change an 
organization and one that is driven on value we have to do what 
is important to those who we serve. And they are the reflection 
of that. They are, and in fact I was very poignantly told that, 
you know, you did not need all your numbers to know there was a 
problem, we have been telling you. You needed to listen to us. 
I take that very much to heart.
    One of the things that we have done just as a top line is, 
so I met yesterday with the group of the VSOs for, well we have 
breakfast once a month but it went much longer than we normally 
do because there were a lot of messages that we were, things 
that we were discussing. Acting Secretary Gibson has been 
meeting with them quite frequently as well as we are moving 
things forward. But the important thing is that the facility 
and facility directors are also meeting with their VSOs on a 
regular basis. And in some facilities, and I guess they are 
probably among the very high performing facilities, they are 
listening. In other facilities, they might be transmitting, but 
without judgment or without trying to figure out who is doing 
what. Our instructions forward is you must sit down with your 
VSOs and listen to them. You must sit and listen to them. 
Because that is going to be how we are going to judge the 
progress that we are making.
    So that is, and it is very insightful on your part, and 
thank you very much.
    Ms. Brownley. So if I return to my district and talk to my, 
the leadership team at my CBOC in my county, that I can be 
assured that they have been instructed to listen to our local 
VSOs?
    Dr. Jesse. You go back--well I hope they have, yes. And if 
you go back and talk to your local VSOs and they are not 
getting the attention that they get, we have asked the senior 
leadership in the VSOs to transmit the message down to their 
folks that work everyday in the facility serving veterans to 
get that back up the chain. Because that is the only feedback 
we will have. You know, the, obviously we can make them send 
minutes of their meetings and things like that, but that is not 
real productive. It is are people being listened to? And we can 
get that back by dialogue through those systems.
    Ms. Brownley. Thank you. And in terms of my local CBOC, we 
know that the demand is greater than the supply. We know that 
we need more space at our CBOC. That has been confirmed both by 
the VA and the community. And so I am just wondering, you know, 
how often the VA looks at long range capital plan updates? And 
if you have any idea when the Oxnard CBOC will be added to a 
long range capital plan?
    Dr. Jesse. So there are two questions there. There is the 
SCIP, as you are aware, which is the capital asset management 
program. I do not know off the top of my head the 
prioritization of Oxnard. Although I did live in Oxnard. My dad 
was stationed at Point Mugu. So I grew up there. But it is, I 
can find out. I do not know what the status is right now.
    Ms. Brownley. I would appreciate it. Thank you. I yield 
back, Mr. Chair.
    The *Chairman.* Thank you very much. Mr. Coffman, you are 
recognized for five minutes.
    Mr. Coffman. Thank you, Mr. Chairman. Dr. Jesse, last year 
Dr. Steven Coughlin testified that VA's 2010 national health 
study included over 20 percent Gulf War veterans and produced 
important data regarding their exposures to pesticides, oil 
well fires, and pyridostigmine bromide pills. Those of us who 
served in the Gulf War remember those. But VA has not released 
these data. Dr. Jesse, is VA hiding vital information about a 
quarter million Gulf War veterans who are waiting for care just 
as VA has been hiding information on veteran patient wait 
times? Will you provide the committee with all of the Gulf War 
data within 30 days?
    Dr. Jesse. Well I answer the first question and say 
categorically not. We are not hiding data. Understanding Gulf 
War Illness is crucial. It is crucial. And we need that data to 
do that. I do not, in these data sets the way that the research 
is worked is to begin to publish the data and the studies that 
they can put together looking into that data set. This is what 
Dr. Coughlin was working on. VA is also actually moving towards 
the whole construct of open science that actually put that 
data, once it can be de-identified, so you do not compromise 
individuals' rights, out into at least in a managed public 
sector that other researchers can have access to it as well.
