[Senate Hearing 113-614]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-614

                      THE STATE OF VA HEALTH CARE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 15, 2014

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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




                                  ______

                         U.S. GOVERNMENT PUBLISHING OFFICE 

88-349 PDF                     WASHINGTON : 2015 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001         
         
         
    
    
    
    
    
    
    
    
    
    
    
    
         
         
                     COMMITTEE ON VETERANS' AFFAIRS

                 Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Dean Heller, Nevada
Mazie Hirono, Hawaii
                    Steve Robertson, Staff Director
                 Lupe Wissel, Republican Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              

                              May 15, 2014
                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     4
    Prepared statement...........................................     5
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     5
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     7
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........     8
Heller, Hon. Dean, U.S. Senator from Nevada......................     9
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................    10
Moran, Hon. Jerry, U.S. Senator from Kansas......................    11
Begich, Hon. Mark, U.S. Senator from Alaska......................    12
Tester, Hon. Jon, U.S. Senator from Montana......................    13
Johanns, Hon. Mike, U.S. Senator from Nebraska...................    49

                               WITNESSES

McCain, Hon. John, U.S. Senator from Arizona.....................    14
    Prepared statement...........................................    15
Shinseki, Hon. Eric K., Secretary, U.S. Department of Veterans 
  Affairs; accompanied by Robert A. Petzel, M.D., Under Secretary 
  for Health.....................................................    17
    Prepared statement...........................................    19
    Response to posthearing questions submitted by:
      Hon. Sherrod Brown.........................................    23
      Hon. Jon Tester............................................    25
      Hon. Johnny Isakson........................................    28
      Hon. Richard Burr for Senator Jeff Flake...................    29
      Hon. Richard Burr for Senator John Cornyn..................    35
    Response to request arising during the hearing by Hon. Mark 
      Begich.....................................................    52
Dellinger, Daniel M., National Commander, The American Legion....    55
    Prepared statement...........................................    56
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    66
Violante, Joseph A., National Legislative Director, Disabled 
  American Veterans..............................................    66
    Prepared statement...........................................    67
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    72
Tarantino, Tom, Chief Policy Officer, Iraq and Afghanistan 
  Veterans of America............................................    72
    Prepared statement...........................................    75
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    79
Blake, Carl, National Legislative Director, Paralyzed Veterans of 
  America........................................................    79
    Prepared statement...........................................    81
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    86
Robinson, D. Wayne, President and Chief Executive Officer, 
  Student Veterans of America....................................    86
    Prepared statement...........................................    88
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    90
Gallucci, Ryan, Deputy Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    90
    Prepared statement...........................................    92
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    94
Weidman, Richard, Executive Director for Policy and Government 
  Affairs, Vietnam Veterans of America...........................    95
    Prepared statement...........................................    96
    Response to posthearing questions submitted by Hon. Jon 
      Tester.....................................................    98
Griffin, Richard, Acting Inspector General, U.S. Department of 
  Veterans Affairs; accompanied by John D. Daigh, Jr., M.D., 
  Assistant Inspector General for Healthcare Inspections.........   115
    Prepared statement...........................................   117
    Response to request arising during the hearing by Hon. Jerry 
      Moran......................................................   154
Marsh, RADM W. Clyde, USN (Ret.), President, National Association 
  of State Directors of Veterans Affairs.........................   122
    Prepared statement...........................................   123
Draper, Debra A., Director, Health Care, U.S. Government 
  Accountability Office..........................................   125
    Prepared statement...........................................   127
Longman, Phillip, Senior Research Fellow, New America Foundation.   143
    Prepared statement...........................................   145

                                APPENDIX

Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia; 
  prepared statement.............................................   155
Brown, Hon. Sherrod, U.S. Senator from Ohio; prepared statement..   155
Isakson, Hon. Johnny, U.S. Senator from Georgia; memorandum for 
  the record.....................................................   157
Boozman, Hon. John, U.S. Senator from Arkansas; prepared 
  statement......................................................   165
Zumatto, Diane M., National Legislative Director, AMVETS; letter.   166
Brown, Ronald E., President, National Gulf War Resource Center 
  (NGWRC); letter................................................   168

 
                      THE STATE OF VA HEALTH CARE

                              ----------                              


                         THURSDAY, MAY 15, 2014

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 106, Dirksen Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.
    Present: Senators Sanders, Murray, Brown, Tester, Begich, 
Blumenthal, Hirono, Burr, Isakson, Johanns, Moran, and Heller.
    Also present: Senator McCain.

          OPENING STATEMENT OF HON. BERNARD SANDERS, 
              CHAIRMAN, U.S. SENATOR FROM VERMONT

    Chairman Sanders. Thank you all for coming, and I want to 
thank our panelists for what is going to be a very important 
hearing.
    The format will be that I will make some opening remarks. 
Senator Burr, the Ranking Member, will make some opening 
remarks. Members will each have 3 minutes--and I will keep 
people to 3 minutes because it is going to be a long hearing. 
We are then going to hear from Secretary Shinseki and Under 
Secretary Petzel. Afterward, we have an excellent second panel 
made up of service organizations. We look forward to hearing 
from them. We have a very good third panel, as well. So, it is 
going to be a long hearing.
    Let me begin by just making a few basic points. Very 
serious allegations have been made about VA personnel and their 
doings in Phoenix and in other locations. I take these 
allegations very seriously, as I know every Member of this 
Committee does, which is why I have supported an independent 
investigation by the VA Inspector General.
    As we speak right now, the Inspector General's Office is in 
Phoenix doing a thorough examination of the allegations, and my 
hope is that their report to us will be done as soon as 
possible. And what I have stated and repeat right now is that 
as soon as that report is done, this Committee will hold 
hearings to see what we learn from that report and how we move 
forward, as soon as we possibly can after their investigation 
is completed.
    I think there is no Member of this Committee who disagrees, 
nor anybody in the United States, that this country has a moral 
obligation to provide the best quality care possible to those 
who have put their lives on the line to defend this Nation. And 
I believe every Member of this Committee will do everything we 
can to get to the truth of these allegations.
    But if we are going to do our job in a proper and 
responsible way, we need to get the facts and not rush to 
judgment. And one of the concerns that I have, to be very 
honest, is there has been a little bit of a rush to judgment. 
What happened in Phoenix? Well, the truth is, we do not know, 
but we are going to find out.
    Now, let me say a word about VA health care in general, 
which is what this hearing is about. What we want to know about 
VA health care is what is going well and what is not going 
well, and in terms of what is not going well, how do we improve 
that.
    Today, we must understand that when we talk about VA health 
care, we are talking about the largest integrated health care 
system in the United States of America. VA has 150 medical 
centers, has over 800 community-based outreach clinics, and 
some 300 Vet Centers. Every year, the VA is serving 6.5 million 
veterans. Today, tomorrow, and next week. VA serves more than 
200,000 veterans every single day.
    Now, what does that mean? And here is my point. If Senator 
Burr and I were to run around the country and visit every VA 
medical center, this is, I suspect, what we would find; we 
would find people coming out and saying, ``I got pretty good 
health care. I like my doctor. I was treated courteously.'' And 
then we would find people who say, ``You know what? I had a bad 
experience. I did not like my doctor.''
    The point I want to make is that when you are dealing with 
200,000 people, if you did better than any other health 
institution in the world, there would be thousands of people 
every single day who would say, ``I do not like what I am 
getting,'' and we have to put all of that in the context of the 
size of VA.
    Does VA, in general, provide good quality care to veterans? 
It is a simple question. The answer is that some people think 
that it provides a very good quality care. The American 
Customer Satisfaction Index ranks VA's customer satisfaction 
among veteran patients amongst the best in the country. And if 
you go out and you talk to veterans, generally speaking--I will 
tell you in Vermont--not 100 percent, but people say, yes, we 
get pretty good health care, not perfect. Are there problems? 
Absolutely, and we are going to talk about those problems.
    The National Commander of the Disabled American Veterans--
these are folks who are dealing with people who have service-
connected injuries, people who were hurt in war--said this 
before the Committee in February, ``Across the Nation, VA is a 
model health care provider that has led the way in various 
areas of biomedical research, specialized services, graduate 
medical education and training for all health professions, and 
the use of technology to improve health care.'' DAV went on to 
say, ``Such quality and expertise on veteran-specific health 
needs cannot be adequately replicated in the private sector.''
    The Paralyzed Veterans of America today will testify, ``The 
simple truth is, the VA is the best health care provider for 
veterans. In fact, VA's specialized services are incomparable 
resources that often cannot be duplicated in the private 
sector.''
    Today, the President of the National Association of State 
Directors of Veterans Affairs, representing all 50 States, will 
tell us, ``The state of VA health care in our Nation is 
strong.''
    Further--and here is another point that has to be made, and 
I know that it does not fit within a 12-second sound bite, but 
this is a point that has to be made--there is no question in my 
mind that VA health care has problems, serious problems. But, 
it is not the case that the rest of health care in America is 
just wonderful. Everybody who walks in, gets immediate care, 
gets great care at no cost, which is all affordable. That is 
not the world we live in. Let me give you one example of that, 
because it is important to put VA health care in context.
    A Scientific American article from September 20, 2013, less 
than a year ago, states, ``How many die from medical mistakes 
in U.S. hospitals? An updated estimate says it could be at 
least 210,000 patients a year, more than twice the number in a 
frequently quoted Institute of Medicine report.'' It goes on to 
summize that medical errors are now the third-leading cause of 
death in America, behind cancer and heart disease.
    What does that mean? Have deaths been reported through 
medical errors in the VA? The answer is, yes, and every one of 
those deaths is a shame and something we have got to address, 
but it is not just the VA. The third leading cause of death in 
America are medical errors in hospitals. That is an issue we 
have to address.
    Now, having said all of that, trying to put this debate in 
context, there is no doubt in my mind that there are serious 
problems facing VA health care and we have got to do everything 
we can to address those problems. Let me just discuss a few.
    Does the VA have adequate staffing? When we talk about 
patient wait times, which is a major concern in certain parts 
of the country--and this issue just came up the other day in 
Phoenix, where a town meeting was held by the American Legion--
the issue of wait times came up. Is the VA adequately staffed? 
Do we have enough doctors and nurses in various parts of the 
country? I do not know the answer to that, but that is 
something I want to find out.
    Further, is VA doing a good job in allocating its resources 
to where the staffing is needed most? There are some places in 
the United States where VA's load is going down, fewer people 
are coming in, other places where it is increasing. Are we 
allocating resources appropriately? And let us remember that in 
the midst of all of that, we are dealing with 200,000 men and 
women who have come back from Iraq and Afghanistan with PTSD 
and TBI, not easy problems to address.
    A few years ago VA changed their wait time measure to an 
ambitious 14 days. If you call up, you are going to get seen in 
14 days. Was that appropriate? Can they accommodate that with 
the level of staffing that they have? We need to discuss that. 
And, what happens at those facilities that are unable, in fact, 
to bring patients in within the 14-day period? Is it possible 
that, in some cases, unrealistic expectations have created a 
situation where some staff is, in fact, cooking the books? I 
want to look at that.
    So, I look forward to this hearing to get at the root of 
some of the health care problems facing VA, and with that, I 
want to give the microphone to Ranking Member Senator Burr.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Mr. Chairman. Thank you for 
calling this hearing.
    Secretary Shinseki, welcome, and to all the other witnesses 
today, thank you for your willingness to be here with us.
    The issue before the Committee today is the state of the VA 
health care system, which we have a sacred obligation to ensure 
that those who have fought for this Nation receive the highest 
quality of services from the Department of Veterans Affairs.
    Now, in the Chairman's opening remarks, he was correct. We 
are not here to analyze a poll that was taken about VA. But, we 
are here, rather, to look at the investigations that have 
already taken place and addressed certain deficiencies within 
the Veterans system that no action was taken on, or at least 
not corrective action.
    In fiscal year 2013, VA reported 93 percent of specialty 
and primary care appointments and 95 percent of mental health 
appointments were made within the 14 days of the patient's or 
provider's desired date. At first glance, these numbers appear 
to demonstrate veterans are receiving the care they want when 
they want it. However, we know this is not the case. I think if 
VA had asked hard questions regarding these statistics, we 
would not be here today discussing recent allegations 
surrounding many--and I stress, many--VA facilities.
    More specifically, we are here to discuss today when senior 
leadership in the Department became aware local VA employees 
were manipulating wait times to show that veterans do not wait 
at all for care. It seems that every day, there are new 
allegations regarding inappropriate scheduling practices, 
ranging from zeroing out patient wait times to scheduling 
patients in clinics that do not even exist, and even to booking 
multiple patients for a single appointment. The recent 
allegations were not only reported by the media, but have even 
been substantiated by the Government Accountability Office, the 
Inspector General's Office, and the Office of Medical 
Inspector.
    Here are a few examples. The GAO released a report on the 
reliability of reported outpatient medical appointment wait 
times and scheduling oversight in December 2012 and has 
testified multiple times on this issue. Several IG reports have 
been issued regarding delays in care and scheduling 
irregularities, including reports on Temple, Texas, in January 
2012, and up to the most recent and egregious report in 
September 2013 at the Columbia VA medical center. Two publicly 
released Office of Medical Inspector reports related to 
whistleblower allegations at Jackson VA medical center and the 
Fort Collins community-based outpatient clinics.
    Even more troubling is that with the numerous GAO, IG, and 
Office of Medical Inspector Reports that have been released, VA 
senior leadership, including the Secretary, should have been 
aware that VA was facing a national scheduling crisis. VA's 
leadership has either failed to connect the dots or failed to 
address this ongoing crisis, which has resulted in disability 
harm and in-patient death.
    The question we must answer today is, even with all the 
information available to the Secretary starting over a year and 
a half ago and specific instances of patient harm and death 
directly related to delays in care, why were the national 
audits and statements of concern from the VA only made this 
month?
    I thank the Chair. I yield back.
    [The prepared statement of Senator Burr follows:]
       Prepared Statement of Hon. Richard Burr, Ranking Member, 
                    U.S. Senator from North Carolina
    Good morning, Mr. Chairman. I would like to welcome all of today's 
witnesses and thank you for being here. The issue before the Committee 
today is the state of the VA healthcare system. We have a sacred 
obligation to ensure those who have fought for this Nation receive the 
highest quality of services from the Department of Veterans Affairs.
    In fiscal year 2013, for established patients, VA reported that 93 
percent of specialty and primary care appointments and 95 percent of 
mental health appointments were made within 14 days of the patient's or 
provider's desired date. At first glance, these numbers appear to 
demonstrate that veterans are receiving the care they want and when 
they want it. However, we know this is not the case. I think, if VA had 
asked hard questions regarding these statistics, we would not be here 
today discussing recent allegations surrounding many VA facilities.
    More specifically, we are here to discuss when senior leadership in 
the Department became aware that local VA employees were manipulating 
wait times to show that veterans do not wait at all for care. It seems 
that every day there are new allegations regarding inappropriate 
scheduling practices ranging from ``zeroing out'' patient wait times, 
to scheduling patients in clinics that do not even exist, and even to 
booking multiple patients for a single appointment.
    The recent allegations were not only reported by the media, but in 
some cases have even been substantiated by the GAO, IG, and the Office 
of the Medical Inspector. Here are a few examples:

     The GAO released a report on the reliability of reported 
outpatient medical appointment wait times and scheduling oversight in 
December 2012 and has testified multiple times on this issue.
     Several IG reports have been issued regarding delays in 
care and scheduling irregularities, including reports on Temple, TX, in 
January 2012, and up to the most recent and egregious report in 
September 2013 at the Columbia VA medical center.
     Two publicly released Office of the Medical Inspector 
reports related to whistleblowers' allegations at the Jackson VA 
medical center and the Fort Collins Community Based Outpatient Clinic.

    Even more troubling is that, with the numerous GAO, IG, and Office 
of the Medical Inspector reports that have been released, VA senior 
leadership, including the Secretary, should have been aware that VA was 
facing a national scheduling crisis. VA's leadership has either failed 
to connect the dots or failed to address this ongoing crisis, which has 
resulted in patient harm and even death.
    The question we must answer today is, even with all of the 
information available to the Secretary, starting over a year and a half 
ago, and specific instances of patient harm and death directly related 
to delays in care, why were the national audits and statements of 
concern from VA only made this month?

    I thank the Chair, and I yield back.

    Chairman Sanders. Thank you, Senator Burr.
    Senator Murray.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Well, thank you very much, Mr. Chairman. I 
am really glad you called this hearing.
    Like most Americans, I believe that when it comes to caring 
for our Nation's heroes, we cannot accept anything less than 
excellence. The government made a promise to the men and women 
who answered the call of duty, and one of the most important 
ways we uphold that is by making sure our veterans can access 
the health care they need and deserve.
    So, while the Department generally offers very high quality 
health care and does many things as well as or better than the 
private sector, I am very frustrated to be here once again 
talking about some deeply disturbing issues and allegations. It 
is extremely disappointing that the Department has repeatedly 
failed to address wait times for health care.
    So, I was encouraged when you announced a nationwide review 
of access to care and I am pleased the President is sending one 
of his key advisors, Rob Nabors, to assist in overseeing and 
evaluating that review. His perspective from outside the 
Department will make this review more credible and more 
effective.
    But, announcing this review is just the first step. These 
recent allegations are not new issues. They are deep, 
systemwide problems and they grow more concerning every day. 
When the Inspector General's report is issued and when the 
access report is given, I expect the Department to take them 
very seriously and to take all appropriate steps to implement 
their recommendations.
    But, there are also cases where the facts are in right now. 
There are problems we know exist, and there is no reason for 
the Department to wait until the Phoenix report comes back 
before acting on the larger problem.
    The GAO reported on VA's failures with wait times at least 
as far back as the year 2000. Last Congress, we did a great 
deal of work around wait times, particularly for mental health 
care. The Inspector General looked at these problems in 2005, 
2007, and again in 2012. Each time, they found schedulers 
across the country were not following VA policy. They also 
found in 2012 that VA has no reliable or accurate way of 
knowing if they are providing timely access to mental health 
care.
    But now, the IG recommendations are still open and the 
Department still has not implemented legislation I authored to 
improve this situation. Clearly, this problem has gone on far 
too long. It is unfortunate that these leadership failures have 
dramatically shaken many veterans' confidence in this system.
    Secretary Shinseki, I continue to believe you take this 
seriously and want to do the right thing, but we have come to 
the point where we need more than good intentions. What we need 
now is decisive action to restore veterans' confidence in VA, 
to create a culture of transparency and accountability, and to 
change the systemwide years' long problems. This needs to be a 
wake-up call for the Department.
    The lack of transparency and the lack of accountability is 
inexcusable and cannot continue. The practices of intimidation 
and cover-ups have to change, starting today. Giving bonuses to 
hospital directors for running a system that places priority on 
gaming the system and keeping their numbers down rather than 
providing care to veterans has to come to an end.
    But, Mr. Secretary, it cannot end with just dealing with a 
few bad actors or putting a handful of your employees on leave. 
It has to go much further and lead to systemwide change. You 
must lead the Department to a place where we prioritize the 
care our veterans receive above everything else. The culture at 
VA must allow people to admit where there are problems and ask 
for help from the hospital leadership, from the VISN 
leadership, or from you. This is the time to make real changes.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Murray.
    Senator Isakson.
    Senator Isakson. Well, thank you for calling the hearing, 
Mr. Chairman.
    Mr. Chairman, I would like to ask unanimous consent that 
the complete statement of Senator John Boozman be entered for 
the record.
    Chairman Sanders. Without objection.

    [The prepared statement of Senator Boozman appears in the 
Appendix.]

    Senator Isakson. And, also, our best wishes from the 
Committee for his speedy recovery from heart surgery.
    Chairman Sanders. Absolutely.
    Senator Burr. Mr. Chairman, could I ask unanimous consent 
that all Members' opening statements be included in the record.
    Chairman Sanders. Of course.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Dr. Petzel, Secretary Shinseki, thank you 
for being here today.
    The Chairman has said we should not rush to judgment, and 
that is always true, but we should have a rush to 
accountability. Even before Phoenix, even before Durham, even 
before some of the others--Cheyenne, Fort Collins, the others 
that have come to matter--we have already known and VA has 
admitted to at least 23 deaths that took place, in part because 
of delays in GI consults. Seven of those were in my area, two 
in North Florida, three in Augusta, GA, four in Atlanta, GA, at 
the VA Hospital in Atlanta, GA, all mental health issues.
    Dr. Petzel was in my State on August 22 of last year for a 
two-and-one-half hour hearing on the Atlanta situation, and we 
knew and determined then that it was problems with delays in 
setting appointments for mental health patients that caused an 
open period of time where, in fact, they took their life 
because of a failure to get the services they should have 
gotten.
    So, while we need to complete the IG's report and find out 
every problem where things are wrong, we have had 50 IG reports 
since 2013, and in those reports, we have found repeatedly, 
over and over again, where there has been a gaming of the 
system, where the system is more important than the patient. I 
think our veterans, and I think you, Secretary Shinseki, 
deserve better from the members of the Veterans Administration 
and the VA health system.
    I told you yesterday on the phone when you were generous 
enough to call and have a long discussion, I think the veterans 
and yourself have been misserved by the senior management of 
VA. We need accountability. What is going on in VA is not a 
mystery anymore. We will find out more from the IG's report. 
But, I would hope we would get an accountability in the chain 
of command at VA likened to the accountability of the chain of 
command in the U.S. Air Force when I was in the service, where 
you are held accountability for your responsibility, mistakes 
are not tolerated--one mistake might be tolerated, but the 
second mistake on the same decision should never be tolerated.
    I thank you for being here today. On behalf of all the 
veterans in Georgia and in the United States of America, let us 
get this right. Let us hold the system accountable. Let us make 
sure no veteran dies because of a failure of the system; and 
see to it they get appointments for the care they need when 
they need it.
    I yield back.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman, and thank you 
very, very much for holding this hearing, which I hope and 
believe will be bipartisan and as non-political as it possibly 
can be.
    Let me thank you, Secretary Shinseki, for your service to 
our Nation. Over many years, you have served and sacrificed for 
this Nation and I deeply respect and thank you for all you have 
given to the United States of America, including your 6 years 
as Secretary of VA. I know you are determined, as the President 
is determined, to unravel and reveal any wrongdoing, to remedy 
any damage, and to restore trust and confidence in VA's Health 
Care System.
    I agree with the Chairman that we should avoid a rush to 
judgment. But, we have more than allegations at this point. We 
have evidence, solid evidence of wrongdoing within the VA 
system, and it is more than an isolated instance of wrongdoing. 
It is a pattern and practice, apparently, of manipulating lists 
and gaming the system, in effect, cooking the books, creating 
false records, which is not just an impropriety or misconduct, 
it is potentially a criminal act. And it is a pattern, as the 
chart submitted by the American Legion as Addendum C shows. 
There is a pattern across the country, in more than ten States, 
of this misconduct occurring. In addition, there is a history. 
The GAO has reported and your own Inspector General has 
reported these kinds of problems in the past.
    So, there is a need now for more than just an 
investigation. There is a need for action to restore trust and 
confidence, to assure accountability and transparency. Our 
Nation's veterans deserve the best medical care, nothing less. 
The situation now presenting serious, pressing, unanswered 
allegations and uncertainty is intolerable.
    I have very severe and grave doubts that the resources now 
at the disposal of the Inspector General are sufficient to meet 
this challenge. I think there is a need for more than just the 
kind of appointment the President has made of Rob Nabors to 
oversee the Department of Veterans Affair's investigation. 
There is a need for resources going to the Inspector General 
and possibly involvement of other investigative agencies from 
the Federal Government, because the resources currently 
available to the Inspector General simply may be insufficient.
    In addition, there are 3,000 job openings across the 
country in VA. They are listed on USAJobs.gov. I urge that 
positions relevant to access to medical care be filled 
immediately and action be taken to restore not only the 
transparency and accountability we all expect from VA, but also 
to deal with the disability claims backlogs that continue to 
plague VA.
    The question now is, what does the evidence show? Is it 
criminal or simply civil? And that judgment has to be made as 
soon as possible.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Blumenthal.
    Senator Heller.

                STATEMENT OF HON. DEAN HELLER, 
                    U.S. SENATOR FROM NEVADA

    Senator Heller. Thank you, Mr. Chairman and Ranking Member 
Burr, for holding this hearing today.
    I want to thank the Secretary and Dr. Petzel for also being 
here. The other witnesses, thank you for taking time to be with 
us today. And also for the veterans that are in the room with 
us today, those that may be watching this hearing, thank you 
very much for your service.
    What has come to light about VA in recent months has proven 
to Congress, to veterans, and to the American people that there 
is a real problem with accountability at all levels within the 
Veterans Administration. Poor management and care from VA is 
also a problem that Nevada veterans are facing, and it is not 
something that is new, and, in fact, it is something I have 
raised repeatedly with VA to no avail. I believe it is long 
overdue for this Committee to exert its oversight and hold 
leadership within VA accountable.
    Just last week I sent a letter to Secretary Shinseki asking 
for immediate answers about the lack of accountability on the 
local level and whether VA leadership finally plans to do 
something about it. I look forward to receiving a timely 
response and action on the concerns that I highlighted.
    As Nevada's representative on this Committee, I believe it 
is also my role and responsibility to get answers for Nevada's 
veterans about the problems they are facing with VA care and 
benefits. In Las Vegas, veterans have complained of excessive 
wait times in the emergency room, which in itself is too small 
to meet demand. Just a month ago, the VA Inspector General 
investigated VA's treatment of a blind female veteran who 
waited over 5 hours in the emergency room and 2 weeks later 
died. The IG also found a quarter of the veterans in the 
emergency room wait over 6 hours before receiving care. 
Furthermore, a Las Vegas veteran wrote me a letter recently and 
said he had to find care elsewhere because the wait time for an 
appointment at VA was longer than 2 months.
    Given these concerns, as VA completes its face-to-face 
audits of VA facilities, I want assurance that all of Nevada's 
VA medical centers and clinics will be thoroughly audited and I 
will receive and be able to review the results immediately.
    As the Co-Chair of VA's Backlog Working Group, I am also 
extremely concerned with the claims backlog in Nevada. Although 
the Secretary promised me there would be changes, Nevada 
veterans are still waiting the longest, at 355 days, on 
average, for their claims to be processed. When my office 
requests the status of veterans' claims, the Reno VARO is 
unresponsive. It is unacceptable that local VA officials would 
limit any Congressional office's ability to get answers for 
their veterans constituents. Despite my repeated requests, 
these ongoing issues have not been resolved.
    At some point, I have to ask if these problems in Nevada 
are the demonstration of failed leadership at the top. VA 
leadership is not holding local officials accountable and is 
failing to care for those who sacrificed on our behalf. 
Promises to change and do better for our veterans have not 
produced results. I want changes. I do not want empty promises. 
If VA continues on this course, I think it is ultimately time 
to look to the top for these changes.
    Thank you, Mr. Chairman.
    Chairman Sanders. Well, thank you, Senator Heller.
    Senator Hirono.

                STATEMENT OF HON. MAZIE HIRONO, 
                    U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you, Chairman Sanders, for providing 
this forum for us to drill down to the roots of the many issues 
facing veterans hospitals and finding solutions to these 
problems.
    I certainly echo the sentiments of my colleagues in 
expressing concerns regarding VA culture, the lack of enough 
accountability, the probable need for structural and systemwide 
changes.
    The Veterans Health Care System is a promise we made to 
America's veterans--that we will take care of them in return 
for their service and sacrifice. The close to ten million 
veterans that access care through VA's system need to trust 
that they are receiving high-quality care when they need it. 
And I do note, ten million veterans signed up for this health 
care system is huge. That is greater than the population of a 
number of States, including the State of Hawaii.
    When we fail to provide proper care for our veterans, we 
not only fail them, but their families, as well, which these 
families have also sacrificed for our Nation's security and 
provide essential care and support for our veterans.
    While the immediate focus may be on the Phoenix case and 
similar allegations regarding a number of other VA hospitals, 
it is important to see what is happening systematically at VA 
to provide veterans high-quality care, and so we must look at 
the totality of the VA system to see what is working and what 
is not. I look forward to hearing from the panel about exactly 
what the challenges and problems are, what actions have been 
taken and need to be taken to serve our veterans better.
    And while the VA Inspector General is investigating and 
Secretary Shinseki has called for a national face-to-face audit 
of the VA Health System, my hope is that this is the first of a 
number of hearings by this Committee to identify other changes 
that should be implemented. I look forward to hearing from you 
once again, Mr. Secretary and the other VA officials, on your 
plans to resolve the underlying issues and restore confidence 
in the veteran community, and, very importantly, to listen to 
what the veterans' community has to say about the changes that 
need to be made.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Hirono.
    Senator Moran.

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you and Senator Burr for 
conducting this hearing.
    Mr. Secretary, good morning.
    I arrived a few minutes late this morning because I just 
returned from the World War II Memorial, where I visited with a 
Kansas Honor Flight group. I had conversations with Kansas 
veterans again this morning. It is a moving experience each and 
every time I have the opportunity to visit with our World War 
II veterans, and again, the conversation was about, ``VA is 
failing them. Please make certain, Senator Moran, that that 
does not continue.''
    Thousands of veterans across the country, but hundreds of 
veterans in Kansas visit with me on an ongoing basis and they 
tell me their struggling and suffering stories because of 
circumstances they find at the Department of Veterans Affairs. 
They would tell me about the sacrifice they encountered--if 
they were willing to say this less than humble sentence, they 
would ask, why can we not have the services we earned and 
deserve? And the reality is, they earned and deserve that 
service, and in my view, the Department of Veterans Affairs is 
not providing those worthy veterans what we have committed to 
do.
    The sad story is many veterans across the country, and 
certainly those Kansans that I speak to, have lost hope in the 
Department of Veterans Affairs and just believe things are 
never going to get any better.
    Your announcement of a face-to-face review across the 
system, Mr. Secretary, I find lacking in what needs to be done. 
The reality is we have had review after review, Inspector 
General report after Inspector General report, questions by 
this Committee and the House Veterans' Affairs Committee, that, 
as far as I can tell, has resulted in no action by the 
Department of Veterans Affairs.
    The idea that you can conduct a systemwide--as you indicate 
in your opening testimony--review of VA using 220 VA employees 
and visiting 153 medical facilities, Mr. Secretary--we have 
1,700 VA points of access to care, and you indicate in your 
testimony this will provide a full understanding of VA's 
scheduling policy and continued integrity in managing patient 
access to care. I do not see a review that lasts 2 weeks using 
220 employees and looking at 153 medical facilities as capable 
of providing that information. So, I would suggest this seems 
to me to be more damage control than solving the problem.
    I actually think we do not have the need for more 
information, although it is always welcome. What we need is 
action based upon the information that has already been 
provided to the Department of Veterans Affairs. I have served 
18 years on the Veterans' Affairs Committee. I have worked with 
nine Secretaries of Veterans Affairs. And what is seemingly 
true to me today is the quality of service and the timeliness 
of that service is diminishing, not increasing, and that was 
not true until recently.
    We have a significant number of veterans that we serve 
today, but, Mr. Secretary, we can anticipate more as our 
military men and women retire from service in Afghanistan and 
Iraq. We have an aging World War II veteran population. If we 
cannot care for the veterans we are trying to care for today, 
how do we expect the Department of Veterans Affairs to care for 
those as the numbers and seriousness of their condition 
increase?
    So, Mr. Secretary, I look forward to hearing what you have 
to say today. I welcome that conversation. But, in my view, an 
additional review by your Department is not the answer. The 
answer is action by the Department of Veterans Affairs that 
changes the system you are leading and that changes the culture 
and nature of the folks that are your employees.
    I look forward to your testimony. I look forward to making 
certain we keep our commitment to those who served our country.
    Thank you.
    Chairman Sanders. Thank you, Senator Moran.
    Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you very much, Mr. Chairman, for 
holding this meeting, and Ranking Member Burr, for offering an 
opportunity to have this discussion and oversight of VA and the 
issues surrounding scheduling, but also many other issues VA 
faces.
    Let me first say to our two panelists, thank you for your 
service to this country in both the ways that you have done.
    But, Secretary Shinseki, immediately after the Phoenix 
story broke, I sent a letter very quickly, because I was 
outraged. It was unbelievable what I was hearing. But after a 
few weeks, it has now become a systemic issue that I am now 
seeing in others, as you have indicated through the 
conversations that I have had with you, it seems to be an issue 
that is occurring in other VA clinics.
    I will say, from a State that has 77,000 veterans, the 
highest per capita in the Nation, it is impactful in 
determining where they get their care. We have been fortunate, 
to be very frank with you. The work we have done with VA to be 
able to create access to Indian Health Care Services which has 
been able to cut some of that wait time and get better services 
throughout the State. But when we look at veterans, may they be 
in Alaska today, tomorrow, they might be in Arizona. Tomorrow, 
they might be in North Carolina. So, it is critical that we 
figure out the systematic problem.
    I do agree with my colleagues here that we have report 
after report after report. I have been here now a little over 5 
years, and all I have seen is GAO reports and other reports 
that always indicate systematic problems we need to correct. 
So, I am going to be anxious for your commentary, as well as 
others, on how we are going to fix this once and for all.
    I know you have been burdened in some cases because we have 
had two wars and VA started to be funded aggressively in the 
last 3 or 4 years after we have already started to wind down in 
Iraq and now Afghanistan, which had caused a lot of pressure. 
So, I need to understand how that has impacted some of the work 
of VA.
    Also, as you look at the issues and you examine what we 
need to be doing, I want to know from your perspective, what 
things are we doing through more regulation or more laws that 
are creating more hurdles and red tape. If there is stuff that 
we should be eliminating to create a more streamlined process, 
I want to know that.
    But, to not have the service delivered at the highest level 
to our veterans is a disservice. They earned it. They fought 
for this country. They served our country. And we need to do 
everything we can to make sure the service is delivered at the 
highest possible level.
    So, today will be a little contentious, no question about 
it. I hope tomorrow, we take what we have learned today and 
move toward increased capacity and performance of VA.
    I thank you both for being here, but I will tell you, I was 
outraged and it is unbelievable what I have now seen over the 
last few weeks. Yet, I am anxious to work with you to get our 
veterans the best care possible, as we have started to do 
aggressively in Alaska. We have a very unique arrangement 
between Indian Health Care Services and VA, which I think is 
delivering better care than ever before; but more work is to be 
done.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Begich.
    Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Yes, thank you, Mr. Chairman, and Ranking 
Member Burr for convening this hearing. I want to thank the 
witnesses for being here--this panel and the next two.
    You know, as an elected official, the most meaningful and 
most difficult decision I confront is the question of sending 
men and women into harm's way, and Montanans tend to enlist in 
high numbers. We have the second highest per capita of veterans 
in our State. It is a very personal issue for me and it is why 
I am very proud to serve on this Committee.
    I am encouraged that folks in Washington are suddenly 
interested in access to health care for veterans. In most 
cases, that is long overdue. Before I got here, VA did not even 
have mandatory funding. They certainly did not have forward 
funding. So, this is a topic many of us have been trying to 
address for years.
    Given my close association with veterans issues, I am 
approached by veterans every time I go home, which is almost 
every weekend, and an overwhelming majority of those folks are 
appreciative of the care from VA in Montana. Yet when they have 
issues or concerns, they are not bashful, as veterans are not, 
about telling me about them. When I get back to my office on 
Monday, I work on those concerns, often with you two.
    The allegations they hear and the allegations I am hearing 
now are very troubling. If any of these allegations in Phoenix 
or elsewhere turn out to be true, swift and appropriate action 
needs to happen. If the issues are systemic, we need to make 
some fundamental changes and we need to make them now. If the 
issues are about employees' misconduct and incompetence, 
specific heads should roll.
    Now, in order to move forward effectively and smartly, we 
do need the facts. I hope we get those today, in part. And, if 
we are truly interested in honoring our veterans by doing them 
right, the facts will drive a productive conversation about 
access to health care for our veterans.
    So, let us talk about ways we can address VA medical 
workforce shortfalls, particularly in rural areas. Let us talk 
about ways we can improve transportation options for veterans 
or expanding telemedicine initiatives. Let us talk about 
buildings and partnerships between VA's local providers and 
providing VA with the resources it needs to address its patient 
workloads. Let us have these conversations so we can provide 
veterans with meaningful action items, not just political 
talking points.
    Veterans deserve our best. They have sacrificed much. Let 
us demonstrate our best by having a productive, constructive, 
truthful conversation about what needs to be done to fix the 
problems out there in our VA.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Tester.
    Senator McCain of Arizona is not a Member of this 
Committee, but given that very serious allegations have been 
raised about treatment in Phoenix, Senator McCain requested to 
come before the Committee and we welcome him today. Senator.

                STATEMENT OF HON. JOHN McCAIN, 
                   U.S. SENATOR FROM ARIZONA

    Senator McCain. I thank you, Mr. Chairman. I want to thank 
you for the opportunity to make a brief statement this morning, 
particularly given that many of the serious allegations that 
will be discussed at today's hearing involve the treatment of 
veterans in my homestate of Arizona.
    Since our Nation's founding, Americans have been fighting 
in far away places to make this dangerous world safer for the 
rest of us. They have been brave. They have sacrificed and 
suffered. They bear wounds from war losses they will never 
completely recover from and we can never fully compensate them 
for. But, we can care for the injuries they suffered on our 
behalf and for their physical and emotional recovery from the 
battles they fought to protect us.
    Decent care for our veterans is the most solemn obligation 
a nation occurs, and we will be judged by God and history how 
well we discharge ours.
    That is why I am deeply troubled by the recent allegations 
of gross mismanagement, fraud, and neglect at a growing number 
of VA medical centers across the country. It has been more than 
a month since allegations that some 40 veterans died while 
waiting for care at the Phoenix VA were first made public. To 
date, the Obama administration has failed to respond in an 
effective manner. This has created in our veterans' community a 
crisis of confidence toward VA, the very agency that was 
established to care for them.
    At a town hall forum I hosted in Phoenix last week, the 
families of four veterans who passed away in recent months 
stood before a crowded room to tell their stories. With tears 
in their eyes, they described how their loved ones suffered 
because they were not provided the care they needed and 
deserved. They recalled countless unanswered phone calls and 
ignored messages, endless wait times, mountains of bureaucratic 
red tape, while their loved ones suffered debilitating and 
ultimately fatal conditions.
    No one should be treated this way in a country as great as 
ours. But, treating those to whom we owe the most so callously, 
so ungratefully, is unconscionable. We should all be ashamed.
    Since the initial reports in Arizona last month, we have 
seen this scandal go nationwide, surfacing in at least ten 
States across America. Secretary Shinseki has ordered a 
nationwide audit to look at the management practices at VA 
medical centers. Several employees have been placed on 
administrative leave. And, the VA Office of Inspector General 
is investigating the Phoenix VA.
    I respect the important role of the Inspector General, but 
my fellow veterans cannot wait the many months it may take it 
to complete its report. They need answers, accountability, and 
leadership from this administration and Congress now.
    Clearly, VA is suffering from systemic problems in its 
culture that require strong reform-minded leadership and 
accountability to address. At the same time, Congress must 
provide VA administrators with greater abilities to hire and 
fire those charged with caring for our veterans. Most 
importantly, we must give veterans greater flexibility in how 
they get quality care in a timely manner rather than continue 
to rely on a Department that appears riddled with systemic 
problems in delivering care.
    How we care for those who risked everything for us is the 
most important test of a Nation's character. Today, we are 
failing that test. We must do better tomorrow, much better.
    For the nine million American veterans enrolled in VA today 
and for the families whose tragic stories we heard last week in 
Phoenix, who I know are still grieving their losses, it is time 
we live up to President Lincoln's injunction, which serves as 
VA's model today--to care for him who shall have borne the 
battle and for his widow and his orphan.
    As I said, it is time for answers, accountability, and 
leadership from this administration, and I look forward to 
hearing from Secretary Shinseki.
    I thank you, Mr. Chairman, and I thank Ranking Member Burr 
and the Members of this Committee.
    [The prepared statement of Senator McCain follows:]
                Prepared Statement of Hon. John McCain, 
                       U.S. Senator from Arizona
    Thank you, Mr. Chairman. I want to thank you for the opportunity to 
make a brief statement this morning, particularly given that many of 
the serious allegations that will be discussed at today's hearing 
involve the treatment of veterans in my home state of Arizona.
    Since our Nation's founding, Americans have been fighting in 
faraway places to make this dangerous world safer for the rest of us. 
They have been brave. They have sacrificed and suffered. They bear 
wounds and mourn losses they will never completely recover from--and we 
can never fully compensate them for. But, we can care for the injuries 
they suffered on our behalf, and for their physical and emotional 
recovery from the battles they fought to protect us. Decent care for 
our veterans is among the most solemn obligations a nation incurs, and 
we will be judged by God and history by how well we discharge ours.
    That is why I am so deeply troubled by the recent allegations of 
gross mismanagement, fraud and neglect at a growing number of Veterans 
Administration medical centers across the country.
    It has been more than a month since allegations that some 40 
veterans died while waiting for care at the Phoenix VA were first made 
public. To date, the Obama Administration has failed to respond in an 
effective manner. This has created in our veterans' community a crisis 
of confidence toward the VA--the very agency that was established to 
care for them.
    At a town hall forum I hosted in Phoenix last week, the families of 
four veterans who passed away in recent months stood before a crowded 
room to tell their stories. With tears in their eyes, they described 
how their loved ones suffered because they were not provided the care 
they needed and deserved. They recalled countless unanswered phone 
calls and ignored messages, endless wait times, mountains of 
bureaucratic red tape while their loved ones suffered debilitating and 
ultimately fatal conditions. No one should be treated this way in a 
country as great as ours. But treating those to whom we owe the most so 
callously--so ungratefully--is unconscionable, and we should all be 
ashamed.
    Since the initial reports in Arizona last month, we've seen this 
scandal go Nation-wide, surfacing in at least 10 states across America.
    Secretary Shinseki has ordered a nationwide audit to look at the 
management practices at VA medical centers; several employees have been 
placed on administrative leave; and the VA Office of Inspector General 
is investigating the Phoenix VA.
    I respect the important role of the Inspector General, but my 
fellow veterans can't wait the many months it may take to complete its 
report. They need answers, accountability and leadership from this 
Administration and Congress now.
    Clearly, the VA is suffering from systemic problems in its culture 
that require strong, reform-minded leadership and accountability to 
address. At the same time, Congress must provide VA administrators with 
greater ability to hire and fire those charged with caring for our 
veterans. Most importantly, we must give veterans greater flexibility 
in how they get quality care in a timely manner, rather than continue 
to rely on a department that appears riddled with systemic problems in 
delivering care.
    How we care for those who risked everything for us is the most 
important test of a Nation's character. Today, we are failing that 
test. We must do better tomorrow--much better.
    For the 9 million American veterans enrolled with he VA today, and 
for the families whose tragic stories we heard last week in Phoenix, 
who I know are still grieving their losses, it's time we live up to 
Lincoln's injunction, which serves as the VA's motto today, quote, ``to 
care for him who shall have borne the battle and for his widow, and his 
orphan.''
    As I said before, it's time for answers, accountability and 
leadership from this Administration, and I look forward to hearing from 
Secretary Shinseki. I thank Chairman Sanders, Ranking Member Burr, and 
the Members of the Committee.

    Chairman Sanders. Thank you, Senator McCain.
    I would like to now welcome Retired U.S. Army General Eric 
K. Shinseki, Secretary of Veterans Affairs, to the first panel. 
As I think most people know, Secretary Shinseki is a graduate 
of West Point, served as the Chief of Staff for the Army from 
1999 to 2003. He retired from active duty in 2003, after nearly 
40 years in the U.S. Army.
    Following the September 11, 2001, terrorist attacks against 
our country, Secretary Shinseki led the Army during Operations 
Enduring Freedom and Iraqi Freedom. He previously served 
simultaneously as Commanding General, U.S. Army Europe, and 
Seventh Army Commanding General, NATO Land Forces, Central 
Europe, and Commander of the NATO-led Stabilization Force, 
Bosnia-Herzegovina.
    I want to also note a few of the many awards Secretary 
Shinseki received during his career: The Defense Distinguished 
Service Medal, the Legion of Merit with Oak Leaf Clusters, the 
Bronze Star Medal with ``V'' Device with two Oak Leaf Clusters, 
and the Purple Heart with Oak Leaf Clusters.
    Mr. Secretary, thank you very much for being with us today.
    Secretary Shinseki is accompanied by Dr. Robert Petzel, who 
is the Under Secretary for Health.
    Mr. Secretary, your prepared remarks will be submitted for 
the record. What I would like to do now is, if both of you 
could rise and take the oath.
    Do you solemnly swear or affirm that the testimony you are 
about to give before the Senate Committee on Veterans' Affairs 
will be the truth, the whole truth, and nothing but the truth, 
so help you God?
    Secretary Shinseki. I do.
    Dr. Petzel. I do.
    Chairman Sanders. Thank you very much. Please be seated.
    Mr. Secretary and Dr. Petzel, the floor is yours.