    In terms of the second question, I am not sure how I can 
answer that. I do not know the size of the database. I can 
probably say with more clarity and accuracy that we can provide 
access to the data. But to say that can we hand it over, I do 
not know that. There are issues related to patient privacy and 
other things. But if there is, I will be glad to work with your 
staff to try and work through----
    Mr. Coffman. Well certainly, you know, we are not looking 
for individual names here. We are looking for the conclusion of 
the research.
    Dr. Jesse. Well----
    Mr. Coffman. And so I think the question, and let me repeat 
it again just to make sure you understand it, as a Gulf War 
veteran I am asking you will you provide the committee with all 
of the Gulf War data within 30 days?
    Dr. Jesse. And I answer you by saying I cannot tell you I 
can do that because I do not know the structure of that 
database. I do not know, can we provide it if it is not, if the 
patient privacy and protections are not taken out. And so to 
hand over a large research database, I do not know----
    Mr. Coffman. So let me ask you this----
    Dr. Jesse. --but I said we could get you access to the 
data----
    Mr. Coffman. So if we say then that, because I want Gulf 
War veterans to have access to this data. Not just me. And so 
if we say then that minus the HIPAA protections that exist in 
law that you are going to turn over all the data relevant to 
this 2010 National Health Study concerning Gulf War veterans? 
That part that concerns Gulf War veterans?
    Dr. Jesse. I think that is a question that is too complex 
for right here and now. I will be glad to personally further 
this conversation with you. I am not sure exactly what you 
want. Large databases are not something that one, it is not 
just the data. So what are the questions that Gulf War veterans 
want to answer? That is our responsibility, to engage with them 
and get answers to the questions that they want and need. You 
know that there are active researchers that have been working 
within the Gulf War databases. There are, you know, several 
incredible studies that have recently come out in terms of 
trying to get to the foundations of what might be behind that. 
But I cannot tell you that I can hand you over a large 
database. I do not know the legal authorities to do that. I do 
not know where it would go. I do not know how it would be 
protected. But we can have that conversation. I just do not 
think we can have it here today. Mr. *Coffman.* Let us have 
that conversation tomorrow. Because I can tell you as a Gulf 
War Veteran I do not share with you your statement about the 
commitment of the VA for Gulf War research. It is not there. It 
is absolutely not there. It tries to veer off into a direction 
that it is kind of ``all in your head.'' And Mr. Chairman, I 
would like to enter this for the record, this letter from the 
President of the Research Advisory Committee on Gulf War 
Illness, if I could put this in the record, Mr. Chairman.
    The *Chairman.* Without objection.
    The *Chairman.* The gentleman's time has expired.
    Dr. Jesse. Mr. Chairman, if I may? I mentioned earlier, 
today, over at VA, there is a state of the art conference going 
on exploring the relationship between mitochondrial function 
and disease and veterans. Much of the research that has come 
through that committee is pointing fundamentally to a basis of 
that disease, much of the muscle aches, the myositis, the 
chronic fatigue syndrome, as being related to mitochondrial 
function. We have pulled national researchers, not just VA, 
together to begin to explore that question, and the hope to 
come out of this conference will be the structure for a 
national multi-center trial that would actually look at 
potential both the basis of the disease and potential 
treatments. There have been several of them out there that 
showed promise in small studies. They need to be looked at in 
larger studies. But they also need to be looked at with a sound 
basis to link the pathophysiology to the disease state to the 
treatments. That is going on today, sir.
    The *Chairman.* Thank you very much. Ms. Titus, you are 
recognized for five minutes.
    Ms. Titus. Thank you, Mr. Chairman. Dr. Jesse, I have been 
hearing a lot of news stories, and even in this committee, 
where members say well the VA lied to me. Now I do not think 
the VA is, most people at the VA are intentionally lying. But I 
want to encourage you to have as much open dialogue as possible 
because with that transparency we can meet our mutual goal of 
helping veterans.
    I have a good relationship with Isabel Duff at the Southern 
Nevada VA Health System. And we talk regularly, meet regularly. 
I would encourage that at all of your facilities, or areas.