STATEMENT OF HON. ERIC K. SHINSEKI, SECRETARY, U.S. DEPARTMENT 
  OF VETERANS AFFAIRS; ACCOMPANIED BY ROBERT A. PETZEL, M.D., 
                   UNDER SECRETARY FOR HEALTH

    Secretary Shinseki. Chairman Sanders, thank you very much 
for that more than generous introduction. To you and Ranking 
Member Burr and the Members of this Committee, thank you for 
this opportunity to discuss the state of VA health care.
    I have been taking oaths most of my life, Mr. Chairman, so 
I--whenever I appear before this Committee, whether I am sworn 
or not, you have my best answers based on what I know, as 
truthful a presentation as I can make.
    I deeply appreciate your unwavering support for our 
Nation's veterans. That has been true for 5 years, now, that I 
have worked with Members of this Committee.
    Mr. Chairman, I would also like to recognize that in the 
room here are others with whom I have worked very closely for 5 
years developing good dialog, good collaboration. They have 
been very helpful in shaping what we thought was the priority 
in the Department of Veterans Affairs, and they have been good 
strong relationships, and I thank them for their partnership. I 
know some of them will be testifying before you today. In those 
cases where we have not always seen eye to eye, we have always 
managed to find common ground on behalf of veterans, and I 
expect we will do that again.
    We at VA are committed to consistently providing our 
veterans the high-quality care, timely benefits, and safe 
facilities necessary to improve their health and well being. 
This commitment mandates a continuous effort to improve quality 
and safety. America's veterans deserve nothing less. Our 
quality and safety meet high standards and veterans should feel 
safe using VA health care.
    That said, in health care, Mr. Chairman, as you point out, 
there are always areas in need of improvement. Any allegation 
about patient care or employee misconduct are taken seriously.
    And, based on the background you just described that I 
followed most of my life--38 years in uniform--and I now have 
this great privilege of being able to care for people I went to 
war with many years ago people I have sent to war, and people 
who raised me in the profession when I was a youngster.
    Any allegation, any adverse incident like this makes me--
makes me mad as hell. I could use stronger language here, Mr. 
Chairman, but in deference to the Committee, I will not. But, 
at the same time it also saddens me, because I understand that 
out of those adverse events a veteran and a veteran's family is 
dealing with--the aftermath--and I always try to put myself in 
their shoes.
    In response to allegations about manipulation of 
appointment scheduling at Phoenix, I am committed to taking all 
actions necessary to identify exactly what the issues are, to 
fix them, and to strengthen veterans' trust in VA health care.
    First, the Office of the Inspector General, as many of you 
have pointed out, is now conducting a thorough and timely 
review. If any of these allegations are true with regard to 
scheduling at Phoenix and elsewhere, where we have invited the 
IG to come and look at issues that surfaced--if any allegations 
are true they are completely unacceptable to me, to veterans. 
And I will tell you, the vast majority of dedicated VHA 
employees come to work every day to do their best by those 
veterans. If any are substantiated by the Inspector General, we 
will act. And I take Senator Murray's encouragement here to do 
something different, and Senator, I will. It is important, 
however, to allow the Inspector General to complete his duty, 
which is to conduct an objective review and provide us the 
results.
    Second, I have directed VHA, as some of you have noted, to 
complete a nationwide access review of all other health care 
facilities to ensure full compliance with our scheduling 
policy. As we have begun that, we have already received reports 
where compliance is under question, so we have asked the IG in 
a number of those cases to also take a look.
    Third, I have asked for and received the assistance from 
President Obama. The President has agreed to let his Deputy 
Chief of Staff for Policy, Rob Nabors, assist us in our review 
of these allegations and in any other issues we may find during 
these reviews. We start with scheduling, but we will go 
wherever the reviews take us.
    Rob is a fresh set of eyes. He is the son of a veteran and 
he is a proven performer who brings broad and significant 
management experience to this task. I welcome his assistance. I 
have known the Nabors family for a long time. Rob's dad and I 
served together for many years; I know his mom and dad well, 
and I welcome the assistance of Rob Nabors.
    Even as we take these proactive measures, it is important 
to remember that VHA conducted approximately 85 million 
outpatient clinic appointments last year. As a large integrated 
health care system, VHA operates, as has been noted, over 1,700 
points of care, including 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 attempting to reach the most remote of 
our veterans. This is a demonstration of concern by this 
Department, trying to make sure that every veteran, no matter 
where they live in this country, and even our overseas 
locations, have an equal opportunity to have access to quality 
health care.
    As the Chairman has noted, VHA conducts approximately 
236,000 appointments every day. Over 300,000 VHA employees 
provide exceptional care to the 6.5 million veterans and other 
beneficiaries annually. VA health care is comparable to that in 
the private sector, meeting or exceeding standards in many 
areas. We always endeavor to be fully transparent, fostering a 
culture that reports and evaluates errors in order to avoid 
repeating them.
    Every VA medical facility is accredited by the Joint 
Commission, the independent organization that assures the 
quality of U.S. health care through comprehensive evaluations. 
In 2012, the Joint Commission recognized 19 VA hospitals as 
among its top performers and last year that number increased to 
32.
    Additionally, as the Chairman has pointed out, the most 
recent American Customer Satisfaction Index ranks VA customer 
satisfaction among the best in the Nation, equal to or better 
than the ratings for private sector hospitals. An overwhelming 
95-96 percent of veterans who use VA health care today 
indicated they would use us again the next time they needed 
inpatient care, 96 percent; and 95 percent for outpatient care. 
I want them to continue to have that level of trust.
    Veterans deserve to have full faith in their VA. VHA is 
committed to a process of full and open disclosure to veterans 
and their families whenever any adverse event occurs. We 
participate in multiple external independent reviews every year 
to ensure the safety and quality of health care. VA will 
continue to aggressively develop and sustain reliable systems 
and train employees to detect and prevent health care incidents 
before they happen. I have detailed some of our many 
significant health care accomplishments of VHA over the past 5 
years in my written testimony.
    I appreciate the hard work and dedication of VA employees, 
our partners from the veterans service organizations, as I 
indicated, in this room, community stakeholders, many of whom 
we deal with on a daily basis, and then our dedicated VA 
volunteers. I deeply respect the important role that Congress 
and the Members of this Committee play in serving our veterans, 
and I look forward to continuing our work with Congress to 
better serve them all.
    Again, Mr. Chairman, thank you for the opportunity to 
appear here today.
    [The prepared statement of Secretary Shinseki follows:]
        Prepared Statement of Hon. Eric K. Shinseki, Secretary, 
                  U.S. Department of Veterans Affairs
    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
the Senate Committee on Veterans' Affairs. Thank you for the 
opportunity to discuss with you the Department of Veterans Affairs (VA) 
healthcare system. We, at VA, are committed to consistently providing 
the high quality care our Veterans have earned and deserve in order to 
improve their health and well-being. We owe that to each and every 
Veteran that is under our care.
    It is important to understand the size and scope of VA care--the 
largest integrated healthcare delivery system in the United States.
    The Veterans Health Administration (VHA) operates over 1,700 points 
of care, including 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. VHA 
conducts approximately 236,000 health care appointments--each day--and 
approximately 85 million appointments each year. Over 300,000 VHA 
leaders and health care employees strive to provide exceptional care to 
approximately 6.485 million Veterans and other beneficiaries annually.
    VA provides safe, effective healthcare, equal to or exceeding the 
industry standard in many areas. We care deeply for every Veteran we 
have the privilege to serve. VA is committed to operating with 
unmatched transparency and fostering an environment that reports and 
evaluates errors in order to avoid repeating them in the future; one of 
our most important priorities is to keep our patients safe in our 
facilities.
    That said, there are always areas that need improvement. We can, 
and we must do better. VA takes any allegations about patient care or 
employee misconduct very seriously. I am personally angered and 
saddened by any adverse consequence that a Veteran might experience 
while in, or as a result of, our care.
    In response to allegations about scheduling and delays at the 
Phoenix VA Health Care System (PVAHCS), I invited an independent 
investigation by the VA Office of Inspector General (OIG) to conduct a 
comprehensive, thorough and timely review. If these allegations are 
true, they are completely unacceptable--to Veterans, to me, and to our 
dedicated VHA employees. If they are substantiated by OIG, responsible 
and timely action will be taken.
    It is important to allow OIG's independent and objective review to 
proceed until completion, and OIG has advised VA against providing 
information that could potentially compromise their ongoing review. 
However, at the request of OIG, I have placed three PVAHCS employees on 
administrative leave until further notice, including two senior 
executives.
    We will work with OIG to ensure that the need to keep the public 
informed is balanced with our obligation to preserve the integrity of 
an important OIG investigation I have also directed VHA to complete a 
nationwide access review. The purpose of this review is to ensure a 
full understanding of VA's scheduling policy and continued integrity in 
managing patient access to care.
    Veterans deserve to have full faith in their VA. Any adverse event 
for a Veteran within our care is one too many. Where challenges occur, 
VA takes direct action to review each incident, and puts in place 
corrections to improve system issues and quality of care provided. We 
hold employees accountable for any misconduct; we incorporate lessons 
learned to avoid and mitigate future incidents throughout the entire 
healthcare system. VHA's first priority is to notify the Veteran or 
their representative of the adverse event, as well as the patient's 
rights and recourses.
    VHA is committed to a process of full and open disclosure to 
Veterans and their families. We participate in multiple external, 
independent reviews every year to ensure safe and quality healthcare. 
VA will continue to develop and sustain reliable systems and train 
employees to prevent and detect avoidable harms before they happen. 
When this does not happen, we act to take necessary corrective actions 
in order to restore the confidence and trust in the system that serves 
so many.
                            quality of care
    Every year, our dedicated VA employees, many of whom are Veterans 
themselves, provide 6.3 million Veterans with the excellent care they 
have earned and deserve. VA provides a broad range of primary care, 
specialty care, and related medical and social support services. We 
have established a record of safe, exceptional care that is 
consistently recognized by independent reviews, organizations, and 
experts on key health care quality measures. Every VA medical facility 
is accredited by The Joint Commission, the independent, non-profit 
organization that ensures the quality of U.S. healthcare by its 
intensive evaluation of more than 20,000 healthcare organizations. In 
2012, The Joint Commission, recognized 19 VA hospitals as top 
performers, and that number increased to 32 in 2013.
    The American Customer Satisfaction Index (ACSI) is the Nation's 
only cross-industry measure of customer satisfaction, providing 
benchmarking between the public and private sectors. In their most 
recent, independent customer service survey, ACSI ranks VA customer 
satisfaction among the best in the Nation--equal to or better than 
ratings for private sector hospitals.
    Since 2004, on average, the ACSI survey has consistently shown that 
Veterans give VA hospitals and clinics a higher customer satisfaction 
score than patients give private sector hospitals. Veterans strongly 
endorsed VA healthcare, with 91 percent offering positive assessments 
of inpatient care and 92 percent for outpatient care.
    Additionally, when asked if they would use a VA medical center the 
next time they need inpatient or outpatient care, Veterans 
overwhelmingly indicated they would (96 and 95 percent, respectively).
    Of our over 300,000 employees in the VA healthcare system, our 
medical providers and appointment scheduling personnel were considered 
highly courteous with scores of 92 and 91, respectively, while VA 
medical providers ranked high in professionalism (90 percent positive). 
Despite these and other favorable statistics, we know that we can 
always improve.
                     improving and expanding access
    The number of Veterans receiving VA benefits and services has grown 
steadily and is projected to continue to rise as ongoing conflicts end 
and more Servicemembers transition to Veteran status. In 2015, the 
number of patients treated within VA's healthcare system is projected 
to reach 6.7 million, an increase of nearly one million patients (17.4 
percent) since 2009.
    VA continues to improve access to VA services by opening new 
facilities and points of care, and improving current facilities and 
points of care closer to where Veterans live. Since January 2009, we 
have added approximately 55 community-based outpatient clinics (CBOC), 
for a total of 820 CBOCs, and the number of mobile outpatient clinics 
and Mobile Vet Centers, serving rural Veterans, has increased by 21, to 
the current level of 79.
    While opening new and improved facilities is essential for VA to 
provide world-class healthcare to Veterans, so too is enhancing the use 
of ground breaking new technologies to reach other Veterans. VA 
continues to invest in ``bringing care to the Veteran''--through 
expanded access to telehealth, sending Mobile Vet Centers to reach 
Veterans in rural areas, and by deploying social media to share 
information Veterans on the VA benefits they have earned.
    VA is using innovative telehealth primary care services to overcome 
geographic access barriers and improve the efficiency of care to rural 
areas. In fiscal year (FY) 2013, VHA provided more than 1.7 million 
episodes of care to 608,900 Veterans through telehealth services 
linking 151 VAMCs and 650 CBOCs, as well as by connecting via 
telehealth with 146,804 Veterans in their own homes, of which 2,284 
were via video. The scope of VA's telemental health services includes 
all mental health conditions with a focus on Post Traumatic Stress 
Disorder (PTSD), depression, bipolar disorder, behavioral pain, and 
evidence-based psychotherapy.
    VHA is aggressively working to increase Veterans' access to high 
quality care. While we are progressing in delivering timely care to our 
Veterans and improving the reliability of reporting wait time 
information, VA is committed to honoring America's Veterans and there 
are a number of ongoing and future actions to improve wait times:

     No measure of wait times is perfect. However, with 
evidence from VHA's 2012 wait time study, ongoing VHA performance 
measures, as well as findings and recommendations from others, VHA's 
action plan is designed to ensure the integrity of wait time 
measurement data collected from our access points of care;
     VHA is constantly evaluating access and scheduling 
policies and technologies, and aggressively monitors reliability 
through oversight and audits;
     We have implemented much of this plan, and we are working 
to implement the remainder of the plan in the next 12 months. VHA has 
also instituted site visits to audit patient access to care using the 
electronic wait list.

    Today, Veterans experience primary care at VA differently than they 
did five years ago. VA's Patient Aligned Care Teams (PACT), the model 
for more personalized and team based primary care delivery, is 
improving both access to healthcare and Veteran satisfaction. Patients 
are assigned a PACT team that to help coordinate and personalize their 
care.
    Since its inception in 2010, the PACT program has transformed the 
way Veterans receive their care by offering a coordinated team approach 
squarely focused on Veterans' wellness and disease prevention. PACTs 
provide the right combination of healthcare professionals to develop 
personalized health plans for Veterans and conveniently deliver care at 
primary care clinics with a goal of personalized, proactive and 
patient-driven care. Veterans are also communicating with healthcare 
professionals through secure electronic means with increasing frequency 
as services are available. Despite the increase of primary care 
patients, access to primary care has improved and continuity of care is 
better. Veteran access to primary care during extended, non-business 
hours has increased 75 percent since January 2013.
               improving access to mental health services
    After numerous military operations over almost 13 years, the state 
of Servicemembers' and Veterans' mental health is a national priority. 
Meeting the individual mental health needs of Veterans is more than a 
system of comprehensive treatments and services; it is a philosophy of 
ensuring that Veterans receive the best mental healthcare possible, 
while focusing on the overall well-being of each Veteran. VA remains 
committed to doing all we can to meet this challenge.
    Through the strong leadership of the President and the support of 
Congress, Veterans' access to mental healthcare has significantly 
improved. Since 2006, the number of Veterans receiving specialized 
mental health treatment has risen from 927,000 to more than 1.3 million 
in 2013. Vet Centers are another avenue for mental healthcare access, 
providing services to 195,913 Veterans and their families in 2013.
    Since March 2012, VA has added over 2,000 Mental Health 
professionals--exceeding requirements in the President's August 31, 
2012 Executive Order to improve access to mental healthcare for 
Veterans, Servicemembers, and military families. VA has also hired 915 
peer specialists, exceeding the goal of 800, to augment the work of 
those clinicians.
    We proactively screen all Veterans for PTSD, depression, Traumatic 
Brain Injury, substance abuse, and military sexual trauma to identify 
issues early and provide treatments and intervention opportunities. We 
know that when we diagnose and treat people, they get better.
    VA is a pioneer in mental health research and high-quality, 
evidence-based treatments. We strive to maintain and improve the mental 
health and well-being of today's Veterans through excellence in 
healthcare, social services, education, and research. In the last three 
years, VA has devoted additional people, programs, and resources toward 
mental health services to serve the growing number of Veterans seeking 
mental healthcare.
    We are developing new measures to gauge mental healthcare 
effectiveness, including timeliness, patient satisfaction, capacity, 
and availability of evidence-based therapies. We are working with the 
National Academy of Sciences to develop and implement measures and 
corresponding guidelines to improve the quality of mental healthcare. 
To help VA clinicians better manage Veteran patients' mental health 
needs, VA is developing innovative electronic tools. Clinical reminders 
give clinicians timely information about patient health maintenance 
schedules, and the High-Risk Mental Health National Reminder and Flag 
system allows VA clinicians to flag patients who are at-risk for 
suicide. When an at-risk patient does not keep an appointment, clinical 
reminders prompt the clinician to follow up with the Veteran.
    Since its inception in 2007, the VA's Veterans' Crisis Line (1-800-
273-TALK (8255), press 1) in Canandaigua, New York, answered nearly 
1,000,000 calls and responded to more than 143,000 texts and chat 
sessions from Veterans in need. The Veterans' Crisis line provides 24/7 
crisis intervention services and personalized contact between VA staff, 
peers, and at-risk Veterans, which may be the difference between life 
and death.
    In the most serious calls, approximately 35,000 men and women have 
been rescued from a suicide in progress because of our intervention--
the rough equivalent of two Army divisions. VA offers expanded access 
to mental health services with longer clinic hours, telemental health 
capability to deliver services, and standards that mandate rapid access 
to mental health services.
                      ending veteran homelessness
    VA is committed to ending Veteran homelessness in 2015. No one who 
has served our country should ever go without a safe, stable place to 
call home. VA's programs provide individualized, comprehensive care to 
Veterans who are homeless or at risk of becoming homeless. Veterans' 
homelessness fell by 24 percent between 2010 and 2013, and we expect 
another reduction when this year's point-in-time counts released. Last 
year, VA helped more than 42,000 Veterans find permanent housing and 
awarded about $300 million in grants to our community partners for 
supportive services for Veteran families. Nearly 260,000 Veterans and 
family members were served through VA's specialized homeless programs 
in FY 2013.
                    other healthcare accomplishments
    President Obama signed the ``Caregivers and Veterans Omnibus Health 
Services Act of 2010,'' into law which helps our most seriously injured 
post-9/11 Veterans and their family caregivers with a monthly stipend, 
access to health insurance, mental health services and counseling, and 
comprehensive VA caregiver training. To date, more than 16,800 
caregivers have been trained to care for our most seriously injured 
post-9/11 Veterans. VA also has a Caregiver Support Coordinator 
stationed at every VA medical center, as well as a national Caregiver 
Support Line (1-800-260-3274) and Web site (www.caregiver.va.gov) to 
provide support and resources to Caregivers of Veterans from all eras.
    VA initiated a multi-faceted approach to reduce the use of opioids 
among America's Veterans using VA healthcare, seeking to reduce harm 
from unsafe medications and/or excessive doses while adequately 
controlling Veterans' pain. To achieve this, VHA has established nine 
goals for safe, evidence-based, Veteran-centric pain care as part of 
VHA's Opioid Safety Initiative (OSI). Launched in October 2013, in 
Minneapolis, OSI is already successful in lowering dependency on these 
drugs. At eight sites of care in Minnesota, OSI practices have 
decreased high-dose opioid use by more than 50 percent.
    OSI places an emphasis on patient education, close patient 
monitoring with frequent feedback, and Complementary and Alternative 
Medicine practices like acupuncture. These join pain management 
guidelines encourage the use of other medications and therapies in lieu 
of habit forming opiates. OSI is an example of VHA's personalized, 
proactive and patient-centered approach to healthcare through an 
innovative and comprehensive plan that monitors dispensing practices 
system-wide, includes patient and provider education, testing and 
tapering programs, and alternative therapies like behavior therapy.
                                summary
    These accomplishments are the results of VA's focus over the past 
five years--during which time we have worked to increase Veterans' 
access to high quality healthcare, education and training, and 
employment opportunities in both the public and private sectors. There 
is always more work to do, and VA is focused on continuous improvement 
to the care we provide to our Nation's Veterans.
    I appreciate the hard work and dedication of VA employees, our 
partners from Veterans Service Organizations--important advocates for 
Veterans and their families--our community stakeholders, and our 
dedicated VA volunteers. I also respect the important role Congress and 
the dedicated Members of this Committee play in serving our Veterans, 
and I look forward to continuing our work with Congress to better serve 
them all. Again, thank you for the opportunity to appear before you 
today and for your unwavering support of those who have served this 
great Nation in uniform.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
 Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs
    VA has been actively downgrading--that is changing the GS-pay scale 
for employees downward for the same job they currently have; same job, 
same service to VA but with lower pay and promotion potential. These 
have devastating effects on morale, recruitment, and retention.
    Question 1. The position of ``Scheduling Clerk'' is one of the 17 
VA is considering downgrading. These are the employees in charge of 
wait lists. Has VA reconsidered its policy of downgrading or done any 
analysis on the effect that downgrading employees has on VA 
performance?
    Response. Title 5, United States Code, Chapter 51 governs the 
classification of positions in the Federal service. This law states 
that positions shall be classified based on the duties and 
responsibilities assigned and the qualifications required to do the 
work. Section 5104 of Title 5 provides definitions for the grade levels 
of the General Schedule.
    The law requires the Office of Personnel Management (OPM) to define 
(via regulations) Federal occupations, establish official position 
titles, and describe the grades of various levels of work. To fulfill 
this responsibility, OPM approves and issues position classification 
standards that must be used by agencies to determine the Title, series, 
and grade of positions covered by Title 5.
    In order to comply with OPM's Regulations, VA must review and 
possibly reclassify multiple VA positions within 17 occupational 
series, which may include changing some positions to a lower grade. VA 
must do this to ensure employees are classified in accordance with 
governmentwide OPM standards, and they are receiving equal pay for 
equal work. Employees impacted by this decision will not experience a 
decrease in their existing rate of pay, as they are protected by grade 
and pay regulations. However, VA recognizes that future earning 
potential may be affected and we will work with employees, union 
partners, and other key stakeholders to identify ways to mitigate any 
adverse effects where appropriate.
    The majority of positions performing patient scheduling duties as a 
major duty of their work time (25 percent or more) are excluded from 
this Title 5 classification review and will not be impacted by the 
reclassification of positions within the 17 occupational series. These 
positions are covered by the GS-0679 Medical Support Assistant Series. 
This series was converted to hybrid Title 38 coverage on July 1, 2012, 
and is no longer subject to Title 5 classification laws, rules, and 
regulations. VA currently has approximately 16,000 employees assigned 
to this series with over 15,000 at the GS-5 to GS-12 levels. While the 
review of the 17 occupational series positions may include positions 
performing patient scheduling duties, these duties would represent a 
minor duty in the overall composition of work assigned to the position. 
During the review, if a position is identified as performing scheduling 
work as a major duty, it will be reviewed critically for conversion to 
the GS-0679 Medical Support Assistant Series.
    While the position of ``Scheduling Clerk'' is not specifically 
listed as one of the 17 occupational groups targeted for consistency 
review, no downgrade of any position has occurred as a result of the 
pending reviews. No action will be taken until a thorough analysis of 
each job series is completed by each impacted office. VA expects that 
this process will take approximately 15 months to complete. As the 
Department takes action to comply with Federal regulations (5 Code of 
Federal Regulations (CFR) 511.612.), it will work with its union 
partners, OPM, and VA human resources experts to ensure that the fewest 
possible employees are affected and that we provide employees with the 
highest possible degree of protection in terms of their position and 
pay.

    Question 2. 1,500 GS-6 Claims Assistants are facing downgrades. Has 
VA considered what this would mean to recruiting and retaining the 
people on the front lines of attacking the backlog?
    Response. The Claims Assistant GS-0998 position review is required 
by 5 CFR 511.612 due to OPM's adjudication and issuance of employee 
initiated appeal decisions C-0998-05-01, C-0998-05-02, and C-0998-05-
02. The Claims Assistant positions included in this review are 
primarily located in the Veterans Health Administration (VHA) and are 
responsible for accepting/disputing/processing/payment of bills/claims 
against VA for medical services Veterans receive from outside of the VA 
health care system.
    The Claims Assistant position in the Veterans Benefits 
Administration (VBA) is also part of this review. VBA believes this 
position is properly classified for the work these employees perform 
pertaining to claims for benefits. VBA is participating in a work 
group, in partnership with the Office of Personnel Management (OPM), to 
ensure any changes to classifications do not negatively impact the 
timeliness and accuracy of benefits decisions for Veterans and their 
families.

    Question 3. If shortages in staffing and number of inpatient beds 
can be fixed with more funding, why is VA not asking this Committee and 
the appropriators for more money? Why isn't it more in line with the 
Independent Budget?
    Response. The 2015 President's Budget is requesting $367.9 million 
in additional funding above last year's advance appropriations request 
of $55.634 billion to meet Veterans' medical care needs, for a total 
direct appropriations request of $56.002 billion, a 3.0 percent 
increase over the 2014 enacted level. In addition to the 2015 
appropriation request, VA anticipates the Medical Care Collections Fund 
(MCCF) to reach $3.065 billion. VA also estimates that it will receive 
$258 million in reimbursements and begin 2015 with $450 million in 
unobligated balances, which will allow VHA to meet its 2015 total 
obligation authority of $59.498 billion and support over 6.7 million 
unique patients, 9.3 million enrolled Veterans, a staffing level of 
275,122 FTE and Inpatient Care exceeding $11.5 billion.
    Final 2016 funding levels will be determined during the 2016 budget 
process when updated data and metrics on these programs' funding needs 
are available. VA's budget estimates are primarily based on an 
actuarial model that includes population changes that can significantly 
impact VA's requirements, such as when Veterans become eligible for 
Medicare or the increased number of women Veterans in the current 
conflicts. The Independent Budget does not use such data, estimating 
future requirements as growth from the latest available obligations.
    a. The Chillicothe Medical Center, for example, has had a high 
turnover of primary care providers in the last 18 months--15 of 20 
individuals have left--they are heavily relying on ``extenders.'' What 
can we do to correct this?
    Response. Chillicothe VA Medical Center (VAMC) leadership has 
authorized recruitment of up to 25 primary care providers, which 
include both physicians and nurse practitioners or physician 
assistants. This authorized staffing level is intended to support the 
long- term strategy of fully operating all Patient Aligned Care Teams 
(PACTs) year round, at the main facility and the Community-Based 
Outpatient Clinics (CBOC), even during planned or unexpected provider 
absences. This increase in PACTs is also meant to assure the smaller 
more rural clinics (such as those in Cambridge and Marietta, Ohio), 
whose patient enrollment would normally support only one provider, have 
the availability of two providers to support Veterans' continuous 
access to care, even during planned or unexpected provider absences or 
turnover.
    There are currently 21.5 primary care providers in place with three 
new providers in pre-employment processes expected to come on board 
within the coming months. Additionally, the Chillicothe VAMC 
established a Locum Tenens contract for primary care providers and is 
now utilizing that resource, as well as assigning providers from 
administrative and leadership roles, to assist in clinic coverage.
    Recruiting primary care physicians is very difficult given the 
rural location of the facility; escalating practice complexity and 
demands; and the limitation of VA's pay scale compared to the private 
sector, which is rapidly increasing pay for such providers. The 
Chillicothe VAMC prefers to engage primarily physicians to serve as 
primary care providers. However, like many rural practices, the 
Chillicothe VAMC must rely on highly qualified nurse practitioners and 
physician assistants to augment provision of primary care services for 
Veterans across the region. Aggressive recruitment efforts continue to 
add to the Chillicothe VAMC's clinical staff and provider team.

    Question 4. Talk to me about the Nation-wide access review at VA 
that you ordered. Will AFGE and others have a role?
    Response. The American Federation of Government Employees (AFGE) 
and the National Partnership Council were briefed before the Nation-
wide access reviews were conducted. The local unions were invited to 
the opening and closing meetings with facility leadership, and all 
statutory and contractual requirements were followed. Changes to 
scheduling practices are also being communicated locally to assure that 
union and labor organizations are informed of revisions in policies and 
procedures as well as training and performance plans.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Jon Tester to Hon. 
    Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs
    Question 5. What steps has the Veterans Health Administration (VHA) 
taken to ensure consistency and oversight in scheduling policy 
implementation and practices across the Veterans Integrated Service 
Networks (VISNs)?
    Response. The Secretary of Veterans Affairs directed VHA to 
complete a Nation-wide Access Audit to ensure a full understanding of 
VA's policy among scheduling staff, identify any inappropriate 
scheduling practices used by employees regarding Veteran preferences 
for appointment dates, and review waiting list management. This audit 
was designed to:

     Gauge front-line staff understanding of proper scheduling 
processes;
     Assess the frequency and pervasiveness of both desired and 
undesirable practices employed to record Veteran preferences for 
appointment dates, manage waiting lists, and process requests for 
specialty consultation; and
     Identify factors that interfere with schedulers' ability 
to facilitate timely care for Veterans.

    As a result of this audit, VHA has taken a number of immediate 
actions to address the very serious issues identified in our audit.

     Mobilized staff and financial resources to ensure that 
patients waiting for care get their needs addressed in a timely manner. 
VHA will either provide care in a timely manner or purchase care, to 
the extent it exists in the private sector. VHA will also contact 
Veterans to see if they desire care sooner than the current scheduled 
date.
     Initiated an across-the-board assessment of VHA's internal 
capacity to meet needs for care.
     Removed the 14-day performance metric from individual 
performance plans.
     Suspended VHA Senior Executive Service performance awards 
for fiscal year 2014.
     Updated guidance on VHA's utilization of non-VA medical 
care, to ensure use of all appropriate resources in the community to 
provide Veterans care when, where, and how they want it. Guidance 
included briefings held with VHA Veterans Integrated Service Network 
(VISN) Directors, virtual training sessions accessible electronically 
by all VA staff, communications to targeted staff of the electronic 
training sessions and written guidance targeted toward field staff 
disseminated though email and placed on internal intranet sites. 
Additionally, updated guidance was provided on VHA's utilization of 
non-VA medical care (NVC), to ensure use of all appropriate resources 
in the community to provide Veterans care when, where, and how they 
want it. This guidance includes offering NVC to the Veteran in an 
effort to ensure they receive care in a timely manner. Updated guidance 
was also provided on the coordination of care to include appropriate 
authorizations, use of contracts, sharing agreements or individual 
authorizations, scheduling of appointments and receipt of medical 
documentation.
     Directed field leadership to continue the process of 
inspection of practices to ensure VHA's leaders have personal 
accountability for the integrity of the practices followed in VA 
facilities.
     Renewed efforts to improve transparency of performance 
data. VHA will increase the measurement and use of data regarding 
Veterans' satisfaction with access to care and overall experience.
     Examined Medical Support Assistant staffing levels and 
compensation. Medical Support Assistants are central to the operation 
of VA medical facilities. VHA must reevaluate these positions to ensure 
staff compensation is fair. VHA will reassess staffing requirements to 
ensure the appropriate internal capacity needed to provide timely care, 
and find cost effective options to purchase that care when necessary.
     Work to modernize software scheduling solution that 
facilitates the processes of modern health care.

    In addition, there are many long-term actions that will need to be 
addressed and assessed as VHA moves forward.

    Question 6. What is the main issue impacting veterans waiting times 
for medical appointments? What are the biggest obstacles to reducing 
those waiting times?
    Response. At the direction of the Secretary of Veterans Affairs, 
VHA conducted an Access Audit which assessed the scheduling practices 
across VA. This audit identified the following obstacles: 1) 
significant lack of clarity regarding scheduling policies and practices 
across our system; 2) an inflexible and unrealistic 14 day performance 
target for new appointments; 3) inadequate staffing of providers and 
clerical support at many of the sites that were experiencing the 
greatest surge in patient demand; 4) rigid and obsolete scheduling 
software. The greatest single barrier identified was the lack of 
provider slots.

    Question 7. To what extent do VHA's access issues reflect the same 
challenges in the delivery of private sector health care? To what 
extent are they VA-specific?
    Response. A recent national survey of Physician Appointment Wait 
Times and Medicaid and Medicare Acceptance Rates offers a snapshot of 
physician availability in 15 large metropolitan markets, many of them 
with physician-to-population ratios higher than the national average. 
For a new patient, the average appointment wait time to see a family 
physician ranged from a high of 66 days in Boston to a low of 5 days in 
Dallas. However, as the example of Boston illustrates, access to health 
insurance does not always guarantee access to a physician. In addition, 
the survey findings indicate that Medicaid is not widely accepted as a 
form of payment in most markets surveyed. http://
www.merritthawkins.com/uploadedFiles/MerrittHawkings/Surveys/
mha2014waitsurvPDF.pdf.
    VA-specific challenges involve the increasing complexity of combat-
related injuries from Vietnam and Persian Gulf conflicts which 
typically require specialty care, such as Traumatic Brain Injury, Post 
Traumatic Stress Disorder, amputations, and environmental exposure-
related illnesses.

    Question 8. What are the current accountability measures in place 
for facilities, or leadership officials at those facilities, if 
timeliness goals are not met on a consistent basis? Are those measures 
appropriate? Do you need additional authorization to enforce stronger 
accountability measures?
    Response. VA takes the allegations and findings of misconduct 
seriously, and is moving quickly to address the situation. Since 
allegations of delayed care and employee misconduct surfaced, VA has 
been conducting internal reviews to evaluate appointment scheduling 
procedures and patient care in Phoenix and nationwide. VA has initiated 
the process for removing senior leaders at the Phoenix VA Health Care 
System (PVAHCS), and VA has directed an independent site team to assess 
scheduling and administrative practices at PVAHCS. This team began 
their work in April, and VA is taking action on multiple 
recommendations from the teams' findings. VA recognizes there is a 
leadership and integrity problem among some of the leaders of our 
health care facilities, which can and will be fixed. That breach of 
integrity is indefensible and VA will use all authorities at its 
disposal to enforce accountability among senior leaders.
    To help regain Veterans' trust, Congress' trust, the trust of the 
American people, and the trust of our employees, when we do hold 
employees accountable we are going to continue to transparently share 
information to the degree permitted by law, while respecting an 
employee's privacy rights. For cases involving senior executives, the 
Veterans Access, Choice, and Accountability Act of 2014 allows us to 
take expedited action when VA has determined that a senior manager has 
committed misconduct or has performed poorly. VA's newly established 
Office of Accountability Review (OAR) is monitoring the progress of all 
ongoing OSC and Office of Inspector General (OIG) investigations, and 
as they are completed, will help VA leadership determine appropriate 
accountability measures.

    Question 9. Understanding the goal of the VHA nationwide access 
review is to ensure facilities are scheduling appointments 
appropriately, will the review also provide feedback on why employees 
might have been motivated to manipulate numbers in the first place? To 
what extent will the review inform ways we can improve or reform the 
system?
    Response. Based on the findings of the audit, VA will critically 
review its performance management, education, and communication systems 
to determine how performance goals were conveyed across the chain of 
command such that some front-line, middle, and senior managers felt 
compelled to manipulate VA's scheduling processes. This behavior runs 
counter to VA's core values; the overarching environment and culture 
which allowed this state of practice to take root must be confronted 
head-on if VA is to evolve to be more capable of adjusting systems, 
leadership, and resources to meet the needs of Veterans and families. 
It must also be confronted in order to regain the trust of the Veterans 
that VA serves.

    Question 10. To what extent has the VHA invested in workforce 
training for those involved in scheduling appointments for veterans?
    Response. VA recently implemented mandatory supplemental training 
for all employees involved with scheduling appointments. Using existing 
internal web-based resources, subject matter development, and 
distributed learning expertise, four new courses were introduced during 
the past 2 months. These courses were developed and produced internally 
so total course cost is primarily staff time with minimal contract 
costs for video production. Details are provided in the table below:


 
----------------------------------------------------------------------------------------------------------------
 TMS                                                                                                     Total
 Item                Course Title                               Modality                    Total       Course
  #                                                                                      Completions     Cost
----------------------------------------------------------------------------------------------------------------
 7532 Scheduling Training--Recall Reminder    Web-based/eLearning....................     90,118      $3,494
----------------------------------------------------------------------------------------------------------------
 7533 Scheduling Training--Soft Skills        Conference/Workshop (conducted face-to-     76,496     $37,044
                                               face at local VA medical facilities).
----------------------------------------------------------------------------------------------------------------
 7534 Scheduling Training--Business Rules     Web-based/eLearning....................     95,092      $3,285
----------------------------------------------------------------------------------------------------------------
 7535 Scheduling Training--Make Appointment   Web-based/eLearning....................     91,740      $3,494
----------------------------------------------------------------------------------------------------------------
                                                    Total............................    353,446     $47,317
----------------------------------------------------------------------------------------------------------------


    Question 11. To what extent have information technology (IT) 
investments been made to ensure the VHA is operating the most reliable 
and effective scheduling system? Do you believe advanced appropriations 
for medical-related IT would help the VHA connect veterans to care in a 
more timely manner?
    Response. VA has invested in upgrades to the scheduling system over 
the last 10 years. The current scheduling application investment 
includes these maintenance upgrades as well as ongoing support. 
However, the current scheduling system is based upon a 25-year old 
scheduling system which consists of a roll-and-scroll system that is 
susceptible to error. The software is segmented into components that do 
not automatically communicate with or connect with each other, but 
require manual processes to operate. VA began an effort, the 
Replacement Scheduling Application (RSA), to replace the legacy 
scheduling system in 2000. This effort failed to deliver a replacement 
system and was stopped in 2009. During this timeframe, major 
enhancements to the legacy system were delayed due to the anticipation 
of a new system which unfortunately, never materialized.
    VA's scheduling system needs improved interfaces for both 
schedulers and patients to increase scheduling efficiency and decrease 
errors--this includes improvements to Clinical Video Teleconferencing, 
Scheduling Manager Applications, and Patient Directed Scheduling 
Applications. Enhancements are also needed to the Core VistA Scheduling 
Software, including a resource management dashboard, aggregated 
clinical schedule and single queue of request lists. The long-term 
solution is to complete the Medical Appointment Scheduling System, 
which will be a commercial solution building on the interfaces 
delivered during the Medical Scheduling Contest. The goal is to 
leverage a commercial solution to provide a proactive resource 
management-based scheduling system. VA expects to deliver a core 
capability of the scheduling system within two years (in six months 
increments) after award using a series of six month incremental 
enhancements until full operational capability is reached.

    Question 12. To what extent can workforce shortages be mitigated by 
more collaboration between the VHA and private providers to deliver 
care at local access points for veterans?
    Response. VA has the authority to utilize non-VA medical care to 
provide care to Veterans where capacity doesn't exist for many reasons, 
including workforce shortages. Non-VA medical care can be purchased 
using contracts. There are local contracts available as well as the 
recently awarded national Patient Centered Community Care (PC3) 
contracts for specialty and primary care. When a VA facility cannot 
readily provide needed care in-house or the care is not feasibly 
available to the Veteran, VAMCs will first look to provide specialty 
care at another VAMC or through existing health care resources sharing 
agreements with the Department of Defense (DOD) medical treatment 
facilities. When it is not feasible to provide the care within the VHA 
system or DOD, the VAMC will consider its options for purchasing the 
care. Consideration will first be given to the availability of the care 
through currently awarded PC3 contracts. However, VAMCs retain the 
authority to execute local contracts with Academic Affiliates (VA 
Directive 1663) or other private sector health care providers when 
deemed to be in the best interests of VA. A goal is to order most 
necessary contract health care from the already awarded PC3 contracts 
to reduce administration burdens associated with additional acquisition 
actions.
    Additionally, Pub. L. 113-146, the Veterans Access, Choice and 
Accountability Act (VACAA), provided $10 billion for the new Veterans 
Choice program and $5 billion to improve access at VA health care 
facilities. As specified in the law, these funds will be used to 
increase the access of veterans to care and to help ensure VA is 
increasing its capacity to meet the current and projected future demand 
for services.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
 Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs
    Question 13. What is VA's official definition of ``delay in 
treatment'' and ``delay in care?''
    Response. VA uses the terms ``delay in treatment'' or ``delay in 
care'' to reflect a situation where a patient has received care beyond 
the timeframe that the medical profession has determined to be the 
standard of care for addressing a medical condition.

    Question 14. I and others believe that veterans should have the 
freedom to choose their own physician to meet their medical needs. 
Several of the VSO panelists cited a lack of access to specialty 
medicine, including a particular case in which a veteran diagnosed with 
skin cancer cells has been on a waiting list for eight months to see a 
dermatologist. What is the Department of Veterans Affairs currently 
doing to ensure continuity of care, particularly specialty care? And do 
you agree that allowing access to specialty care outside of the VA 
could improve continuity of care for veterans?
    Response. Non VA Care (NVC) is used when the facility cannot 
provide the care in a timely manner and is primarily used for specialty 
care. When a Veteran needs care, a determination is made if the care 
can be provided at VA. If VA is unable to provide the care timely to 
meet the clinical need of the Veteran, then the use of NVC is reviewed. 
When authorizing for NVC, consideration is taken as to where the care 
can be provided in a timely manner to ensure the clinical need is met. 
While allowing Veterans access to specialty care outside of VA may 
improve access to care, it does not necessarily improve continuity of 
care. Therefore, the VA has developed a Non VA Care Coordination model 
to ensure the care is appropriately authorized, scheduled and medical 
documentation is received in an effort to improve the continuity of 
care.
    The Non VA Care Coordination (NVCC) model provides several steps to 
help in the coordination of care for our Veterans. Once a Veteran is 
notified of the approval of non-VA medical care, they are contacted to 
identify availability, preferences, and needs. Once this information 
has been obtained, the non-VA medical care provider is contacted by 
NVCC staff to schedule an appointment for the Veteran. The appointment 
is then captured in VistA. The Veteran and non-VA medical care provider 
are sent the authorization and the appropriate release of information 
form(s), to ensure the medical records are received by VA.
    After the appointment date, the Veteran is contacted to verify that 
the authorized non-VA medical care has been received. If the Veteran 
missed or did not attend his/her medical appointment, VA staff will 
work with the Veteran to reschedule the missed appointment. NVCC staff 
will then work with the non-VA medical care provider to obtain the 
required clinical documentation. The documentation will then be scanned 
into the appropriate system, and uploaded to the Veteran's electronic 
medical record. If additional review and follow-up action is required 
from the referring VA provider once the clinical documentation is 
received, an alert will be sent to notify the VA provider of the 
required action.

    Question 15. Physician anesthesiologists possess 12,000 to 16,000 
hours of clinical training and nurse anesthetists have 1,500 hours of 
training on average. How is the care provided to veterans improved by 
replacing a physician anesthesiologist with a nurse anesthetist as the 
anesthesia team leader?
    Response. The presence of anesthesiologists or certified registered 
nurse anesthetists (CRNA) in VHA health care facilities helps ensure 
that our Veterans have access to safe, high quality anesthesia care, as 
well as the procedures and services that anesthesia care enables. The 
peer-reviewed literature points to the high quality of care provided by 
both provider types practicing together or separately. VHA does not 
require anesthesiologist or physician supervision of CRNAs; in a number 
of VHA facilities CRNAs are the sole anesthesia providers. Currently 
either anesthesiologists or CRNAs may serve as part of the anesthesia 
care team. Private hospitals, ambulatory surgery centers and the 
Department of Defense commonly use CRNAs to provide anesthesia services 
for patients without physician supervision. The proposed nursing 
handbook would not authorize CRNAs to replace or act as 
anesthesiologists, but rather increase access to care, decrease 
variability throughout VHA, and ensure continuity of the highest 
quality of care for veterans. CRNAs would not be authorized to provide 
any anesthesia services that are beyond the scope of their clinical 
education, training or competencies.

    Question 16. Are there specific examples of deficiencies or delays 
in care that led to the decision to change the VHA Nursing Handbook? 
What stakeholders were consulted in the development of the proposed 
handbook?
    Response. The Office of Nursing Services began the development of a 
VHA nursing handbook in 2009 to establish policy for the process of 
care delivery and the elements of practice for nursing. Within the 
nursing handbook, VHA is proposing the authorization of FPA for all 
APRNs without regard to their individual State Practice Acts, except 
for the dispensing, prescribing, and administration of controlled 
substances. This proposed change to nursing policy would standardize 
APRN practice throughout the VA system, and increase access to the 
highest quality of care for all the Nation's Veterans. Implementation 
of FPA would increase patient access by alleviating the effects of 
national health care provider shortages on VA staffing levels, as well 
as enabling VA to provide additional health care services in medically 
underserved areas.
    The 2010 Institute of Medicine (IOM) landmark report, The Future of 
Nursing: Leading Change, Advancing Health, recommended removal of 
scope-of-practice barriers, to allow APRNs to practice to the full 
extent of their education and training. This evidenced-based 
recommendation by the IOM prompted VHA to propose FPA for APRNs. Thus, 
VHA's proposed nursing handbook is consistent with the IOM 
recommendation to remove barriers including the variation in APRN 
practice that exists across VHA as a result of disparate state 
regulations. The proposed change is being driven by the efficacious use 
of resources and to standardize APRN practice throughout the VA system. 
As an integrated Federal health care system, the proposed policy 
parallels current policies in DOD and Indian Health Service. In 2012, 
all VA Program Offices provided input and concurred on the nursing 
handbook including Anesthesia Services. VHA has conducted meetings with 
several outside stakeholders including the American Society of 
Anesthesiologists and the American Medical Association.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr on 
  behalf of Hon. Jeff Flake to Hon. Eric K. Shinseki, Secretary, U.S. 
                     Department of Veterans Affairs
    Question 17. According to GAO and OIG reports, some VHA facilities 
do not always follow VHA's scheduling policies and processes.
    a. Do certain VHA facilities have any leeway regarding the 
scheduling policies that they are obligated to follow?
    Response. No, VHA facilities are expected to follow scheduling 
policies. However, the Access Audit findings illustrate that eight 
percent of scheduling staff indicated they used alternatives to the 
Electronic Wait List (EWL) or the Veterans Health Information Systems 
and Technology Architecture (VistA) package. Some of the respondents 
indicated that the scheduling policy was not well-understood. VA 
recently implemented mandatory supplemental training for all employees 
involved with scheduling appointments. Using existing internal web-
based resources, subject matter development, and distributed learning 
expertise, four new courses were introduced during the past 2 months. 
These courses were developed and produced internally so total course 
cost is primarily staff time with minimal contract costs for video 
production. Details are provided in the table below:


 
----------------------------------------------------------------------------------------------------------------
 TMS                                                                                                     Total
 Item                Course Title                               Modality                    Total       Course
  #                                                                                      Completions     Cost
----------------------------------------------------------------------------------------------------------------
 7532 Scheduling Training--Recall Reminder    Web-based/eLearning....................     90,118      $3,494
----------------------------------------------------------------------------------------------------------------
 7533 Scheduling Training--Soft Skills        Conference/Workshop (conducted face-to-     76,496     $37,044
                                               face at local VA medical facilities).
----------------------------------------------------------------------------------------------------------------
 7534 Scheduling Training--Business Rules     Web-based/eLearning....................     95,092      $3,285
----------------------------------------------------------------------------------------------------------------
 7535 Scheduling Training--Make Appointment   Web-based/eLearning....................     91,740      $3,494
----------------------------------------------------------------------------------------------------------------
                                                    Total............................    353,446     $47,317
----------------------------------------------------------------------------------------------------------------


    b. If not, what disciplinary measures does the VA typically pursue 
when presented with evidence of VHA facilities not complying with 
scheduling policies and processes?
    Response. VHA has progressive disciplinary policies that are 
followed per human resource guidelines. Disciplinary measures can vary 
based on the nature of the offense.
    c. What is the existing recourse for any VA employee, service 
provider, or patient that believes scheduling policies and processes 
are not being followed? Specifically who would they report such 
instances to and what actions would the VA take subsequent to the 
report?
    Response. Employees and service providers who believe that 
scheduling policies and processes are not being followed are encouraged 
to report this through their supervisory chain of command. Patients may 
report this to their patient advocate, clinic supervisor, or Medical 
Center Director. Facility leadership is responsible for ensuring that 
training and education is provided to all employees involved in 
scheduling appointments.

    Question 18. In December 2012, GAO reported that some VHA facility 
officials stated that they did not use the electronic waiting list, 
which the VHA uses to track patients with whom the facility does not 
have an established relationship. In some instances, it was reported 
that patients were tracked by printing paper copies of consult requests 
from the electronic medical record.
    a. What measures have you taken to ensure that the electronic 
waiting list is used properly at VHA facilities? Has there been any 
progress in this regard?
    b. Currently, what ability do you or any of your subordinates have 
to terminate the employment of anyone found to be operating afoul of 
these procedures?
    VA Response (a. and b.): VA has taken aggressive action through its 
Accelerating Care Initiative, launching a coordinated, Nation-wide 
effort to accelerate care to Veterans throughout the VA system and in 
communities where Veterans reside. This effort increases timely access 
to care for Veterans and improves standardization of ongoing 
monitoring, productivity, and access to care. While the Accelerating 
Care Initiative is a near-term activity, VA will continue to monitor 
productivity, capacity, and access to care at local, regional, and 
national levels.
    VA will establish follow-up accountability actions based on the 
results of the audit. Senior leaders will be held accountable to 
implement policy, process, and performance management recommendations 
stemming from this audit and other reviews. Where audited sites 
identify concerns within the parent facility or its affiliated clinics, 
the VA will trigger administrative procedures to ascertain the 
appropriate follow-on actions for specific individuals.
    Based on the findings of the audit, VA will critically review its 
performance management, education, and communication systems to 
determine how performance goals were conveyed across the chain of 
command such that some front-line, middle, and senior managers felt 
compelled to manipulate VA's scheduling processes. This behavior runs 
counter to VA's core values; the overarching environment and culture 
which allowed this state of practice to take root must be confronted 
head-on if VA is to evolve to be more capable of adjusting systems, 
leadership, and resources to meet the needs of Veterans and families. 
It must also be confronted in order to regain the trust of the Veterans 
that VA serves.
    To help regain Veterans' trust, Congress' trust, the trust of the 
American people, and the trust of our employees, when we do hold 
employees accountable we are going to continue to transparently share 
information to the degree permitted by law, while respecting an 
employee's privacy rights. For cases involving senior executives, the 
Veterans Access, Choice, and Accountability Act of 2014 allows us to 
take expedited action when VA has determined that a senior manager has 
committed misconduct or has performed poorly. VA's newly established 
Office of Accountability Review (OAR) is monitoring the progress of all 
ongoing OSC and Office of Inspector General (OIG) investigations, and 
as they are completed, will help VA leadership determine appropriate 
accountability measures.

    Question 19. It is my understanding that the VA officials who have 
been placed on administrative leave in Phoenix and elsewhere are still 
being paid while the office of the VA Inspector General conducts its 
investigation.
    If these allegations are found to be true, what measures will you 
consider to not only discipline those responsible for the practices in 
question, but also to reform VA policies and procedures to ensure that 
the department is better able to provide timely and adequate care to 
veterans?
    Response. VA takes the allegations and findings of misconduct 
seriously, and has moved quickly to address the situation. Since 
allegations of delayed care and employee misconduct surfaced at Phoenix 
VAHCS, VA has been conducting internal reviews to evaluate appointment 
scheduling procedures and patient care in Phoenix and nationwide. VA 
has initiated the process for removing senior leaders at PVAHCS, and VA 
has directed an independent site team to assess scheduling and 
administrative practices at PVAHCS. Final decisions on the senior 
leader actions will be made when all relevant evidence is available.
    On May 23, 2014, VHA executed the Accelerating Care Initiative, a 
coordinated, Nation-wide initiative to accelerate care to Veterans 
throughout the VA system and in the communities where Veterans reside. 
This initiative was designed to increase timely access to care for 
Veteran patients; decrease the number of Veteran patients on the 
Electronic Wait List (EWL) and waiting greater than 30 days for care; 
and standardize the process and tools for ongoing monitoring and access 
management at VA facilities. VA will continue to accelerate access to 
care for Veterans nationwide who need it, utilizing care both in and 
outside the VA system.

    Question 20. Earlier this year, before allegations of manipulated 
wait time reporting at the Phoenix VA hospital came to light, you 
stated in a letter to Chairman Jeff Miller of the House Committee on 
Veterans' Affairs that you believe that ``the VA has sufficient 
authority to take swift action to hold employees and executives 
accountable for performance.'' You went on to say that one of the ways 
in which the VA holds these individuals accountable is through ``a 
rigorous performance appraisal program.'' While VA employees and 
executives failure to meet performance goals is one thing, accusations 
of intentional manipulation and mismanagement resulting in delayed care 
for hundreds of veterans is another.
    a. In a letter to Chairman Jeff Miller of the House Committee on 
Veterans' Affairs, you noted that ``it does not appear that PVAHCS 
patients who were not able to be seen within 90 days were handled 
consistently.'' What will be the repercussions for those involved in 
the already discovered inconsistent handling of patient appointments at 
the Phoenix facility?
    b. Beyond these apparent inconsistencies, if the troubling 
allegations related to the Phoenix facility are found to be true, would 
you agree that decisive and incontrovertible action--to include the 
possibility of termination--against those responsible for the sort of 
practices in question at the Phoenix VA hospital is warranted?
    VA Response (a. and b.): VA takes the allegations and findings of 
misconduct seriously, and has moved quickly to address the situation. 
Since allegations of delayed care and employee misconduct at Phoenix 
VAHCS surfaced, VA has been conducting internal reviews to evaluate 
appointment scheduling procedures and patient care in Phoenix and 
nationwide. VA recognizes there is a leadership and integrity problem 
among some of the leaders of its health care facilities, which can and 
will be fixed. That breach of integrity is indefensible and VA is using 
all authorities at its disposal to enforce accountability among senior 
leaders as quickly as possible within the bounds of the law. VA has 
also directed an independent site team to assess and improve scheduling 
and administrative practices at PVAHAC. This team began their work in 
April, and VA is taking action on multiple recommendations from their 
findings.

    Question 21. In the past, GAO has studied and been critical of VA 
bonus awarding practices.
    a. Since 2012, how many employees of VA facilities in the state of 
Arizona have received bonuses? What percentage of the entire VA 
workforce received bonuses? What was the range of bonuses awarded, in 
dollar value and percentage of the recipients' salary? What is the 
total dollar figure associated with bonuses awarded by the VA in 
Arizona?
    Response. The following data excludes Senior Executive Service 
(SES) employees and SES Equivalents.
    Since 2012, how many employees of VA facilities in the state of 
Arizona have received bonuses?

 
------------------------------------------------------------------------
           Number of employee of VA facilities in the state of  Arizona
   FY                       that have received bonuses
------------------------------------------------------------------------
   2012   2,710
   2013   2,199
------------------------------------------------------------------------


    What percentage of the entire VA workforce received bonuses?

 
------------------------------------------------------------------------
   FY          Percent of entire VA Workforce that received bonuses
------------------------------------------------------------------------
   2012   55% (180,728 awards divided by 325,889 employees)
   2013   58% (195,954 awards divided by 338,932 employees)
------------------------------------------------------------------------

    What was the range of bonuses awarded, in dollar value and 
percentage of the recipients' salary?

                    Dollar Amounts of Bonuses Awarded
------------------------------------------------------------------------
                        FY                           Minimum    Maximum
------------------------------------------------------------------------
2012..............................................    $11.00  $23,091.00
2013..............................................     $6.00  $16,173.00
------------------------------------------------------------------------


                            Percent of Salary
------------------------------------------------------------------------
                        FY                           Minimum    Maximum
------------------------------------------------------------------------
2012.............................................     0.02%      99.91%
2013.............................................     0.01%      46.72%
------------------------------------------------------------------------

    What is the total dollar figure associated with bonuses awarded by 
the VA in Arizona?

              Dollar Amount of Bonuses Awarded in Arizona.
------------------------------------------------------------------------
                            FY                              Award Amount
------------------------------------------------------------------------
2012......................................................  $2,589,793
2013......................................................  $2,647,236
------------------------------------------------------------------------


    The following data represents SES and SES Equivalents.
    NOTE: For reporting purposes, the data below reflects the fiscal 
year in which awards were actually paid.
    Since 2012, how many employees of VA facilities in the state of 
Arizona have received bonuses?

 
------------------------------------------------------------------------
                               FY                                 Count
------------------------------------------------------------------------
2012...........................................................       4
2013...........................................................       4
                                                                --------
  Total........................................................       8
------------------------------------------------------------------------


    What percentage of the entire VA workforce received bonuses?

 
------------------------------------------------------------------------
                    FY                          Percent of Workforce
------------------------------------------------------------------------
2012.....................................  71% (468 rated/331 awards)
2013.....................................  60% (459 rated/276 awards)
------------------------------------------------------------------------


    What was the range of bonuses awarded, in dollar value and 
percentage of the recipients' salary?

                    Dollar Amounts of Bonuses Awarded
------------------------------------------------------------------------
                        FY                          Minimum     Maximum
------------------------------------------------------------------------
2012.............................................  $6,705.00  $23,091.00
2013.............................................  $7,604.00  $16,173.00
------------------------------------------------------------------------


                            Percent of Salary
------------------------------------------------------------------------
                       FY                           Minimum     Maximum
------------------------------------------------------------------------
2012............................................     5.0%         14.0%
2013............................................     5.5%          9.0%
------------------------------------------------------------------------


    What is the total dollar figure associated with bonuses awarded by 
the VA in Arizona?

               Dollar Amounts of Bonuses Awarded at PVAHCS
------------------------------------------------------------------------
                            FY                              Award Amount
------------------------------------------------------------------------
2012.....................................................    $42,860.00
2013.....................................................    $40,791.00
------------------------------------------------------------------------


    b. Has the Department at any point explicitly linked bonuses to 
efforts to decrease patient wait times?
    Response. Performance Awards are monetary awards given to high-
performing employees based on annual job performance appraisals. Senior 
Executives are held specifically accountable for achieving realistic, 
but challenging performance targets within defined timeframes, 
identified within the five critical elements: Leading Change, Leading 
People, Business Acumen, Building Coalitions, and Performance Results. 
Within those five critical elements, each Senior Executive is rated 
against position specific performance requirements. Among those 
requirements, leadership skills in managing wait times may be one of 
many factors considered in the evaluation. SES performance is evaluated 
through a minimum of five levels of review. The result of this 
evaluation is a rating and score. Performance awards are given based on 
the individual's final approved rating/score.
    It is significant to note that VHA's evaluation of SES performance 
is conducted annually in accordance with VA Handbook 5027, VA SES and 
Title 38 SES-Equivalent Performance Management System policy, and all 
applicable laws. VHA's internal process includes a multi-level review 
process which increases transparency and accountability and ensures 
meaningful distinctions in ratings and awards. The rating official 
(supervisor) provides an initial narrative summary and submits to the 
reviewing official who provides an overall narrative evaluation. Next, 
VHA's Performance Review Committee (PRC) reviews the evaluation and 
makes a rating recommendation to the VA Performance Review Board (PRB). 
The PRB reviews and makes a rating recommendation to the Secretary. The 
criteria for determining who receives a monetary award and the amount 
of the award is determined through collaboration between Corporate 
Senior Executive Management Office (CSEMO) and the Office of the 
Secretary. The Secretary has the final approval authority for the 
rating of record and any monetary award given.
    c. Did any of those placed on administrative leave or associated 
with the inconsistency related to patient scheduling received a bonus 
within the last two years?
    Response.

 
------------------------------------------------------------------------
        Position/Title                 FY 2013              FY 2012
------------------------------------------------------------------------
Medical Center Director.......  $0 (rescinded)*......  $9,345 (effective
                                                        5/22/13)
Associate Director............  $5,000 (effective 11/  $3,000 (effective
                                 06/13).                11/19/12)
Third Employee................  $3,000 (effective 11/  $3,000 (effective
                                 20/12).                11/25/13)
------------------------------------------------------------------------
* The process to recoup this FY 2013 payment was initiated, but is on
  hold pending an appeal.


    Question 22. Regardless of the VA Inspector General's findings, 
there is clearly a need to reform VA scheduling practices, and to 
ensure that the department is better able to provide timely and 
adequate care to veterans.
    a. Aside from conducting a nationwide audit of the scheduling 
practices at VA medical facilities, what steps is your office currently 
taking to reduce the backlog for disability claims, and ensure that 
veterans are able to receive timely appointments at VA medical 
facilities?
    Response. VA is committed to improving the quality, efficiency, and 
effectiveness of the delivery of benefits and services to Veterans, 
Servicemembers, and their families. VBA is currently undergoing the 
largest transformation in its history to eliminate the backlog of 
disability compensation claims, and substantially improve the way 
Veterans, their families, and Survivors receive benefits and services. 
VA is aggressively implementing its plan to eliminate the backlog using 
a series of actions targeted at reorganizing and retraining its people, 
streamlining its processes, and deploying technology designed to 
achieve VA's goal of processing all claims within 125 days in 2015.
    Since April 2013, VA has focused on completing its oldest claims, 
resulting in benefit determinations for those who have been waiting the 
longest, many of whom are awarded VA compensation benefits for the 
first time or who have medical conditions that have worsened. As a 
result of its transformation initiatives and the focus on the oldest 
claims, VA has made significant progress, reducing the claims backlog 
(i.e., claims pending over 125 days) from its peak of 611,073 in 
March 2013 to 254,778 as of September 22, 2014--a 58.3-percent 
reduction. Veterans are now waiting less time for their decisions and 
benefits. As of September 22, 2014, claims in the inventory have been 
pending an average of 153 days, a 46-percent reduction from the peak of 
282 days in February 2013.
    At the same time, the accuracy of our rating decisions continues to 
improve. VA's national ``claim-level'' accuracy rate, determined by 
dividing the total number of cases that are error-free by the total 
number of cases reviewed, is currently 90 percent--a seven-percentage-
point improvement since 2011. When measuring the accuracy of rating 
individual medical conditions inside each claim, the 3-month accuracy 
level is 96 percent.
    VBA and VHA work together to support the Compensation and Pension 
(C&P) disability examination process for Veterans. In FY 2013, VHA 
clinicians completed nearly two million disability examinations. 
Additionally, VBA and VHA are maximizing the use of disability contract 
examiners to help maintain and improve VA disability examination 
services. In FY 2013, VHA contractors completed approximately 178,000 
disability examinations, and VBA contractors completed over 225,000 
disability examinations. Utilizing contract examiners ensures timely 
scheduling of examination appointments and ultimately more timely 
completion of disability claims. Contract exams also ensure Veterans 
receive quality disability examinations in locations near their homes.
    VBA and VHA have instituted several initiatives to improve the 
timeliness and accuracy of claims processing based on medical evidence. 
For example, 71 different Disability Benefits Questionnaires (DBQ) are 
available to support Veterans' claims. DBQs are designed to more 
efficiently gather medical evidence from VHA clinicians and private 
physicians, including disability contract examiners, by capturing all 
the medical information needed to process a claim for a specific 
condition at once and up front.
    Similarly, in the Acceptable Clinical Evidence (ACE) process, VHA 
clinicians review existing medical evidence and determine whether that 
evidence can be used to complete a DBQ without requiring the Veteran to 
report for an in-person examination. For many Veterans, this means they 
no longer need to travel and take time off for an examination, which 
can be a significant burden. Clinicians also have the option to 
supplement medical evidence with telephone interviews with the Veteran, 
or to conduct an in-person examination if determined necessary.
    VHA is providing certified C&P clinicians at VBA regional offices. 
The clinicians provide medical opinions, answer staff questions, 
correct insufficient examinations, and serve as a key communication 
link between VBA and VHA. Along with communication at the local level, 
the Administrations have weekly meetings to discuss the disability 
examination process and established mailboxes for any questions 
employees may have about the process. VBA and VHA also collaborate on 
training programs and development of national policy and procedures to 
ensure consistency and quality.

    Question 23. Although the VA Inspector General has yet to conclude 
its investigation, you stated in your testimony before the House 
Committee on Veterans' Affairs that an administrative team from the VA 
has visited Phoenix and found ``no evidence of a secret list,'' and no 
indication that patients had ``died because they have been on a wait 
list.'' However, an NBC report indicates that internal VA memos show 
that in 2010, the VA's deputy undersecretary for health, William 
Schoenhard, was aware that some VA employees were using inappropriate 
scheduling practices to cut down on the officially reported time that 
patients wait for care.
    a. In light of this report by NBC, do you believe that your 
testimony before the House Committee on Veterans' Affairs was 
inconsistent?
    b. According to the report from NBC, Deputy Under Secretary 
Schoenhard was aware of inappropriate scheduling practices at some VA 
medical facilities--were you aware as well?
    c. Given that the VA Inspector General has yet to conclude its 
investigation, do you believe that your statements regarding the 
conclusions of the preliminary findings of the VA administrative team 
that recently visited Phoenix were premature and unwise?
    d. What, if any, steps are you taking to ensure that swift and 
decisive disciplinary action will be taken if the allegations are found 
to be true?
    Response. While VHA has made efforts to address health care 
appointment scheduling and wait times for health care, further 
improvement is needed. On May 16, 2014, Robert Petzel, M.D., resigned 
as VHA's Under Secretary for Health. VHA's testimony was based on the 
data that was available at that time. However, we acknowledge that 
within many of our health care facilities there were systemic and 
unacceptable scheduling practices. VA is taking corrective action to 
address these issues.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr on 
 behalf of Hon. John Cornyn to Hon. Eric K. Shinseki, Secretary, U.S. 
                     Department of Veterans Affairs
    Question 24. Secretary Shinseki, according to recent reports, you 
have ordered a ``face-to-face audit'' of all Department of Veterans 
Affairs clinics. Can you describe in detail how you intend for this 
audit to be conducted, its timeline for completion, and what measures 
are being taken to ensure these audits are conducted in an independent 
and transparent manner? If the allegations are substantiated, what type 
of action are you willing to take to right these wrongs, and how will 
the responsible officials be held accountable?
    Response. On May 23, 2014, VHA executed the Accelerating Care 
Initiative, a coordinated, Nation-wide initiative to accelerate care to 
Veterans throughout the VA system and in the communities where Veterans 
reside. This initiative was designed to increase timely access to care 
for Veteran patients; decrease the number of Veteran patients on the 
Electronic Wait List (EWL) and waiting greater than 30 days for care; 
and standardize the process and tools for ongoing monitoring and access 
management at VA facilities.
    The Nation-wide Access Audit covered a total of 731 separate points 
of access, and involved over 3,772 interviews of clinical and 
administrative staff involved in the scheduling process at VAMCs, large 
Community-Based Outpatient Clinics (CBOC) serving at least 10,000 
Veterans and a sampling of smaller clinics. VA released the results of 
this audit on June 9, 2014, which can be accessed online at the 
following link: http://www.va.gov/health/access-audit.asp. VA will 
continue to accelerate access to care for Veterans nationwide who need 
it, utilizing care both in and outside the VA system.
    We are in the midst of following up on the Nation-wide audit, 
interviewing senior leaders at facilities that had been flagged for 
further review but where OIG is not conducting scheduling-related 
investigations, or where the OIG has completed its investigation and 
found no basis for criminal action. This is in follow--up to the access 
audit and is intended to determine which supervisors, managers and 
employees may have intentionally directed or carried out inappropriate 
scheduling practices. We are also following up on OIG's scheduling-
related investigations, as OIG releases its findings to us, and will 
ensure accountability for anyone implicated in wrongdoing by the IG.

    Question 25. Secretary Shinseki, a whistleblower in Texas claims 
that during his time as a scheduling clerk for VA facilities in Austin, 
San Antonio, and Waco, he was directed by supervisors to hide true wait 
times by inputting false records into the VA's scheduling system. VA 
officials in San Antonio deny this, while VA officials in Austin claim 
employees may have been discouraged from using the electronic 
scheduling tool that would reveal long wait times, but that those 
orders did not come from ``executive leadership.'' Can you confirm that 
supervisors at VA facilities in Texas have not and are not ordering 
employees to ``game the system'' by concealing wait times?
    Response. April 25-28, 2014, an internal fact-finding review by 
South Texas Veterans Health Care System (STVHCS) was completed and 
claims made by the employee could not be substantiated. STVHCS and 
Central Texas Veterans Health Care System (CTVHCS) leaders have made it 
clear to scheduling clerks that no wait list formats of any kind other 
than VistA Scheduling software should be used.
    Officials do confirm that scheduling clerks were not using the 
Electronic Wait List (EWL) and once leadership became aware, they 
conducted training sessions for clerks to begin using the EWL. The EWL 
is a valuable tool to help monitor appointments and determine where 
more resources might be needed.
    VA encourages employees to bring forth any concerns they may have 
regarding scheduling of patients so their concerns may be addressed. If 
during any external or internal review, allegations of employee 
misconduct are substantiated, swift and appropriate action will be 
taken. In addition, as a part of positive employee relations, VA 
management continues to meet with scheduling clerks both in Central and 
South Texas to encourage the hard work they do on a daily basis and to 
hear their concerns.

    Question 26. Secretary Shinseki, an Austin-based surgeon recently 
contacted my office to inform me he is not accepting any further 
subcontracts from the VA due to failures in patient care that he has 
personally witnessed. Specifically, he saw a veteran in August 2013 who 
was referred to him by the VA after they detected a lesion they 
suspected was cancerous. Already two months had lapsed between the time 
they detected the lesion and the time he saw the veteran. This surgeon 
performed a biopsy and diagnosed it as laryngeal cancer. He informed 
the VA that the veteran needed immediate chemotherapy--that they had a 
real chance to treat his cancer if they started chemotherapy right 
away. Almost two months later, he followed up on his case only to learn 
the VA never provided chemotherapy, with no good excuse as to why. The 
veteran died several days later. Can you confirm that veterans 
diagnosed with cancer of any kind that requires chemotherapy are 
provided that treatment in a timely manner by the VA?
    Response. VHA is committed to timely care for all Veterans 
including those undergoing treatment for cancer. The referenced case 
was reviewed by clinical leadership in Central Texas and Veterans 
Integrated Service Network 17. At this time, the information provided 
indicates no evidence was found indicating that patients with cancer of 
any kind undergoing chemotherapy treatment experienced that care in an 
untimely manner. VHA investigates allegations of less than adequate 
care, and when warranted, takes appropriate corrective actions.

    Question 27. Secretary Shinseki, a whistleblower in South Texas who 
formerly served as associate chief of staff for the VA Texas Valley 
Coastal Bend Health Care System in Harlingen, TX, told the Washington 
Examiner this week that roughly 15,000 patients who should have had the 
potentially life-saving colonoscopy procedure either did not receive it 
or were forced to wait longer than they should have. He also claims 
that approximately 1,800 records were purged to give the false 
appearance of eliminating a backlog. Can you confirm that veterans 
requiring colonoscopies to detect cancer are provided with the 
procedure in a timely manner?
    Response. The claims against VA Texas Valley Coastal Bend Health 
Care System (VATVCBHCS) by the former Associate Chief of Staff are 
outlined in the Office of Special Counsel (OSC) report OSC File # D-11-
3558 available on their Web site: https://osc.gov/Pages/PublicFiles-FY 
2014.aspx . In the report, the allegations of poor patient care are 
unsubstantiated. In FY 2012, the completion rate within 90 days for 
VATVCBHCS Veterans requiring diagnostic colonoscopies to detect cancer, 
following positive fecal occult blood test results, was 82 percent (65 
percent were completed within 60 days). In FY 2013, the completion rate 
within 90 days for VATVCBHCS Veterans requiring diagnostic 
colonoscopies to detect cancer, following positive fecal occult blood 
test results, was 86 percent (57 percent were completed within 60 
days). All diagnostic colonoscopies are reviewed quarterly by the 
Invasive Procedures Committee.

    Question 28. In 2012, VA medical facilities in Central Texas 
reported that 96 percent of veterans were seen by providers within 14 
days of their preferred appointment date. In the South Texas region 
that includes San Antonio, the statistics were even more impressive: 97 
percent of veterans were seen within two weeks, according to annual 
performance reports. Can you produce documents that show the original 
dates of veterans' requests for appointments for 2012?
    Response. There is no mechanism in the VistA program to allow for a 
retrospective review of the original dates of a Veteran's request for 
an appointment after the Veteran has been seen for that appointment.

    Question 29. Secretary Shinseki, according to public records, the 
director of the Phoenix VA hospital, where news investigations have 
discovered at least 40 veterans died while waiting for care and 
languishing on secret lists, received more than $9,000 in bonus pay in 
2013. Can you confirm that any bonuses or pay raises are on hold for 
senior leaders at VA facilities in San Antonio, Austin, Waco, 
Harlingen, and all VA facilities where similar allegations have been 
made?
    Response. Acting Secretary Sloan Gibson announced on June 9, 2014, 
that VHA SES performance awards were suspended for FY 2014. FY 2013 
performance incentives were paid in accordance with VA established 
recommendations and timelines for leaders at CTVHCS, STVHCS, and 
VATVCBHCS.

    Question 30. Secretary Shinseki, my staff attended a Quarterly 
Congressional Staffer and Veterans Service Organization Representative 
Meeting at the Central Texas Veterans Health Care System (CTVHS) 
Friday, May 9, 2014. Sallie Houser-Hanfelder, director of the Central 
Texas Veterans Health Care System, told meeting attendees that, as part 
of the face-to-face audits you have ordered, a quality systems manager 
from CTVHS would be sent to another VA facility to assist with 
investigations there. Can you confirm that staff at facilities 
currently under investigation for allegations of falsified reports will 
not be assigned to investigate other VA facilities?
    Response. The individual from CTVHCS that served on the phase one 
portion of the VA-directed site visits has no oversight or involvement 
with the scheduling of appointments.

    Question 31. Secretary Shinseki, former VA employee at the VA 
Greater Los Angeles Medical Center told the Daily Caller that employees 
at the Center destroyed veterans' medical files in a systematic attempt 
to eliminate backlogged veteran medical exam requests. The former 
employee said, ``The waiting list counts against the hospital's 
efficiency. He said the chief of the Center's Radiology Department 
initiated an ``ongoing discussion in the department'' to cancel exam 
requests and destroy veterans' medical files so that no record of the 
exam requests would exist, thus artificially reducing the backlog. In 
addition, you have been subpoenaed by the House Veterans' Affairs 
Committee over concerns by Chairman Jeff Miller that evidence in 
Phoenix may have been destroyed after the Committee issued a document-
preservation order on April 9. A top VA official testified on April 24 
that a spreadsheet of patient appointment records, which may have been 
a ``secret list'' proving misconduct, was shredded or discarded. Can 
you confirm that documents are being preserved at all Texas VA 
facilities?
    Response. All four VISN 17 facilities are in receipt of the 
Memorandum from General Counsel ``Subj: Litigation Hold Concerning 
Alleged Consult and Appointment Delays with VA Health Care System 
(VHA)'' dated May 13, 2014. They confirm that the message has been 
distributed and all records are being preserved that leadership is 
aware of.

    Chairman Sanders. Thank you very much for your testimony, 
Mr. Secretary.
    I am going to start off with a simple question, and then I 
am going to ask some harder questions, and you or Dr. Petzel 
can answer.
    First, a very simple question. VA's Health Care System is 
the largest integrated health care system in the United States 
of America. Six-point-five million veterans access it every 
single day. Gen. Shinseki or Dr. Petzel, what are the strengths 
of VA's Health Care System? What are its problems, in your 
judgment? Is it a good system?
    Secretary Shinseki. Mr. Chairman, it is a good system and 
it is comparable to any other health care system in the 
country. In some areas and some specific occasions, we exceed 
even those good systems.
    For 5 years now, we have focused on three major goals for 
VA, all of it focused on doing better by veterans, which is 
what the President asked me to do when I came here. The first 
was to increase access. I think we have been successful at 
this. We have enrolled two million more veterans into VA health 
care. I think there is a net here somewhere around 1.4 million, 
1.5 million who are net overall increases. But, over 5 years, 
we have enrolled 2 million more veterans.
    The second focus was to go after this thing called the 
backlog, and we have had this discussion for a number of years 
now. But, we did not simply go after the backlog just to end 
what was then, 5 years ago, a set of claims. We also 
acknowledged that we had not done very well by veterans of 
previous conflicts. And so even as we committed to ending the 
backlog in 2015, we also went and tried to bring justice to 
those who had never had an opportunity to submit a claim. I 
called on the good people in the Veterans Benefits 
Administration to take this on, and they did. And I promised 
them we would give them a new tool called the Veterans Benefits 
Management System, and in 3 years, we fielded this new 
automation tool that make them----
    Chairman Sanders. How did we used to do benefits?
    Secretary Shinseki. All paper.
    Chairman Sanders. All paper.
    Secretary Shinseki. All paper, and if you wanted to go 
faster, Mr. Chairman, you had to hire more people, which we had 
done over many years. I think we have, I do not know, 11,000 
people who process claims, which is----
    Chairman Sanders. What I want to do now, Mr. Secretary, is 
pick up on some of the points, I think legitimate points, made 
by Democrats and Republicans. And the major allegation--I think 
everybody here understands that when you treat 230,000 people a 
day, mistakes are going to be made, which is true of any 
institution of that size. But, here is the major criticism that 
I hear from Senator Burr, Senator Murray, Senator Begich, and 
others, that this is not new news. These concerns did not arise 
yesterday. They did not arise in Phoenix. But, in fact, there 
have been reports by the Inspector General, by the Government 
Accountability Office, on numerous occasions about problems 
having to do with scheduling and waiting lists. Could you 
address how it could happen that, year after year----
    Secretary Shinseki. Sure.
    Chairman Sanders [continuing]. These reports were made and 
there has not been significant action.
    Secretary Shinseki. Yes. I think it is important here to 
look at the GAO and the IG reports and what they intend to do, 
and they come in and give us some sense of where we could be 
doing better. And we get in there and we address those issues 
and take corrective action and, in essence, close out the 
report. It does not mean that we have solved every issue. It 
does mean that we have taken care of addressing those issues, 
and then when they come back, there may be another set of 
issues to deal with.
    I do understand Senator Murray's suggestion that we ought 
to take a comprehensive look at this----
    Chairman Sanders. I think what you are hearing from a 
number of Senators including myself, is that everybody knows 
problems will arise tomorrow. That is not the criticism. The 
criticism is that year after year reports have been made 
talking about these problems and the problems continue to 
exist. Can you give us some assurance of what happens tomorrow? 
Where do we go from here so that we do not have this hearing 
next year or 2 years from now?
    Secretary Shinseki. Sure. And I think that is what the 
audit that we have created is intended to do. So, while the 
Inspector General is looking at Phoenix for evidence of 
employee misconduct and evidence that 40 veterans may have 
perished awaiting scheduling, the IG is going to get to the 
bottom of that. What we are attempting to do is to address the 
Senator's broader question, to take a look at ourselves and not 
wait for the IG's outcomes. And already, we have begun to see 
some evidence that--people are coming forward and saying, hey, 
I think there is an issue here, which I encourage. I mean, that 
is what we are after here. And if there were performance issues 
in the past, if they are continuing today, we want to put a 
stop to----
    Chairman Sanders. All right. My last question is, in your 
judgment, based on what you know, are people, ``cooking the 
books?'' Is that, in fact, a problem within VA's health care 
system?
    Secretary Shinseki. I am not aware, other than a number of 
isolated cases where there is evidence of that. But, the fact 
that there is evidence in a couple of cases behooves us to go 
and take a thorough look, and that is why we have structured 
this audit so that a set of clinicians are not going to inspect 
their own areas. We have offset them so that a VISN 1 will 
inspect a VISN 10, and we will get a comprehensive--a good 
look. But I----
    Chairman Sanders. I apologize, but my time has long 
expired.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Mr. Secretary, again, welcome. These questions are for you, 
and I will try to go as quickly as I can for the time 
constraints.
    Mr. Secretary, were you aware that on October 25, 2013, the 
Office of Special Counsel requested that VA conduct an 
investigation into the allegations of the inappropriate 
scheduling at the Fort Collins Community Outpatient Clinic, and 
that since then, the media has reported about Mr. Freeman's e-
mail of June 19, 2013, that explains how to game the system to 
avoid being on the bad boy list. Were you aware of those?
    Secretary Shinseki. Senator, I became aware of that screen 
shot, I believe is what it was, of an employee who was 
suggesting there are ways to game. I put that employee on 
administrative leave----
    Senator Burr. When was that?
    Secretary Shinseki. That was last Friday.
    Senator Burr. OK. Mr. Secretary, it is my understanding 
that on June 21, 2013, VA received a report from the Office of 
Medical Inspector regarding chronic understaffing issues at the 
Jackson VA medical center and that report described multiple 
patient scheduling problems, including scheduling two patients 
for the same appointment slot, and scheduling patients for a 
clinic that does not have any assigned providers, often 
referred to as ghost clinics; and that on September 17, 2013, 
the Office of Special Counsel submitted a letter to the 
President of the United States, on which the VA was courtesy 
copied, describing the findings of that June 21 Office of 
Medical Inspector report on the Fort Jackson Medical Center, 
including the practice of double-booking patients and the use 
of ghost clinics. Do you remember reading that report and 
receiving that copied letter to the President?
    Secretary Shinseki. I cannot say that I remember it today, 
here----
    Senator Burr. OK. There was a December 23, 2013, report by 
the Office of the Medical Inspector regarding the Cheyenne 
Medical Center and Fort Collins Clinic that found that several 
medical support assistants reported that, ``medical center's 
Business Office training included teaching them to make the 
desired date the actual appointment, and if the clinic needed 
to cancel appointments, they were instructed to change the 
desired date to within 14 days of the new appointment.'' Did 
you read that report?
    Secretary Shinseki. That report has come to my attention 
here recently.
    Senator Burr. OK. On February 25, 2014, your Chief of 
Staff, Mr. Riojas, submitted a response to the Office of 
Special Counsel which included the December 23, 2013, Office of 
the Medical Inspector report on Fort Collins, and in that 
letter, Mr. Riojas states, ``However, as OMI,'' Office of 
Medical Investigation, ``was not provided any specific 
veterans' cases affected by these practices, it cannot 
substantiate the failure to properly train staff resulting in 
danger to public health or safety.'' Were you aware of what 
your Chief of Staff wrote?
    Secretary Shinseki. I was.
    Senator Burr. OK. Mr. Secretary, were you aware that the 
GAO report entitled, ``VA Health Care: Reliability of Reported 
Outpatient Medical Appointment Wait Times and Scheduling 
Oversight Need Improvement,'' which was publicly released in 
January 2013, and then on December 11, 2012, to that same 
report, your former Chief of Staff, John Gingrich, sent a 
letter to the GAO which stated, ``VA generally agrees with the 
GAO conclusions and concurs with GAO recommendations to the 
Department.'' Do you remember that letter, that report and your 
Chief of Staff's response?
    Secretary Shinseki. In general, I do remember that report.
    Senator Burr. Mr. Secretary, you knew that there were 
specific issues relating to scheduling and wait times as early 
as June 21, 2013, at Jackson; December 23, 2013, at Fort 
Collins; as well as numerous IG reports related to excessive 
wait times in January 2012 in Temple, TX; September 2012, in 
Spokane, WA; October 2012, in Cleveland, OH; September 2013, in 
Columbia, SC; and December 2012, a GAO report which questions 
the validity and the reliability of the reported wait time 
performance measures, which brings us to today and Phoenix.
    On May 1, you publicly stated that you had removed Ms. 
Hellman as the Medical Director, and you stated then that that 
was to ensure the integrity of the IG's current investigation. 
On May 5, Dr. Petzel conducted a conference call with all VISN 
Directors, all Medical Directors, and the Chief of Staffs--a 
rather large group--to discuss the ongoing face-to-face audits 
of all VA centers and large community-based outpatient clinics. 
I have been told by sources that were on that call that during 
that call, Dr. Petzel made the statement that the removal of 
Ms. Hellman was, ``political and that she has done nothing 
wrong.''
    If you are asking us to wait until the investigation is 
over, does the same not apply to people who work for you? And, 
Mr. Secretary, from all I have described to you and the current 
investigation that is currently going on, why should this 
Committee or any veteran in America believe that change is 
going to happen as a result of what we are going through?
    Secretary Shinseki. I was not aware of the phone call you 
referred to, and I will look into it. I would just tell you 
that my removal of the Director, placing her on administrative 
leave, was at the request of the IG. He is the lead in this 
comprehensive review. I do not get out ahead of him. He 
requested it and I put Director Hellman and two other 
individuals on administrative leave.
    Senator Burr. I thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Burr.
    Senator Murray.
    Senator Murray. Secretary Shinseki, as I said in my 
opening, the announcement that the President is sending one of 
his top advisors to assist in this nationwide review is good 
news and I am confident Mr. Nabors will help make sure that 
this review is comprehensive and accurate. It is critical that 
this review is effective, because at a hearing of this 
Committee that I called in November 2011, I asked Dr. Mary 
Schoen, VA's Director of Mental Health Operations, whether 
facilities were gaming the system and not fully reporting wait 
times, and she told me she was unaware of any facilities doing 
that and that VHA was doing audits to make sure it was not 
happening. But there, as you know, have been an overwhelming 
number of allegations systemwide that wait times are being 
doctored, and the oversight organizations have reported on it 
for years.
    The Department, so far, has been unable to provide me even 
the most basic information on how this nationwide review is 
going to be conducted or what it will look like, and I hope 
that is about to change. I want you to explain how this review 
is going to be conducted.
    Secretary Shinseki. Let me call on Dr. Petzel to give you 
details.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Murray, there are going to be several phases to 
what we do. This week, we are auditing with in-person teams and 
an anonymous survey the first tranche of facilities, all 151 
medical centers and our largest clinics. Starting next week, we 
are going to work our way down to all of the other sites of 
care, gathering information--and I think the anonymous nature 
of the questionnaire is particularly important--information 
about whether or not people have felt forced to do things that 
were inappropriate and lacking trust and integrity in the 
scheduling system.
    The second part of this is an assessment, as a number of 
people have mentioned, as to whether or not we have our 
resources deployed appropriately, whether or not we have the 
appropriate amount of resources, and just as importantly, 
whether or not we are using those resources in the best way in 
each one of--at each one of our sites.
    I think everybody needs to remember that we do 85 million 
outpatient visits every year. Ninety-five percent of those 
visits are with established patients and those are all 
accomplished within 14 days.
    Senator Murray. I appreciate that. I just want the details 
of how this is going to occur so that we get good information.
    Dr. Petzel. So, we are going to focus on the new patient 
and the scheduling system that we have for new patients and all 
the other access points besides our clinics and our medical 
centers that we have got available for new patients. So, first 
is the review----
    Senator Murray. OK----
    Dr. Petzel [continuing]. To see how the scheduling system 
is being done. Second----
    Senator Murray. The assessment.
    Dr. Petzel [continuing]. The look at whether or not we 
have----
    Senator Murray. OK. Well, I would like to get the details 
from you on that, I do not want to use all my time, but it is 
important that we know how that is going to be used and we know 
that real change occurs.
    But, I just have a minute and one half left and I want to 
ask you, Secretary Shinseki, Deputy Under Secretary for Health, 
Bill Schoenhard, told me at a hearing in 2012 that gaming is so 
prevalent, as soon as new directives are put out, they are torn 
apart to find out how to get around the requirements. Testimony 
from a VA mental health employee said the exact same thing.
    And, at that same hearing, Linda Halliday from the IG's 
Office told us, ``If we have seen scheduling practices that 
resulted in gaming the system to make performance metrics look 
better at the end of the day over the past 7 days, they need a 
culture change. To get that culture change, I think they really 
need to hold the facility directors accountable for how well 
the data is actually being captured.''
    That was more than 2 years ago, and the standard practice 
at VA seems to be to hide the truth in order to look good. That 
has got to change once and for all. And I want to know how you 
are going to get your medical directors and your network 
leaders to tell you--whether it is through this survey or in 
the future--when they have a problem and will work with you to 
address it, rather than pursuing these secret lists and playing 
games with these wait times.
    Secretary Shinseki. Well, Senator, if there is anything 
that gets me angrier than just hearing allegations is to hear 
you tell me that we have folks that cannot be truthful because 
they think the system does not allow it.
    Senator Murray. Right.
    Secretary Shinseki. You know, trust is an important aspect 
of everything we do here, and it has been in my previous life, 
as well. In order to do that we have to be transparent and we 
have to hold people accountable. So, what I will say to you is 
we are going to get into this; and it is important for me to 
assure veterans, to regain their trust, whatever has been 
compromised here, that when they come to VA they come to a 
good, safe, caring system and that they will be cared for.
    And for all the employees that are listening in today, I 
expect our employees to provide the highest quality, safest 
care we can provide, given all the comments about how tough it 
is in the health care industry, and provide access to benefits 
as quickly as we can. That is our mission. We only have one 
mission. It is taking care of these veterans, and not ``these'' 
veterans, I am one of them, a hundred thousand of our employees 
at VA are veterans. We have a vested interest here to get this 
right.
    Senator Murray. OK. This is absolutely critical. This 
review will not work if those people who are telling you the 
information do not tell you the truth.
    Secretary Shinseki. Agreed.
    Chairman Sanders. Thank you, Senator Murray.
    Senator Isakson.
    Senator Isakson. Thank you, Mr. Chairman.
    For both of you gentlemen, do you remember or do you know 
William Schoenhard?
    Secretary Shinseki. I do.
    Dr. Petzel. Yes.
    Senator Isakson. Do you know him, Dr. Petzel?
    Dr. Petzel. I do.
    Senator Isakson. On the 26th of April in 2010, he sent out 
a memo to all the VISN Directors throughout VA entitled, 
``Inappropriate Scheduling Practices.'' Paragraph two begins, 
``It has come to my attention that in order to improve scores 
on assorted access measures, certain facilities have adopted 
use of inappropriate scheduling practices, sometimes referred 
to as gaming strategies.''
    Then, paragraph three, and I am going to read the whole 
paragraph because this is the key to the question and, I think, 
is the key to the issue at VA. ``For your assistance''--and 
there is an eight-page attachment to this--``for your 
assistance, attached is a listing of the inappropriate 
scheduling practices identified by a Multi-VISN Working Group 
chartered by the System Redesign Office. Please be cautioned 
that since 2008, additional new or modified gaming strategies 
may have emerged, so do not consider this list a full 
description of all current possibilities of inappropriate 
scheduling practices that need to be addressed. These practices 
will not be tolerated.''
    Are you familiar with that memorandum?
    Secretary Shinseki. I am--I was not. I am not.
    Senator Isakson. Dr. Petzel?
    Dr. Petzel. I am familiar with that memorandum, yes.
    Senator Isakson. Well, if it is not going to be tolerated, 
and over 4 years ago you had eight pages of known practices for 
gaming the system, what action, if any--and I do not think any 
took place--did VA take to respond to William Schoenhard's 
memorandum to see to it the VISN and the hospital directors 
followed the orders?
    Dr. Petzel. We have worked very hard, Senator Isakson, to 
root out these inappropriate uses of the scheduling system and 
these abuses. We have been working continuously to try to 
identify where those sites are and what we need to do to 
prevent that from happening. It is absolutely inexcusable. The 
scheduler's responsibility is to be sure that that program is 
administered with integrity?
    Senator Isakson. What do you do when you uncover one? 
Surely, you have uncovered one. What do you do to hold them 
accountable?
    Dr. Petzel. The individuals are, as you mentioned, held 
accountable. I cannot give you an example specifically, but if 
someone were found to be manipulating inappropriately the 
scheduling system, they would be disciplined.
    Senator Isakson. So, would they lose their job?
    Dr. Petzel. I do not know whether that is the appropriate 
level of punishment or not.
    Secretary Shinseki. Senator, we can probably give you a 
little better answer to this, because you are focused on 
scheduling. What I can tell you is that in 2012, we 
involuntarily removed 3,000 employees for either poor 
performance or misconduct. In 2013, another 3,000 employees 
were involuntarily removed, and among them, there were some 
senior executives, as well.
    Senator Isakson. Are those removals a reassignment within 
the VA Health Care System?
    Secretary Shinseki. Some may be reassignments. Others were 
departure, some by retirement and others by, in effect, being 
let go by VA.
    Senator Isakson. Well, I just--I have read this entire 
eight-page memorandum and there is no gray area. It is not 
saying we think this is happening. It is saying we know this is 
happening; and there may be other ways of gaming the system. It 
talks about being done specifically for the purpose of 
improving scores on assorted access measures, which I guess 
means the way in which their performance is evaluated as an 
employee. Is that correct?
    Secretary Shinseki. I--I am going to take your direction 
here.
    Senator Isakson. No, no, no----
    Secretary Shinseki. I have not read the memo----
    Senator Isakson. No, no, no. I----
    Secretary Shinseki [continuing]. So, I would assume that 
that is the----
    Senator Isakson. And I would assume, if the System Redesign 
Office had a Multi-VISN Working Group--do you know what the 
System Redesign Office is?
    Secretary Shinseki. Dr. Petzel?
    Dr. Petzel. Yes. That----
    Senator Isakson. What is that?
    Dr. Petzel. That is the group that is responsible for 
ensuring that we are designing the work within our clinics and 
operations in the most effective and efficient way; and they 
have been given--at that time, they were given responsibility 
for monitoring and keeping track of access.
    Senator Isakson. It says that the listing of inappropriate 
scheduling practice was identified by the Multi-VISN Working 
Group. So, you had a group within the Veterans Administration 
that identified on August 26, 2010, various and numerous 
practices where numbers were being manipulated for the purpose 
of better outcomes, I presume, in terms of how those people 
would be rated. It would seem to me like there should have been 
a systematic, written practice where the chain of command would 
see to it that was not tolerated, as the memo said, and there 
was accountability to be had, including the loss of a job.
    Dr. Petzel. I absolutely agree with you. And we did 
institute that appropriate level of accountability. I will find 
out--I do not know whether anybody was specifically disciplined 
around that issue, but this has been a very important thing to 
us for at least the last 4 years, Senator Isakson. We have 
tried to root out those places where the scheduling system was 
being used inappropriately.
    Senator Isakson. So----
    Dr. Petzel. It is intolerable.
    Senator Isakson. I know my time is up, but let me just say 
two things. One is, for the sake of the integrity of the 
Veterans Administration, you need to find out if there is an 
accountability system to respond to this memorandum from August 
26 and what it was.
    And, second, I would like to ask unanimous consent to 
submit this Memorandum for the record.