    Second, I would like to join Ms. Brownley in her request 
for information. If, when you find out about where Oxnard is on 
the priority list and what is happening there, would you also 
look at Pahrump and Laughlin? Those are two areas where you 
have got CBOCs that we have been waiting for some update on. If 
you could get that back to me, I would sure appreciate it.
    Dr. Jesse. Absolutely.
    Ms. Titus. Thank you. And then the third question I would 
like to go back to what the ranking member was talking about, 
the VISNs and the restructuring or realignment of that whole 
system. I know you realigned the headquarters and you said it 
was an ongoing process to look at the realignment of the areas. 
Just to give you an example of how this does not seem to make 
much sense. My district is Las Vegas. And so the constituents 
there are part of the Desert Pacific Healthcare Network. Now 
this ranges from rural Nevada to Central California, all the 
way down to the Mexican border. And the State of Nevada is 
split into three different VISNs. Surely we could try to bring 
a little more order to that regional division. Is that, are you 
all doing that? Is that part of what you are considering?
    Dr. Jesse. Yes, and that is the next step. When the VISNs 
were originally set up, and brilliantly so, I might add, they 
were built to provide an equity both in numbers of populations, 
you know so they were all roughly to be the same size. 
Obviously the geographies were quite different. But also to 
follow the logical local referral patterns.
    Ms. Titus. Mm-hmm.
    Dr. Jesse. All right? So if a small facility was referring 
to a big facility, you would not want to split them up and put 
then into two different VISNs. And so that is the way it was 
originally built. It was modified once. If you remember VISN 13 
and 14 became VISN 23. But we are relooking at that. Because 
clearly the referral patterns have changed. Clearly the 
demographics have changed.
    Ms. Titus. Right.
    Dr. Jesse. And it needs, that needs to be relooked at. It 
also does need to be relooked at in terms of the overall 
structure. If we do not, if we do not examine every one of our 
assumptions today, then we are not going to get where we need 
to be. So we have to question is 21 VISNs, are 21 VISNs the 
right number? Are the structures the right number? Are the 
referral patterns the right number? And that needs to be done.
    Ms. Titus. Is there a time table for doing this? Or are 
you----
    Dr. Jesse. Well I think any time table we had is probably 
changed, if truth be told. Because I think, you know, 
particularly what you heard today, and frankly many of these 
ideas that were discussed in the first panel are things that we 
have actually been looking deeply into. But I would hate to say 
that we are going to put out a plan to change the VISN lines 
because today we really need to be relooking at the entire 
structure of the organization moving forward. So I apologize. 
That is not a solid answer. But I think the more important 
statement is that we will examine everything.
    Ms. Titus. Well I hope when you do you will consider 
potential changes in the future, demographic changes and growth 
especially. Because the hospital in Las Vegas, you anticipated 
there would be a two percent increase in demand on the system 
when that hospital was built, it is a 19 percent increase. I 
think the veteran population is going to grow generally. It is 
certainly going to grow in Las Vegas now that the economy is 
coming back. So we do not want it to be a snapshot in time. We 
want it to have that projected growth as part of the formula 
when you realign these areas.
    Dr. Jesse. The, and as that hospital was put together there 
was great thought going into how the primary care base was 
going to be distributed around it and I hope that is meeting 
some of that need as well.
    Ms. Titus. Thank you. I yield back.
    The *Chairman.* Thank you. Ms. Kuster, you are recognized 
for five minutes.
    Ms. Kuster. Thank you very much, Mr. Chair. And thank you, 
Dr. Jesse, for appearing here with us. We appreciate it. I want 
to focus in on some of the testimony that we heard earlier in 
the day and see if I could get some reaction from you, or 
response. We have heard a pretty incredible statistic in this 
committee that I believe almost 50 percent of the appointments 
are no-shows. And I understand you are often dealing with an 
older population, and transportation, and such. But it does not 
seem to be a very efficient or effective way to run the VHA. 