    [The Memorandum from August 26, 2010, is posted in the 
Appendix under Senator Isakson.]

    Chairman Sanders. Without objection.
    Senator Isakson. Thank you both.
    Chairman Sanders. Thank you.
    Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman. Again, thank 
you to you and the other veterans who are here and who are 
listening for their interest and involvement in this issue.
    Secretary Shinseki, can you tell me how quickly we will 
have some preliminary results to both the review and the IG 
investigation?
    Secretary Shinseki. The Inspector General has his own time 
table and I do not have insight into what that is. On our 
audit, we are taking care of most of the large facilities this 
week. There will be some follow-up next week. Perhaps in about 
3 weeks we will have been able to assemble all the data, do a 
good analysis, and then respond in detail in a way that Members 
have asked.
    Senator Blumenthal. Can you commit that within 3 weeks, you 
will have a report for us?
    Secretary Shinseki. I--I think we should be able to do 
that, but that is preliminary right now. I do not know what 
data is being assembled and----
    Senator Blumenthal. And----
    Secretary Shinseki [continuing]. Collating it every day, 
but we will shoot for 3 weeks.
    Senator Blumenthal. And I apologize for interrupting, but 
as you know, all of our time is limited.
    Secretary Shinseki. Sure.
    Senator Blumenthal. As part of your management 
responsibility, do you not believe as I certainly believe, that 
there is a responsibility from the IG to complete this report 
as quickly as possible, within a matter of days and weeks, not 
months?
    Secretary Shinseki. I agree that it would be helpful for 
the IG to complete his report as quickly as----
    Senator Blumenthal. And can you give the IG a deadline?
    Secretary Shinseki. I am not able to do that. The IG is an 
independent reviewer here, and once I turn this over to him, I 
am primarily supporting his needs here. So, in terms of----
    Senator Blumenthal. Let me raise sort of the elephant in 
the room. Is there not evidence here of criminal wrongdoing, 
that is, falsifying records, false statements to the Federal 
Government? That is a crime under the----
    Secretary Shinseki. It should be, yes.
    Senator Blumenthal. And would it not be appropriate to ask 
for assistance from the Federal Bureau of Investigation or some 
other similar agency, given that the IG's resources are so 
limited, that the task is so challenging, and the need for 
results is so powerful?
    Secretary Shinseki. Again, I will work with the IG to make 
that available to him if that is his request.
    Senator Blumenthal. Well, may I suggest, respectfully, Mr. 
Secretary, that it is your responsibility to make that judgment 
about the IG's resources, and without rushing to judgment, 
without reaching any conclusions----
    Secretary Shinseki. Sure.
    Senator Blumenthal [continuing]. To involve appropriate 
Federal criminal investigative agencies if there is sufficient 
evidence of criminality, which, in my judgment, there is more 
than sufficient reason to involve other investigative agencies 
here in light of the evidence--more than allegations, but 
evidence--of potential false statements to the Federal 
Government, and the need for timeliness and promptness in 
results to restore trust and confidence.
    What I am hearing from my colleagues is the background 
about the systematic failures here and the need for also 
greater transparency and accountability, so let me ask my next 
question.
    Secretary Shinseki. Well, that is a discussion on resources 
that I have had repeatedly with the IG to make sure. But, 
again, every discussion about, do you have enough resources, 
based on what is underway, each new discovery adds to that 
workload, and, fair enough. I will have that discussion with 
him again.
    Senator Blumenthal. Let me ask, will you change your 
management team given that the background here shows systematic 
failings over a period of, apparently, years, not just months?
    Secretary Shinseki. Yes. Senator, I do not want to get 
ahead of myself or ahead of the IG here. I want to see the 
results. I want to see the results of the audit, and if changes 
are required, I will take those actions.
    Senator Blumenthal. If this evidence that we have seen 
already is as probative and powerful as it seems to be, would 
not changing your management team be appropriate?
    Secretary Shinseki. Perhaps. I am still waiting for the 
results of the audit.
    Senator Blumenthal. Thank you very much, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Blumenthal.
    Senator Heller.
    Senator Heller. Thank you, Mr. Chairman.
    Mr. Secretary, I pointed out in my opening statement about 
the IG investigation revealed the treatment of a blind female 
veteran and the way she was treated at the emergency room in 
the VA hospital in Las Vegas. Have you had an opportunity to 
see the results of that investigation?
    Dr. Petzel. Senator Heller, I have had an opportunity to 
review that investigation, yes.
    Senator Heller. What was the conclusion?
    Dr. Petzel. The--without revealing details about the 
individual----
    Senator Heller. Sure.
    Dr. Petzel [continuing]. It was that she did wait too long 
and that there were others that waited too long in the 
emergency room. It did not have, in the estimation of the 
inspector, an impact on the eventual course of her illness, but 
it was inappropriate that a service-connected blind veteran 
should have to wait that long in our emergency room.
    Senator Heller. Thank you for the answer.
    Mr. Secretary, do you agree?
    Secretary Shinseki. I do not think any veteran, whatever 
the condition, should have to wait that long in any of our 
facilities, whether it is an emergency room or a clinic.
    Senator Heller. Mr. Secretary, have you received complaints 
about patients' wait times, scheduling practices, for any other 
facility in Nevada?
    Secretary Shinseki. I am not aware of another facility----
    Dr. Petzel. I am not, either.
    Secretary Shinseki [continuing]. In Nevada. Dr. Petzel?
    Dr. Petzel. I am not aware of it, either. We are not--I do 
not know the results of our visits to either Reno or the Las 
Vegas hospital, but I have not heard anything.
    Senator Heller. Will all of Nevada's VA hospitals and 
clinics have face-to-face audits?
    Dr. Petzel. Yes, they will.
    Senator Heller. Will VA conduct more thorough audits later 
with the IG?
    Dr. Petzel. If we find that there were instances where 
there might have been inappropriate criminal activity, we 
certainly will enjoin the IG to come. That is difficult to 
predict, depending on what we find.
    Secretary Shinseki. Senator, are you talking about a 
continuing series of audits?
    Senator Heller. Correct.
    Secretary Shinseki. I think, based on what we find, if 
there is a widespread, systemic issue here, we will set up a 
program of sustaining looks to make sure that we have rooted 
out the kind of behaviors that we are talking about, either 
alleged or in fact.
    Senator Heller. After conducting those investigations, will 
you make that available to myself and my staff?
    Secretary Shinseki. Yes.
    Senator Heller. To any member of the Nevada delegation?
    Secretary Shinseki. Yes.
    Senator Heller. Great. To go back, obviously, with the 
issues, Mr. Secretary, with what is going on in Phoenix, the 
waiting room, the time waits that we are seeing across the 
country and, of course, in my State of Nevada, and, of course, 
the disability claims backlogs that we are seeing three times 
longer in the State of Nevada than what it should be, do you 
believe that you are ultimately responsible for all this?
    Secretary Shinseki. I am. You and I had this discussion 
yesterday. I think I need to provide you data that would be a 
little more current than three times the national average on 
waits on backlog claims. Perhaps true at one time, I am told 
that those numbers are down.
    Senator Heller. OK. Today's numbers are 355 days.
    Secretary Shinseki. That is on----
    Senator Heller. That is still three times longer than the 
national average.
    Secretary Shinseki. OK.
    Senator Heller. Would you explain to me, after knowing all 
this information, why you should not resign?
    Secretary Shinseki. Well, I tell you, Senator, that I came 
here to make things better for veterans. That was my 
appointment by the President. Every day, I start out with the 
intent to, in fact, provide as much care and benefits for the 
people I went to war with and the people that I spent a good 
portion of my life doing. This is not a job. I am here to 
accomplish a mission that I think they critically deserve and 
need, and I can tell you, over the past 5 years, we have done a 
lot to make things better. We are not done yet, and I intend to 
continue this mission until I have satisfied either that goal 
or I am told by the Commander in Chief that my time has been 
served.
    Senator Heller. Mr. Secretary, thank you for being here 
today.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Heller.
    Senator Hirono.
    Senator Hirono. Thank you, Mr. Chairman.
    In his testimony, Acting IG Mr. Griffin states that VA's 
core mission is to provide quality health care. Is providing 
quality health care still VA's core mission, or have the goals 
of VA shifted over time as they have expanded into providing 
other benefits to veterans, as well? Of course, I note that 
Congress has tasked VA to provide job training, housing 
assistance, education assistance, and reduce homelessness. So, 
can you share your thoughts about what is the core mission now, 
with all these other tasks that you now have, programs that you 
now have, are there--are you able to focus on your core mission 
of providing quality health care to our veterans?
    Secretary Shinseki. Yes. Providing quality, safe, 
accessible health care for our veterans who have earned them is 
a core mission. But, in order to provide that kind of health 
care, they still have to access the system, and that means we 
have to do a good job at dealing with disability claims. If we 
are not able to process those claims, the opportunity to access 
health care is something less.
    For the current generation of Iraq and Afghanistan 
veterans, it is automatic that they have 5 years of health care 
from VA. So, for that group, that generation of veterans, it is 
a little different than others.
    So, disability claims becomes an issue here because that 
then renders the opportunity to take advantage of health care 
benefits.
    I would say homelessness is also part of our 
responsibility. Five years ago, we talked about homelessness as 
though it were a thing out there, and what we have learned in 5 
years, because we have focused on ending it, is that 
depression--major factors that lead to homelessness--
depression, insomnia, pain, substance abuse, substance use 
disorders, and then----
    Senator Hirono. Mr. Secretary, I am sorry to interrupt, but 
my time is rapidly expiring. The point of my question is that 
all of these areas that we have asked you to address with 
regard to our veterans--education needs, homeless issues, all 
of that--whether that is making it much harder for you to meet 
your core mission? That may be a rhetorical question, so let me 
just move on to another area.
    As we look at the potential need for making systemic 
changes to how VA operates, I again note the IG's testimony 
today on page eight where he says that there is no national 
process to establish what are deemed essential positions to the 
delivery of health care. There is no standard organizational 
chart for VA hospitals and clinics. So it is very hard to 
determine what clinics are doing better than others. Would you 
consider these two areas to be potential systemic changes that 
we should be looking at making within the VA operations?
    Secretary Shinseki. I think that is good insight here, and 
we will take a look at that. Part of our challenge is the 
complexity of VA Health Care System. We have a series of 
hospitals that go from the very largest and most sophisticated, 
comprehensive kind of health care--organ transplants, you know, 
brain surgery. We call them 1As; and then there are 1Bs and 
1Cs; and then Level 2 and Level 3s, all of this distinguishing 
between the level of care that can be provided there. It is a 
complex system, but I think standardizing the definitions of 
key leaders within that kind of framework would be helpful and 
sensible.
    Senator Hirono. This next question may be one for Dr. 
Petzel to very briefly respond to. We have heard that VA has 
used bonuses and compensation as staff incentives to help bring 
down the patient wait times, and my question is, are these 
individual bonuses? Are these clinic bonuses? Are these 
individual compensations that occur? And, how do you hold staff 
accountable to ensure that these incentives are earned in an 
appropriate manner? What do you have in place to make sure that 
the gaming of the system is not occurring?
    Dr. Petzel. What you are referring to, I think, Senator, is 
the performance awards that are given at the end of the year, 
and each senior executive has a performance contract that has 
many, many elements, one of which, a subset of which, may 
relate to access. It could be stated in a variety of different 
ways. Has access improved, and then the percentage of 
improvement. Very few of them would state the absolute. Most of 
them are statements of what has been the improvement. So, it is 
a part of a much more comprehensive evaluation system for 
senior executives.
    Senator Hirono. But, if you do not have accountability 
systems in place, I think it certainly encourages the kind of 
activities that we are scrutinizing today.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you very much.
    Senator Johanns.

                STATEMENT OF HON. MIKE JOHANNS, 
                   U.S. SENATOR FROM NEBRASKA

    Senator Johanns. Thank you, Mr. Chairman. Thanks for 
holding this important hearing, which I hope is the first of 
many, many hearings.
    Mr. Secretary, as you know, I occupied a Cabinet post for a 
part of my career. There are some Cabinet posts, as you know, 
by their nature, that are kind of a lightening rod. If you are 
going to be the Attorney General or the Secretary of State, you 
are going to get fired at every day. It is just part of the job 
description. The VA, on the other hand, in my judgment, does 
not fit into that category.
    And the other thing about VA is, because of the Ranking 
Member and Chair and those who preceded them, it is a pretty 
nonpartisan committee. We do not sit around and talk about 
Republican or Democrat stuff. We talk about how to improve the 
lives of veterans who have served our country. And I have 
always applauded that. I think that we need more of that in 
Washington and not less.
    The other thing I would mention is that there have been 
tough budget cycles. We know that. And yet, you, yourself, have 
come to this Committee many times and said you are resourcing 
us appropriately and generously under the circumstances and we 
thank you for that. We applaud you for that. So, then I look at 
this stuff and I go, what the heck?
    Mr. Secretary, one of the submissions we got from the 
American Legion was a map. Have they shared that with you, or 
has that come to your attention?
    Secretary Shinseki. I think I may have seen a copy of that 
last evening.
    Senator Johanns. This map is entitled, ``Epidemic of VA 
Mismanagement,'' and it goes down through Burlington, VT, 
Pittsburgh, PA, Durham, NC, Columbia, SC, Augusta, GA, Atlanta, 
GA, Jackson, MS, Chicago, IL, St. Louis, MO, Austin and San 
Antonio, TX, Cheyenne, WY, Fort Collins, CO, Phoenix, AZ, just 
place after place where the American Legion has thrown up their 
hands and said, my goodness, what the heck is going on here? Do 
you dispute what they are saying in this map? Do you think they 
are saying something here that is not true?
    Secretary Shinseki. I am not aware of the basis for that 
map, but I accept that there are places that are listed here 
where we have had adverse events, and I would also point out 
that, I do not know if in all, but in a good number, maybe a 
majority of those events, they were self-identified, initiated 
from within the Veterans Administration, Veterans Health 
Administration, which then allows us to go and investigate, 
figure out what happened, get to the root causes, and then be 
transparent, tell people what happened.
    Senator Johanns. But, here is where I am going with this. 
So many hearings I have come to where we have talked about the 
waiting lists and the disability claims, just kind of one thing 
after another. I just walk out of the hearing like I have been 
given an explanation so I will quiet down and let you go back 
to work, yet I do not see the change that is necessary. And, 
what worries me about this and what worries me about what we 
are dealing with here is it is systemic. It is cultural. It is 
people have just adopted this mode of operation as the way of 
doing business.
    Do you share my concern? Do you feel that VA culture is 
such that every rule you put out, even after this, you say, OK, 
folks, from now on, we are going to do A, B, C, and D. That is 
an order. It comes from the very top, the Secretary. Do you 
fear that people say, how do we game that? How do we get around 
that?
    Secretary Shinseki. I am sure someplace in a large 
organization, you are always going to have something like that, 
but this is part of the reason why I engage the Veterans 
Service Organizations on a near-monthly basis. If there are any 
straight shooters here, it will be them in terms of being 
direct with this Secretary. This is why I have spent a good bit 
of time traveling the country, going to our facilities and 
talking to them about what is important and engaging veterans 
in those locations, as well.
    The voices that are most important to me are the voices of 
the veterans I encounter out there, and I will say there is an 
occasional concern that is voiced to me, which I always bring 
back and go to work on. But I have not received that systemic 
look that is being described.
    There is a distinction between a medical mistake and 
manipulation or cooking the books. In the case of a medical 
mistake, I want people to stand up and say, hey, something is 
wrong here. Something is not working, or we made a mistake, or 
I made a mistake. To do that, you have to have the confidence 
and honesty on the part of the workforce. And in many of those 
examples cited on that map, that is what initiated our concern. 
Manipulation, we will get to the bottom of.
    Senator Johanns. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Johanns.
    At this point, I would like to offer Senator Begich the 
opportunity to speak. Senator Begich, do you have some 
questions?
    Senator Begich. Thank you, Mr. Chairman. I just wanted to 
catch that first vote as we were getting ready.
    First, again, I want to thank you all very much for being 
here. Thank you for the work we have done in Alaska. Let me 
just say that some of the comments I want to follow up on that 
other Members have had, but let me first start with one. I am 
struggling here, I will be very frank with you, Mr. Secretary. 
I have--again, all the good work we have done in Alaska to 
really go after some of these issues. Even though we are a 
small State, we have been able to accomplish some things that, 
I think, have made an improvement in delivery of services for 
veterans. And to remind folks, having 77,000 veterans is a huge 
amount in Alaska.
    But, the bigger issue, as I was listening to Senator Burr's 
note of the 4-year memo and regarding identification of the 
issues that talked about scheduling and other issues, we talked 
about trust a little bit earlier. That is important, that we 
have trust with delivery of services and that we trust the 
people who are delivering the services at VA.
    But, if you have--and, I will tell you from my time as 
mayor, if you have people that have been identified to have 
manipulated records, I will tell you from the city side, we 
would fire them----
    Secretary Shinseki. Yes.
    Senator Begich [continuing]. Because we lost trust. If they 
are cheating, they are not trustworthy. If you just transfer 
them to another part of the government, then they just 
perpetuate what they have done, maybe in a different field.
    So, my question is--I know you talked about the 3,000 
people you have moved, dismissed, retired, whatever--but I want 
to know specifically on this issue, have you ever fired anybody 
on this issue, when you find out that they manipulated the 
records? To me, it is the fundamental question, because if it 
is just shifting around, then we are not changing the system to 
improve it. Help me--and if you cannot answer that right now, I 
do want an answer later, because this, to me, is a fundamental 
issue. As a former mayor, we would fire them. They would be 
gone.
    Secretary Shinseki. I would have to give you an answer that 
looked out across the specific reasons that we released 3,000 
people, Senator. Manipulation, a very specific--this is 
something, for me, more recent. Without getting ahead of 
decisions, I would say manipulation of data, of the truth, is 
serious with me----
    Senator Begich. Would you fire them?
    Secretary Shinseki. I will do everything I can within the--
--
    Senator Begich. That is not the question. I understand----
    Secretary Shinseki. There is a process here, Senator. Let 
me not get out ahead of it, so that, in the end, it gets 
reversed because of predetermination.
    Senator Begich. OK. Let me ask you this, then.
    Secretary Shinseki. Yes.
    Senator Begich. In the last--since that last document, was 
it Schoenhard's--William Schoenhard's? I cannot remember the 
memo, but----
    Secretary Shinseki. Schoenhard.
    Senator Begich [continuing]. That report----
    Secretary Shinseki. Right.
    Senator Begich. Clearly, that report identified some people 
who have been doing some manipulation. So, the question is, 
from that report--let us not talk about the future for a 
second. Let us talk about that report. Was anyone fired for 
that activity?
    Secretary Shinseki. I do not know. I had not seen that 
memorandum, but I would say if there was any manipulation that 
identified individuals, I would expect to have seen their names 
in that list of 3,000, and that is what I cannot tell you 
today. I need to do some research.
    Senator Begich. Can you submit that for the record?
    Secretary Shinseki. I will. Let me just ask Dr. Petzel if 
he has any better insight.
    Senator Begich. OK.
    Dr. Petzel. I do not have any specific information, Senator 
Begich, but we can go back and try to determine whether or not 
that has occurred.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Begich. Because if we are going to try to rebuild 
the system--and again, I want to say that we saw this problem 
in Alaska when I first came in. We had backlogs on claims. We 
had scheduling issues. We had a lot of things. But we took--we 
went after it, right; we went after it jointly to figure out 
how to do this. We did MOUs with the Alaska Native Health 
Clinics. We went after it with the Care Closest to Home 
program, which I know is going to run out of money at the end 
of this fiscal year if we are not careful. There were a variety 
of things we went after to try to fix, so, I know we can fix 
this problem.
    But, we still have challenges, and I think the biggest 
challenge is holding people accountable for actions that they 
manipulated or they redrafted the records to make them look 
better. Without accountability we are never going to solve this 
problem. And sometimes, you have got to have some heads roll in 
order to get the system to shape up, because sometimes if they 
think, well, I am just going to get transferred, or I am on 
leave and I still get paid, what is the real penalty? I can 
just tell you, again----
    Secretary Shinseki. We are not in disagreement here, 
Senator.
    Senator Begich. Great. OK. I just wanted to hear that 
clearly.
    And let me again say, Mr. Chairman, I know this is just one 
of many opportunities we will have. I know you are waiting for 
the IG report. That will give us some more opportunity. I am 
hopeful that IG report, when it comes out, that there will be 
immediate action based on the report, not a further study of 
the report. When the IG says, here are the problems, we need to 
get after them, because if we do not get after them, the VAs in 
this country and in Alaska will be the ones who lose out at the 
end of the day. And I think you recognize that the veterans 
will be on the back end of this. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Begich.
    Senator Burr wanted 2 minutes. I will take 2 minutes, as 
well, and those will be the last questions before we hear from 
the veteran service organizations.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Mr. Secretary, in your testimony, you said, ``I invited an 
independent investigation by they VA Office of Inspector 
General to conduct a comprehensive, thorough, timely review. If 
any allegations are true, they are completely unacceptable to 
veterans, to me, and to our dedicated VHA employees. If they 
are substantiated by the OIG, responsible and timely action 
will be taken.'' How do you define responsible and timely 
action?
    Secretary Shinseki. There is a process to be able to 
implement those findings--decisions regarding those 
substantiated findings. I will tell you, it will be as 
aggressive and swift as I can make it. But, there is a process 
here that is not entirely under my control.
    Senator Burr. Mr. Secretary, I am sure you are aware of the 
IG report that was released April 17 of last year regarding the 
mismanagement of inpatient mental health care at the Atlanta VA 
medical center, because Senator Isakson and Dr. Petzel went 
personally and addressed it. And, I am sure you are aware of 
the IG report regarding the unexpected patient deaths in a 
substance abuse residential rehabilitation treatment program in 
the Miami VA Health Care Center, because that was released on 
March 27, 2014.
    In the IG's testimony that Mr. Griffin will give later, it 
says that in both Miami and Atlanta, as the reports indicate, 
standard steps to ensure veterans were kept safe while under VA 
control were not taken and two veterans died. In each instance, 
VA managers did not ensure the hospital staff performed their 
jobs.
    One, I would assume that you find Miami and Atlanta 
unacceptable, and if you will, tell me what we have done in a 
responsible and timely manner to remediate that problem.
    Secretary Shinseki. Dr. Petzel.
    Dr. Petzel. In Atlanta, Senator Burr, there have been seven 
disciplinary actions, including the retirement or removal of 
three senior officials.
    Senator Burr. And Miami?
    Dr. Petzel. And Miami is still in process, but we will do 
this as quickly as we are able to do.
    Senator Burr. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Burr.
    I have two questions in my brief time. Question number 1, 
you have heard serious problems about wait times in various 
locations around the country. I think Dr. Petzel informed us 
that in the last few years, we have seen 2 million additional 
veterans coming into the system. Is that correct, Dr. Petzel?
    Dr. Petzel. Two million new patients have arrived since 
2009, with a net increase of 1.4 million.
    Chairman Sanders. OK. And, I would suspect some of those 
patients are coming in with some serious problems in terms of 
PTSD, TBI, and difficult issues, yes?
    Dr. Petzel. Yes, sir.
    Chairman Sanders. All right. So, let me ask you a very 
simple question. To what degree does VA not have the resources 
to address that increase in patients? Are a lot of patients 
coming in to certain parts of the country and are we seeing 
waiting lists because you simply do not have the resources? 
What is the answer?
    Dr. Petzel. The--may I--Mr. Chairman? The ability to, as I 
have said earlier, the ability to provide appropriate access to 
these groups of veterans depends on several things. One is the 
people. Do we have enough people?
    Chairman Sanders. Right.
    Dr. Petzel. Two, are we using these people most 
effectively.
    Chairman Sanders. Right.
    Dr. Petzel. And, three, are we using all the other things 
that are available to us--telehealth----
    Chairman Sanders. Right.
    Dr. Petzel [continuing]. The fee basis program, et cetera.
    Chairman Sanders. Those are the issues. What is the answer?
    Dr. Petzel. Yes. One of the things that we are going to do 
is we are going to look at those places that are having access 
difficulties as a result of this audit and make a determination 
as to whether or not we have adequate resources there. My 
feeling now, my thought now, is that we do, but we need to look 
carefully at those places where we are having access issues to 
see if it is a resource problem.
    Chairman Sanders. All right. Let me simply conclude, and we 
are going to get to the----
    Secretary Shinseki. Mr. Chairman?
    Chairman Sanders. Yes?
    Secretary Shinseki. May I add, this is not a once and done, 
or whenever we have a crisis, we do. This is an ongoing set of 
looks at ourselves.
    Chairman Sanders. OK.
    Secretary Shinseki. Our patient load grows each year and 
the complexity of the issues, as you have described. So, this 
is an ongoing assessment that we try to get in the budget 
process so there is an orderly decisionmaking.
    Chairman Sanders. My time has expired. Let me thank both of 
you very much for being here, and I would like to call up our 
second panel.
    [Pause.]
    Chairman Sanders. The VA is a little bit different than 
other agencies because, while it obviously serves and 
represents all of the people in our country, it has a very 
special constituency, who are men and women who have put their 
lives on the line to defend their country. Those are the people 
who utilize VA every day. And today, we are very pleased to 
have representatives from many of the major veterans service 
organizations here with us and I thank them all very much for 
being here.
    We are all interested to hear about your members' 
experiences with VA health care services. You know more about 
it because your members access the system every day, so we look 
forward to hearing your suggestions and your criticisms.
    I would like to remind each of you to keep your oral 
presentation to 5 minutes, and, of course, your full statement 
will be included in the record of the hearing.
    Our guests today are Daniel M. Dellinger, who is the 
National Commander of The American Legion; Joseph A. Violante, 
the National Legislative Director for Disabled American 
Veterans; Tom Tarantino, Chief Policy Officer for Iraq and 
Afghanistan Veterans of America; Carl Blake, who is the 
National Legislative Director of Paralyzed Veterans of America; 
D. Wayne Robinson, President and CEO of Student Veterans of 
America; Ryan Gallucci, Deputy Director, National Legislative 
Service, Veterans of Foreign Wars of the United States; and 
Rick Weidman, Executive Director for Policy and Government 
Affairs of Vietnam Veterans of America.
    I want to thank all of you for your honorable military 
service and for being with us today.
    Commander Dellinger, we will begin with you, please.

   STATEMENT OF DANIEL M. DELLINGER, NATIONAL COMMANDER, THE 
                        AMERICAN LEGION

    Mr. Dellinger. Good afternoon. Yesterday, we learned of a 
veteran in Vermont who died while trying to get mental health 
care from his local VA. His wife complained he would have to 
wait for hours, just to be bounced around to different 
counselors. The American Legion expressed our concern about 
this very issue before the House Veterans' Affairs Committee at 
the beginning of April and again before this Committee at the 
end of April. Our testimony is a matter of public record.
    Chairman Sanders, Ranking Member Burr, and distinguished 
Members of this Committee, on behalf of the 2.5 million members 
of The American Legion plus another million of our Auxiliary 
and Sons family members, thank you for holding this hearing and 
inviting me to share the views of the largest Veterans Service 
Organization in the Nation.
    Two days ago, I was in Phoenix, AZ, where I hosted a 
Veterans Hall meeting--a System Worth Saving--which lasted 
almost 4 hours. Attended by over 200, 62 spoke passionately 
about scheduling issues, overmedication, and various other 
concerns at the hospital. I will be happy to discuss the 
details of that meeting with you during the question and answer 
period if you would like to hear more about that information 
gathering session.
    I am here today to help you understand why The American 
Legion believes VA needs to address specific deficiencies and 
also to let you know that The American Legion fully supports 
the Department of Veterans Affairs.
    We supported the creation of the Veterans Administration in 
1930 and fought hard to get VA elevated to Cabinet-level in 
1989. We donate hundreds of thousands of hours each year to VA, 
along with millions of dollars, and have scores of claims 
representatives. We helped fund a brain research center in 
Minnesota and are currently representing three-quarters of a 
million veterans as they file their claims with VA. Make no 
mistake about it, The American Legion believes in the VA.
    The allegation of secret waiting lists at Phoenix 
Department of Veterans Affairs Medical Center that are now 
being investigated, along with the 40 or more patient deaths, 
have rocked the veterans' community. In addition to Phoenix, we 
now understand at least six additional VA locations have been 
identified as participating in veteran patient wait time 
manipulation.
    The allegations in Phoenix were not the only reason The 
American Legion decided to call for a leadership change at the 
VA. They were simply the final straw in a long list of 
systematic leadership failures that include: construction 
delays and cost overruns; patient deaths due to Legionella; 
patient infections due to unsanitary colonoscopy equipment and 
dental equipment; unacceptable wait times for colonoscopies, 
resulting in patient deaths; the abandonment of efforts to 
create a true unified and interoperable Joint Health Care 
Record for use by both the Department of Defense and Department 
of Veterans Affairs; VA's refusal to answer Congressional 
inquiries; and VA's witnesses' failure to disclose all relevant 
truths when testifying before Congress.
    On Tuesday, we heard that Senator McCaskill is concerned 
enough about mismanagement and mental health waits at the St. 
Louis VA that she drafted a bipartisan letter with Senator 
Blunt to get to the bottom of it. The list continues to grow.
    When are things going to get better? It seems that a day 
cannot pass without a news report about the problems and 
difficulties VA faces with delays and quality of care 
challenges. While we wait for things to get better, hundreds of 
thousands of veterans are waiting for a decision on their 
initial disability claim or appeal, which prevents them from 
receiving VA health care. While we wait, transitioning 
servicemembers are falling through the cracks due to DOD and 
VA's inability to create a single interoperative medical 
record. While we wait, officials in VA's central office are 
preventing hospitals from being transparent during a crisis. 
While we wait, veteran suicides continue to plague our Nation 
at a rate of 22 per day, with no clear strategy from VA on 
proactively addressing suicides.
    Again, I would like to thank you for this opportunity to 
speak with you today and welcome your questions.
    [The prepared statement of Mr. Dellinger follows:]
    Prepared Statement of Daniel M. Dellinger, National Commander, 
                          The American Legion
    The Department of Veterans Affairs (VA) has come under scrutiny by 
Congress, Veteran Service Organizations, the media, and in the 
veterans' community for its failures in leadership, performance, and 
accountability which have resulted in quality of care or patient safety 
issues that have directly affected veterans. If there is a lack of 
performance and accountability among a senior executive service 
employee, the only disciplinary actions the Secretary of Veterans 
Affairs can take are to issue reprimands or transfer VA senior 
executive service employees to other VA facilities, even if that lack 
of performance results in the death of a veteran.
    Chairman Sanders, Ranking member Burr, and distinguished Members of 
this Committee, thank you for inviting The American Legion to testify 
before you today and discuss our views on The State of Healthcare at 
the Department of Veterans' Affairs.
    The allegations of secret waiting lists at the Phoenix Department 
of Veterans Affairs Medical Center that are now being investigated 
along with 40 or more patient deaths has rocked the veterans' 
community. In addition to Phoenix, we now understand that at least six 
additional VA locations have been identified as participating in 
veteran patient wait time manipulation just this week. The allegations 
in Phoenix were not the only reason The American Legion decided to call 
for leadership change at VA, they were simply the final straw in a long 
list of systemic leadership failures that include:

     Construction delays and cost overruns
     Patient deaths due to Legionella
     Patient infections due to unsanitary colonoscopy equipment 
and dental equipment
     Unacceptable wait times for colonoscopies resulting in 
patient deaths
     The abandonment of efforts to create a true, unified, 
interoperable joint healthcare record for use in the Department of 
Defense (DOD) and the Department of Veterans Affairs (VA)
     VA's refusal to answer congressional inquiries
     VA witnesses failure to disclose all relevant truths when 
testifying before Congress

And the list continues to grow.