Has there been any consideration to either and/or telephonic 
scheduling, where there is a conversation about whether or not 
the veteran can actually make that appointment? And number two, 
some type of automated appointment reminder?
    Dr. Jesse. Right. So actually we do much of that. I am a 
little bit baffled to hear as much conversation as there was 
today about the fact that we do not. You know, the whole 
principle of missed opportunities in practice management has 
been one of the things VA has been working very diligently on 
for years now. So actually when that comment was made I asked 
them to fact check what we are. For primary care, the no show 
rate is 11.4 percent.
    Ms. Kuster. Okay.
    Dr. Jesse. In my clinic the no-show rate is about zero 
because if somebody does not show up, everybody is worried 
about them and we track them down. But we do use phone calls. 
We do, looking, and in fact the EWL, the function of the EWL is 
this is where patients are, and if you get an opening when you 
make that phone call and somebody says I cannot make the 
appointment, you pull people down off that list. That is the 
point of doing that. So we actively do practice management in 
that regard. So as I, you know, said, I will acknowledge the 
variation that occurs in the system. Some places probably do it 
great and others maybe not so well. But the beauty of an 
integrated system is that we actually can have those who do it 
great help bring up those who are struggling and we try and do 
that when we identify those.
    Ms. Kuster. So that leads to another question that has come 
up repeatedly today, is what is the practice about sharing best 
practices? Why do we have such variation across 21 different 
regions? And why if you are citing an 11 percent missed 
opportunity, why are we hearing these statistics about 50 
percent? Half? More than half?
    Dr. Jesse. I do not know. Because there is, first of all 
there will be variation around it, and it may be clinic by 
clinic or provider by provider. And getting that variation----
    Ms. Kuster. But if there is a system----
    Dr. Jesse. But getting that variation out of the system is 
absolutely what is key, right?
    Ms. Kuster. And is that a metric, we have heard a lot about 
metrics and data----
    Dr. Jesse. Yes.
    Ms. Kuster. --obviously that ran amok in the scheduling, 
trying to deal with these wait lists, because it led to bad 
behavior.
    Dr. Jesse. Right.
    Ms. Kuster. Is there a way to incent good behavior by 
having some type of metric about patients actually getting 
seen? This notion of patient focused care for veterans so that 
we are focused on the veterans, how can we make sure that they 
get to see their medical care provider in a timely way?
    Dr. Jesse. So we actually do have a measure of missed 
opportunities, no shows, and cancellations. And that is 
cancellations both by the patient and by the clinic. And that 
is, I want to be careful not to give the sense that that is 
used as a tool to drive----
    Ms. Kuster. Well let us not get into a situation where we 
pretend people show up who did not show up.
    Dr. Jesse. But it is a practice management tool, so that 
individuals who have their own clinics can understand if they 
have a problem of all their patients not showing up, if there 
is a different issue. If practice managers are not leveraging 
using open slots, slots that come open because people say I 
cannot make that appointment, then that is not a very effective 
use of the clinician's time. So we do actually pay a lot of 
attention to this. We may not be as, some places as good as it 
is in the private sector. The private sector clearly has dealt 
with this very strongly because for them it is a revenue issue. 
But I would not say that we wait for people not to show up 
because it is a snow day. You know, our providers are busy and 
we want our patients in there. We worry about then when they do 
not show up if we are expecting them because, you know, and 
particularly in mental health. We track them down because we 
are worried that something might have happened.
    Ms. Kuster. Well my time is up. But it is something that I 
think if you could take back to your administration, this is a 
critical point and something that is extremely frustrating to 
all of us here. So----
    Dr. Jesse. And may I thank you for your nice comments about 
the Manchester VA.
    Ms. Kuster. We are fortunate.
    Dr. Jesse. My dad used the Manchester VA and he always 
thought highly of it.
    Ms. Kuster. We are very fortunate.
    Dr. Jesse. Yes, you are.
    Ms. Kuster. Thank you.
    Dr. Jesse. It is a good spot.
    The *Chairman.* Thank you, Ms. Kuster. Mr. O'Rourke, you 
are recognized for five minutes.
    Mr. *O'Rourke.* Thank you, Mr. Chairman. A month ago, just 
about, May 9th, I received this report from your predecessor, 
Dr. Petzel, and John Mendoza, the Director of the El Paso VA. 
And it is entitled, ``Wait Time For Initial Visit to Mental 
Health Among Patients New to the VA.'' And it shows that right 
now zero patients are waiting longer than 14 days to see a 
mental healthcare provider. Actually, that was for March. And 
then for the month before that it was zero. And it was like 
that all the way through the last 12 months, where the longest 
average wait time was three days.
    The audit that we got from the VHA this week shows that 
that same group, these are new patients seeking mental 
healthcare appointments, it is actually 60 days which makes El 
Paso VHA the fourth worst in the country. When we look at 
established patient mental healthcare average wait times it is 
the absolute worst among all VHAs in the country. I want to 
know what the consequences are going to be for publishing 
false, inaccurate data. You know, I am sensitive to the comment 
that my colleague Ms. Titus made about saying that these are 
lies. But I do not know what explains it. And the consequences 
could not be more dire for the people depending on this. So I 
would like to hear concisely what the consequences are going to 
be.
    Dr. Jesse. So we have had a little bit of a discussion 
about this. And I cannot say what the consequences are, because 
I do not know how it happened and by whom. And I think at the 
bottom of this is that we looked at data that we assumed to be 
correct, we did not challenge ourselves to find out that it was 
not until we got down and did this audit. So I do not, and I do 
not know that, you know, without looking into it and frankly 
this is why we have the IG and others do these investigations. 
If somebody deliberately misled you or anybody else on this 
data, there will be consequences. I am not a lawyer. I cannot 
speak to what those would be. So.
    Mr. *O'Rourke.* Let me follow up with this.
    Dr. Jesse. Sure.
    Mr. *O'Rourke.* I also shared with you a survey that we 
did----
    Dr. Jesse. Yes.
    Mr. *O'Rourke.* --because it was such a discrepancy between 
what VHA has been reporting since I have been in office the 
last year and a half and what veterans are telling me. And we 
found in that statistically valid survey that 36 percent, more 
than one-third of the veterans that I represent, who seek 
mental healthcare appointments not only cannot get in within 14 
days, they cannot get in at all. That to me is a crisis. When 
you have 22 veterans a day killing themselves in this country, 
when I learned from one of my constituents Bonnie D'Amico that 
her son, a veteran, came to one of my town hall meetings, heard 
veteran after veteran go up to the mike and say I cannot get 
in. On the drive home with his mom that night from the town 
hall meeting he said, you know, these guys are a lot older than 
I am. They have been trying to get into the VA system longer 
than I have. What does that say about my chances? Four days 
later he killed himself.
    I think this is a crisis. And frankly I do not see the 
urgency from you. I do not see the commitment to accountability 
from you or others to address this. If I knew what you now know 
and I were in your position, I would fly down to El Paso 
immediately and try to discover who those 36 percent of the 
veterans seeking mental healthcare appointments who have been 
denied and locked out of the system are. You are not doing it. 
You know, we spoke the day after I released the report. We 
asked for a plan of action. We spoke then Monday of this week, 
we asked for a plan of action. I asked you before when we sat 
down, you said you were going to back to the office and take a 
look at this. I have been very patient and very cooperative in 
working with the VA. That has not served me or the veterans 
that I represent very well.
    I understand you have a lot of demands on your time right 
now given what we have learned from Phoenix. But we have a 
crisis in El Paso and I would argue in many other places. But I 
have identified it for you. I have given you the information. I 
am willing to help you. I will use my own resources to track 
these folks down with you. But you have the list, the 
information, the veterans who have sought care and not been 
able to get it. When are going to get that urgency from you, 
and when are we going to connect them with the care that they 
deserve and that they have earned?