    Veterans are frustrated and concerned with VA's construction 
processes and the continued delays and cost overruns. Every day the 
construction goal is not met for medical centers in Denver, Orlando, or 
New Orleans, is a day VA is failing to take care of our Nation's 
veterans. According to a Government Accountability Office Report--Cost 
Increases and Schedule Delays at the Four Largest Projects--``cost 
increases ranged from 59 percent to 144 percent representing a total 
cost increase of nearly $366 million per project with average schedule 
delays ranging from 14 to 74 months with an average delay of 35 per VA 
major construction project.'' In one case, a hospital was completed, 
but they forgot to install an ambulance bay, which then had to be 
renegotiated, contracted for, and installed.
    During a Subcommittee on Oversight & Investigations hearing in 
November 2013 on ``Correcting Kerfuffles,'' there were several 
complaints on the G.V. (Sonny) Montgomery VA Medical center that cited 
poor sterilization procedures. The hearing also mentioned that pieces 
of bone were still attached to surgical instruments that were being 
used on other patients.
    For nearly 18 years, the dental clinic at the Dayton VA Medical 
Center allowed unsanitary practices, potentially exposing hundreds of 
patients to hepatitis B and hepatitis C. Dayton VA Medical Center 
Director Guy Richardson then collected an $11,874 bonus despite an 
investigation into the exposures. After nine of the exposed patients 
tested positive Hepatitis B and Hepatitis C, Richardson was promoted.
    The American Legion has also spoken out recently regarding the 
billion dollar botched development of the iEHR--Individual Electronic 
medical Health Record project. After years of promises and more than a 
billion dollars wasted, VA simply walked away from the mission and 
started over in January by reissuing a new procurement request. The 
American Legion believes that the introduction of a joint Department of 
Defense and VA electronic health records would have all but eliminated 
the disability backlog already, yet as of May 6, 2014, 308,285 (52.3%) 
of all disability claims have been backlogged over 125 days.
    VA's claims adjudication accuracy is questionable. The American 
Legion does not question the ethics of the accuracy, we question the 
formula utilized. The American Legion's Regional Office Action Review 
(ROAR) conducts comprehensive and holistic claims reviews, while VA's 
review looks solely at the claim and not how it may interrelate with 
other service-connected conditions.
    Nearly three years ago The American Legion partnered with the White 
House and the VA to institute the Fully Developed Claim (FDC) pilot 
program. The goal for this initiative was for VA and American Legion 
Service Officers to submit claims that were complete and ready for a 
rating decision, and wasn't absent any supporting evidence or 
documentation. VA agreed that they would then process these Fully 
Developed Claims within 90 days or less. Today, only four VAROs 
nationwide are meeting the objective for claims with Legion Power of 
Attorney (POA), four years after the publishing of the fast letter and 
nearing two years after nationwide implementation. Eight VAROs exceed 
200 days on average with Legion POA.
    During one of our most recent ROAR visits earlier this year in 
Seattle, Undersecretary of Benefits Alison Hickey attempted to impede 
our ROAR team from attending the necessary meetings to satisfy the 
visit, and then did not allow the proper access for The American Legion 
to adequately complete the visit. As a result, The Chairman of the 
House Veterans' Affairs Committee sent a letter to VA and offered to 
accompany The American legion on future visits.
    Local facilities are not empowered to address a crisis when it 
happens. With 152 medical centers to look after nationwide, the VA 
cannot manage every crisis from Washington. Instead, The American 
Legion believes VA needs to empower its leadership at medical centers 
to respond to crises--quickly. With incidents such as the Legionella 
outbreak in Pittsburgh, the facility had a press release ready to 
disseminate but VA Central Office never approved it to be sent 
publicly.
    The allegations of secret wait lists in Phoenix have caught some by 
surprise, and some may call for caution, waiting until the results of 
VA's Office of the Inspector General (VAOIG) are complete before 
leaping to conclusions about VA's healthcare system. Unfortunately, 
Phoenix is not an isolated event, nor is it the first such event to be 
investigated by VAOIG. Between January 2013 and the present day, VAOIG 
has conducted 18 investigations in response to concerns about the VA 
healthcare system. The majority of these investigations dealt with 
delays in appointment scheduling,\1\ delays in lab results,\2\ and 
lapses in notifying patients of biopsy results.\3\ More serious 
investigations addressed patient deaths under emergency care.\4\
---------------------------------------------------------------------------
    \1\ http://www.va.gov/oig/pubs/VAOIG-12-04108-96.pdf
    \2\ http://www.va.gov/oig/pubs/VAOIG-13-00636-104.pdf
    \3\ http://www.va.gov/oig/pubs/VAOIG-13-00940-193.pdf
    \4\ http://www.va.gov/oig/pubs/VAOIG-13-00505-348.pdf
---------------------------------------------------------------------------
    The veterans of The American Legion have a vested interest in 
ensuring that VA operates efficiently and we were instrumental in 
seeing that the VA became a cabinet position in the first place. We did 
so, in order that the Secretary would have the power and authority to 
serve and fight for the best interests of veterans through the second 
largest agency within the Federal Government.
    On Monday, May 5, 2014, American Legion staff scheduled a 
conference call with Dr. Mike Davies, National Director of Systems 
Redesign to discuss national wait times and was told three days later 
that Dr. Davies would not be able to meet with The American Legion 
until June.
    The American Legion has a dedicated team that travels around the 
country visiting VA hospitals, conducts veteran town halls, and speaks 
directly with VA healthcare and administrative staff. This program is 
overseen by our System Worth Saving Task Force, and had conducted 
visits over the past year to problem areas in Pittsburgh, Jackson, 
Atlanta, Augusta, and Columbia, South Carolina, as well as Phoenix, to 
attempt to understand the challenges these centers face while trying to 
provide the best possible healthcare to our Nation's veterans. A brief 
overview of some of these visits can be found in addendum ``A'' of this 
testimony.
    Overwhelmingly, our taskforce finds that veterans are extremely 
satisfied with their healthcare team and medical providers. We also 
find that administrative oversight of VA operations is a constant 
concern and growing frustration among patients. We've found veterans 
who are happy when they can get care, but struggling with a system that 
makes it difficult even to get primary care appointments. While a 
veteran might wait more than two weeks for most primary care 
appointments, specialty care appointments can take many months or even 
years. And when it comes to informing patients of potential problems 
within the VA system, we find that local facilities are not empowered 
to interact with the community and are under restrictive communications 
lockdowns imposed by VACO.
    In addition to our System Worth Saving Taskforce, which is now in 
its 10th year, American Legion volunteers donate nearly 900,000 hours 
of service in VA facilities annually at a value of over $19 million, 
and maintain a network of over 2,900 accredited service officers who 
assist nearly three-quarter of a million veterans with their disability 
claims. Wherever veterans interact with VA, The American Legion is 
there attempting to work within the system to ensure that the VA 
continues to serve the best interests of veterans. Not only has The 
American Legion donated millions of dollars to create and support VA 
programs; we have even sponsored a brain research center that is named 
after us in Minnesota.\5\
---------------------------------------------------------------------------
    \5\ http://brain.umn.edu/about--us.shtml
---------------------------------------------------------------------------
    Over the past two weeks The American Legion has received over 500 
calls, emails, and online contacts from veterans struggling with the 
healthcare system nationwide. They cite concerns ranging from the 
common complaint of substantially delayed appointments, to an inability 
to receive specialty care. One parent of a veteran in Phoenix spoke 
painfully of losing their daughter while she waited for care, and one 
veteran reported calling his local VA medical center for an appointment 
only to be told ``there are no appointments within the next 30 days, 
please call back in 4 weeks to schedule an appointment.'' Even if there 
is not a formal ``secret'' list at many of these facilities, 
administrative staff are finding a variety of ways to game the system.
    According to Dr. Sam Foote, one of the first whistleblowers to come 
forward regarding VA's waiting list manipulation accusations, the 
attempts to create a work around on appointments grew out of a response 
to VA's attempts to address scheduling problems\6\ (More information on 
this and other recent whistleblower complaints are attached as Addendum 
``B''). Because there were previous complaints about lengthy wait times 
at VA facilities, VACO officials made changes to the appointment system 
to automate the process and prevent employees from lying about wait 
times. The new electronic system was designed to automatically enter 
the time the appointment was requested and provide a more accurate 
assessment of how long it was taking to find appointments for veterans. 
To circumvent this, VA employees developed strategies to wait until 
they could guarantee an appointment within two weeks, and only then 
enter the information into the electronic system.\7\
---------------------------------------------------------------------------
    \6\ http://onpoint.wbur.org/2014/05/12/veterans-affairs-scandal-
death
    \7\ Ibid--Dr. Foote
---------------------------------------------------------------------------
    A VA employee in Cheyenne, Wyoming, provided documentation to CBS 
News that explicitly details how VA employees need to ``game the system 
a bit * * * when we exceed the 14 day measure, the front office gets 
very upset, which doesn't help us.\8\ '' There is a culture created, 
and enforced by leadership within VA that the most important measure is 
meeting the numbers. This is true whether in the Veterans Health 
Administration (VHA) or Veterans Benefits Administration (VBA). VA 
schedulers who can't find appointments for veterans resort to keeping 
secret lists. VA claims workers who can't keep up with the demanded 
number of claims per day shred vital documents that could help prove a 
veteran's disability.
---------------------------------------------------------------------------
    \8\ http://www.cbsnews.com/news/email-reveals-effort-by-va-
hospital-to-hide-long-patient-waits/
---------------------------------------------------------------------------
    A year later, as the problems continue to mount and the VA appears 
no closer to solutions, we sadly feel there must be change. VA is in 
need of a real reformer who is not afraid of exposing the full extent 
of the problems and bringing all stakeholders in to forge a VA for the 
21st century and beyond. When Arlington National Cemetery was beset 
with a disgusting scandal involving mismarked graves in 2010, they 
brought in Kathryn Condon to right the ship. During the time of 
transition, Director Condon reached out to stakeholders including The 
American Legion for guidance and support. During the crisis, officials 
at Arlington did not dismiss further discovery of mismanagement issues 
but rather sought to expose everything while accepting responsibility, 
and then engaged stakeholders to express how they were amending the 
system to ensure these problems would never occur again at the Nation's 
most prestigious resting place for our military fallen. The handling of 
the Arlington crisis is indicative of courageous leadership that owns 
their own failures and sincerely works to correct deficiencies.
    Unfortunately, the response from Undersecretaries Petzel and Hickey 
at VA has been to question those who would impugn VA's reputation. When 
VA's accuracy figures were questioned, VA's response was to limit 
access of those who advocate for veterans,\9\ rather than sincerely 
attempt to reform the process and retrain employees to actually end the 
error prone processing practices. When allegations of dangerous medical 
practices emerged, Dr. Petzel's first response is to be dismissive.\10\ 
The tone is consistent. The pattern is consistent. It is perhaps most 
telling that when The American Legion Health Policy Unit contacted the 
VACO staff responsible for the nationwide scheduling operations last 
week, that VA staff chose not to engage the community or work with 
stakeholders to better understand this problem. Instead VACO staff 
informed The American Legion they could not possibly schedule a meeting 
until sometime in June to discuss the topic.
---------------------------------------------------------------------------
    \9\ http://www.military.com/daily-news/2014/02/21/lawmaker-says-va-
obstructed-legion-quality-review.html
    \10\ http://www.cnbc.com/id/101187855 ``There have been some public 
kerfuffles in the paper that don't in my mind reflect the Jackson VA 
facility.''
---------------------------------------------------------------------------
    We can't wait months for a solution. How many more veterans will 
die waiting to see doctors? Hearings, reports, analyses and testimonies 
won't fix this. America's veterans deserve a solution that starts 
today.
    The solution MUST include input in correct measures from the 
Department of Veterans Affairs, Congress and most importantly the 
stakeholders--it is absurd to make decisions about what veterans need 
in their healthcare system without consulting the veterans. As the 
Nation's largest wartime service organization for veterans, The 
American Legion will not shy away from providing a voice for those 
veterans.
    For many years now, going back to the budget troubles of 2006, 
Congress has asked VA if they had the resources they need to accomplish 
their mission. All parties on the Hill, from both sides of the aisle, 
and both the Senate and House of Representatives, have made abundantly 
clear that even in this austere time of belt-tightening budget 
measures, if VA needed funds to provide proper care for veterans, they 
would find them the money they need. VA has consistently answered that 
they could execute their plan with the budget they had asked for, a 
budget usually increased by Congress in the final tally. If VA needs 
more to accomplish their mission, and many VSOs including The American 
Legion have questioned whether their budget meets their needs, they 
need leadership with the courage to be honest about those needs.
    The American Legion has testified in nearly every hearing before 
this Committee, and the House Committee on Veterans' Affairs concerning 
the VA, in which stakeholder testimony is considered and has seen 
firsthand how the VA has stonewalled congressional requests for 
information. The American Legion has followed the investigations and 
requests for information with special concern, as VA has developed a 
pattern of unresponsiveness to Congress and crises while developing a 
tendency to downplay legitimate concerns of veterans that do not do 
service to the veterans in these communities.
    While addressing patient deaths at the Jackson VA Medical Center, 
Undersecretary Robert Petzel referred to the concerns dismissively as 
``kerfuffles \11\ '' and in a subsequent follow up visit to that site 
by American Legion System Worth Saving Task Force members, the facility 
director was hampered from cooperating with the local veterans and 
American Legion by VA Central Office restrictions. During the 
January 2014 visit, facility director Joe Battle was unable to provide 
the action plan the facility was using to address problems with patient 
deaths. Director Battle stated he could not release the report because 
it had not been cleared by VACO. Repeated follow up requests for 
information to VACO officials by American Legion staff have been met 
with the response that VHA cannot release this information to The 
American Legion.
---------------------------------------------------------------------------
    \11\ http://www.cnbc.com/id/101187855 ``There have been some public 
kerfuffles in the paper that don't in my mind reflect the Jackson VA 
facility.''
---------------------------------------------------------------------------
    The American Legion believes there must be corrective measures 
taken. There are several improvements VA could begin implementing to 
start addressing these issues.
    As we are now over a decade into the 21st century, The American 
Legion believes that VA should also begin implementing 21st century 
solutions to its problems. In 1998, GAO released a report that 
highlighted the excessive wait times experienced by veterans trying to 
schedule appointments, and recommended that VA replace its VISTA 
scheduling system.\12\ To address the scheduling problem, the Veteran's 
Health Administration (VHA) solicited internal proposals from within VA 
to study and replace the VISTA Scheduling System, with a Commercial 
Off-the-Shelf (COTS) software program. VA selected a system, and about 
14 months into the project they significantly changed the scope of the 
project from a COTS solution to an in-house build of a scheduling 
application. After that, VHA ended up determining that it would not be 
able to implement any of the planned system's capabilities, and after 
spending an estimated $127 million over 9 years, The American Legion 
learned that VHA ended the entire Scheduling Replacement Project in 
September 2009.\13\ We believe that this haphazard approach of fits and 
starts is crippling any hope of progress.
---------------------------------------------------------------------------
    \12\ U.S. Medicine Magazine, VA Leadership Lacks Confidence in New 
$145M Patient Scheduling System, May 2009
    \13\ GAO-10-579, Management Improvements Are Essential to VA's 
Second Effort to Replace Its Outpatient Scheduling System, May 2010
---------------------------------------------------------------------------
    It has now been over three years since VHA canceled the Replacement 
Scheduling Application project, and as of today, The American Legion 
understands that there is still no workable solution to fixing VA's 
outdated and inefficient scheduling system. In 2012 The American Legion 
passed Resolution number 42 that asked the VA to implement a system 
``To allow VA patients to be able to make appointments online by 
choosing the day, time and provider and that VA sends a confirmation 
within 24 hours.'' Last December, VA published an opportunity for 
companies to provide adjustments to the VISTA system through the 
Federal Register--all submissions are due by June 2013. While this is a 
laudable attempt to address the problem, it hardly seems sufficiently 
proactive given that the problem has been identified for over fifteen 
years, and excessive wait times are still being experienced by many 
veterans across the Nation.
    The American Legion recognizes that over the past decade, VA has 
taken some steps aimed at improving its scheduling and access to care; 
we believe that there is still much to be done. In order to adequately 
address the problems of veterans, The American Legion believes VA 
should adopt the following steps toward a solution:

    1. Devote full effort toward filling all empty staff positions. The 
problems with mental health scheduling clearly indicate how a lack of 
available medical personnel can be a large contributing factor to long 
wait times for treatment. Despite VA's efforts to hire 1,600 new staff, 
as recently as last month VA was noting only two thirds of those 
positions had been filled. This does not even address the previous 
1,500 vacancies, and stakeholder veterans' groups are left to wonder if 
VA is adequately staffed to meet the needs of veterans.
    We believe they are not.
    If VA needs more resources to address these staffing needs, The 
American Legion hopes they will be forthright and open about their 
needs, and ask for the resources they need to get the job done. The 
Veteran Service Organizations and Congress have been extremely 
responsive to get VA the resources they need to fulfill their mission, 
but VA must be transparent about what their real needs are.
    2. Develop a better plan to address appointments outside 
traditional business hours. With the growing numbers of women veterans 
who need to balance family obligations and other commitments, our 
veterans' abilities to meet appointments during regular business hours 
is greatly hampered. The American Legion believes VA can better address 
the community's needs with more evening and weekend appointment times. 
American Legion Resolution number 40 calls on the VA to provide more 
extended hour options, and believes VA should recruit and hire adequate 
staff to handle the additional weekend and extended hour appointments 
for both primary and specialty care.
    3. Improve the IT solution. Last year The American Legion also 
passed resolution number 44, which called on the VA to create a records 
system that both VBA and VHA could share to better facilitate 
information exchange. A common system could even synchronize care 
visits in conjunction with compensation and pension examinations. We 
had hoped such a system might be included in the improvements brought 
by the Virtual Lifetime Electronic Record; however VA and DOD appear to 
be content to pursue individual legacy systems for that project, so 
veterans must continue to contend with VBA and VHA systems that do not 
communicate as well as they should. In any case, as VA looks outward 
for a solution to their scheduling program, all can agree that the 
current system is not serving the needs of veterans and needs to be 
updated.
    4. The American Legion urges Congress to enact legislation that 
provides the Secretary of Veterans Affairs the authority to remove any 
individual from the senior executive service if the Secretary 
determines the performance of the individual warrants such removal, or 
transfer the individual to a General Schedule position at any grade of 
the General Schedule the Secretary determines appropriate.
    5. The American Legion supports legislation and congressional 
oversight to improve future Department of Veterans Affairs (VA) 
construction programs, and urges VA to consider all available options, 
both within the agency and externally, to include, but not limited to 
the Army Corps of Engineers, to ensure major construction programs are 
completed on time and within budget.

    There is still room for VA to improve their triage processes. The 
current consult management program needs work to ensure it is providing 
better triage for veterans in need of life saving procedures. Primary 
Care Providers have relayed to American Legion System Worth Saving Task 
Force members concerns that the current triage process has bureaucratic 
hurdles which make the process frustrating and presents a challenge to 
retaining top quality Primary Care Providers.
    Furthermore, regarding VA's current 14 day wait policy, review of 
this policy is necessary to determine whether the enforcement is 
causing problems. The goal to see veterans in a timely manner is 
crucial; however, care must be taken to see how the regional facilities 
are viewing the policy. If they are reluctant to report longer wait 
times up to VACO because of fears of being ``put on a Bad List'' as 
relayed in the Cheyenne email,\14\ then a reassessment of the culture 
that breeds this attitude is warranted. The observance by VACO of 
lengthy wait times at a facility should trigger questions to VACO about 
whether the facility is adequately staffed and resourced to meet the 
needs of the community. VISNs struggling to meet timeliness standards 
need to be assessed to determine if they have the tools to treat the 
veterans in their communities.
---------------------------------------------------------------------------
    \14\ http://www.cbsnews.com/news/email-reveals-effort-by-va-
hospital-to-hide-long-patient-waits/
---------------------------------------------------------------------------
    Finally, revision of these standards is only as good as the 
integrity of staff you hire and accountability and transparency for 
those who break the rules should be disclosed. VA should put a map on 
their Web site of hospitals that had issues and what corrective actions 
were taken to include disciplinary actions such as transfers or 
reprimands. Veterans ought to be able to see there is a top down and 
bottom up culture of accountability. That is how to restore trust in 
the system to the veterans' community.
    The American Legion thanks this Committee again for their 
commitment to seeking answers about the troubling trends emerging in 
VA. The commitment of all parties to ensuring veterans receive quality 
healthcare in a safe environment is a sacred duty. Questions concerning 
this testimony can be directed to The American Legion Legislative 
Division (202) 861-2700, or [email protected].
                               Addendum A
             Highlights from The American Legion's recent 
                 System Worth Saving Task Force visits
            2013
Pittsburgh, Pennsylvania (Site Visit Nov. 5-6)
     After persistent management failures led to a deadly 
Legionnaires' disease outbreak in the VA Pittsburgh Healthcare System, 
VA Pittsburgh director Terry Gerigk Wolf received a perfect performance 
review and regional director Michael Moreland, who oversees VA 
Pittsburgh, collected a $63,000 bonus.
Nashville, TN (SWS Visit Nov 13-15)
     Tennessee Valley Healthcare System struggles to fill 
critical leadership positions across multiple departments. These gaps 
could cause communication breakdowns between medical center leadership 
and staff that work in these departments.
El Paso, TX (SWS Visit Nov. 18-20)
     The current situation with the future of William Beaumont 
Army Medical Center is uncertain and troubling for veterans in the 
area, and veterans need to know where they will be able to receive 
their health care.
Huntington, WV (SWS Visit Dec. 9/11)
     Huntington VAMC has found it difficult to recruit talent 
(surgeons/physicians) due to pay freezes, a lack of bonuses/retention 
incentives, and the geographical location of the hospital.
Leavenworth, KS (SWS Visit Dec. 9/11)
     Due to the age of the Leavenworth campus (83 years-old), 
space is an issue. Additionally, because the Kansas Historical Society 
has designated the Leavenworth campus as a historical site, there are 
limitations on what infrastructure changes can be made.
            2014
Roseburg, Oregon (Site Visit Jan.9-10)
     An active Legionnaire from American Legion Post 61 in 
Junction City, went to the Roseburg VA Medical Center this past June 
for what should have been a routine hernia operation. After the 
surgery, Roseburg VA Medical Center staff told the veteran's daughter, 
that her father's blood pressure had ``dropped suddenly and he was 
having difficulty breathing.'' Since the Roseburg VA Medical Center 
does not have an Intensive Care Unit, the veteran was taken to 
PeaceHealth Sacred Heart Medical Center at Riverbend in Springfield, 
Oregon. Unfortunately, the veteran passed away en route PeaceHealth 
Sacred Heart Medical Center due to ``intra-dominal bleeding, shock, 
hyperkalemia, acidosis, respiratory failure and recent ventral hernia 
surgery.''
     The American Legion is not comfortable with the current 
status of the medical center following the closure of their Intensive 
Care Unit. The American Legion recommends that VARHS consider one of 
the three alternatives: fully reinstating the Intensive Care Unit, 
standing down all surgical procedures, or strengthening their 
Memorandum of Understanding with Mercy Medical Center to ensure that an 
Intensive Care Unit bed will be available in case of emergency, which 
includes remaining without an ICU and continue to perform ambulatory 
procedures that meet the strict criteria established by the VA as 
appropriate for facilities without an ICU.
Jackson, Mississippi (Site Visit Jan. 21-22)
     At the G. V. Sonny Montgomery VA Medical Center in 
Jackson, MS, multiple whistleblower complaints have been raised by 
employees who were losing confidence in the medical center's ability to 
treat veterans. The complaints ranged from improper sterilization of 
instruments to missed diagnoses of fatal illnesses, as well as hospital 
management policies.
Butler, Pennsylvania (Site Visit Jan. 8-9)
     An attorney for the prime contractor of a Department of 
Veterans Affairs outpatient center being built in Butler County 
declined to comment Friday, July 12, 2013 about the VA's investigation 
of the contractor that led the agency to stop work on the $75 million 
project.
     The VA Butler Healthcare Center was scheduled to open in 
2015, but the termination of the lease left its future in doubt. The VA 
broke ground on the center in April 2013. The Department of Veterans 
Affairs yanked its lease with an Ohio company that was building a $75 
million health center for vets in Butler, accusing the firm of ``false 
and misleading representations'' during bidding. The VA ordered work 
halted in June when it began to uncover problems with the project.
     The Department of Veterans Affairs failed to properly 
check the qualifications of the former developer of an outpatient 
center in Butler County, according to a highly critical report by the 
VA's Office of Inspector General released Monday. The report says the 
VA improperly calculated that a 20-year lease with Westar Development 
Co., valued at $157 million, would be cheaper than the VA building and 
owning the $75 million outpatient center on its own.
Atlanta, Georgia (Site Visit Jan. 28)
     Despite four preventable patient deaths, three of which 
VA's inspector general linked to widespread mismanagement, former 
Atlanta VA Medical Center Director James Clark received $65,000 in 
bonuses over four years. Additionally, the facility's current director, 
Leslie Wiggins, maintains that no employees responsible for the 
mismanagement linked to the deaths should be fired.
Orlando, Florida/Denver, Colorado (Orlando SWS Visit-Feb.11-12, 2014) 
        (Denver SWS Visit-May 13-14)
     Costs substantially increased and schedules were delayed 
for Department of Veterans Affairs' (VA) largest medical-center 
construction projects in Denver, Colorado; Las Vegas, Nevada; New 
Orleans, Louisiana; and Orlando, Florida. As of November 2012, the cost 
increases for these projects ranged from 59 percent to 144 percent, 
with a total cost increase of nearly $1.5 billion and an average 
increase of approximately $366 million. The delays for these projects 
range from 14 to 74 months, resulting in an average delay of 35 months 
per project. In commenting on a draft of this report, VA contends that 
using the initial completion date from the construction contract would 
be more accurate than using the initial completion date provided to 
Congress; however, using this date would not account for how VA managed 
these projects prior to the award of the construction contract. Several 
factors, including changes to veterans' health care needs and site-
acquisition issues contributed to increased costs and schedule delays 
at these sites.
Dallas, Texas (SWS Visit Feb 4-5)
     Dallas VA Medical Center Director Jeff Milligan and 
regional director Lawrence Biro have received a combined $50,000 in 
bonuses since 2011 despite a series of allegations from VA workers, 
patients and family members regarding poor care at the facility as well 
as more than 30 certification agency complaints against the medical 
center in the last three years.
Hot Springs, SD (SWS Visit Feb 17-19)
     The VA Black Hills Healthcare System (VABHHS) is going 
under a reconfiguration proposal which is opposed by the local 
community. The issue is whether relocating services from the Hot 
Springs VA Medical Center to the Fort Meade VA Medical Center and the 
domiciliary to Rapid City are in the best interest of veterans. This 
would require veterans to travel further to receive their health care.
Augusta, Georgia (Site Visit Mar. 11-12)
     CNVAMC leadership first learned of delays in providing 
gastrointestinal (GI) services to veterans on August 30, 2012. Of the 
4,580 delayed GI consults, a quality management review team determined 
81 cases for physician case review. Seven of the 81 cases may have been 
adversely affected by delays in care. Six of seven institutional 
disclosures were completed and three cancer-related deaths may have 
been affected by delays in diagnosis. Factors contributing to the 4,580 
patient backlogs included an explosion of baby boomers turning 50 and 
requiring screening, the medical center's non-anticipation of a spike 
in GI consult demand, lack of an integrated database for tracking GI 
procedures, and GI physician recruitment challenges.
Columbia, South Carolina (SWS Visit April 15, 16)
     In September 2013, six deaths were linked to delayed 
screenings for colorectal cancer at the veterans medical center in 
Columbia, S.C., the Veterans Affairs Department reported. The VA's 
inspector general determined that the William Jennings Bryan Dorn VA 
Medical Center fell behind with its screenings because critical nursing 
positions went unfilled for months. It also found that only about 
$275,000 of $1 million provided to the hospital to alleviate the 
backlog had been used over the course of a year.
                               Addendum B
                          recent developments
     Former employee, Dr. Sam Foote, claimed the Phoenix system 
is afflicted by ``gross mismanagement of VA resources and criminal 
misconduct ``that produced ``systemic patient safety issues and 
possible wrongful deaths.''
     Foote and other employees alleged a variety of other 
institutional breakdowns in Arizona's VA, including:

     Medical recordkeeping so backed up the system is 250,000 
pages behind, and millions of records reportedly are missing.
     A compromised mental-health system where patient suicides 
doubled in the past few years, while staff suicides also emerged as a 
serious concern.
     A swamped emergency room that becomes the last resort for 
veterans who cannot get appointments with primary-care doctors or 
specialists. In some cases, VA health system employees have told the 
newspaper, vets with life-threatening conditions have waited hours 
without diagnosis or treatment because nurses are overworked and 
undertrained.
     Discrimination, cronyism and security breakdowns in the VA 
police department that endanger the safety of patients and employees.
     Hostile working conditions that caused an exodus of 
quality doctors and nurses, producing backlogs in specialty areas such 
as urology, where bladder cancer and other serious diseases are 
detected. Patients reportedly are referred to out-of-state VA centers 
or private physicians for treatment.
     On Sunday, April 27, 2014, a second whistleblower, Dr. 
Katherine Mitchell reported that ``patient appointment records in the 
Phoenix VA Health Care System were in danger of being destroyed.''
     On Sunday, May 4, 2014, a whistleblower reported that 
clerks at the Department of Veterans Affairs clinic in Fort Collins, 
Colorado were instructed in 2013 how to falsify appointment records so 
it appeared the small staff of doctors was seeing patients within the 
agency's goal of 14 days.
     The VA's official policy is that all patients should be 
able to see a doctor, dentist or some other medical professional within 
14 days of their requested/preferred date. Any wait longer than two 
weeks is supposed to documented.

    Yet on Friday, May 9, 2014 Brian Turner, a Veterans Affairs 
scheduling clerk based in San Antonio, said that some who called to 
make appointments at his facility did end up waiting longer, yet such 
delays were never reported.
    For example, he said, they might be told the next available 
appointment wasn't for several months. It would be scheduled for then, 
but marked in official files as if the patient had put off their 
appointment until then by choice.
    ``What we've been instructed was that--they are not saying fudged, 
there is no secret wait list--but what they've done is come out and 
just say 'zero out that date,' '' Turner said. The ``zero,'' in this 
case, suggests the patient didn't have to wait at all.
    ``It could be three months and look like no days [wait],'' he 
added. ``It looked like they had scheduled the appointment and got 
exactly what they wanted.''
                               Addendum C

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                          The American Legion
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you very much, Commander Dellinger.
    Mr. Violante.

STATEMENT OF JOSEPH A. VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR, 
                   DISABLED AMERICAN VETERANS

    Mr. Violante. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, thank you for inviting DAV to testify 
today about the state of VA health care.
    DAV remains deeply concerned about allegations that VA 
employees or management took actions that obscure the true 
picture of access problems at some VA facilities. We fully 
support the ongoing investigation by the Inspector General and 
will demand full accountability for anyone found to have 
violated the law or failed to follow and enforce VA rules and 
regulations.
    We also support Secretary Shinseki's initiative to audit 
all VA facilities to determine whether similar problems are 
occurring. However, we strongly recommend the VA include 
outside third-party experts to increase its objectivity and 
credibility and help regain the full trust of veterans and the 
American people.
    Mr. Chairman, while no health care system is perfect and 
medicine is far from an exact science, veterans have earned the 
right to expect the VA Health Care System to provide high-
quality medical care. While it may be weeks or months before 
the investigations and audits are completed, we continue to 
have confidence that VA, led by Secretary Shinseki, can and 
will correct any problems identified or uncovered. This 
Secretary has a track record of directly and honestly 
confronting problems and working with stakeholders to correct 
them.
    Mr. Chairman, we continue to believe that VA provides high-
quality health care for the vast majority of veterans treated 
each year and that veterans are now and will be better served 
in the future by a robust VA Health Care System than any other 
model of care. The real challenge facing VA and the root cause 
of the problems being reported today have to do with access to 
care rather than the quality of care delivered.
    For the past decade, DAV and our partners in the 
Independent Budget (IB) have pointed out funding shortfalls in 
VA's medical care and construction budgets. In the prior ten VA 
budgets, funding for medical care provided by Congress was more 
than $5.5 billion less than the IB recommended. For fiscal year 
2015, the IB recommends over $2 billion more than VA requested. 
I would point out that you, Mr. Chairman, did call for an 
increase of $1.6 billion for fiscal year 2015, but based on 
available information today, it appears your Senate colleagues 
will not significantly increase the administration's inadequate 
request, just as the House already failed to do.
    Similarly, over the past decade, funding requested by VA 
for construction and the amount appropriated by Congress has 
been more than $9 billion less than the IB recommendations. For 
fiscal year 2015, the VA budget request is $2.5 billion less 
than the IB recommendation, which was based upon VA's own 
analysis. We agree with your views and estimate letters for the 
past 2 years, Mr. Chairman, where you stated that the 
administration's budget request for construction has been, 
``clearly insufficient to meet the identified needs,'' but 
unfortunately, Congress took no action to increase construction 
funding.
    Finally, VA needs to better utilize its purchased care 
authority. DAV believes that whenever an enrolled veteran is 
unable to receive care directly from VA within established 
timeframes, VA must take responsibility to find alternative 
means to provide and coordinate such care. However, since each 
dollar used to pay for non-VA care is one dollar less that is 
available to hire new VA staff required to treat veterans in a 
timely manner, VA must provide accurate estimates of the 
additional funding required and Congress must appropriate those 
dollars.
    Even with sufficient funding, how will non-VA care be 
coordinated with VA care? Are there even sufficient qualified 
providers available in each community? Simply giving a veteran 
a plastic card and wishing them good luck in the private sector 
is no substitute for a fully-coordinated system of health care.
    Mr. Chairman, looking at VA today and putting it into 
proper perspective against the entire American system of health 
care, we continue to have confidence that veterans are well 
served by seeking their care from VA. We remain confident that 
VA and Secretary Shinseki, working with stakeholders and 
Congress, can, will, and must address these challenges. 
American veterans deserve nothing less.
    Thank you.
    [The prepared statement of Mr. Violante follows:]
    Prepared Statement of Joseph A. Violante, National Legislative 
                  Director, Disabled American Veterans
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee: Thank you for inviting DAV to testify today about ``The 
State of VA Health Care.'' As the Nation's largest veterans service 
organization comprised completely of wartime disabled veterans, no one 
has more interest or greater experience and expertise when it comes to 
the quality and timeliness of health care provided to veterans by the 
Department of Veterans Affairs (VA).
    DAV is dedicated to a single purpose: empowering veterans to lead 
high-quality lives with respect and dignity. Our 1.2 million members--
all of whom were wounded, injured or made ill through their military 
service--rely heavily on VA for some or all of their physical and 
mental health care needs. We have an enormous stake in making certain 
that VA continues to provide high-quality health care, and that it does 
so in a timely manner.
    Mr. Chairman, while I am pleased to be here today to share some 
insights about what DAV members see, hear and experience firsthand at 
VA's 1,700 points of care, the circumstances that precipitated this 
hearing are troubling indeed. DAV remains deeply concerned about 
allegations of secret waiting lists, falsification of medical 
appointment records and the destruction of official documents that may 
have occurred in Phoenix, Arizona; Fort Collins, Colorado; Cheyenne, 
Wyoming; Austin, Texas; and potentially, other sites as well. These 
reports raise troubling questions about whether VA employees or 
management took actions that, whether by design or not, obscured the 
true picture of access problems at some VA facilities, whether proper 
procedures concerning scheduling and wait list were followed, and 
whether any laws were broken.
    We fully support the ongoing investigation by the Inspector General 
and look forward to receiving and analyzing its results and 
conclusions. We will demand full accountability for anyone found to 
have violated the law or failed to responsibly follow and enforce VA's 
rules and regulations, no matter who or where they are inside VA.
    We also support Veterans Affairs Secretary Shinseki's initiative to 
audit all VA facilities immediately to determine whether similar 
scheduling issues or waiting list problems may be uncovered. We expect 
that this audit will bring greater accuracy to assess the number of 
veterans waiting to receive different services at each VA facility. We 
strongly recommend that VA bring in outside, third-party experts to 
increase the objectivity and credibility of this audit process in order 
to help regain the full trust of veterans and the American people. 
Further, it is imperative that VA release all data, information, 
findings and conclusions of this audit to both Congress and the public 
in a fully transparent manner. We stand ready to provide any assistance 
to VA that can help in achieving these objectives.
    Mr. Chairman we also take very seriously recent news reports that 
raise questions about whether VA's inability to provide timely access 
to certain health care services may have caused or contributed to 
negative patient health outcomes or even deaths. Such grave questions 
must be aggressively pursued by VA as well as by outside experts to 
determine their validity. While no health care system is perfect, and 
medicine is far from an exact science, veterans have earned the right 
to expect the VA health care system to provide medical care at the 
highest level, equal to if not better than private sector care. 
Furthermore, when problems and challenges arise, as they will from time 
to time in all health care systems, VA must act swiftly, transparently 
and effectively to correct the problems and overcome the challenges. In 
the coming weeks, we will closely monitor how well and how quickly VA 
responds to these serious questions and allegations.
    Unlike private providers and health care systems, VA is required by 
its own policy to admit and publicly report all medical errors and 
fully investigate all untimely deaths. VA uses the information from 
these investigations for self-improvement and to strengthen prevention 
protocols system wide. To be effective, VA must have sufficient 
internal monitoring and reporting systems that detect and report 
problems rapidly through the chain of command in order to correct them 
and develop prevention strategies nationwide. These recent revelations 
indicate that there are troubling gaps in this reporting system that 
need to be addressed.
    Although it may be weeks or months before we have all the results 
of the ongoing investigations and audits, we continue to have 
confidence that VA, led by Secretary Shinseki, can and will correct any 
problems identified or uncovered. This Secretary has a track record of 
directly and honestly confronting problems that he has inherited or 
that were uncovered during his tenure, and then working with Congress 
and stakeholders to correct them. For example, after decades of 
inaction and inattention, the Secretary laid out a bold course four 
years ago to finally modernize the VA disability claims processing 
system, a transformation that has already reduced the backlog of 
disability compensation claims by about half in the past year. 
Similarly, when IT problems interrupted payments to thousands of 
student veterans under the new Post-9/11 GI Bill, VA leadership moved 
aggressively to confront and resolve the problems, building an entirely 
new IT system in less than 13 months. When access to mental health 
services became a crisis a couple of years ago, at the direction of the 
Secretary, VA rapidly hired an additional 1,600 mental health 
professionals, 952 peer counselors, 300 support personnel, and 
increased staffing for the Veterans Crisis Line (1-800-273-8255) by 50 
percent, to break down stigma barriers and increase access.
    Mr. Chairman, let me be clear, by no means have all of VA's 
problems been solved or challenges overcome, nor is it yet clear the 
full scope of the problems that may be uncovered by current 
investigations and audits into waiting times and alleged preventable 
deaths. However, based on our experience, we continue to have full 
confidence that the Secretary can and will confront any such problems 
directly and honestly, just as he has throughout his career. For our 
part, we stand ready to work with him, this Committee and others in 
Congress to openly investigate problems, honestly discuss constructive 
solutions, and collaboratively work to fix them.
    Moreover, let me emphasize one point on which we are resolute: the 
VA health care system is both indispensable and irreplaceable; there is 
no substitute for it. Based upon our collective knowledge and 
experience, we continue to believe that VA provides high-quality health 
care for the vast majority of veterans treated each year, and that 
veterans are now and will be better served in the future by a robust VA 
health care system than by any other model of care. The real challenge 
facing VA, and the root cause of the issues being reported today, have 
to do with access to care rather than the quality of care that is 
delivered.
    Mr. Chairman, as I stated at the outset, DAV and our members are 
not just observers of the VA health care system, but active consumers 
of it. Our testimony reflects both current research and analysis as 
well as the collective experience of our professional staff, which 
includes over three hundred National Service and Transition Service 
Officers and nearly two hundred hospital coordinators covering every VA 
medical center. We also have thousands of Department and Chapter 
Service Officers and leaders who use VA and work directly with millions 
of veterans enrolled in the system. Our transportation network, which 
provides more than 770,000 rides for veterans to and from VA health 
care facilities each year, is another point of contact that we have 
with which to assess the State of VA Health Care. There are also 1.2 
million DAV members across the Nation who regularly receive care at 
VA's Community-Based Outpatient Clinics (CBOCs), medical centers and 
other facilities. Let me assure you that when our members see, hear or 
personally experience problems at VA, we hear from them at our 
meetings, during our conventions, in phone calls, via email and on 
Facebook. It is from this broad and diverse base of knowledge and 
expertise that we come to our conclusions.
    VA today operates nearly 1,700 sites of care including 152 
hospitals, almost 900 community-based and mobile outpatient clinics, 
300 Vet Centers for psychological counseling and other facilities that 
provide vital health care and services to millions of veterans. VA 
provides medical services to more than 6 million veterans annually, out 
of almost 9 million enrolled in the VA system. For more than a decade, 
numerous independent auditors and analysts have concluded that the 
quality care provided by VA is equal to or better than similar care 
provided by private sector systems and at lower costs to the taxpayer. 
The 2013 American Customer Satisfaction Index reported that veterans 
themselves ranked VA hospitals among the best in the Nation with equal 
or better ratings than private hospitals. This is not to imply that VA 
faces no challenges or that no problems occur within the VA system. 
However, it is important to put in context the quality of care 
delivered by VA compared to private sector alternatives.
    The VA health care delivery model provides comprehensive, patient-
centered and evidence-based care that leads the Nation in many areas. 
VA's clinical research program has elevated the American standard of 
care and invented cutting edge devices and treatment techniques that 
have improved the lives of millions of veterans and non-veterans in 
areas such as spinal cord injury, blind rehabilitation, amputation 
care, advanced rehabilitation (such as polytrauma and Traumatic Brain 
Injury), prosthetics, Post Traumatic Stress Disorder, substance-use 
disorder, multiple sclerosis, diabetes, Alzheimer's, Parkinson's and 
dementia. VA's model of care emphasizes preventive strategies that 
elevate the quality of life for millions of veterans while reducing 
health care costs overall. With its focus on preventative medicine, 
life-time care of veterans in a patient-centered model and the use of 
low-cost, bulk-procured medications, VA is able to provide high-quality 
care for less than the cost of Medicare and private sector providers.
    It is worth noting that in addition to providing high-quality 
health care to veterans, VA is also the largest single provider of 
health professional training in the world. Each academic year, VA helps 
train over 100,000 students in the health professions through its 
academic affiliation with 152 schools of medicine and over 1,800 
schools in total.
    Mr. Chairman, to better understand why the VA health care system is 
so uniquely suited to veterans' needs today, it is useful to look at 
how the current system evolved. Twenty years ago, VA was still based 
upon the post-World War II model of care, with large hospitals located 
in major cities providing primarily inpatient care. At that time, VA 
based eligibility for services on inpatient admission status and 
routine care was often delivered in major medical centers at very high 
cost, and in often inconvenient locations and times for an increasingly 
suburban population. In the mid-1990s, with the approval of Congress, 
VA leadership developed a new paradigm that decentralized the delivery 
of health care and with the help of Congress reformed eligibility 
allowing more veterans to receive comprehensive care. As a result, 
hundreds of CBOCs were opened in every state over the next decade and 
millions of veterans living in suburban, rural and remote areas now 
found VA a convenient provider of high-quality care. In addition, as VA 
moved to a model of care that emphasized preventative services and 
focused on the comprehensive health care needs of veterans, both the 
quality and cost-efficiency of care dramatically increased. In 
addition, VA built a forward-looking electronic medical record system 
that contributed to the efficiency and safety of the system. Within a 
decade, VA was being hailed as the ``best care anywhere'' by major 
independent studies, publications and by author Philip Longman, who 
wrote a book by that name.
    Today, VA has undertaken another major step forward by evolving the 
system to a patient-centered care model focusing on the needs of 
veterans, rather than VA processes. We believe that VA is on the right 
path forward and that the vast majority of veterans receiving medical 
services from VA receive high-quality care. The real challenge facing 
VA is providing all veterans seeking medical care with access to the VA 
system.
    As we have testified consistently over the past decade, we continue 
to find that access remains a problem for too many veterans at too many 
VA facilities. Based on our information, not all facilities have access 
problems and even at those that do, it may only be related to some of 
the services they provide. We have heard often from VA employees and 
sometimes local VHA leadership that there have been shortfalls in 
staffing or resources that forced them to take actions limiting 
services sought by veterans. There is now a growing body of evidence 
validating our concerns.
    For example, in December 2012, GAO investigated reports of long 
wait times for outpatient medical appointments and found that the 
metrics provided by VHA were ``unreliable.'' Furthermore, GAO found 
that VHA's scheduling policy and training documents were ``unclear'' 
and led to inconsistent reporting of wait times. They also found that 
scheduler training was inconsistent from one VA facility to the next. 
GAO made four recommendations that VA generally agreed with, and VA 
outlined an implementation with target dates of March 30 and 
November 1, 2013. We expect to hear from VA today if, when and how 
these plans were implemented, and the results from those changes.
    Investigations have also been reported in the news media regarding 
scheduling problems and possible violations of VA policies identified 
by the VA Office of Medical Inspector, and the Office of Special 
Counsel over the past year regarding access, scheduling and waiting 
times. Again, we look to VA to forthrightly address those management 
and administrative issues with specific responses.
    However, improved administrative procedures and management can only 
address part of VA's access challenges. The ability of VA to provide 
veterans timely access to medical care is primarily driven by four 
factors: how many medical personnel are available to provide medical 
care (resources), how much usable space is available to treat veterans 
(infrastructure), can VA leverage health care capacity in the community 
(purchased care), and can VA produce accurate and valid data to 
properly manage access issues (metrics).
    Mr. Chairman, for the past decade, DAV and our partners in The 
Independent Budget (IB) have consistently testified before this 
Committee and others about shortfalls in VA's medical care and 
construction budgets. In the prior ten VA budgets, the amount of 
funding for medical care requested by the Administration and ultimately 
provided to VA by Congress was more than $5.5 billion less than what 
was recommended by the IB. Over the past five years, the IB recommended 
$3.5 billion more than VA requested or Congress approved and for next 
year, FY 2015, the IB has recommended just over $2 billion more than VA 
requested. I would point out that you, Mr. Chairman, did call for an 
increase of $1.6 billion for FY 2015 medical care funding, which we 
believe is fully justified, but based on available information today, 
it appears that your Senate colleagues will not significantly increase 
the Administration's inadequate request, just as the House failed to 
do.
    Even worse, the funding shortfalls that we have consistently 
pointed out have been exacerbated by annual budget gimmicks that 
replace actual dollars to be appropriated with ``projected'' savings 
from proposed ``management efficiencies'' and ``operational 
improvements.'' As GAO has consistently pointed out, VA's projections 
of such future ``savings'' have rarely, if ever, been documented or 
substantiated, leaving VA facilities short of the funding needed to 
provide medical care to all veterans using the system. A similar 
problem occurs when VA also replaces appropriated dollars in their 
budget requests with anticipated collections from third party insurers. 
When the actual amounts collected through the Medical Care Collection 
Fund (MCCF) fall short of the projected levels, as has been the case 
almost every year, VA is once again forced to make do with less than 
its actuarial model estimates is needed to provide care to enrolled 
veterans. If just these two ``gimmicks'' were removed from the budgets 
proposed by the Administration and subsequently approved by Congress, 
VA would have had significantly greater resources, billions more, with 
which to increase staffing and better address access issues that have 
become so prevalent now.
    Mr. Chairman, in your Views and Estimates letter to the Senate 
Budget Committee last year you made this same point when you said, 
``based upon operational efficiencies identified as cost savings in 
previous VA budgets, I am concerned there will be a similar shortfall 
next fiscal year.'' You went on to express concerns about the ``* * * 
potential impact that failing to achieve the identified costs savings 
may have on VA's provision of health care.'' Unfortunately, neither the 
Senate nor the House heeded this advice and we find ourselves today in 
this dilemma.
    The second challenge in access, and over the long term probably the 
greatest challenge that must be addressed, is providing VA sufficient 
resources to properly maintain, realign or expand its infrastructure. 
Over the past decade, the amount of funding requested by VA for major 
and minor construction, as well as the final amount appropriated by 
Congress, has been more than $9 billion less than what the IB has 
estimated was needed to continue delivering timely, high-quality care. 
Over the past five years, that shortfall is more than $6 billion and 
for next year, the VA budget request is more than $2.5 billion less 
than the IB recommendation. Furthermore, the IB recommendations are 
primarily based upon VA's own internal analysis of funding needed to 
maintain VA's existing physical infrastructure.
    According to VA's Strategic Capital Investment Plan (SCIP), VA 
needs to invest between $56 to $69 billion in facility improvements 
over the next ten years; however, the Administration's budget requests 
have averaged between $1 to $1.5 billion for major and minor 
construction over that time. Again, Mr. Chairman, I want to commend you 
for pointing out this fact in your Views and Estimates letters the past 
two years. You very honestly stated that the funding level proposed by 
the Administration for construction and maintenance has been ``clearly 
insufficient to meet the identified needs * * *'' Unfortunately, as 
with medical care funding, neither your Senate colleagues nor the House 
took actions to increase funding for VA's construction and maintenance 
accounts, ignoring not just the IB's recommendations, but VA's own 
internal SCIP analysis.
    Mr. Chairman, a little over a decade ago, VA faced a similar and 
serious crisis over access to VA health care, as hundreds of thousands 
of veterans were found waiting six months or longer just to receive 
primary care medical appointments. The root cause of that situation 
also was insufficient resources to meet the actual demand for services. 
Even after VA moved to close its doors to new Priority 8 veterans, the 
shortfall in funding soon became unmanageable. By 2005, shortly after 
testifying before this Committee and the House Veterans' Affairs 
Committee that the Administration's budget was sufficient, then-VA 
Secretary Jim Nicholson was forced to return to Congress and admit that 
there was a shortfall of about a billion dollars, which Congress 
subsequently appropriated. Only after the funding levels for medical 
care were increased closer to the levels recommended by the IB did the 
wait lists finally begin to decline. Today it appears that VA may once 
again be approaching that same dangerous crossroad; unless the 
Administration begins to request more adequate funding, and/or unless 
Congress starts to increase insufficient funding requests, the growing 
problems related to access will continue. And no amount of 
administrative or management changes, or replacement of VA leadership, 
can begin to make up for the $15 billion shortfall identified by the IB 
over the past decade.
    The third challenge is for VA to utilize its purchased care 
authority when necessary to supplement and bolster the VA health care 
system. DAV believes that whenever an enrolled veteran is unable to 
receive care directly from VA within established timeframes, VA must 
take responsibility to find alternative means to provide and coordinate 
such care, regardless of where the veteran lives.
    In the near term, VA must to do a better job of providing non-VA 
care when VA is unable to provide timely care. The determination of 
which and how many veterans receive care paid for by VA is left to the 
discretion of each facility; however they must balance the fact that 
funding to purchase care comes out of the same pot of money for direct 
VA health delivery. Each dollar used to pay for non-VA care is one 
dollar less that is available to hire new VA staff required to treat 
veterans in a timely manner. If the VA's purchased care program is to 
truly function as intended, the first step is for VA to provide 
accurate, complete and transparent estimates of the amount of funding 
required to purchase care from the private sector. Once VA provides an 
accurate estimate, Congress must appropriate the amounts necessary to 
support both VA provided and purchased care if we are to avoid 
rationing care.
    However, even with sufficient funding, there remain many questions 
to be answered and challenges to be overcome before VA's purchased care 
program can be successful. For example, how will non-VA care be 
coordinated with VA care so that the holistic needs of the veterans are 
met? How will non-VA providers integrate their medical records into 
VA's electronic health record system so that there is seamless record 
keeping ensuring integrated care and patient safety? Even if VA has the 
resources to pay for non-VA care, are there sufficient, qualified 
providers available in each community to provide such care? Simply 
giving a veteran a plastic card and wishing them good luck in the 
private sector is no substitute for a fully coordinated system of 
health care.
    The fourth challenge is even with sufficient infrastructure and 
resources, VA can only manage and improve what they can measure. VA 
currently uses the Medical Scheduling Package (MSP), a component in its 
VistA electronic health record (EHR) system, to perform multiple 
interrelated functions to coordinate clinical and administrative 
resources as well as to capture data that allows VA to measure, manage, 
and improve access to care, quality of care, operating efficiency, and 
operating and capital resources. VA's current MSP is more than 26 years 
old and does not meet current requirements or provide the flexibility 
to support new and emerging models of care.
    On October 16, 2012, VA announced its intention to replace the 
current MSP by open competition for a product that effectively performs 
VA's scheduling and related legacy business functions. The winners of 
the competition were announced on October 3, 2013; however, no plans 
have been made public about next steps or when an actual replacement 
will occur. VA must quickly come forward with a detailed plan to 
replace and modernize their scheduling software, including an accurate 
estimate of all the funding and other resources needed to make it 
operational. In addition, this new system should have the capability to 
provide real-time measures of waiting times on a facility-by-facility 
basis and other metrics needed for effective management. In addition, 
VA must develop a public method or regularly reporting such data to 
Congress, veterans and the American public, similar to how the Veterans 
Benefits Administration reports detailed data about claims processing 
timeliness and accuracy.
    Mr. Chairman, looking at the VA health care system today, and 
putting it into the proper perspective of the entire American system of 
health care, we continue to have confidence that the vast majority of 
veterans are well served by seeking their care at the VA. We recognize 
that there continue to be access problems at some locations for some 
services, and there are troubling questions about how VA has responded 
to these problems that must be answered. In addition, there are serious 
questions about whether access challenges have led to negative health 
outcomes or even untimely deaths. And while we believe that VA can and 
must address any administrative or management challenges related to 
scheduling, the underlying problem has been and remains one of 
insufficient resources to meet veterans' needs. Until and unless both 
the Administration and Congress openly and honestly work to align VA's 
resources to veterans' needs for care, problems related to access, such 
as waiting lists, will remain a threat to the health of veterans. 
However, we remain confident that VA and Secretary Shinseki, working 
together with stakeholders and Congress, can, will and must address 
these challenges. America's veterans deserve nothing less.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                       Disabled American Veterans
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you very much, Mr. Violante.
    Mr. Tarantino.