    Dr. Jesse. So as I said when we spoke earlier, when I get 
back to the office I will get the final answer. I do not know 
why you have not gotten the plan yet. I would hope that by now 
all of the veterans would have been called. And as I said, my 
concern is the 36 percent number that you have in your survey. 
Because I am concerned about the ones that we know, but I know 
we can help them and get them in. I am really concerned about 
the ones that we do not. And how we reach out to then and 
ensure that, you know, people who think that they are waiting 
for an appointment, and somehow we have missed them, or dropped 
off. I do not know. I am really worried about them. And I have 
offered to come down. We will get a time and figure it out.
    Mr. *O'Rourke.* Okay. I am going to use every opportunity I 
have when you or someone else from the VA or the VHA appears 
before us to press this issue. Because we know about it. You 
say that you have a commitment to it. We have yet to see a plan 
of action. I think we need a SWAT team flown down to El Paso to 
go connect these people. Again, I would like to be part of the 
solution. I offer myself and my office, our resources to that 
effort. But we need to get it done.
    Dr. Jesse. And actually, I thank you for that. I very much 
appreciate you wanting to be part of that solution. Mr. 
*O'Rourke.* Thank you. Mr. Chair, I yield back.
    The *Chairman.* Thank you, Mr. O'Rourke. I would like to 
read to you from Title 18, United States Code, Section 15.05.
    It says, ``whoever corruptly or by threats or force or by 
any threatening letter or communication influences, obstructs, 
or impedes, or endeavors to influence, obstruct or impede the 
due and proper administration of the law under which any 
impending proceeding is being had before any department or 
agency of the United States, or the due and proper exercise of 
power of inquiry under which any inquiry or investigation is 
being had by either house or any committee of either house, or 
any joint committees of the Congress, shall be fined under this 
title, imprisoned not more than five years."
    This is serious stuff.
    Dr. Jesse. Yes, sir.
    The *Chairman.* And I hope the department gets it. Are 
there any other questions? Ms. Brownley?
    Ms. Brownley. One last question, at least for myself. In 
the earlier testimony today, well let me just say there have 
been a lot of recommendations made to this committee on how 
things can be improved. And I would certainly be curious to 
know how the VA is digesting that and how they are responding 
to it. But there was one I think compelling recommendation 
today to, you know, before we move forward with a major fix to 
this situation that we should first do with an outside 
consultant a cultural assessment within the VA. And I am just 
wondering, you know, what your reaction is to that? What your 
response is to that recommendation to this committee?
    Dr. Jesse. So the answer is absolutely, but more. Yes, the 
cultural piece is crucial. And culture is established by 
leadership. I think, you know, I take that very much to heart. 
The organizational structure and design was part of that 
discussion and again absolutely. And we have been over the past 
several weeks meeting with a number of people who work in this 
area, with expertise in this area, absolutely agree it needs to 
be done. We cannot redesign it ourselves. We need the input and 
you know I have been having a number of conversations with, for 
instance, folks at Kaiser. How does Kaiser's organizational 
structure, you know, seemingly to work well? How does Mayo's 
structure work well? How does Geisinger's structure work well? 
We need people who can see across those systems and, like Mr. 
Collard does and can, and bring that shared knowledge to bear 
to us.
    So yes, we definitely plan on doing that. We will do it 
expeditiously.
    Ms. Brownley. Thank you. Thank you----
    Dr. Jesse. We will include the veterans and the veterans 
services in that discussion as well, by the way.
    The *Chairman.* If I can just in closing ask one question. 
In testimony that you presented to this committee in February 
of 2013, you stated that the Pittsburgh VA Healthcare System's 
copper silver ionization system may have failed to consistently 
prevent legionella growth. Do you recall that----
    Dr. Jesse. Mm-hmm.