  STATEMENT OF TOM TARANTINO, CHIEF POLICY OFFICER, IRAQ AND 
                AFGHANISTAN VETERANS OF AMERICA

    Mr. Tarantino. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of the Committee, on behalf of Iraq and 
Afghanistan Veterans of America, I thank you for this 
opportunity to share our views and recommendations regarding 
the current state of health care with VA.
    For nearly a decade, IAVA has been a tireless leader, 
working on behalf of veterans and their families to ensure that 
VA meets the needs of our community. After spending 13 years at 
war, VA has been confronted with significant challenges 
administering timely care and services to veterans. Many have 
been overcome, but still, clearly, far too many remain.
    In the past few weeks, serious allegations of misconduct 
have arisen from several VA medical facilities, indicating that 
records are being intentionally doctored in order to falsely 
portray patient wait times as reasonable and satisfactory. 
Disturbingly, long wait times are alleged to be the result of 
40 deaths, 40 veterans who perished while waiting for care at 
the Phoenix VA medical facility alone, and since Phoenix, more 
allegations of misconduct at other facilities from coast to 
coast are painting a similar picture. Unfortunately, these 
types of incidents are not new, nor are they apparently unique.
    It is time for bold reform and new measures of 
accountability and oversight. Our members are outraged and 
expect substantive and meaningful evidence that longstanding 
inefficiencies are being appropriately addressed and 
appropriate VA personnel are being held accountable. Veterans 
must be assured that VA can deliver quality care in a timely 
manner, and veterans are tired of business as usual.
    IAVA also expects VA to fully comply with the subpoena 
issued by the House Committee on Veterans' Affairs. Full and 
swift compliance with this subpoena will be a good first step 
in not only figuring out what happened in Phoenix, but 
demonstrating how allegations of misconduct will be addressed 
at other VA facilities.
    And, just like the Secretary, we are also awaiting the 
results of the Inspector General's investigation of alleged 
misconduct in Phoenix, but we cannot sit around idle while the 
investigation is underway. We applaud the full audit of all 
1,700 points of care at VA. However, we expect results and 
action in weeks, not months. Additionally, we support and 
encourage concurrent investigations that are completely 
independent of VA.
    Veterans need to see the Secretary step out in front on 
this issue and lead. We want a proactive Secretary, not a 
reactive one. Controlling the public message is critical, and 
if the Secretary cannot do it, veterans and the American public 
will continue to lose faith in the VA system. Accountability is 
a fundamental principle necessary for any organization to 
properly function, yet, VA's incidence of mismanaged care would 
indicate that such a thing is missing from all levels at VA.
    Secretary Shinseki has finally started to emerge publicly 
and address these allegations, but we need to be clear that 
short-term reactive measures will not eradicate the most 
pervasive problems causing veterans to lose faith in this 
system. VA has a long way to go to earn back the confidence of 
millions of veterans shaken by this growing controversy.
    Although recently exposed by whistleblowers, allegations of 
long wait times at VA are actually nothing new. The GAO has 
conducted numerous studies over the last decade touching on 
scheduling inefficiencies at VA and their findings continue to 
center around lack of oversight, inadequate training, ambiguous 
policies and procedures; in other words, weak leadership.
    Now, long wait times are one thing. Essentially, they are a 
management and process problem. They can be solved with a 
combination of people and time and resources, and more 
effective business practices. They are solvable as long as good 
leaders have the tools and information they need to fix it. 
That does not seem to be the case here. Instead of leaders 
coming forward to fix the system, they appear to be fixing the 
books. This is indicative of a culture of failed oversight and 
no accountability.
    Now, reasons for highlighting VA mismanagement and 
bureaucratic flaws are not taken lightly, nor should they be. 
The worst thing that can happen in our community is a sense 
that VA is so inefficient and terrible at administrating care 
that veterans lose faith in the system designed to take care of 
their needs. Now, the right answer to this is not to cover up 
problems in VA, but to solve them or keep them from happening 
in the first place.
    And this is not just a matter of communication, it is a 
matter of lives. Of the estimated 22 veterans who die by 
suicide per day, 17 have not sought care at VA. Despite VA's 
many problems, seeking care works and can save lives. It is 
absolutely critical that veterans who need care feel encouraged 
to seek it.
    In order to improve the system of care and reassure 
veterans about VA's capabilities, legislation such as the 
Suicide Prevention for American Veterans Act and the VA 
Management Accountability Act should be enacted into law 
immediately. Our membership and the veterans community as a 
whole need to be reassured by VA and the Congress that, despite 
these issues, VA is there to serve them and that any charges of 
misconduct will be addressed and swiftly corrected.
    We also need to ensure that we know the full scope of 
mismanagement and cover-up at the VA system. This is why IAVA 
is proud to work with the Project on Government Oversight to 
protect VA whistleblowers. VA employees can come forward 
confidentially by going to VAoversight.org.
    Mr. Chairman, we, again, appreciate the opportunity to 
offer our views on this critically important and urgent topic. 
We look forward to continuing to work with you, your Committee, 
your staff, and VA to improve the lives of veterans and their 
families. Thank you for your time and attention.
    [The prepared statement of Mr. Tarantino follows:]
      Prepared Statement of Iraq & Afghanistan Veterans of America

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Jon Tester to Iraq 
                & Afghanistan Veterans of America (IAVA)

                    Iraq & Afghanistan Veterans of America,
                                                      June 30, 2014
Hon. Jon Tester,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
    Dear Senator Tester: Iraq & Afghanistan Veterans of America is 
pleased to provide the following answers to the question for the record 
you sent to us following the May 15 hearing entitled ``The State of VA 
Health Care'' before the Senate Committee on Veterans Affairs:

    Question 1.  When we talk about access to health care, it's not 
only about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response. There are currently over 22.4 million veterans living in 
the United States, but only 8.9 million are currently enrolled in the 
Veteran Health Administration according to VA. VHA currently uses 
multiple platforms and strategies to conduct outreach to veterans, but 
the fact that less than half of eligible veterans are connected with 
VHA raises concerns that current outreach efforts are not enough.
    Congress has directed VHA to provide outreach to specific veteran 
populations such as homeless veterans, elderly veterans, woman veterans 
and eligible dependents of veterans via legislation. VHA also uses 
staff to directly contact veterans using telephone and mailers to 
provide information on benefits however, these methods are inefficient. 
Additionally, VHA also disseminates information to veterans via press 
releases and social media, including on platforms like Twitter (44,300 
followers) and Facebook (124,500 likes). While VHA's use of social 
media to reach out to its target audience is commendable, the combined 
total of just over 168,000 social media followers is far below what the 
outreach goals of VHA should be.
    VHA is on the right track by expanding its outreach efforts into 
the social media sphere, but the department can certainly do more to 
grow and expand its social media presence. In addition to using these 
web 2.0 platforms, VHA should also bring in more Iraq and Afghanistan-
era veterans who understand the target outreach audience. Finally, VHA 
should partner with both traditional veteran service organizations and 
newer, hybrid veteran advocacy groups to help vouch for and spread the 
word about VA benefits and services.

    If you have any additional questions, please don't hesitate to 
reach out to me or to our Legislative Director, Alexander Nicholson.
    Thank you again for giving IAVA the opportunity to offer our 
analysis and the views of our members as the Committee continues to 
consider and debate this very important issue for the military and 
veteran community.
            Respectfully,
                                       Thomas A. Tarantino,
                                              Chief Policy Officer.

    Chairman Sanders. Thank you, Mr. Tarantino.
    Carl Blake is the National Legislative Director, Paralyzed 
Veterans of America. Mr. Blake.

    STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 
                 PARALYZED VETERANS OF AMERICA

    Mr. Blake. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, on behalf of Paralyzed Veterans of 
America, I would like to thank you for the opportunity to 
testify today on the state of health care delivered by the 
Department of Veterans Affairs and the spinal cord injury 
system of care. No group of veterans understands the full scope 
of care provided by VA better than PVA's members, veterans who 
have incurred a spinal cord injury or a dysfunction. PVA 
members are the highest percentage users of VA health care.
    Let me begin by saying that PVA is deeply disappointed by 
the number of reports from around the country that suggest that 
veterans' health care is being compromised. There are 
undoubtedly serious access problems in the VA.
    I would like to associate myself with the comments made by 
Senator Isakson and Senator Begich regarding gaming the system, 
and for all intents and purposes, cheating the standard. If 
that is going on, and when cases are found when that is going 
on, serious and appropriate action should be taken. If that 
means people have to be fired, so be it. That is what has to 
happen.
    However, we believe that a thorough analysis to understand 
the depth of the situation across the system should be 
completed before any final decisions about VA leadership are 
made. At this time, PVA fully stands behind Secretary Shinseki. 
We believe he is committed to fixing these problems and he 
should be afforded the opportunity to get it right.
    I would like to emphasize, however, that the narrative that 
has been created by the media does not necessarily reflect what 
is happening inside the walls of the VA Health Care System. If 
the Committee really wants to gauge what is going on and how 
the quality of care is being delivered, I would ask you to 
spend a day walking around inside a local VA hospital talking 
to veterans and discussing their health care experiences, not 
sitting in front of a pre-screened, pre-selected panel of 
veterans to support sweeping generalizations and to stoke 
public outrage.
    The fact is that VA health care services, by and large, are 
excellent. Patient satisfaction surveys of VA support that 
assertion.
    The primary complaint that we hear all of the time from 
veterans is how long they had to wait to be seen for an initial 
appointment or to receive care. At its core, this is an access 
problem, not a quality of care problem. These are not the same 
thing.
    And, to be clear, sending veterans outside of the VA to get 
private care is not the solution to this problem. It might be 
part of a solution. It is not the solution, particularly for 
veterans who rely on VA's specialized services. The fact is 
that there are not comparable services in the private sector to 
VA's SCI service, blinded care, amputee care, and the wide 
variety of specialized care that the VA provides.
    Our written statement provides a snapshot of VA's spinal 
cord injury system of care. We have clearly identified serious 
staffing shortages that exist in the SCI service, particularly 
on the nurse staffing side. The site visits that we have 
conducted with our medical services teams for nearly three 
decades provide us the unique authority to affirm those 
problems. Unfortunately, those staffing shortages severely 
limit access to the system while also placing the health care 
delivery for veterans at risk.
    Insufficient staffing, and by extension insufficient 
capacity, is ultimately a reflection of insufficient resources 
that this administration and previous administrations have 
requested for health care and insufficient resources that 
Congress has ultimately provided. The Independent Budget, co-
authored by PVA, AMVETS, DAV, and the VFW, has made 
recommendations to adequately fund VA health care for 28 years. 
For the last several years, Congress has essentially ignored 
our recommendations. And now, here we are discussing, how could 
this have all happened?
    I would agree with Senator Johanns, who indicated, you 
know, what the heck is going on, when he looks at this and 
considers the budgets that have been requested.
    I would suggest that the great irony of this hearing today 
is the discussion about whether the OIG adequately funded to do 
these investigations. Is the VA Health Care System adequately 
funded to deliver timely, quality care? I would suggest the 
answer to that question is no. Until the Congress and the 
Administration commit to providing truly sufficient resources 
to hire adequate staff and establish real capacity, the 
problems being reported around the country will only get worse.
    The Administration and Congress both bear the 
responsibility of these problems. Veterans pay the costs, 
sometimes with their lives, of inaction resulting from partisan 
bickering and political gridlock. Political interests do not 
come before the needs of the men and women who have served and 
sacrificed for this country.
    We call on this Committee, Congress as a whole, and the 
Administration to redouble your efforts to ensure that veterans 
get the absolute best health care provided when they need it, 
not when it is convenient. PVA members and all veterans will 
not stand for anything less.
    I thank you again, Mr. Chairman. I would be happy to answer 
any questions that you might have.
    [The prepared statement of Mr. Blake follows:]
 Prepared Statement of Carl Blake, Acting Associate Executive Director 
        for Government Relations, Paralyzed Veterans of America
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to testify today on the current state of health 
care provided by the Department of Veterans Affairs (VA) and the spinal 
cord injury and disorder (SCI/D) system of care. No group of veterans 
understands the full scope of care provided by the VA better than PVA's 
members--veterans who have incurred a spinal cord injury or 
dysfunction. PVA members are the highest percentage of users among the 
veteran population. They are also the most vulnerable when access to 
health care and other challenges impact quality of care. I will first 
offer PVA's thoughts on the specialized services provided by the VA, 
particularly in the area of SCI/D care, and then I will focus my 
remarks on the VA health care system in general.
           the va spinal cord injury/disorder system of care
    The SCI/D system of care is one of the crown jewels of the VA 
health care system. Spinal cord injury care is provided use the ``hub-
and-spoke'' model. This model establishes the 24 spinal cord injury 
centers that exist with the VA system as the hubs of care. All other 
major medical facilities in the system serve as outpatient clinics 
(spokes) that direct and refer care back to the hubs. This model has 
proven to be very successful in meeting the complex needs of PVA's 
members. In fact, this model system of care has been so successful that 
the VA used the same model to establish the poly-trauma system of care.
    Unfortunately, the ability of the SCI/D centers to function 
properly is dictated by the numbers of qualified SCI/D trained staff 
that are employed within the system. As a result of frequent staff 
turnover and a general lack of education and training in outlying 
``spoke'' facilities, not all SCI/D patients have the advantage of 
referrals, consults, and annual evaluations in an SCI/D center.
    This is further complicated by confusion as to where to treat 
spinal cord diseases, such as Multiple Sclerosis (MS) and Amyotrophic 
Lateral Sclerosis (ALS). Some SCI/D centers treat these patients, while 
others deny admission. We recognize that there is an ongoing effort to 
create a continuum of care model for MS, and this model should be 
extended to encompass MS and other diseases involving the spinal cord, 
such as ALS. Ultimately, we believe admission to an SCI/D center is the 
most appropriate setting for treatment for all SCI/D veterans.
    In December 2009, VA developed and published Veterans Health 
Administration Handbook 1011.06, Multiple Sclerosis System of Care 
Procedures, which clearly identifies a model of care and health care 
protocols for meeting the individual treatment needs of SCI/D veterans. 
However, VA has yet to develop and publish a Veterans Health 
Administration (VHA) directive to enforce the aforementioned handbook. 
Without a directive, the continuity and quality of care for both SCI/D 
veterans and veterans with MS could be compromised. The issuance of a 
VHA directive for the handbook is essential to ensuring that all local 
VA medical centers are aware of and are meeting the health care needs 
of SCI/D veterans. Additionally, and perhaps most importantly, no 
dedicated funding has been provided to VA medical centers to implement 
the guidelines in the handbook. However, we believe that the current 
SCI/C system can appropriately handle all SCI/D veterans if properly 
resourced.
    Additionally, historical data has shown that SCI/D units are the 
most difficult places to recruit and retain nursing staff. Caring for 
an SCI/D veteran is physically demanding and requires nursing staff to 
provide hands-on care that involves bending, lifting, and stooping in 
order to transfer patients, prevent bed sores, and deliver care to 
individuals who are completely reliant on another individual for 
functions and activities that most people take for granted. These 
repetitive movements and heavy lifting often lead to work related 
injuries, even with the advent of patient lifts and other innovations. 
Also, veterans with SCI/D often have complex psychological issues and 
other hidden health dangers as a result of their injury/disorder. 
Special skills, knowledge, and dedication, which call for a set of 
competencies that can prove extremely esoteric even for the most 
skilled non-SCI/D providers, are required in order for nursing staff to 
care for SCI/D veterans.
    Recruitment and retention bonuses have proven effective at several 
VA SCI/D centers, resulting in an improvement in both quality of care 
for veterans as well as in the morale of the nursing staff. 
Unfortunately, facilities are faced with local budget challenges that 
result in the deprioritization of recruitment and retention bonuses. 
The funding necessary to support this effort is taken from local 
facility budgets, essentially forcing a choice between maximizing care 
for the most vulnerable versus providing care for the greatest number. 
A consistent national policy of salary enhancement should be 
implemented across the country to ensure that qualified staff is 
recruited. Funding to support this initiative should be made available 
to the medical facilities from the network or central office to 
supplement their operating budgets.
    Moreover, the VA has a system of classifying patients according to 
the hours of bedside nursing care needed. Five categories of patient 
care take into account significant differences in the level of care 
required during hospitalization, amount of time spent with the patient, 
technical expertise, and clinical needs of each patient. Acuity 
category III has been used to define the national average acuity/
patient classification for the SCI/D patient. These categories take 
into account the significant differences in hours of care in each 
category for each shift in a 24-hour period. The hours are converted 
into the number of full-time equivalent employees (FTEE) needed for 
continuous coverage.
    However, the emphasis of this classification system is based on 
bedside nursing care that may work in non-SCI/D systems of care, but 
that are not necessarily appropriate for SCI/D care. It does not 
include administrative nurses, non-bedside specialty nurses, or light-
duty nursing personnel as these individuals do not, and are not able, 
to provide full-time, hands-on bedside care for the high acuity 
veterans patient with SCI/D whose health needs vastly exceed that of an 
ICU, hospice, or geriatric patient with special needs. Because of this 
specialized quality, nurse staffing in SCI/D units has been delineated 
in VHA Handbook 1176.01 and VHA Directive 2008-085 based on VA and 
PVA's joint assessment of need. It was derived from the basis of 71 
FTEEs per 50 staffed beds, based on an average acuity category III SCI/
D patient, which reflected a younger average age among veterans with 
SCI/D. However, this national acuity average was established over a 
decade ago. Currently, SCI/D inpatients require a higher level of care 
than category III due to higher average age and multiple chronic 
complications that accompany aging with an SCI/D. While VA has 
recognized our requests in the past that administrative nurses not be 
included in the nurse staffing numbers for patient classifications, the 
current nurse staffing numbers still do not reflect and accurate 
picture of bedside nursing care. VA nurse staffing numbers incorrectly 
include non-bedside specialty nurses and light-duty staff as part of 
the total number of nurses providing bedside care for SCI/D patients. 
When the minimal staffing levels include non-bedside nurses and light-
duty nurses, the number of actual nurses available to provide bedside 
care is misrepresented in staffing reports. This leads to ``floating'' 
SCI/D nurses to other units, understaffing that results in mandatory 
overtime for existing staff, and other practices that erode quality of 
care over time. It is well documented in professional medical 
publications that adverse patient outcomes occur with inadequate 
nursing staff levels.
    VHA Directive 2008-085 mandates 1,504 bedside nurses to provide 
nursing care for 85 percent of the available beds at the 24 SCI/D 
centers across the country. This nursing staff consists of registered 
nurses (RNs), licensed vocational/practical nurses, nursing assistants, 
and health technicians. Unfortunately, the SCI/D centers recruit only 
to the mandated minimum nurse staffing required by VHA Directive 2008-
085. As of April 2014, the actual number of nursing personnel 
delivering bedside care was 161.9 FTEEs below the minimum nurse 
staffing requirement. Factoring in the actual average acuity level, 
there is a deficit of 746.2 FTEE between nurse staffing needed and the 
actual number of nurses available. The low percentage of professional 
RNs providing bedside care and the high acuity level of SCI/D patients 
put these veterans at increased risk for complications secondary to 
their injuries. Translated into lay terms that are relevant to why we 
are here today, the low percentage of professional RNs providing 
bedside care coupled with the high acuity of SCI/D patients presents us 
with a completely foreseeable, remarkably costly scenario where the 
next headline will read ``paralyzed veterans suffer secondary 
complications due to failure to properly staff SCI/D centers,'' a claim 
that would be far from hyperbolic. Studies have shown that low RN 
staffing causes an increase in adverse patient outcomes, specifically 
with urinary tract infections, pneumonia, shock, upper gastrointestinal 
bleeding, development of pressure ulcers, and longer hospital stays. 
SCI/D patients are prone to all of these adverse outcomes because of 
the catastrophic nature of their conditions. We have steadily 
maintained, and VA at one point agreed, that a minimum 50 percent RN 
staff in the SCI/D service is crucial in promoting optimal outcomes.
    Unfortunately, the nurse shortage has also resulted in VA 
facilities restricting admissions to SCI/D centers (an issue that we 
believe mirrors the larger access issues that are being reported around 
the country). Reports of bed consolidations or closures have been 
received and attributed to nursing shortages. When veterans are denied 
admission to SCI/D centers and beds are consolidated, leadership is not 
able to capture or report accurate data for the average daily census. 
The average daily census is not only important to ensure adequate 
staffing to meet the medical needs of veterans; it is also a vital 
component to ensure that SCI/D centers receive adequate funding. Since 
SCI/D centers are funded based on utilization, refusing care to 
veterans does not accurately depict the growing needs of SCI/D veterans 
and stymies VA's ability to address the needs of new incoming and 
returning veterans.
    As an example of this point, VA's projections for long term care 
SCI/D beds in VISN 22 (Southern California and Southern Nevada) called 
for 30 beds per the Capital Asset Realignment for Enhanced Services 
(CARES) model, which estimated demand for health care services in order 
to determine capacity of its infrastructure to meet that demand. It 
seems logical to presume that more aging veterans over time will need 
extended care services in Southern California, not fewer. However, VA 
advised us that new, lowered projections based on the Enrollee Health 
Care Projection Model (EHCPM) dictated a decrease in scope of new 
construction for the San Diego SCI/D center in VISN 22. This leads to 
serious concerns about future timely access to specialized care. 
Moreover, the EHCPM fails to account for suppressed demand that can 
lead to false assumptions about future utilization. Such situations 
severely compromise patient safety and serve as evidence for the need 
to enhance the nurse recruitment and retention programs to build 
capacity.
    In order to better track these issues and ensure they are addressed 
by the VA, PVA developed a memorandum of understanding with the VA more 
than 30 years ago that authorizes site visit teams managed by our 
Medical Services Department to conduct annual site visits of all VA 
SCI/D centers as well as spoke facilities that support the hubs. This 
opportunity has allowed us to work with VHA over the years to identify 
concerns, particularly with regards to staffing, and offer 
recommendations to address these concerns. More importantly, PVA is the 
only veterans' service organization (VSO) that employs a staff of 
licenses physicians, registered nurses, and architects to conduct these 
visits and report on the conditions. Our most recent site visits have 
yielded the information that is included below. This information 
reflects the Bed and Staffing Survey as of April 2014 for beds, 
doctors, nurses, social workers, psychologists, and therapists in the 
SCI/D system of care.
    Physician personnel across the SCI/D system are below the required 
staffing level by 21.8 FTEEs. Social workers are below the requirement 
by 15.2 FTEEs. Psychologists are below the required level by 15.4 
FTEEs. Finally, therapists are 33.4 FTEEs below the required level. As 
mentioned previously, the actual number of nursing personnel delivering 
bedside care is 161.9 FTEEs below the minimum nurse staffing 
requirement. The nurse shortages alone resulted in 114.0 SCI/D beds 
staffed below the minimum required number. Factoring in the actual 
average facility acuity level, this amount increases to 372.9 SCI/D 
beds staffed below the requirement. This means that there are currently 
281 unavailable SCI/D beds throughout the system. If this number is 
adjusted based on the actual average facility acuity level, this amount 
increases to 539.9 unavailable SCI beds throughout the system. This 
absurdly staggering number has proven easy to dismiss by leaders within 
VHA who insist that we provide by-name lists of veterans with SCI/D who 
languish on waiting lists rather than interrogate the merits of our 
claim and objectively examine their own data.
    These facts are simply unacceptable. The statistics reflect the 
fact that many veterans who might be seeking care in the VA are unable 
to attain that care. But to be clear, these facts reflect an access 
problem, not a quality of care problem. Access and quality is not the 
same thing. Veterans who have incurred a spinal cord injury or disorder 
and who get regular care at the VA are very satisfied with the care 
they are receiving. In fact, patient satisfaction surveys bear out this 
point. Unfortunately, for too long the VA has been provided 
insufficient resources to properly address the tremendous staffing 
shortages that exist, not only in the SCI/D system of are, but across 
the entire system.
    Within the VA health care system, the capacity to provide for the 
unique health care needs of severely disabled veterans--veterans with 
spinal cord injury/disorder, blindness, amputations, and mental 
illness--has not been maintained as mandated by Public Law 104-262, the 
``Veterans Health Care Eligibility Reform Act of 1996.'' This law 
requires VA to maintain its capacity to provide for the specialized 
treatment and rehabilitative needs of catastrophically disabled 
veterans. As a result of Public Law 104-262, the VA developed policy 
that required the baseline of capacity for the spinal cord injury/
disorder system of care to be measured by the number of staffed beds 
and the number of full-time equivalent employees assigned to provide 
care (the basis for PVA's site visits today). This law also required 
the VA to provide Congress with an annual ``capacity'' report to ensure 
that the VA is operating at the mandated levels of ``capacity'' for 
health care delivery for all specialized services.
    Unfortunately, the requirement for the capacity report expired in 
2008. PVA's Legislation staff, in consultation with PVA's Medical 
Services Department, identified reinstatement of this annual 
``capacity'' report as a legislative priority for 2014. We have worked 
extensively with our partners in the VSO community as well as with Hill 
offices to formulate legislation that would reinstate the annual 
``capacity'' report. This report affords the House and Senate 
Committees on Veterans' Affairs as well as veteran stakeholders the 
ability to analyze the accessibility of VA specialized care for 
veterans seeking that care at little to no cost. Currently, legislation 
is pending in the House Committee on Veterans' Affairs--H.R. 4198, the 
``Appropriate Care for Disabled Veterans Act''--that would reinstate 
this report. We urge the Senate Committee on Veterans' Affairs to 
consider similar legislation as soon as possible.
                 protection of va specialized services
    The simple truth is the VA is the best health care provider for 
veterans. In fact, the VA's specialized services are incomparable 
resources that often cannot be duplicated in the private sector. 
However, these services are often expensive, and are severely 
threatened by cost-cutting measures and the drive toward achieving 
management efficiencies. Even with VA's advances as a health care 
provider, some political leaders and policymakers continue to advocate 
expanding health care access for veterans by contracting for services 
in the community. While we recognize that VA must tap into every 
resource available to ensure that the needs of veterans are being met, 
such changes to the VHA would move veterans out of the ``veteran-
specific'' care within VA, leading to a diminution of VA health care 
services, and increased health care costs in the Federal budget.
    Specialized services, such as spinal cord injury care, are part of 
the core mission and responsibility of the VA. These services were 
initially developed to care for the complex and unique health care 
needs of the most severely disabled veterans. The provision of 
specialized services is vital to maintaining a viable VA health care 
system. The fragmentation of these services would lead to the 
degradation of the larger VA health care mission. With growing pressure 
to allow veterans to seek care outside of the VA, the VA faces the real 
possibility that the critical mass of patients needed to keep all 
services viable could significantly decline. All of the primary care 
support services are critical to the broader specialized care programs 
provided to veterans. If primary care services decline, then 
specialized care is also diminished.
    We believe that the VA itself has created conditions that require 
contract (or privatized) health care as a solution. The Committee needs 
to look no further than the wholly inadequate budget requests over many 
years and multiple Administrations for Major and Minor Construction to 
see this scenario playing out. For example, this year the 
Administration requested $561 million for Major Construction. This 
included funding for only four primary projects and secondary 
construction costs--this despite a backlog of construction projects 
that requires a minimum of $23 billion over the next 10 years in order 
to maintain adequate and serviceable infrastructure. If the 
Administration refuses to properly address this construction funding 
problem, then Congress should be filling this void. Unfortunately, 
Congress has punted on this responsibility as well. Ultimately, if VA 
is not provided sufficient resources to address the critical 
infrastructure needs throughout the system, then it will have no choice 
but to seek care options in other settings, particularly the private 
section. However, calls for using contract care options to alleviate 
these problems are not the answer for SCI/D veterans because comparable 
specialized health care options do not really exist in the private 
sector.
                             va health care
    PVA believes that the quality of VA health care is excellent, when 
it is accessible. In fact, as mentioned previously, VA patient 
satisfaction surveys reflect that more than 85 percent of veterans 
receiving care directly from the VA rate that care as excellent (a 
number that surpasses satisfaction in the private sector). The fact is 
that the most common complaint from veterans who are seeking care or 
who have already received care in the VA is timely access. PVA cannot 
deny that there are serious access problems around the country. The 
broad array of staff shortages that we previously mentioned in our 
statement naturally lead to the access problems that VA is facing 
across the Nation. Many of the problems that the media continues to 
report are really access problems, not quality of care problems. While 
there are many detractors of the VA who would like to convince veterans 
and the public at large that the VA is providing poor quality care that 
is simply not true. If the Committee wants to get the truth about the 
quality of VA health care, spend a day walking around in a major VA 
medical facility (not conducting a panel with four pre-selected 
veterans' opinions) and ask veterans their impressions of the care. We 
can guarantee that you will likely hear complaints about how long it 
took to be seen, but rare is the complaint about the actual quality of 
care. In fact the complaints of veterans about access often ring true 
about health care delivery in private hospitals and clinics as well. It 
is no secret that wait times for appointments for specialty care in the 
private sector tend to be extremely long.
    As we have already testified, access problems are primarily a 
reflection of insufficient staffing and by extension capacity. While 
insufficient staffing can be traced in some areas to the VHA 
inefficiently managing the resources it is provided, limited funding 
provided over many years has superseded the savings that can be 
generated from operational efficiencies and increased demand for health 
care services. We believe many of the access problems facing the VA 
health care system are the responsibility of Congress and the 
Administration together. The Administration (and previous 
Administrations) has requested wholly insufficient resources to meet 
the ever-growing demand for health care services, while at the same 
time attempting to fragment the VHA health system framework. Meanwhile, 
it has committed to operation improvements and management efficiencies 
that are not adequate enough to fill the gaps in funding. Similarly, 
Congress has been equally responsible for this problem as it continues 
to provide insufficient funding through the appropriations process to 
meet the needs of veterans seeking care.
    For many years, the co-authors of The Independent Budget--AMVETS, 
Disabled American Veterans, Paralyzed Veterans of America, and Veterans 
of Foreign Wars--have advocated for sufficient funding for the VA 
health care system, and the larger VA. In recent years, our 
recommendations have been largely ignored by Congress. Our 
recommendations are not ``pie-in-the-sky'' wish lists based on nothing. 
They reflect a thorough analysis of health care utilization in the VA 
and full and sufficient budget recommendations to address current and 
future utilization. Moreover, our recommendations are not clouded by 
the politics of fiscal policy. Despite the recommendations of The 
Independent Budget for FY 2015 (released in February of this year), the 
House just recently approved an appropriations bill for VA that we 
believe is nearly $2.0 billion short for VA health care in FY 2015 and 
approximately $500 million short for FY 2016.
    While we understand that significant pressure continues to be 
placed on Federal agencies to hold down spending and Congress has moved 
more toward fiscal restraint in recent years, the health care of 
veterans outweighs those priorities. If Congress refuses to acknowledge 
that it has not provided sufficient resources for the VA, and that many 
of these access problems that are being reported around the country are 
a result of those decisions, then we will. Until Congress and the 
Administration make a serious commitment to providing sufficient 
resources so that adequate staffing and capacity can be established in 
the VA health care system, access will continue to be a problem.
    And unfortunately for those clamoring for it, contract health care 
is not the answer to this problem. Studies have shown that contract 
health care providers cannot provide the same quality of care as the VA 
at any less cost, despite claims by some that it can. Similarly, 
contract care simply is not a viable option for veterans with the most 
complex and specialized health care needs. A veteran with a cervical 
spine injury whose autonomic dysreflexia was mistakenly treated as a 
stroke is not better served at a local outpatient clinic or the local 
doctor's office closer to his or her home. Sending those individuals 
outside of the VA actually places their health at significant risk 
while abrogating VA of the responsibility to ensure timely delivery of 
high quality health care for our Nation's veterans.
    Mr. Chairman and Members of the Committee, we appreciate your 
commitment to ensuring that veterans receive the best health care 
available. We also appreciate the fact that this Committee has 
functioned in a generally bipartisan manner over the years. 
Unfortunately, even veterans issues are now held hostage to political 
gridlock and partisan wrangling. It is time for this to stop! Political 
interests do not come before the needs of the men and women who have 
served and sacrificed for this country. We call on this Committee, 
Congress as a whole, and the Administration to redouble your efforts to 
ensure that veterans get the absolute best health care provided when 
they need it, not when it is convenient. PVA's members and all veterans 
will not stand for anything less.

    This concludes my statement. I would be happy to answer any 
questions that you may have.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                     Paralyzed Veterans of America
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you very much, Mr. Blake.
    D. Wayne Robinson is the President and CEO of Student 
Veterans of America. Mr. Robinson.

 STATEMENT OF D. WAYNE ROBINSON, PRESIDENT AND CHIEF EXECUTIVE 
              OFFICER, STUDENT VETERANS OF AMERICA

    Mr. Robinson. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, thank you for inviting Student 
Veterans of America to submit our testimony on the state of VA 
health care. As the premier advocate for student veterans in 
higher education, it is our privilege to share our on-the-
ground perspective with you today.
    I would like to begin by addressing the family members of 
the veterans for whom we are gathered today. We at Student 
Veterans of America honor the service of your loved ones and 
stand with you in seeking answers related to their deaths.
    Student Veterans of America, or SVA, is a network of over 
1,000 chapters on as many campuses across all 50 States and 
three countries. These chapters are comprised of veterans from 
multiple eras of service, with the majority having served after 
9/11. Paramount to their success is the ability to remain 
healthy and utilize the health care system provided by the 
Department of Veterans Affairs.
    In this testimony, we speak on student-level issues of 
health and well-being, with our main focus being on higher 
education. As the G.I. Bill makes up a major portion of the 
benefits administered by VA, we believe it is essential to 
consider education and the role it plays in the life of 
veterans who may simultaneously be receiving health care.
    As a former Command Sergeant Major in the Army, with 
service spanning nearly three decades, and as the current 
leader of a large disparate organization, I understand how 
difficult it is to be responsible for many locations and 
workforces. I also understand the position of older and younger 
veterans, as I have served alongside, have led, and have been 
taught by both. Many of these friends and former leaders of 
mine ensure that I remain abreast of the issues they face while 
accessing care.
    Our student veterans are as diverse as our Nation and are 
progressing toward degrees at varying stages of their lives. 
Likewise, our members have millions of experiences with VA and 
other large institutions integral to their success on a daily 
basis. They rely on VA every day for their livelihood, their 
health care, and the future success of themselves and their 
families.
    This support system for student veterans may be understood 
by looking at three levels of support which we term the three 
pillars. We encourage this Committee to focus on the following 
three pillars of student veteran well-being individually as 
well as collectively.
    Pillar one, institutions. Institutional support for student 
veterans is an important aspect of maintaining a strong 
pipeline of successful veteran graduates.
    Pillar two, individuals. Establishing an environment for 
the student veteran to fluidly interact with the institution 
and the community is a determining factor of well-being.
    Pillar three, communities. An established network across 
various university offices, academic networks, and career 
services enables the student veteran to make the transition 
from the campus to a fulfilling career.
    It is the firm belief of SVA that VA has successfully 
overhauled the education benefits process and that the same 
level of production should result within all levels of the 
Department. Over the last 5 years, Secretary Shinseki has led 
the VA as it brought G.I. Bill processing times down to just 1 
week and tripled the number of Vet Success on Campus sites 
across the country. In that same time, VA has paid out more 
than $40 billion in tuition and benefits to nearly 1.2 million 
veterans, servicemembers, and their families since the Post-9/
11 G.I. Bill went into effect on August 1, 2009.
    We recognize that VA has a long way to go on some of its 
programs. It is our sincere hope that the Secretary is able to 
achieve the kind of outcomes across the Department that he has 
accomplished for student veterans with the implementation of 
its benefits programs.
    SVA believes that Secretary Shinseki is dedicated to 
America's veterans more than ever. It has been under his 
leadership that VA has seen substantial improvements over the 
years. While the recent allegations are disturbing, indeed, we 
would encourage the Secretary to take swift and decisive action 
when the full facts become clear. This action would demonstrate 
his continued commitment to student veterans who utilize the VA 
Health Care System and to veterans everywhere.
    We thank the Chairman, the Ranking Member, and the 
Committee Members for your time, attention, and devotion to 
this cause. As always, we welcome your feedback and your 
questions.
    [The prepared statement of Mr. Robinson follows:]
 Prepared Statement of Mr. D. Wayne Robinson, President & CEO, Student 
                          Veterans of America
    Chairman Sanders, Ranking Member Burr and Members of the Committee: 
Thank you for inviting Student Veterans of America (SVA) to submit our 
testimony on ``The State of VA Health Care.'' As the premier advocate 
for student veterans in higher education, it is our privilege to share 
our on-the-ground perspective with you today.
    I'd like to begin by addressing the family members of the veterans 
for whom we are gathered today. We at Student Veterans of America honor 
the service of your loved ones and stand with you in seeking answers 
related to their deaths.
    SVA is a network of over 1,000 chapters on as many campuses across 
all fifty states and three countries. These chapters are comprised of 
veterans from multiple eras of service, with the majority having served 
after 9/11. Our recently released Million Records Project showed that 
these student veterans are succeeding in higher education. Paramount to 
that success is the ability to remain healthy and utilize the 
healthcare system provided by the Department of Veterans Affairs. While 
our constituents may be younger, they also face very similar issues as 
the brave men and women who have come before.
                              our approach
    As a former Command Sergeant Major in the Army with service 
spanning nearly three decades, and as the current leader of a large 
disparate organization, I understand how difficult it is to be 
responsible for many locations and workforces. I also understand the 
position of older and younger veterans, as I have served alongside, 
have led, and have been taught by both. Many of these friends and 
former leaders of mine ensure that I remain abreast of the issues they 
face while accessing care. Also in my travels, I speak to our chapter 
members who are seeking to raise their kids, attend classes, and deal 
with the effects of serving in a protracted war on two fronts. I am 
very familiar with the difficulties of developing strategy and tactics 
simultaneously, especially in a resource constrained environment. It is 
with this purview that I approach the current VA issues concerning 
healthcare and those deserving of it.
    In this testimony, we touch on student-level issues of health and 
well-being with our main focus being on higher education, for that is 
our area of expertise. As the GI Bill makes up a major portion of the 
benefits administered by the VA, we believe it is essential to consider 
education and the role it plays in the life of veterans who may 
simultaneously be receiving healthcare.
    Student veterans are as diverse as our Nation, progressing toward 
degrees at varying stages of their lives. Likewise, our members have 
millions of experiences with the VA and other large institutions 
integral to their success on a daily basis. They rely on the VA every 
day for their livelihood, their healthcare, and the future success of 
themselves and their families. This support system for student veterans 
may be understood by looking at three levels of support, which we term 
the ``three pillars.''
            the three pillars of student veteran well-being
    We encourage this Committee to focus on the following Three Pillars 
of Student Veteran Well-Being individually as well as collectively:

     Pillar 1--Institutions: Institutional support for student 
veterans is an important aspect of maintaining a strong pipeline of 
successful veteran graduates. The ability of the VA to connect with and 
administer care at the university level--for both mental and physical 
health--is critical. The lack of coordination and communication at this 
level continues to be a major concern.
     Pillar 2--Individuals: Establishing an environment for the 
student veteran to fluidly interact with the institution and the 
community is a determining factor in whether or not they will achieve 
their goals, as those who do not feel welcome may not persist in their 
studies. Empowering on-campus health systems to meet the needs of 
student veterans can supplement VA services.
     Pillar 3--Communities: An established network across 
various university offices, academic networks, and career services 
enables the student veteran to make the transition from the campus to a 
fulfilling career. Another area of improvement would be to connect 
student veterans with the various veteran-related points of contact, 
such as the VA certifying official, the counseling center, and 
potentially the VetSuccess advisor. The VA could facilitate these 
connections by making it easier to contact these individuals through a 
transparent directory available to both university staff and student 
veterans.
                         successes in education
    It is the firm belief of SVA that the VA has successfully 
overhauled the education benefits process, and that this same level of 
production should be sought within all components of the Department. 
Over the last five years, Sec. Shinseki led the VA as it brought GI 
Bill processing times down to just one week, and tripled the number of 
VetSuccess On Campus (VSOC) sites across the country. In that same 
time, the VA has paid out more than $40 billion in tuition and benefits 
to nearly 1.2 million veterans, servicemembers, and their families, 
since the Post-9/11 GI Bill went into effect on August 1, 2009.
    With programs like VSOC, and support from postsecondary 
institutions signing onto the Principles of Excellence, veterans are 
operating in environments where they are prone to excel. The VA's VSOC 
is intended to, ``help Veterans, Servicemembers, and their qualified 
dependents succeed and thrive through a coordinated delivery of on-
campus benefits assistance and counseling, leading to completion of 
their education and preparing them to enter the labor market in viable 
careers.'' We see the VSOC program as a means to further enrich student 
veteran support across a variety of benefits to include healthcare.
    The targeted expansion of this program to a current total of 94 
schools continues to show positive outcomes, and we have heard 
overwhelmingly positive feedback from our members at the campuses where 
it is in place. We should note that we feel the program is difficult to 
bring to a university if they have a need or interest due to the 
selective criteria of having large veteran populations of 800+ and a 
25-mile proximity to VA medical centers. As such, some schools in rural 
areas or with smaller yet just as deserving veteran populations may 
never be eligible for these services at the present requirements.
                   what is best for student veterans?
    With the right tools and resources, SVA sees no limit to the 
potential of student veterans in higher education and beyond. When 
empowered and in the right environment, we know veterans lead 
productive and healthy lives. For student veterans, acting as leaders 
amongst our peers, balancing multiple competing priorities, and 
succeeding with limited resources are all natural challenges; indeed 
they are the very circumstances for which the Department of Defense has 
so effectively trained them. It is up to our schools, the VA, and the 
Nation to ensure that those veterans are met half-way with the proper 
care and benefits that they have earned.
    We recognize that the VA has a long way to go on some of its 
programs. It is our sincere hope that the Secretary is able to achieve 
the kind of outcomes across the Department that he has accomplished for 
student veterans with the implementation of its benefits programs. We 
urge the VA to nominate a candidate for the soon-to-be-vacant Under 
Secretary of Health position to replace the retiring Dr. Petzel as soon 
as possible for Senate consideration, so that new leadership can come 
to VHA to address this issue head on.
    SVA believes that Sec. Shinseki is dedicated to America's veterans 
more than ever; it has been under his leadership that the VA has seen 
substantial improvements over the years. While the recent allegations 
are disturbing indeed, we would encourage the Secretary to take swift 
and decisive action when the full facts become clear. This action will 
demonstrate his commitment to student veterans who utilize the VA 
healthcare system, and to veterans everywhere.

    We thank the Chairman, Ranking Member, and the Committee members 
for your time, attention, and devotion to the cause of veterans in 
higher education. As always, we welcome your feedback and questions, 
and we look forward to continuing to work with this Committee, and the 
Congress to ensure the success of all generations of veterans through 
education.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                      Student Veterans of America
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you very much, Mr. Robinson.
    Ryan Gallucci is the Deputy Director of the National 
Legislative Service for VFW. Mr. Gallucci.

     STATEMENT OF RYAN GALLUCCI, DEPUTY DIRECTOR, NATIONAL 
  LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
                             STATES

    Mr. Gallucci. Thank you, Mr. Chairman, Ranking Member Burr, 
and Members of the Committee. I wish I did not have to be here 
today, but on behalf of the 1.2 million members of the Veterans 
of Foreign Wars, I want to thank you for the opportunity to 
share the VFW's concerns on VA health care delivery.
    Simply put, VFW members are outraged and I am personally 
outraged that the health care system that I use may be doing 
harm to my fellow veterans. What is more frustrating is that 
nearly a month after some of these allegations came out, we 
still do not have the facts. We do not know who the veterans 
are who may have died waiting for care in Phoenix. We do not 
know where hospitals are cooking the books in appointment 
scheduling to keep up appearances while veterans wait for care 
or pay for it out of pocket.
    Regardless of what comes out in Phoenix, Wyoming, Atlanta, 
Chicago, Spokane, or elsewhere, the VFW knows that veterans 
have died waiting. This is inexcusable. VA is supposed to have 
protocols in place to make sure this never happens. So, what 
happened?
    The VA tells us the situation is improving, but to the 
veterans affected, this is not good enough. Over the last 
month, we see VA may not be living up to its obligation to 
provide our veterans with the best care our Nation has to 
offer. Veterans deserve the truth, not vague platitudes about 
quotas, wait times, and pending investigations. The VFW has 
been frustrated at the situation, but we have been reticent to 
condemn individuals without all the facts.
    We are here today to say that enough is enough. 
Whistleblowers first brought problems in Phoenix to the 
attention of VA and Congress as early as 2010. CNN broke the 
doors off this story a couple of weeks back. Why are we still 
waiting? Last week, the VFW grew tired of waiting and told 
veterans to call our help line, 1-800-VFW-1899, to voice their 
concerns and connect with some of our service officers to help. 
While some said they were satisfied, most painted a picture of 
a VA Health Care System that is overburdened, under-resourced, 
and many times paranoid.
    In Durham, NC, an Iraq veteran told me that he can see his 
primary care doctor only once a year and that he has sought 
care elsewhere, out of pocket, after 10 years of misdiagnoses.
    What we heard over the last week is only a small sample of 
the hundreds of concerns we heard from veterans from coast to 
coast, but the outpouring of concern was alarming and seemingly 
systemic. So, what is causing this failure? Is it a lack of 
resources, personnel? Is it leadership?
    The VFW also plans to conduct a series of veterans' town 
hall meetings, talking to veterans face to face. Once we have 
finalized locations and dates, we will invite this Committee to 
attend and hear directly from our veterans.
    As a veteran who uses VA care, I worry that the recent 
allegations are causing veterans and their families to lose 
confidence in the system that is designed to support them and 
care for their needs. If one veteran is not receiving the care 
he or she needs, it is one too many. VFW members demand answers 
and we want those responsible for any wrongdoing held 
accountable at all levels of leadership and to the fullest 
extent of the law. With this in mind, the VFW believes it may 
be time to commission an independent review of VA care.
    We hope that VA would never intentionally deny care to 
veterans, but there have to be reasons why care takes so long 
to be delivered. The VFW worries that the current culture may 
be focused on making funding fit at every level, as my 
colleagues from Paralyzed Veterans of America outlined. If this 
is the case, the culture must change. Leadership at every level 
must have the confidence that if they have a need, they can ask 
for it to be addressed.
    We know capacity is an issue. The VFW and our other 
partners on the Independent Budget have for years highlighted 
the need to increase VA capacity. In 2004, utilization was at 
80 percent. In 2010, 122 percent. And, in 2013, down to 119 
percent, which is still unacceptably high. This undoubtedly 
affects VA's ability to deliver care. Plus, when there is a 
lack of resources, there is a tendency to make tradeoffs, 
whether through delaying care or gaming the schedule to satisfy 
quotas.
    The VA health care system was commissioned to care for 
those who served and bled for our Nation. Men and women who are 
chosen as stewards of this system have been entrusted with a 
mission that cannot fail. If the system is failing, it is their 
duty to fix it. It is their duty to hold underperforming 
employees accountable. Most important, if they are unwilling to 
perform the mission, it is their duty to either ask for help or 
step aside.
    However, in addressing any failures, we must resist any 
suggestion that VHA is a fundamental failure and it should be 
dismantled in favor of an alternative model. This only relieves 
VA of its responsibility.
    Last year, the President met with then-VFW Commander-in-
Chief, John Hamilton, and promised that he would not leave VA's 
problems to his successor. Last week, VFW Commander-in-Chief, 
Bill Thien, sent a letter to the President reiterating these 
concerns. We learned last night that the President shares the 
concerns of the VFW.
    Today, we ask not only for the President to live up to his 
word, but we implore Congress to do the same. We cannot sit on 
our hands and wait for the system to slowly improve. The 
situation that is unfolding across the country demands 
immediate, decisive action. The mission of VA health care is 
far too important, and as veterans' advocates and users of the 
system, we will not allow it to fail.
    Mr. Chairman, this concludes my testimony and I am happy to 
answer any questions you or the Committee may have.
    [The prepared statement of Mr. Gallucci follows:]
   Prepared Statement of Ryan M. Gallucci, Deputy Director, National 
    Veterans Service, Veterans of Foreign Wars of the United States
    Chairman Sanders, Ranking Member Burr and Members of the Committee: 
I wish I did not have to be here today, but I want to thank you for the 
opportunity to share the Veterans of Foreign Wars' concerns on the 
Department of Veterans Affairs' (VA) health care delivery.
    Simply put, the VFW is outraged over the allegations that have 
surfaced in recent weeks that VA denies care to veterans. What is more 
frustrating is that nearly a month after these allegations surfaced, we 
still do not have all the facts. We do not know who the veterans are 
who died waiting for care in Phoenix. We do not know if other hospitals 
are cooking the books in appointment scheduling to keep up appearances, 
while veterans either wait for care, or pay for it out of their own 
pockets.
    Regardless of the forensic facts in Phoenix, Wyoming, Atlanta, 
Chicago, or Jackson, Mississippi, the VFW knows that veterans have died 
waiting for care. This in and of itself is inexcusable. VA is supposed 
to have protocols in place to make sure this never happens. So, what 
happened?
    VA tells us the situation is improving, but to the veterans' 
community, this is not good enough. VA's obligation is to provide our 
veterans with the best health care our Nation has to offer. Over the 
last month, we can clearly see that VA is not living up to this 
obligation.
    Veterans want and deserve the truth, but instead we are fed vague 
platitudes about quotas, wait times, waiting lists, and ongoing 
investigations. The VFW has been vocally frustrated at the situation, 
but we have been reticent to condemn individuals because of these 
``ongoing investigations.'' We are here today to say that enough is 
enough. Whistleblowers first brought the problems in Phoenix to the 
attention of VA and Congress as early as 2010. CNN broke the doors off 
this story in April. Why are we still waiting?
    Last week, the VFW grew tired of waiting and told veterans to call 
our help line, 1-800-VFW-1899, to voice their concerns about VA health 
care, and connect with our service officers for help. While some said 
they were satisfied, or acknowledged improvements, most veterans 
painted a picture of a VA health care system that is overburdened, 
under-resourced, and many times paranoid:

     In Durham, North Carolina, an Iraq veteran told us that he 
can see his primary care doctor only once a year, and that he has 
sought care elsewhere after 10 years of misdiagnoses.
     In Denver, a veteran told us that when he moved to the 
city in 2011, it took a year and a half to book an appointment, and now 
he cannot get in for treatment of his service-connected conditions.
     In Florida, a veteran who was diagnosed with prostate 
cancer told us that he had to wait five months to see his primary care 
doctor.
     In Nevada, a veteran who was diagnosed with skin cancer 
tells us he is waiting eight months for an appointment after the 
hospital's dermatologist quit.
     And finally, in Phoenix, a veteran told us that he has 
been waiting three years for a surgical consult, and was told that if 
his condition gives him problems, he should just come to the emergency 
room.

    If one veteran is not receiving the care he or she needs, it is one 
too many. This is only a small sample of the hundreds of concerns we 
heard from veterans at VA facilities from coast to coast, but the 
outpouring of concerns was alarming, and seemingly systemic. So, what 
is causing this failure? Is it a lack of resources? Is it personnel? Is 
it leadership?
    As a result, the VFW will also conduct a series of veterans' Town 
Hall meetings, talking to veterans face-to-face, allowing them to voice 
their concerns. Once we have finalized locations and dates, we invite 
this Committee to attend and observe, hearing directly from the 
veterans about VA care delivery.
    Although we are still waiting for the full reports to be issued on 
the latest allegations, recent preventable deaths at other VA 
facilities have already been confirmed. In South Carolina and Georgia, 
we learned that 23 veterans died due to recent consultation errors. 
Last year, VA's Inspector General released a report detailing the 
improper handling of an outbreak of Legionella at the Pittsburgh 
Veterans Affairs Medical Center (VAMC) which took the lives of at least 
five veterans. Another report revealed the mismanagement of inpatient 
mental health care at the Atlanta VAMC, costing at least four veterans 
their lives. The Jackson, Mississippi VAMC has been plagued by multiple 
problems which endangered veterans' safety and lead to preventable 
deaths, including chronic understaffing, failure to sterilize 
instruments, and thousands of unread radiology images leading to missed 
diagnoses. Most recently, the VFW learned that as many as 19 veterans 
died nationwide in 2010 and 2011 due to unacceptably long wait times 
for routine cancer screening procedures.
    In the past three weeks, whistleblowers in Phoenix, Colorado, 
Wyoming, Texas and North Carolina have alleged that these locations 
have ``gamed'' their patient appointment schedules to make it appear 
these facilities are achieving their appointment wait times. VA's 
assertion that wait times for primary care appointments in Phoenix have 
decreased from more than a year to 55 days on average is unacceptable. 
Mental health access also continues to be an issue. VA has hired more 
than 1,000 mental health care providers, but they still are not sure 
how many providers they need to fulfill the current demand.
    The lack of timely care for veterans is unacceptable. The VFW 
certainly hopes that VA would never intentionally deny care to 
veterans, but there have to be reasons why care takes so long to be 
delivered. We know capacity is an issue. The VFW, in partnership with 
the Independent Budget, has highlighted for years the need to increase 
VA medical facility capacity. Even VA's own 10-year Strategic Capital 
Investment Plan (SCIP) identifies capacity as an issue. In 2004, VA's 
medical center capacity was 80 percent. It peaked at 122 percent 
capacity in 2010, and in 2013 capacity remained unacceptably high at 
119 percent. Since FY 2010, appropriations for major construction 
projects have decreased from $1.2 billion annually to an FY 2014 
appropriation of less than $350 million for the same account. Access to 
care can be directly linked to capacity. VA's major lease authority is 
also placing a burden on capacity, which directly effects access. Since 
FY 2012, Congress has not authorized VA major medical lease authority. 
That is 27 facilities in 18 states, most of which should be providing 
direct care to veterans.
    These allegations are causing veterans and their family members to 
lose faith and confidence in a system that is supposed to care for 
them. VFW members and their families are outraged. They want answers, 
and they want those responsible for any substantiated allegations held 
accountable from the lowest to the highest level of leadership. With 
this in mind, it may be time to commission an independent review of 
VA's health care system. We must all work together to ensure that the 
culture across VA is one of placing veterans' needs first, and when 
veterans' care suffers because of one of these reasons, those 
responsible must be held accountable to the fullest extent of the law.
    To provide timely access to care, VA must use all available tools, 
including purchasing non-VA care when necessary. Ideally, VA would have 
the capacity to provide timely, quality direct care to all those who 
need it, but it has become apparent to the VFW that they do not. 
Although we support expanding VA infrastructure and hiring enough 
health care professionals to meet demand at VA facilities, we recognize 
that this will not happen overnight. In the meantime, it is absolutely 
unacceptable for veterans to suffer. Non-VA care must be used as a 
bridge between full access to direct care and where we are now.
    If it appears that certain facilities are not making proper outside 
referrals due to improper training, lack of standards, or institutional 
resistance, VA must move swiftly to correct those problems. If VA's new 
fee basis care model, PC3, is not being used to its full potential due 
to insufficient funding at the local level, we will call on VA and 
Congress to give them the resources they need.
    When there is a lack of resources, there is a tendency to make 
tradeoffs, whether it is delaying care or manipulating scheduling 
systems to satisfy quotas.
    It appears that the culture of leadership, management and 
accountability is focused on making the funding fit at every level. If 
this is the case, this culture must change. Leadership at every level 
must have the confidence that if they have a need, they can ask for 
that need to be addressed. VA, the Administration and Congress must 
resolve to make the true need the priority, not the need to make budget 
lines fit.
    There is no question that the Veterans Health Administration (VHA) 
faces significant challenges in efficiently and effectively running the 
largest health care system in the United States. Successfully executing 
its four major missions of providing care to veterans, conducting 
medical and prosthetic research, training this Nation's physicians, and 
providing medical support to the public during domestic emergencies is 
a massive undertaking. When failures are identified, it must be the 
responsibility of VA, Congress, veterans service organizations, and all 
of America to swiftly correct those problems with better oversight, 
sufficient funding, and accountability of those responsible.
    In doing so, however, we must resist any suggestion that VHA is a 
fundamental failure which should be dismantled in favor of an 
alternative model. Such suggestions not only serve to relieve VA of its 
responsibilities, but fail to take into account the contributions that 
VHA makes to veterans, their families, and the medical community as a 
whole.
    The VA health care system was commissioned to care for those who 
served and bled for our Nation. The men and women who are chosen as 
stewards of the VA health care system have been entrusted with a 
mission that cannot fail under any circumstances. If the system is 
failing, it is their duty to fix it. It is their duty to hold 
underperforming employees accountable. Most importantly, if they are 
unwilling to perform this mission, it is their duty to either ask for 
help or step aside.
    Last year, when the President met with then-VFW Commander-in-Chief 
John Hamilton at the White House, he promised that he would not leave 
the problems within VA for his successor to deal with. Today we ask not 
only the President to live up to his word, but we implore Congress to 
do the same.
    We absolutely cannot sit on our hands and wait for the system to 
slowly improve. Every day we hear of new allegations in another VA 
facility. The situation that is unfolding in VA facilities across the 
country demands immediate, decisive action. The mission of the VA 
health care system is far too important, and as a society that cares 
for the men and women who volunteer to defend our way of life, we 
cannot allow it to fail.

    Mr. Chairman, this concludes my testimony, and I am prepared to 
take any questions you or the Committee members may have.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
          Veterans of Foreign Wars of the United States (VFW)
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response from VFW: Senator, as you will recall, DAV was a strong 
proponent of VA's establishing an Office of Rural Health (ORH) in 
Public Law 109-461, and of Congress providing that office access to 
funds outside the regular allocation system used in VHA, so that ORH 
could sponsor rural health initiatives and innovations to account for 
health shortages in rural and highly rural areas. Over the past several 
years, using a special $250 million annual appropriation, the ORH has 
done a remarkable job in not only outreaching to rural veterans, but 
ensuring they can gain access to care in some communities and regions 
that are hundreds of miles from the nearest VA facilities. The ORH is 
also the co-managing office of Project ARCH, a pilot program authorized 
in Public Law 110-387, that provides veterans in four geographic areas 
access to managed care, but monitored closely by VA. While we have not 
seen VA's report to Congress on this pilot project, from all 
appearances and from our contacts with ORH and the Rural Veterans 
Advisory Committee, we believe this pilot has been very successful and 
well-received.
    We are grateful to Congress for providing this partitioned health 
care funding for rural health initiatives by ORH, but we note that all 
those funds are now obligated and committed to a series of distinct 
initiatives, and the amount of funds has not been adjusted by Congress 
since the first authorizing year. In order for ORH to continue 
expanding health care options and outreach to new rural veterans and 
rural areas, additional funding will be needed in that account.
    In terms of the general waiting problem now confronting VA that 
suddenly has been so much in the news, we know of no special 
initiatives VA may be conducting to assuage that situation in terms of 
outreach, and we defer to VA for that response to you. VA is required 
by law, however, to periodically and routinely report to Congress on 
outreach efforts.
    Our public statements on the current situation in VA are a matter 
of record. We demand that any VA official or personnel who orchestrated 
or participated in covering up or hiding waiting lists be held 
accountable. However, DAV has long held that VA's ability to meet its 
own standards and policies for waiting time could not be met given the 
funding levels requested for health care by Administrations during 
recent years, or those insufficient funding levels that were approved 
by Congress.
    Encouraged by Congress and the veterans service organization (VSO) 
community, strong outreach by VA in the 1990s to enroll more veterans 
in VA health care, combined with the onrush of patients enrolling after 
serving in Iraq and Afghanistan more recently, have caused demand for 
VA health care to exceed available resources. Additional outreach by VA 
in this environment would seem foolish without an infusion of 
significant new health resources and facilities to deal with the 
outcome of VA outreach. However, as a part of the military discharge 
process, VA and VSO counselors do brief veterans in transition about 
the nature, scope and variety of VA programs available to them, and do 
encourage new veterans to explore VA, for health, education, 
compensation and other benefits and services to which they are 
entitled. Given the continual rise in demand being seen in VA, we 
believe these efforts are effective.

    Chairman Sanders. Thank you, Mr. Gallucci.
    Rick Weidman is the Executive Director for Policy and 
Government Affairs of Vietnam Veterans of America. Mr. Weidman.

STATEMENT OF RICHARD WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND 
        GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

    Mr. Weidman. Thank you, Mr. Chairman and the panel for the 
opportunity to be here today.
    Let me just share one thing that has troubled us for a long 
time, and that is the lack of truthfulness on the part of some 
people in senior grades at VA, both in shading the truth in 
hearings on the Hill, but also in reporting up. And there is 
something else that baffles all of us from the VSOs. If I lie 
to our National President, John Rowan, I am toast. I am out of 
here. I am fired, as in, you are gone, pal. And, I would agree 
with that decision. You cannot run an organization, certainly 
not a medical organization, where people do not tell the truth 
to their superiors, because otherwise, if they do not have good 
information, they cannot manage properly.
    I will say that it is our firm contention that the majority 
of people who use VA get good-to-excellent care. The problem 
has to do with access and with poor quality assurance. It is 
very uneven.
    The plain fact is that there are not enough clinicians. It 
is very much analogous to Walter Reed MC, which I think many of 
you remember, in 2006. It is a question of too many clinical 
needs chasing too few clinicians, and what happens is 
distortion in the system and breakdown of the sequencing of 
care, and that was what was wrong with their care. That is what 
is wrong with the care at VA. There are not enough clinicians 
and it is the getting people to care exactly when they need it 
that is not happening.
    The question is, are there enough resources for the 
Veterans Health Administration? We have to say we do not know. 
What we have been saying for 5 years is, when the budgets 
started to go up--the largest increase in the health care 
budget for VA since the end of World War II--that too many 
middle-management positions were being created. Congress gave 
that huge increase to VA to hire more direct service 
providers--more doctors, more nurse practitioners, more 
clinicians and counselors, et cetera--but it ended up that, in 
some places, the resources are deployed all wrong.
    It may be that there has to be a supplemental, but we would 
urge that the review that goes on be a position-by-position and 
facility-by-facility review with everybody who is not directly 
involved in patient care. You have to justify that position and 
why and how it adds to the overall enterprise of delivering 
quality care to veterans in a timely manner in a place where 
they can access it.
    Part of that problem with resources is--we have said it 
ever since they started using it at VA--the Millman formula is 
a civilian formula. It does not take into account--that is what 
they use to estimate the amount of resources that they would 
need. We have exposures to things that, from my lips to God's 
ear, the civilian population of the United States will never be 
exposed to, and not just hostile fire, but chemicals, and on 
and on.
    What it means is that when--at VA hospitals, the average 
presentations or things wrong with an individual is five to 
seven per individual. The Millman formula was built on middle-
class PPOs and HMOs and they had one to three average 
presentations or things that were wrong with them. What that 
means is the burn rate of resources at VA is much higher. That 
is particularly true as us old guys from Vietnam age and become 
even more aged, plus our uncles from Korea and our fathers from 
World War II, but it is also true of the young people coming 
home today. The presentations per individual of OIF, OEF, and 
OND veterans is over a dozen for each individual who comes 
through.
    So, the point is, we need to reprogram some money. We need 
to have picked up the Management Accountability Act on this 
side of the Hill and pass that; then reprogram money and, 
frankly, go for a supplemental, if it turns out it is needed.
    In the meantime, we would urge everybody, every hospital--
something we have been urging is to screen everybody at the 
hospital for the five major killers. The Lung Cancer Alliance, 
VVA has worked with for the last couple of years. VA has yet to 
do one of these screenings on a mass basis, and do it for the 
five major killers: lung cancer, prostate cancer, colorectal 
cancer, bladder cancer, and for heart conditions. If you screen 
everybody, then it is not--you do not have the kind of 
situation that developed in Phoenix.
    I thank you very much, Mr. Chairman.
    [The prepared statement of Mr. Weidman follows:]
Prepared Statement of Vietnam Veterans of America Submitted by Richard 
Weidman, Executive Director for Policy and Government Affairs, Vietnam 
                          Veterans of America
    Mr. Chairman, Ranking Member Burr, and other distinguish members of 
the Senate Veterans' Affairs Committee, thank you for allowing us to 
appear here today. We appreciate you giving Vietnam Veterans of America 
(VVA) the opportunity to express our views in regard to the State of VA 
Health Care.
    As we did for the 112th Congress, VVA stressed again in our annual 
statements for the 113th Congress to the Committees on Veterans Affairs 
that we again wanted to make it clear: ``Funding is not the primary 
issue'' when it comes to timely adjudication of claims and of appeals 
at VA.
    Similarly, VVA stressed that Funding is not the primary issue when 
it comes to the delivery of timely, quality medical care to veterans at 
the Veterans Health Administration facilities.
    We are aware that some have called for Secretary Shinseki to step 
down in the wake of press reports of significant problems with timely 
access to medical care at many VA medical centers. Some of those so 
speaking out are our own members. With all due respect, the departure 
of Shinseki would not change nor ``fix'' anything, as these problems 
with timely access, proper use of tools to assist in the delivery of 
medical care, and being honest in portrayal of the status of wait times 
by VA clinics (both for primary care and for specialty care) did not 
begin with the tenure of Secretary Shinseki, but rather long before he 
left active duty in the Army.
    The crux of the problem is that VA does not have enough clinical 
care deliverers who actually see patients for care. The reasons for 
this are basically that the Veterans Health Administration (VHA) has 
spent the enormous increases from FY 2007 to date on hiring way too 
many ``middle'' people, often at salaries higher than the front line 
clinicians, who do not see veteran patients, and whose contribution to 
the overall enterprise is dubious at best.
    VVA has voiced this directly to the Undersecretary of Health and to 
the Deputy Undersecretary for Health and others in the VHA hierarchy 
for the last six years at least. We have also spoken directly to the 
VISN Directors en masse about this problem virtually every chance we 
have been given. VVA has also noted that having two management lines up 
and down the chain of command, one for policy and one for operations, 
is just too many people in management, VVA has phrased this in such a 
way that the while most of the world's medical and other enterprises 
are going toward fewer levels of management between the CEO/COO and the 
actual workers (in this case clinicians) ( or a wide fairly flat 
pyramid, the VHA was becoming a steeper pyramid, with way too many VISN 
staff and others in slots that can best be characterized as 
administrative overhead. Much of this has been done is such a way as to 
mask this fact, both internally and externally. Whether this is 
intended to be less than honest is for others to decide. We do believe 
that this is the fact, however.
    There have been some remarkable Americans who have tried to make 
dramatic changes to the VA, and all of them have tried to improve the 
corporate culture and effective service to veterans. All have succeed 
somewhat, and failed somewhat. From Max Cleland to Harry Walters to 
Jesse Brown to Tony Principi to Eric Shinseki they have all striven 
mightily to improve the quality of the VA services from adjudication of 
claims to improving access to health care, as well as improving the 
quality of health care.
    And the fact of the matter is that while there was always some 
great clinical work going on at VA medical facilities, the quality 
assurance was lacking. VA had always tried to be prescr4iptive as to 
what to do and how with its clinicians, and shifted in 1994 to say to 
local VA medical centers ``just take care of veterans in the best way 
you know how.'' And that worked to some degree, but what it did not 
account for was the need for specialized services that were relatively 
rare outside of VA, such as Spinal Cord Injuries, PTSD, and prosthetics 
of every sort, Blind Rehabilitation Centers, and the like. What this 
VISN run healthcare did not do also was given a true account of the 
need.
    All of the funding models that VHA have in place consistently 
underestimate the number of clinicians needed to optimally run this 
system. VVA has not altered our position that they are systematically 
underestimating needs of VAMC because VHA is using is still using a 
variation of the Millman formula, which is a civilian needs estimation 
tool designed for use by private Health Maintenance Organizations (HMO) 
and PPOs who have middle-class patients.
    That formula estimates needs for resources based on an average of 
one to three presentations (things wrong with you that need to be 
medically addressed). Among veterans it was averaging three to five 
presentations per individual before the recently fought wars. Even with 
after VHA made adjustments for additional mental health and some 
specialized services, the formula continues to underestimate the ``burn 
rate'' of resources for every veteran seeking care.
    Among IOF/OEF/OND/Global War on Terror veterans the presentations 
per individual are even higher than for earlier generations. Further, 
the needs of older veterans only increase as we get older. 
Additionally, the formula does not take into account the wounds, 
maladies, injuries, illnesses and adverse medical conditions that stem 
from military service, depending on what branch , what MOS, where, and 
when one served, all of which could and should be taken into account.
    By and large these are not taken into account because the 
clinicians have not been trained what to look for, never mind the 
interns and residents on which VA depends so heavily.
    There has been much talk about ``secret lists,'' but the basic 
information that should be known by all service providers is one of the 
best kept secrets in VHA. Efforts to put this into the VistA electronic 
health care record at VA could be accomplished without any major re-
programming, but VHA always has ostensible reasons and excuses about 
why they cannot do it, or not do it now.
    For a rundown of many of these conditions, please see: http://
www.va.gov/oaa/pocketcard/military-health-history-card-for-print.pdf 
and http://www.publichealth.va .gov/vethealthinitiative/
    For reforms to truly succeed there must be far better oversight of 
and by Managers who are paid very well (not counting bonuses) to 
administer a system that is all too obviously not functioning as it 
ought to.
    Management audits and assessments must be a component of annual 
performance reviews that are clear, specific, and success-oriented. 
There must also be focused and hard-hitting oversight by the Veterans' 
Affairs Committees in both the House and Senate, as well as in the 
Appropriations and Budget Committees. VVA has suggested joint hearings 
of the authorizers with the appropriators.
    Such hearings have taken place in this Congress yet we are still 
shy of our common objective of real accountability in the management of 
the Veterans Health Administration.
    With Advance Appropriations now law for VHA's medical accounts, 
there can be no excuses as to why a VA medical center fails to hire the 
nurses it needs as it enters a new fiscal year, or does not purchase 
the new MRI machine that its radiologists insist they must have, or 
give the go-ahead for several of the small yet pivotal construction 
projects that in the past would have been put off pending passage of 
the budget for the next fiscal year.
    VVA maintains that measures to ensure accountability must be 
essential elements in funding the VA. Key to achieving this is to 
significantly overhaul the system of bonuses for Senior Executive Staff 
to reward only those who have taken that extra measure, who have walked 
that extra mile, to ensure that what they are responsible for has been 
done well, on time and within budget; and for those who innovate and 
improve the systems and projects under their auspices. Bonuses should 
be withheld from those who just do their job--that is, after all, why 
they are handsomely paid. Those who perform poorly need to be removed 
or reassigned; and any manager or supervisor who gets caught lying to a 
veteran, to their supervisor, or to a Member of Congress should be 
dismissed. And bonuses should be given with a caveat attached: If you 
accept the bonus, you promise to stay with the VA for a given period of 
time, and not just take the money and run (retire) the very next year.
    VVA believes that it will take several things to get a grip on 
fixing the VHA.

    1. A thorough review of all positions that do not involve direct 
patient care, from the Central Office to the VISN offices, to each VAMC 
and other remote locations.
    2. Since all of the games with scheduling appointments basically 
stem from not enough clinical direct care providers, there needs to be 
a thorough re-assessment of the number needed in each discipline at 
each VAMC. The increase of the numbers of clinicians can flow from a 
re-allocation of funds from middle-middle positions to actual care 
delivery.
    3. A facility by facility review to ensure that unfilled cr4itical 
specialties are o0ffering enough money to at least be reasonably 
competitive with the private sector and other sources of clinician 
employment.
    4. Where needed ask for the money needed to adequately staff each 
service delivery point as appropriate.
    5. Speed up the efforts for a ``Grow Our Own'' clinical training 
program within VA up to scale within the next 24 months.
    6. Force VHA to start to legitimately reach out to the veterans' 
community at every level, to involve us as major stakeholders and 
beneficiaries. Among other things, this will result in better 
decisions, and will also hold those within the system honest, and 
grounded in what veterans seeking services actually see.
    7. A complete re-thinking of a scheduling program that obviously 
does not work as intended. Once again, if they do not involve veteran 
stakeholders, then this effort will prove fruitless.

    There are further enhancements that we believe would be helpful in 
making VHA into a ``veterans' health care system'' that delivers 
quality, timely care with systems in place to ensure quality for every 
veteran. There are many tens upon tens of thousands of veterans who get 
high quality health care every year at VA. However, we must make sure 
that there are enough clinicians to do the job at each location.
    As to the situation at hand, VVA restates our position that there 
are people who should leave VA immediately, but that does not include 
Secretary Shinseki. Just as we did not think that firing then-Secretary 
Principi when there were judge scandals at VHA, we do not think 
starting over with anew Secretary is necessary. VVA would remind all; 
however, tin the above cited instance, the Undersecretary for Health 
and others did depart.