    The *Chairman.* --testimony? But in a December, 2012 VA 
report, VA leadership was made aware that it was poor record 
keeping, lack of oversight and documentation, failure to test 
the hospital's water pH level, and other problems were at the 
heart of Pittsburgh VA's Legionnaire's disease outbreak. So now 
we know that it has led to at lest six preventable deaths at 
that facility. So explain to me how you could testify to 
Congress contrary to something that had already----
    Dr. Jesse. So I was not aware of that report at the time I 
made that testimony. And I apologize----
    The *Chairman.* Are you aware of the report today?
    Dr. Jesse. What is that?
    The *Chairman.* Are you aware of the report today?
    Dr. Jesse. Yes.
    The *Chairman.* Has anybody been held responsible for 
writing your speech, or intentionally misleading the Congress?
    Dr. Jesse. Well, I do not know that anybody intentionally 
misled. I do not know where that said report was given to 
senior leadership. I do not know the trail on that report. And 
in fact, I was made aware of it only relatively recently. And 
so somewhere in the traveling of information it did not get 
widely distributed. I apologize. I do not know the answer to 
that, but----
    The *Chairman.* Has the person that wrote your testimony 
been held accountable, now that you know about the report, and 
it does in fact contradict your testimony?
    Dr. Jesse. Well I do not know that the person who wrote the 
testimony was aware of it at the time, either. And I do not 
know what it means, that central office was aware of it. So I 
apologize. I do not know the answer to that.
    The *Chairman.* But we do know----
    Dr. Jesse. There was no intent to mislead, I assure you of 
that. I have always been----
    The *Chairman.* But we now know your testimony was not in 
fact true.
    Dr. Jesse. Well no, the testimony, the testimony is true. 
It is not complete, but it is true. You know, let me put a 
reference point on it. The CDC came in. They took extensive 
water samples. And in those water samples in fact the copper 
silver ion levels were at manufacturer's instructions levels 
and they grew legionnella out of them. So we know that in water 
samples that had appropriate cooper silver ion levels it failed 
to control legionella. And that has not happened just in 
Pittsburgh VA, it has happened in other hospitals. So.
    The *Chairman.* Does it, I guess my question is, and this 
is, and again----
    Dr. Jesse. Yes?
    The *Chairman. This is pretty critical. But does it bother 
you that you testified to something, there was a report that 
differed from your testimony, and you were not provided that 
information?
    Dr. Jesse. It bothers the heck out of me, yes, sir.
    The *Chairman.* Okay. All right.
    Dr. Jesse. Absolutely.
    The *Chairman.* Thank you for being here. We thank the 
earlier panel for being with us. Thank you, members. And this 
hearing is adjourned.
    [Whereupon, at 1:42 p.m., the subcommittee was adjourned.]
                                APPENDIX

                        STATEMENT FOR THE RECORD

Letter From Robert Jesse to Chairman Miller
    The Honorable Jeff Miller, Chairman
    Dear Mr. Chairman:
    Following the June 12, 2014, Committee on Veterans' Affairs 
hearing, I asked staff to confirm my response to a question by Ranking 
Member Michaud. When asked about the Veterans Integrated Service 
Network (VISN) structure; specifically ``The VISN structure has been 
under scrutiny for a few years now. And I understand that VHA has 
reduced the number of headquarters staff through a realignment effort. 
Is that process finished?''
    I would like to clarify my response where I stated that the size of 
the VISNs is ``now between, I think, about 55 and 65.'' This is correct 
with the exception that VISN 16 was granted a waiver in February 2014, 
by the prior Under Secretary of Health to hire an additional 10 staff. 
VISN 16 is a large and very complex network of facilities with an 
influx of new leadership, and it was felt the VISN required additional 
staff to provide needed clinical and administrative support across the 
network.
    I would ask that this letter be made an official part of the 
record.
    Sincerely,
    Robert L. Jesse, MD, PhD
    Acting Under Secretary for Health
    cc: The Honorable Michael Michaud

                                 
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