    Thank you for this opportunity to share our position, I will be 
pleased to answer any questions.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                      Vietnam Veterans of America
    Question. When we talk about access to health care, it's not only 
about reducing waiting times for veterans seeking a medical 
appointment. It's also about reaching the population of veterans that 
may not be aware of the benefits or care to which they are entitled. 
What is the VHA doing to provide outreach to this population of 
veterans? Is it enough?
    Response.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you, Mr. Weidman, and thank you all 
very much for your excellent testimony.
    Let me start off with a fairly simple question. In general, 
we all are aware--and no one here disputes--that there are 
serious problems and serious allegations. But, some of you have 
said the quality of care that your members are receiving at VA 
is good to excellent. Do you agree with that? Is the quality of 
care your members receive adequate? Is it good care, or is it 
not? We all know there are exceptions out there, but let me 
hear that answer, briefly, if I could.
    Commander Dellinger.
    Mr. Dellinger. We would agree with your assessment, Mr. 
Chairman. The overall quality of care, after they get into the 
system and actually get into the hospitals and the clinics, is 
very good.
    Chairman Sanders. OK. Mr. Violante.
    Mr. Violante. Yes, Mr. Chairman. Our members believe the 
same thing. The quality of care they receive when they get in 
is excellent.
    Chairman Sanders. Mr. Tarantino.
    Mr. Tarantino. Mr. Chairman, we survey our members. We find 
that their experience with VA, while a bit negative, their 
actual individual care is incredibly positive.
    Chairman Sanders. Incredibly positive?
    Mr. Tarantino. But, that is also including the use of their 
G.I. Bill and----
    Chairman Sanders. Right.
    Mr. Tarantino [continuing]. Home loans and medical care, 
yes.
    Chairman Sanders. OK. Mr. Blake.
    Mr. Blake. My comments spoke for themself [sic], Senator.
    Chairman Sanders. Mr. Robinson.
    Mr. Robinson. Yes, I would agree with my colleagues, that 
once the system has been accessed, the quality is good.
    Chairman Sanders. Mr. Gallucci.
    Mr. Gallucci. I would agree that the issue lies within 
access. To expand on that a little, one of things that I wanted 
to point out is I said I use VA, and I do. I was there last 
week. But, what happens is sometimes the person you get on the 
other end of the phone may not understand policies, may not 
understand proper procedures. When I see my clinicians, they 
offer me top-notch care, and that is a lot of what we heard 
from our veterans who responded to our inquiry last week.
    Chairman Sanders. Mr. Weidman.
    Mr. Weidman. It is generally good to excellent. The problem 
has to do with case management and access to the system.
    Chairman Sanders. OK. Let me ask another question. We all 
recognize, that anybody who is lying within VA, anybody who is 
cooking the books in the VA, is absolutely unacceptable. We 
demand accountability. People lying should be fired. I do not 
think there is much debate. We do not have to go into that at 
great length.
    But, I want to ask, what seems to be a problem, not all 
over the country but in many parts and all of you basically 
referred to it, is access. What I am hearing you say is once 
people get into the system, the quality of care is pretty good. 
The problem is access. We have heard Mr. Blake talk about the 
Independent Budget, which is the budget done by a number of the 
veterans service organizations assessing what they believe the 
needs of the VA are. I support that budget.
    The bottom line is, and I will start with Commander 
Dellinger, do you believe VA needs more funding in order to 
deal with the access issue, make sure that people all over the 
country can get into the system in a timely manner?
    Commander.
    Mr. Dellinger. I do believe it is underfunded, but I also 
believe that there should be reallocation of funds within the 
system.
    Chairman Sanders. Good point, and others can speak to that, 
as well.
    Mr. Violante.
    Mr. Violante. Yes, Mr. Chairman. I think, clearly, the 
problem rests with a log of the management efficiencies that 
the administrations have tried to put into the budget. A recent 
GAO report in February 2012 indicated VA reduced their budget 
by $2.5 billion based on management efficiencies, which were 
not realized and which are impacting the resources. So, this 
has gone on in previous administrations----
    Chairman Sanders. Right.
    Mr. Violante [continuing]. And that needs to be stopped. 
That is like gaming the system.
    Chairman Sanders. Right.
    Mr. Tarantino.
    Mr. Tarantino. The VA is underfunded, but throwing money at 
the problem does not help unless you have clear lines of 
accountability and reform for the things that are not working.
    Chairman Sanders. Mr. Blake.
    Mr. Blake. I would agree with Mr. Tarantino. I mean, you 
cannot just throw money at the problem if it is not done 
smartly. Mr. Weidman pointed out that there were a lot of 
people hired and they were not necessarily hired where the need 
is. Our own written testimony points out serious staffing 
shortages in the entire SCI Service. So, clearly, people are 
not being hired there, where there is a demonstrated need. So, 
you could do reallocation of resources, but we believe, by 
extension, there is even more need for additional resources.
    Chairman Sanders. Mr. Robinson.
    Mr. Robinson. I will agree with my two colleagues to my 
right that, yes, VA is underfunded. However, I would say, 
first, there should be infrastructure and systemic reviews and 
issues addressed. After that, after we are intelligent on where 
the funds will be allocated, then they should be funded. Thank 
you.
    Chairman Sanders. Mr. Gallucci.
    Mr. Gallucci. I would agree with our Independent Budget 
partners that we support the IB's numbers and we believe that 
VA, in its current form, is underfunded.
    Chairman Sanders. You guys are part of the Independent 
Budget, are you not?
    Mr. Gallucci. Yes.
    Chairman Sanders. Yes. Right.
    Mr. Gallucci. And, I would echo the concerns of everyone at 
the table about resource utilization and proper distribution of 
resources. And in my written testimony spoke about VA's 
capacity: what this has to do with is construction and 
facilities, a little to what my colleague, Wayne, was talking 
about. If we do not have the space, where are these clinicians 
supposed to practice? We have seen that problem with mental 
health hiring. They are able to hire more mental health 
practitioners, but where are they going to see their patients?
    Chairman Sanders. Mr. Weidman.
    Mr. Weidman. Part of it is the allocation of resources, but 
in addition, I would associate particularly not the major 
construction, but remodeling and adding to existing facilities. 
You have got to have a place to actually deliver the care. But, 
we are underfunded and do not have enough clinicians. That is 
why they game the system, not because they are bad people. They 
are under pressure not to admit there are not enough doctors.
    Chairman Sanders. OK. I am going to take a little bit more 
time; and Sen. Isakson, I will give you an equal amount of 
time. I just wanted to ask one brief question, which is 
important.
    When you deal with a public system like VA, every problem, 
in a sense, sometimes makes the front pages. I mentioned 
earlier that there are studies out there, 200,000 or 300,000 
people are dying from medical errors in private hospitals. You 
usually do not have hearings like this with TV cameras talking 
about it. On the other hand, the advantage of a public system 
is that, as citizens of the country and as representatives of 
millions of veterans, which you guys do, you have input into 
the process.
    Let me ask you this question. I do not know what the answer 
is. My understanding is that the Secretary meets with 
representatives of organizations like ours fairly frequently, 
that he wants to hear your input. Is that true, Mr. Commander?
    Mr. Dellinger. Yes, it is, Mr. Chairman. We have a sit-down 
breakfast with him approximately once a month----
    Chairman Sanders. Once a month----
    Mr. Dellinger [continuing]. To discuss the issues.
    Chairman Sanders. OK. And, I assume everybody thinks that 
that is a sensible idea, yes?
    Mr. Dellinger. Yes. Input from the veterans' organizations, 
of course.
    Chairman Sanders. Right. And, Mr. Violante.
    Mr. Violante. Yes. Our Executive Director meets with both 
the Secretary and the Under Secretaries on a regular basis.
    Chairman Sanders. Mr. Tarantino.
    Mr. Tarantino. That is not true for IAVA. We had our first 
meeting with the Secretary at VA Headquarters last week, and 
that was the first time since he was----
    Chairman Sanders. OK. So, you have not been meeting on a 
regular basis?
    Mr. Tarantino. No.
    Chairman Sanders. OK. Mr. Blake?
    Mr. Blake. Our situation is the same as the DAV. Our 
Executive Director meets with him on a monthly basis.
    Chairman Sanders. Mr. Robinson.
    Mr. Robinson. Yes. We meet with the Secretary on a regular 
basis.
    Chairman Sanders. Mr. Gallucci.
    Mr. Weidman. We meet with the Secretary----
    Chairman Sanders. Mr. Gallucci first.
    Mr. Weidman. I am sorry.
    Mr. Gallucci. Thank you, Mr. Chairman. The VFW's executive 
leadership does meet with the Secretary on a regular basis, and 
our front-line leaders meet with his deputies on a regular 
basis, as well.
    Chairman Sanders. OK. Mr. Weidman.
    Mr. Weidman. VVA meets on a regular basis at the national 
level. Where it is not on that basis is programmatic things. 
The only place in VA that is sticking to the President's 
Executive Order on consultation of stakeholders before 
decisions are made is the Under Secretary for Benefits, because 
it does not happen in many other areas, and if it did, the 
decisions would be better.
    Chairman Sanders. Sen. Isakson, I have gone way over my 
time. You will have equal time.
    Senator Isakson. Thank you, Mr. Chairman. That is the 
prerogative of the Chair, too, I might add, so----
    [Laughter.]
    Chairman Sanders. But it is going to be the prerogative of 
the Acting Ranking Member. You will have that time.
    Senator Isakson. Following up on the tone of the 
discussion, it needs to--I am going to make a statement and I 
would like each one of you to tell me whether you agree with 
this statement or not. The question before us today is not the 
quality of health care delivered to veterans by VA. The 
question is access to the quality of care. Would you agree with 
that, Commander?
    Mr. Dellinger. Senator, we do agree with that, but there 
are also pockets within it, like a cancer, like a skin cancer. 
If you get the small pockets out, the overall system will live. 
But, eventually, if you do not take care of that, the system 
will die.
    Senator Isakson. OK.
    Mr. Violante.
    Mr. Violante. Yes, DAV certainly agrees with that. And I 
would like to point out a task that President Bush force back 
in 2003 established to look at health care, pointed out at that 
time that there was a mismatch of funding and demand, and if 
something was not done about that, access was going to be 
affected, which is what we are seeing now.
    Senator Isakson. That is going to be my next point, but go 
ahead, Mr. Tarantino.
    Mr. Tarantino. We would agree with that statement, Senator.
    Senator Isakson. Mr. Blake.
    Mr. Blake. Yes, sir, Senator. It is definitely access.
    Senator Isakson. Mr. Robinson.
    Mr. Robinson. Our concern certainly would be the access, 
especially in rural areas.
    Senator Isakson. Right.
    Mr. Gallucci.
    Mr. Gallucci. Senator Isakson, we would agree with that, 
but with access, that can leach into care delivery. One of the 
concerns that we received from a veteran in Nevada was that he 
was diagnosed with skin cancer, a proper diagnosis. But, 
because a dermatologist had left the VA medical center, they 
were not going to be able to schedule him for a proper 
consultation until that person was replaced.
    Senator Isakson. Which is somewhat an access problem in and 
of itself.
    Mr. Gallucci. It is an access problem, but that is where 
access leaches into the quality of care that can be delivered.
    Senator Isakson. Well, capacity is one of the problems for 
access.
    Mr. Gallucci. Exactly.
    Senator Isakson. Mr. Weidman.
    Mr. Weidman. It is primarily access, and an additional 
thing is that VA still is not systematically in the medical 
system addressing the wounds, maladies, and injuries of war and 
taking a military history and using it in the diagnosis and 
treatment modalities.
    Senator Isakson. The reason I am taking this track is I do 
not want us to leave this hearing with a mixed message. If 
there is any problem with VA quality of health care, we need to 
talk about that. But, if there is not, except for isolated 
cases, and the dermatology case is a good example, we need to 
talk about what the problem is, which is access to that health 
care, which is a capacity problem, number 1, but it also 
appears to be an attitudinal problem within the VA where there 
is more of a motivation to make the numbers look good than give 
access to the care to make the veteran well. Am I stating it 
fairly? Does anybody disagree with that statement?
    Mr. Blake. No, Senator, I think you are right. I mean, I 
think there have been concerns raised that maybe the 
performance accountability system promotes something like that, 
and so access is controlled in order to make performance look 
better.
    Senator Isakson. And, capacity is a function of 
appropriations, I understand that, but it is also a function of 
the management of the system internally within the VA. I do not 
ever recall--and I could be wrong, Mr. Chairman--us receiving a 
report from the Veterans Administration on any study it has 
done to improve its access to capacity, or improve its capacity 
so we improve access. What we always tend to talk about is the 
time it takes to get a determination for a disability, or how 
long it takes to get into a VA center, or some other isolated 
case like that, when it seems like we ought to have a very 
thorough examination of the capacity situation in terms of the 
VA.
    And then we have got to take a look at the issues that you 
addressed, Mr. Blake. I know you are not for any private 
delivery of service. You want the veterans' hospitals to 
operate. And I know, Commander, that is the same for you. But, 
the option of having that access could help solve the capacity 
problem, particularly on a selected specialty, like 
dermatology, like melanoma, like most surgery or something like 
that. So, is that an idea that--not replacing the VA Health 
Care System, but having veterans have options to access the 
private health care system. Would that work, Mr. Blake?
    Mr. Blake. Senator, I think veterans have options, even 
now----
    Senator Isakson. They do.
    Mr. Blake [continuing]. And I think they are improving on 
it. The PCCC is an example of how they are trying to improve 
upon that. We certainly believe that if they are going to move 
some in that direction, there needs to be coordinated care. My 
point was that that does not particularly work, though, for 
veterans with specialized care needs, like SCI or blinded care 
or amputation, because those types of services do not really 
exist----
    Senator Isakson. In the private sector.
    Mr. Blake [continuing]. In the private sector; at least not 
in the way that our members have come to expect it. But, we 
certainly could see where privatized care plays a role in it, 
or contracted for services with coordinated care plays a role.
    One thing I would suggest, though, is that as a solution 
suggests that that is what veterans want. But, I think some of 
the problem that we see right now validates that veterans want 
into VA. So, why would we create an option where they 
necessarily where they would go somewhere else? They want into 
VA. They cannot get into VA. So, we are not sure that allowing 
them to go outside is addressing what their immediate desire 
is.
    Senator Isakson. Except that wants and needs are two 
different things, and the need is the most important. If it 
gets them the service they need in a timely manner, even though 
it might not be in a VA hospital because of the particular 
problem, it is better than having them wait so long to have a 
life-threatening condition come about.
    Mr. Blake. I would agree with that point, Senator.
    Senator Isakson. All of your testimony was outstanding, by 
the way. I appreciate all of it very much. And, I am going to 
leave this hearing with a clear message for the veterans of 
Georgia. We need to solve the access and the scheduling problem 
and we need to do it now, and we need--VA needs to go 
internally--which Secretary Shinseki and I talked about this--
have an accountability mechanism all the way down, because I 
think the senior leadership is disserving the American veteran. 
I think we have known what the problems are for some period of 
time and I think we know what the needs are. I hope we will 
take this hearing and move forward to solve those problems, 
hold everybody appropriately accountable, and have an attitude 
toward solving problems rather than masking problems.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Begich, I think, is next.
    Senator Begich. Mr. Chairman, thank you.
    I am going to follow up on Senator Isakson's comments. You 
know, we had a similar problem. I first want to thank many of 
you because you had concerns about what I am about to talk 
about but you came--and, Carl, you are one of them, and you 
were really good in helping us figure this out--and that is, we 
have a huge Alaska Native veteran population, American Indian 
population, in Alaska: 150,000-plus. We have an Indian Health 
Service system which was not very good, to be frank, many, many 
years ago. Now, in Alaska, the tribes took it over and now 
deliver, we consider, the best health care in this country, in 
my opinion and I think many others' opinion. As a matter of 
fact, CMS has said it is some of the best health care in the 
country.
    So, because we do not have a veterans' hospital, and many 
of us had these conversations over the last few years, we were 
trying to figure out a system to create better care--access is 
really what it is about. If you live in Nome, AK, and you want 
to come into Anchorage to the clinic, you could spend $1,500, 
$2,000 from one of the outer villages going to Nome and then 
coming to--very expensive for our veterans. We have 800 
veterans living in Nome, AK, that are both native and non-
native. We built a brand new hospital there with stimulus 
money, which I am very proud of--a $170 million facility for 
Indian Health Services, which is actually run by our tribal 
consortium. Indian Health Services does not run health care in 
Alaska. It gives a check to the tribal consortium who then 
delivers health care for our tribes.
    Because of the work you all did with our office, we now 
have access for our veterans. Those 800 veterans have a choice 
now. They can go to Indian Health Care Services, get that 
health care anywhere near their home, their village. I can tell 
you story after story about how that system has now come to be 
very valuable. Or, they can go to the clinic or go to Seattle 
to the hospital, because it was an access issue. The care that 
VA offers, and I think you all said it, we have great 
professionals there. They work hard. I think they are 
overworked for the amount of time they have. They have not 
enough staffing, and we can go through all those lists.
    But, the moral is, we found a solution, protecting the 
importance of VA health care, which is veterans want to be part 
of the VA Health Care System. They want to be--that is their--
they earned it. They fought for it. It is a benefit of theirs.
    But, in Alaska, we had an access issue. We could not afford 
to have a veteran sitting out in rural Alaska waiting to catch 
the next plane when there is a hospital right next door. So, we 
figured this out. We have a model called Nuka, which, when you 
walk into the Indian Health Care Services, the odds of you 
getting a same-day appointment is probably 75 percent or 
better.
    And, when you come in--the question you brought up is the 
amount of ailments that someone comes in with is different than 
the model that VA has been designed for years ago. The Nuka 
Model, same situation and problem: too many ailments per one 
individual. So, now when you come in, you get a mental health 
provider, eye doctor, dentist, full health care. They meet with 
you as a team. So, they resolve the issues collectively rather 
than individually, and the care quality is superb.
    You know, we have been pushing on VA to look at the Nuka 
Model, because that is how we have got to deal with multiple 
ailments of an individual, and also same-day access. To be able 
to schedule a routine appointment and have to wait weeks or 
months is outrageous. And so maybe it is more of a statement, 
but I would be interested in--and again, I know many of you 
worked with us, and I point Carl out because he and I had some 
good debates on this, but I think it is working. I have 
veterans now who call me and say thank you; not that they are 
not going to always go to VA. They are going to go to VA. But 
now, in a situation where they are living in a village or a 
small community, they can go across the street and there it is. 
They have a choice.
    So, I guess I would like your--you have heard kind of my 
comments here. I would be interested in any comments folks 
have. And, again, the Nuka Model--N-u-k-a--is a very unique 
delivery system. It is all about access. Any comments from 
folks?
    Mr. Dellinger. Senator, Dan Dellinger. Thank you for that 
question, because it just so happens, I was in Alaska last 
month, and I was in Kenai, and----
    Senator Begich. A beautiful new hospital down there.
    Mr. Dellinger [continuing]. And they want to expand what 
they are doing in that area, and they are in a strip mall with 
the CBOC there----
    Senator Begich. That is right.
    Mr. Dellinger. But, they are also are looking for 
additional space. VA spent 3 years trying to get a lease worked 
up and they are frustrated. They want to do additional things. 
But, I agree with your assessment as far as accessibility, 
especially out West. The East Coast is something different----
    Senator Begich. I agree.
    Mr. Dellinger [continuing]. But, as I travel through the 
Western States, I see more----
    Senator Begich. Like ours.
    Mr. Dellinger [continuing]. Services--exactly. And, I think 
it is something we should build upon in----
    Senator Begich. Kenai has a brand new, it is a Kenaitze 
Tribe hospital, a beautiful hospital that will partner, 
actually, with that CBOC----
    Mr. Dellinger. Exactly.
    Senator Begich [continuing]. Which is unbelievable care. 
Thank you for that.
    Any other comments on that? And, I know my time is almost 
up here, so----
    Mr. Violante. The only thing I would like to say, Senator, 
is right now we have 27 points of access that are on hold 
because we cannot get the funding, and it is important that we 
move forward on that. I mean, going back to the Clinton 
administration, when they put a lot of construction on hold 
under CARES to determine where they wanted to build. I mean, VA 
has been underfunded in construction since the Clinton 
administration.
    Senator Begich. Good point.
    Mr. Violante. So, we need to do something about that, also.
    Senator Begich. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Begich.
    Senator Moran.
    Senator Moran. Mr. Chairman, thank you very much, and 
Secretary Shinseki, thank you for remaining for the testimony. 
I appreciate you being here.
    Let me raise a topic about the assessment that is now going 
on, the face-to-face review across our country. One of my 
Congressional colleagues had a conversation with VA personnel 
in Jackson, MI, after the assessment presumably took place, and 
this is a bit of a paraphrase of his or her report back from 
what they heard about this assessment.
    We asked about their face-to-face review. They stated that 
the team came in on Monday, interviewed some clerks and some 
supervisors, and they did not find any evidence of scheduling 
issues. No veterans were interviewed. What struck this person 
was the apparent superficiality of this so-called audit. A day, 
at most, visit that did not comb through the electronic system 
or actually audit any reports is not indicative of a thorough 
review.
    And so what I tried to raise in my opening statement is we 
are going to have one more review that is to be completed 
within 2 weeks. We have 1,700 facilities across the country. 
And so, in part, my concern is the quality of the review. It 
appears to me that this is more of damage control. It is what 
people do when there are allegations of mismanagement, improper 
conduct. You have another review planned. And so my concern is 
how credible will the review be based upon the amount of time 
and resources that is being devoted to it.
    But, perhaps more troubling to me is how many reports, 
allegations, IG, GAO, Congressional hearings do we have to have 
before there is a different approach or attitude at VA to solve 
the problem. And so, I guess I do not disagree with an audit 
across the country but what is this really going to accomplish? 
Will we be here 6 months from now in which VA has a plan in 
place to transform itself so that these access issues that you 
all described are not the same ones that we heard today, we 
heard last week, we heard last month, we heard last year?
    The Phoenix situation seems to have brought national 
attention to this problem, but I cannot imagine that there is 
anyone at the table who believes that the Phoenix situation is 
really what the--is the problem. It is a symptom of a much 
broader problem that has been ignored for a long time.
    So, Commander--and here, let me add this. I understand that 
the testimony of the Secretary this morning in response to the 
Senator from North Carolina in which the Senator, outlined a 
long list of audits and reviews, GAO reports, Inspector General 
audits, and the Secretary indicated that he was unaware of 
those audits and reports and, therefore, had not been used in 
any conclusions that I assume would be made at VA.
    There was an IG report that is included in that list that 
said the unexpected death report could be avoided if the VA 
focused on its core mission, to deliver quality health care. 
Because no two VA medical centers are alike, it is difficult to 
implement VHA directives when there are no standard position 
descriptions or organizational structures. The IG believes it 
is time to review the organizational structure and business 
rules of VHA.
    How can that be an IG report that a Secretary of Veterans 
Affairs would be unaware of? It is directly related to the 
management and organization of the Department of Veterans 
Affairs.
    So, my question, if there is one in my commentary, is what 
assurance can we have, or what assurance do you have, that when 
this face-to-face review is done, that something will be 
different in the direction that VA is taking in regard to 
creating higher quality care for veterans and making certain 
that they have access?
    Commander.
    Mr. Dellinger. Senator, that is quite a task. With the IG 
audit, yes. In the findings, once they come out, I think this 
Committee needs to establish, along with VA, milestones so as 
to rectify these issues as they go through. But, as you noted 
in your comments, each hospital is different, and even when a 
director changes, a hospital that was doing excellent then 
could possibly slip below the standard. So, it is going to be 
an ongoing challenge; and we would hope that the Secretary and 
VA would move forward as soon as possible with the changes 
necessary to give us the quality health care that all veterans 
deserve.
    Senator Moran. My time is soon to expire, and I do not know 
whether the Chairman is intending to allow you to answer my 
question, but I would add that you all--almost all--indicated 
that you have, or your senior staff have, ongoing conversations 
with the Secretary or high-level individuals at the Department 
of Veterans Affairs. But, the question that I would ask is, 
does that result in a change in approach, style, management, or 
attitude at VA that actually results in higher quality care for 
our veterans?
    Mr. Chairman, thank you for the opportunity to issue a 
statement and to ask the questions.
    Chairman Sanders. Thank you, Senator Moran.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman, and I want to 
thank this panel for their testimony, their perspective, and 
their vision.
    I also want to thank Secretary Shinseki for staying here 
for this part of the hearing and to express my apologies. I got 
tied up in the Banking Committee and votes on the floor, but we 
will follow up with you in private.
    It is good to be asking questions about fifth or sixth down 
the list because I think we have all agreed that access is the 
issue. And, we have had everything talked about from dollars, 
to allocation, to construction, to milestones, to manpower, to 
all sorts of stuff, which it all is good and it all is helpful.
    I am going to ask each one of you folks--because you 
represent veterans in this country that are being served by the 
VA, I think you have an understanding of what the challenges 
are out there, so, you are not Secretary of VA, you are not 
President of the United States, you are above all them. You 
tell me what you would do first to fix the VA and what you 
would do second. And, I assuming there would be three or four 
or five more down the line, but is it money? Is it the 
resources they have need to be allocated different? Is it we 
need to put a focus on hiring professionals? And you cannot 
say, do all of them, because we want to hold folks accountable. 
So, if you could give me your priorities for what we need to 
do, I think it could be helpful.
    Mr. Dellinger. Senator, assessment, I think, is the first 
thing that needs to happen, because as we have heard VA speak 
about they have enough money, but they do not have the accurate 
numbers. If they are gaming the system, how many actual visits 
are they going to have a year? Instead of having 85 million, is 
it going to be 150 million? So, you cannot assess a money value 
to that until you can make the assessment as to what exactly 
the problem is.
    Senator Tester. OK. And so, then, I assume that once you 
get the assessment, you follow that assessment as a blueprint 
to fixing VA.
    Does anybody else have anything they would like to add to 
that? Go ahead, Mr. Gallucci.
    Mr. Gallucci. Senator, thank you for asking that question. 
I actually have a list of four things----
    Senator Tester. Perfect.
    Mr. Gallucci [continuing]. That I would really want to talk 
about. First is resources, as the VFW and our Independent 
Budget partners have talked about. And, it may not be a numbers 
game. It may be allocation of resources.
    Second----
    Senator Tester. So, what are you telling us to do?
    Mr. Gallucci. We would recommend taking the IB's 
recommendations on how to properly fund VA and things like 
capital infrastructure and VHA's baseline budget.
    Senator Tester. Continue.
    Mr. Gallucci. Second would be training and outreach for 
your gatekeepers, the people who man the call centers at VA 
facilities.
    Senator Tester. OK.
    Mr. Gallucci [continuing]. On outreach to veterans so they 
know what to expect when they call VA.
    Senator Tester. OK.
    Mr. Gallucci. Consistency across the board, so that your 
experience at one VA center is very similar to your experience 
at another VA center.
    And, finally, one that I have been chomping at the bit to 
talk about is accountability. We have had a lot of talk about 
accountability. The Secretary said that 3,000 employees were 
sanctioned in some way, whether that was termination, 
retirement, transfer, or demotion, what have you.
    There is a problem--in having conversations over recent 
weeks about this internally with VFW, with some of our 
advocates and veterans, there are two things that we know. 
First of all, reprimanding or firing an employee in the Federal 
Government is a difficult process, a difficult legal process 
with significant EEO and other legal protections. It can take a 
long time to take punitive action against an employee.
    Second, when there is a vacancy in the Federal Government--
this is, again, not VA exclusive--it can take between 6 months 
and 1 year to fill it. So, if you have an underperforming 
employee----
    Senator Tester. Yes.
    Mr. Gallucci [continuing]. You have to then make--and I am 
really asking the question here--do you make the tradeoff 
decision. So, I have an underperforming employee. Is it better 
to keep them on the books at least serving some veterans or 
terminate them and have that vacuum of care for 6 months to a 
year, or possibly longer?
    Senator Tester. I appreciate that, and that might, Mr. 
Chairman, bring us around to another discussion about how we 
can work with the Department--and, by the way, this could apply 
to all agencies in government--to reduce the red tape for 
hiring, because it takes far too long to get that done.
    I want to just ask a little bit about the accountability 
portion, because accountability is really, from my perspective, 
really easy to talk about, but sometimes very difficult to put 
your finger on where the problem is, who is the problem, and, 
quite frankly, how you deal with it. Any ideas on--I mean, for 
example, the argument could be made that because we have hired 
all these middle-management folks--and I think you guys made a 
very good point on that; this is crazy, we should not be doing 
that. These should be on-the-ground folks. But, we have hired 
these middle-management folks to make sure the folks on the 
ground are actually doing the job. Now, how do you deal with 
accountability? Do you contract it out? Do oversight? What do 
you do? Or, does it strictly fall at the Secretary's feet and 
everybody else is held harmless? Go ahead, Mr. Weidman.
    Mr. Weidman. I think that the bill introduced by Mr. Miller 
on the House side is a good start--and people said, do you 
favor that bill--which strips SES people at VA of any 
protections whatsoever. But, there is a reasonable point in 
between Mr. Miller's bill as it currently is and what we have 
now, because they cannot fire SES people. They say they can, 
but they cannot. I mean, I remember the lady from Kansas City a 
few years ago. They removed her as a VISN Director----
    Senator Tester. Yes.
    Mr. Weidman [continuing]. But, every Monday morning, flew 
her to Washington, kept her here at government expense, and 
flew her back for 3 years, paying her $180,000. So, they need 
flexibility.
    Senator Tester. Thank you, and thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman, and to everybody 
who is here. This has been extremely helpful.
    I think we are going to find that the access issue, which 
you all consistently say is the problem, is going to be easier 
to identify than to solve. You know, I think about, let us say, 
a VA hospital needs five specialists. They are probably going 
to recruit from the area around and they are going to compete 
with private doctors' practices, they are going to compete with 
hospitals, and on and on, and that is true whether it is the 
doctor or the nurse or the medical technician, whatever it is. 
So, building that capacity, even with lots of money, would be a 
challenge, and I think we all agree to that.
    So, let me ask you a question, because I also agree--we are 
waiting for a hospital in Omaha. I am beginning to wonder if it 
will happen during my lifetime, and I am a fairly young man. I 
am, you know, not too old. And even if we could get all the 
money all at once, which would be very hard to accomplish, how 
much construction can you get up and going, and on and on.
    So, let me ask you a question about access. Let us say that 
we are thinking about this and we have got all this population 
that is needing more access, not less--us Vietnam-era people. 
It is a whole group of people, and we are aging. We are the 
Baby Boomers and we need more access, not less.
    Would your members be open to an idea that said something 
like this: They call, they say, I need to see a health care 
professional because I have got a spot on my leg that does not 
look right. I think it might be cancer. And they say, well, we 
want to see you just as quick as we can, but that will be 4 
months, or 6 months, or whatever. Would your members be open to 
an idea that says, look, if you cannot get in within 2 weeks, 
or 3 weeks, or whatever the appropriate timeline is, you can 
seek private care. You can go to your local doctor or a 
specialist or whatever. The government will pay the cost of 
that and we will cover that, because we do not want you to wait 
and we believe that that is the best way to deal with access, 
the quickest way, the most effective way.
    And the other thing I would mention in asking you this 
question is, in States like mine--we are a Western State, the 
State of Nebraska--access for rural veterans is especially 
difficult and it is especially difficult in some areas like 
mental health and specialized care.
    Commander, what is your thought about that?
    Mr. Dellinger. Well, you know, VA right now utilizes 
telemedicine, so if they are at a CBOC, and even though there 
is only a nurse there, they can, by utilizing telehealth, be 
seen at a hospital----
    Senator Johanns. Yes, I appreciate that, but how would your 
members react if I said, look, we are just not going to make 
you wait anymore. If VA cannot meet your needs within a certain 
period of time, then we will allow you, if you choose, to seek 
private care. If you want to wait, it is a free country. You 
can wait, too.
    Mr. Dellinger. I understand that. We would not be opposed 
to that, because we want the best health care as fast as 
possible. But, we also have to put a caveat on that that it 
cannot happen exceedingly, because then there goes the entire 
budget as fee-based, which is going to be higher in the private 
sector versus the ability in the VA.
    Senator Johanns. Well, I get that, but we are all saying we 
want----
    Mr. Dellinger. I understand.
    Senator Johanns [continuing]. The best care. Yes, sir.
    Mr. Violante. Senator, I mean, that is the exact point; if 
you are not willing to give VA the resources it needs to allow 
for access in their facilities, you are going to need to give 
them more resources by sending veterans out into the community. 
Now, VA has the authority--I do not think they use it enough--
for purchased care. And, again, as I pointed out, if a veteran 
cannot be seen in a certain timeframe, they should be able to 
get that care by a private doctor, but VA needs to coordinate 
that care.
    We need to be careful that we do not start increasing the 
money going out to private doctors and taking away from VA's 
ability to hire internally, because all we are doing is robbing 
Peter to pay Paul, and if they do not have the money to do it 
now, they are going to have less money to do it with the 
private sector.
    Senator Johanns. I am out of time on a complex issue, but 
here is my point, again. If it results in better care, is that 
not what we are trying to achieve? And, boy, I hope some day I 
can have a discussion with all of you.
    Thank you, Mr. Chairman.
    Mr. Blake. Senator, could I address that real quick?
    Senator Johanns. Sure.
    Mr. Blake. It is my understanding that the PCCC, which is 
Patient Centered Coordinated Care, is sort of envisioned to 
address part of what the problem is that you outlined 
specifically, and that is what we want. We want coordinated 
care, because the key is the continuity of care and ensuring 
that VA is ultimately responsible for that veteran, so they 
know the spectrum of what that veteran is receiving. So, I 
think maybe PCCC is moving in the direction of addressing the 
kind of concerns that you are raising.
    Senator Johanns. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you.
    Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman.
    I want to thank all of the leaders here for your presence 
today, but also your tireless and relentless work on behalf of 
the veterans of America. And, truly, your leadership has made a 
big difference, not only in the performance and outcomes from 
the Veterans Administration, but in countless communities and 
other areas across the country. So, my thanks to you.
    My questions are very simple. All of you, I believe, would 
agree with me that the investigation should be as hard hitting, 
aggressive, thorough, and prompt as possible, and that if that 
requires the resources of other investigative agencies, they 
ought to be called upon, as well. Would you agree?
    Mr. Dellinger. I do, sir--Senator.
    Senator Blumenthal. And, second----
    Mr. Weidman. We not only----
    Senator Blumenthal. I am sorry, Mr. Weidman.
    Mr. Weidman. We not only agree, but our National President, 
John Rowan, wrote to the Attorney General of Arizona last week 
and to the U.S. Attorney for the District of Arizona, asking 
each of them to launch criminal investigations into reckless 
endangerment, possibly resulting in loss of life.
    Senator Blumenthal. Well, if you were not here earlier, let 
me just tell you that I urged the Secretary of VA, Secretary 
Shinseki, to strongly consider--in fact, I recommended that he 
involve the Department of Justice because there is ample 
evidence--and, I emphasize, evidence, not just allegations--of 
criminal wrongdoing, including destruction of documents and 
falsification of statements--to warrant the FBI to review this 
situation, as they do commonly when there are allegations of 
this kind, and determine, in fact, whether there is a basis for 
that investigation.
    The reason is, quite simply, not only the evidence of 
possible criminal wrongdoing, but also the Inspector General 
lacks the jurisdiction and authority, the resources, and the 
expertise to do a prompt and effective criminal investigation. 
Only the FBI can provide the resources, expertise, and 
authority, and the Department of Justice includes the U.S. 
Attorney in Arizona and every U.S. Attorney in every State that 
may be affected here.
    So, I think what we share is a determination--and I believe 
that the Secretary of VA shares it, as well--to get to the 
bottom, to remedy the wrongdoing, to provide relief to anyone 
denied access; and I think that is a determination that unites 
us in this room and that accountability means changing the 
team, if necessary, at VA. I believe that there may, at some 
point, be a need to consider those changes, as well.
    So, again, thanks for being here. My time is limited. I 
thank the Chairman.
    Chairman Sanders. Thank you very much, Senator Blumenthal.
    Senator Hirono.
    Senator Hirono. Thank you very much.
    I do apologize if this question has already been asked, but 
Senator Murray had asked earlier of, I believe, Secretary 
Shinseki, as to what a face-to-face audit should involve; and I 
would like to ask you--perhaps we can start with Mr. 
Dellinger--what needs to happen in a face-to-face audit to 
truly elicit the kind of information we need to address the 
challenges and the problems at VA hospitals and clinics.
    Mr. Dellinger. Thank you, Senator, for that question. I 
feel it has to start with IT first. They have to look at the 
process of the books as far as what actually occurs there. They 
also have to go through the administration, through the 
physicians, the employees, and also get input from the 
stakeholders in this, including the veterans.
    Senator Hirono. Did that happen the last time? Apparently, 
there have been audits before, and when those audits were 
conducted, were the stakeholders, i.e., the veterans' 
organizations, included?
    Mr. Dellinger. I do not have that information.
    Senator Hirono. Do the rest of you have any information 
that will help us? Yes.
    Mr. Weidman. Often, we are not included. Actually, even 
more important than the organizations at the local level is to 
talk to veterans at the local level who are not hand-picked and 
ask, what is happening here? If you ask the veterans, they are 
smart. We got hurt. We got wounded. We did not get dumb. The 
veterans will tell you how to fix the facility.
    Senator Hirono. So, would you all agree that any face-to-
face audit should include--probably, this is a rhetorical 
question, but--input from the veterans' organizations as well 
as veterans at the particular facility?
    Mr. Weidman. Yes.
    Mr. Violante. Senator, I would agree with that. I would 
also, as we pointed out in our testimony, recommend that there 
be an independent third-party expert involved. It would 
alleviate a lot of the questions that Senator Moran raised 
about the audit and I think it would help everyone be assured 
that these audits were being done properly and everything was 
being looked at.
    Senator Hirono. What do you mean by an independent third 
party----
    Mr. Violante. Someone who is--I mean, I do not have the 
expertise----
    Senator Hirono. Like whom?
    Mr. Violante. I do not have the expertise to determine, you 
know, are the people cooking the books, are the veterans 
getting timely care, are they spending sufficient time or too 
much time with the doctor. There needs to be someone who is an 
expert in time management, in accessing medical care, that can 
be there to make a determination if they are asking the right 
questions and are the answers sufficient to address this 
problem.
    Mr. Blake. Senator, I would suggest, also, if they are 
going to do a thorough audit, it would take more than a couple 
weeks, certainly, because a thorough audit would be an 
examination of what the entire capacity of the system currently 
is. That might involve clinicians, nurses, whatever it may be.
    I will suggest that if the audit that is going on right now 
is what Senator Moran suggested is happening, that is pretty 
damn disheartening, because that is not going to solve any 
problems as far as we are concerned. It is going to take a more 
thorough analysis, for sure, than a couple of hours out of 1 
day in a week to sit down and figure out what is happening. It 
might get to the bottom of a problem, a shallow-depth problem 
at a local facility, but I am not sure that is going to solve 
the deeper-rooted problems.
    Senator Hirono. I would envision that any kind of an 
assessment of the entire VA health care system would involve 
not just this process that Secretary Shinseki has described to 
us, but that it will be an ongoing kind of an assessment, which 
I hope will be the case. The Secretary is still here and I am 
sure that he is taking to heart the suggestions and comments 
that you are now providing.
    I had asked the Secretary, in view of all that we are 
asking the VA with regard to education issues, housing issues, 
homelessness, all of that, whether he thinks that this is 
taking away from VA's core mission of providing health care for 
the veterans. Does anybody care to respond to that?
    Mr. Weidman. There is no such thing as a homeless veteran. 
There are veterans whose problems have become so acute and have 
not been addressed that they have ended up without a home. So, 
it is not a whole different class of veterans, if you will. 
And, if the other services come through, then people do not end 
up on the street. Each one is a failure. It does not mean that 
people set out to fail, but somehow, we have failed those folks 
coming home.
    Mr. Gallucci. Senator, I would like to add to that the VFW 
believes that the resources and services the VA can provide 
should never come at a tradeoff. VA's obligation is to provide 
holistic services to the veteran. That can come in the form of 
education benefits, employment assistance--like the resource 
that they launched a couple of weeks ago through e-Benefits--
but, health care has to remain a cornerstone of that.
    When veterans transition off of active duty, there are a 
litany of transitional resources that need to be made available 
to them. The VA has the primary mission in delivering most of 
those, except for possibly what the Department of Labor, 
Veterans Employment and Training Service, has.
    So, we would never want to see tradeoffs made on how we 
deliver other benefits, because if we start injecting resources 
into health care, will G.I. Bill administration suffer, or will 
other benefits administration suffer?
    Senator Hirono. Thank you for that perspective.
    Thank you, Mr. Chairman.
    Chairman Sanders. Senator Burr.
    Senator Burr. Mr. Chairman, just 1 second, because in my 
absence, Senator Moran did talk specifically about the audits 
and he read a statement. I just wanted the witnesses to know, 
that was the assessment of Chairman Miller from the House 
Committee. He actually was at Jackson, and I am not sure how 
many facilities he is covering, but that was his assessment of 
the audit process.
    Not that I do not love you guys, but we are going to try to 
get the next panel in before we get into a series of votes that 
will bring a finality to this, so thank you.
    Chairman Sanders. Thank you, Senator Burr.
    First of all, thank you for what you do every day 
representing veterans, and thanks for being here. More 
importantly, I think we all know we are not going to create the 
great health care system we need in the VA without your active 
participation. We need you. So, thank you very much for being 
here and keep up the good work. [Pause.]
    And, if we could bring up the third panel. [Pause.]
    OK. Let me introduce our third panel of the day. 
Representing VA's independent Inspector General's Office is its 
Acting Inspector General, Richard Griffin; he is accompanied by 
Dr. John D. Daigh, Assistant Inspector General for Healthcare 
Inspections.
    From the National Association of State Directors of 
Veterans Affairs, we have its President, Retired Rear Admiral 
W. Clyde Marsh.
    From the Government Accountability Office, the GAO, we have 
their Director of Health Care, Debra Draper.
    Finally, joining us today is Phillip Longman, Senior 
Research Fellow at the New America Foundation.
    Thank you all very much for being here.
    Mr. Griffin, you may begin.

 STATEMENT OF RICHARD GRIFFIN, ACTING INSPECTOR GENERAL, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOHN D. DAIGH, 
     JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE 
                          INSPECTIONS

    Mr. Griffin. Mr. Chairman, Ranking Member Burr, and Members 
of the Committee, thank you for the opportunity to provide 
testimony at this hearing. I would like to provide an overview 
of our ongoing review at the Phoenix Health Care System.
    The OIG has assembled a multi-disciplinary team comprised 
of auditors, health care inspectors, board-certified 
physicians, and criminal investigators from across the country 
to address these allegations. I have directed our team to focus 
on two questions. Number 1, whether the facility's electronic 
wait list purposely omitted the names of veterans waiting for 
care, and if so, at whose direction. And, number 2, whether the 
deaths of any of these veterans were related to delays in care.
    To get to the bottom of these allegations, the OIG has an 
exhaustive review underway that includes seven components:

          Number 1, interviewing staff with direct knowledge of 
        patient scheduling practices and policies, including 
        scheduling clerks, supervisors, patient care providers, 
        management staff, and whistleblowers who have stepped 
        forward to report allegations of wrongdoing.
          Number 2, collecting and analyzing voluminous reports 
        and documents from VHA information technology systems 
        related to patient scheduling and enrollment.
          Number 3, reviewing medical records of patients whose 
        deaths may be related to days in care.
          Number 4, reviewing performance ratings and awards of 
        senior facility staff.
          Number 5, reviewing past and newly received 
        complaints to the OIG Hotline on delays in care, as 
        well as those complaints shared with us by members of 
        Congress and by the media.
          Number 6, reviewing other prior reports relevant to 
        these allegations, including Administrative Board of 
        Investigations or reports from Veterans Health 
        Administration Office of the Medical Inspector.
          Finally, number 7, reviewing massive amounts of e-
        mail and other documentation pertinent to this review.

    To facilitate our work, on May 1, I asked Secretary 
Shinseki to place the Phoenix Director, Associate Director, and 
another individual on administrative leave. This was done 
because of the gravity of the allegations and to ensure 
cooperation by Phoenix staff, some of whom expressed concern 
about talking to the OIG team. Secretary Shinseki immediately 
agreed to my request.
    I am confident that we have the resources and talent to 
complete a thorough review of these allegations at Phoenix. We 
are using our top audit experts, who have reviewed VA 
scheduling over the years, to examine all of the scheduling-
related records.
    Dr. Daigh's board-certified physicians from our Office of 
Healthcare Inspections will be reviewing medical records, 
treatment, and harm that may have resulted from delays in care.
    OIG criminal investigators, including IT forensic experts, 
are also assisting the team. We are working with Federal 
prosecutors from the U.S. Attorney's Office for the District of 
Arizona and the Public Integrity Section of the Department of 
Justice here in Washington so that we can determine any conduct 
that we discover that merits criminal prosecution.
    Since the Phoenix story broke in the national media, we 
have received additional reports of manipulated waiting times 
at other VHA facilities, either through the OIG Hotline, 
members of Congress, or the media. In response, we have opened 
simultaneous reviews at several other VHA facilities. These 
reviews are being conducted by other OIG staff to enable the 
team working on the Phoenix review to focus their efforts on 
completing their project. We expect that these reviews will 
give us insight into the extent to which these scheduling 
issues are present at other VHA facilities.
    My staff is working diligently to determine the facts of 
what happened at Phoenix and who is accountable. While much has 
been done, much more remains ahead. Be assured, however, this 
review is the OIG's top priority and that maximum resources are 
dedicated to bring about its timely conclusion.
    We intend to brief you and other members of the Congress 
once we have reached final findings of facts and are ready to 
publish our report. We project finishing the project and 
publishing a report in August of this year.
    Thanks again for holding this hearing. Dr. Daigh and I will 
be pleased to answer any questions.
    [The prepared statement of Mr. Griffin follows:]
  Prepared Statement of Richard J. Griffin, Acting Inspector General, 
      Office of Inspector General, Department of Veterans Affairs
    Chairman Sanders and Members of the Committee, thank you for the 
opportunity to testify today to discuss the quality of health care 
provided to veterans at Department of Veterans Affairs (VA) medical 
facilities. The VA Office of Inspector General (OIG) has issued many 
reports that have addressed the care at VA medical centers (VAMC). I am 
accompanied by John D. Daigh, Jr., M.D., Assistant Inspector General 
for Healthcare Inspections. For the purposes of this statement, I will 
focus on seven recent reports that I believe are indicative of issues 
facing VA in providing quality health care.\1\
---------------------------------------------------------------------------
    \1\ Healthcare Inspection--Gastroenterology Consult Delays, William 
Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina (9/6/
2013); Healthcare Inspection--Mismanagement of Inpatient Mental Health 
Care, Atlanta VA Medical Center, Decatur, Georgia (4/17/2013); 
Healthcare Inspection--Unexpected Patient Death in a Substance Abuse 
Residential Rehabilitation Treatment Program, Miami VA Healthcare 
System, Miami, Florida (3/27/2014); Healthcare Inspection--Patient Care 
Issues and Contract Mental Health Program Mismanagement, Atlanta VA 
Medical Center, Decatur, Georgia (4/17/2013); Healthcare Inspection--
Emergency Department Patient Deaths Memphis VAMC, Memphis, Tennessee 
(10/23/2013); Healthcare Inspection--Inappropriate Use of Insulin Pens, 
VA Western New York Healthcare System, Buffalo, New York (5/9/2013); 
Healthcare Inspection--Review of VHA Follow-Up on Inappropriate Use of 
Insulin Pens at Medical Facilities (8/1/2013).
---------------------------------------------------------------------------
                               background
    The VA provides medical care to 6.5 million veterans through a 
system of medical facilities including 151 Medical Centers, 300 Vet 
Centers, and 820 Community Based Outpatient Clinics (CBOC). The 
Veterans Health Administration (VHA) Central Office provides leadership 
and policy guidance to the nationwide system of care. Hospitals, 
clinics, and related medical facilities are grouped into 21 Veterans 
Integrated Service Networks (VISN). VISNs and their related hospitals' 
organization and business practices have evolved at different paces and 
have been significantly influenced by local preferences since their 
creation, resulting in 21 different VISN organizations, each charged 
with the same mission.
                         colon cancer screening
    Colon cancer has long been recognized as a silent killer in that 
the cancer is often able to grow within the intestine to significant 
size before being discovered. Patients may be screened for this cancer 
by a variety of tests, some of which focus upon the presence of blood 
within stool or the physical presence of a mass within the intestine. 
Examinations that test stool for the presence of blood or other 
chemicals or visualize the intestine are common diagnostic tests used 
to discover the presence of this silent killer.
    In 2006, the OIG published a review, Colorectal Cancer Detection 
and Management in Veterans Health Administration Facilities 
(February 2, 2006), of aspects of VHA's performance in the delivery of 
colon cancer screening and management of positive screening tests. This 
review found that the time between having a positive screening test for 
colon cancer and the provision of the next test to diagnose a tumor 
took several months. VA agreed that this delay in action was not 
acceptable. When colon cancer was diagnosed, surgeons and oncologists 
responded quickly with treatment, yet the lag between the 
identification of a specific risk and the determination that there was 
or was not colon cancer was not timely.
    In that report, the Under Secretary for Health concurred with the 
findings and recommendations we made to more efficiently and more 
timely address the lag between the positive screening test and the 
diagnostic test for colon cancer. The Under Secretary for Health 
indicated in the response to this report that timelines would be 
established to monitor the timeliness of colon rectal cancer diagnosis 
after a positive screening test and that a directive would be issued to 
establish national standards for the management of this process. This 
was accomplished with the issuance of VHA Directive 2007-004, 
``Colorectal Cancer Screening,'' in January 2007.
    In September 2013, the OIG reported a disturbing set of events at 
the William Jennings Bryan Dorn VAMC in Columbia, South Carolina, that 
led to thousands of delayed gastroenterology (GI) consults for colon 
cancer screening and the determination that over 50 veterans had a 
delayed diagnosis of colon cancer, some of whom died from colon 
cancer.\2\ After patients are screened positive for possible colon 
cancer or require a GI procedure, a consult to GI is usually sent by 
the primary care provider. Network and facility leaders became aware of 
the GI consult backlog at Columbia in July 2011 involving 2,500 delayed 
consults, 700 of them deemed ``critical'' by VA physicians. Additional 
funds were requested by the facility upon determining the need for a 
large number of GI procedures, and the VISN awarded the facility $1.02M 
for Fee-Basis colonoscopies in September 2011.\3\ However, facility 
leaders did not ensure that a structure for tracking and accounting was 
in place and by December 2011, the backlog stood at 3,800 delayed GI 
consults. The facility developed an action plan in January 2012 but had 
difficulty making progress in reducing the backlog. The delayed 
diagnosis of a patient with cancer in May 2012 prompted facility 
leaders to re-evaluate the GI situation, and facility, network, and VHA 
leaders aggressively pursued elimination of the backlog. This was 
essentially accomplished by late October 2012. However, during the 
review ``look-back'' period, 280 patients were diagnosed with GI 
malignancies, 52 of whom were associated with a delay in diagnosis and 
treatment. The facility completed at least 19 institutional disclosures 
providing patients and their family members with specific details of 
the adverse event or delay of care and their right to file a claim.
---------------------------------------------------------------------------
    \2\ Healthcare Inspection--Gastroenterology Consult Delays, William 
Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina (9/6/
2013).
    \3\ Fee basis care is non-VA/private sector care paid for by VA 
when the service is not available in a timely manner within VHA due to 
capability, capacity, or accessibility.
---------------------------------------------------------------------------
    A confluence of factors contributed to the GI delays and hampered 
efforts to improve the condition. Specifically, the facility's Planning 
Council did not have a supportive structure; Nursing Service did not 
hire GI nurses timely; the availability of Fee Basis care had been 
reduced; low-risk patients were being referred for screening 
colonoscopies, thus increasing demand; staff members did not 
consistently and correctly use the consult management reporting and 
tracking systems; critical network and facility leadership positions 
were filled by a series of managers who often had collateral duties and 
differing priorities; and Quality Management staff was not included in 
discussions about the GI backlogs.
    In its response to the report, VHA indicated that national VHA 
leadership considered delays in consult responsiveness to be of 
significant concern. VHA Central Office leadership took specific steps 
to address these issues in Columbia as well as system-wide. In 
January 2013, VHA undertook a national review of open consults to gain 
a better perspective on nationwide demand for consultative services. In 
May 2013, VHA launched an initiative to standardize use of the clinical 
consultation software package in the electronic health record.
    The appropriate management of patients who are at risk for colon 
cancer is standard medical practice. This issue has been discussed by 
VHA for years, and yet veterans were not timely diagnosed with colon 
cancer at this academic VA medical center.
                 mental health policies and procedures
    The OIG has issued two reports recently on veterans who died of 
narcotic drug overdoses while in VA facilities for mental health 
care.\4\ In both cases, the hospital staff failed to ensure that 
veterans, who by their prior behavior were known to be at risk of 
abusing narcotic medication, were placed in environments that were 
secure from those drugs.
---------------------------------------------------------------------------
    \4\ Healthcare Inspection--Mismanagement of Inpatient Mental Health 
Care, Atlanta VA Medical Center, Decatur, Georgia (4/17/2013); 
Healthcare Inspection--Unexpected Patient Death in a Substance Abuse 
Residential Rehabilitation Treatment Program, Miami VA Healthcare 
System, Miami, Florida (3/27/2014).
---------------------------------------------------------------------------
    At the Miami VA Healthcare System, in Miami, Florida, we found that 
a patient died in his room in the substance abuse residential 
rehabilitation treatment program (SARRTP), and autopsy results 
indicated the patient died from cocaine and heroin toxicity. This 
veteran had a history of multiple positive urine drug screens while in 
the SARRTP. We found that the SARRTP security surveillance camera was 
not working at the time of the patient's death, was still not working 
at the time of our site visit, and no alternative arrangements were 
made to monitor patients in the absence of an operational camera. 
Moreover, we found that evening, night, and weekend SARRTP staff often 
sat in a backroom where they had an extremely limited view of the unit 
and no view of the unit's entrance and exits. We also found that staff 
were not consistent in their methods of contraband searches and did not 
monitor patient whereabouts or unit visitors as required.
    In our report on the Atlanta VA Medical Center in Decatur, Georgia, 
we received allegations that the VA did not protect a veteran from 
illicit drugs while an inpatient on the locked mental health unit and 
that he died of an overdose. We substantiated that the facility did not 
have adequate policies or practices for patient monitoring, contraband, 
visitation, and urine drug screening. We found inadequate program 
oversight including a lack of timely follow up actions by leadership in 
response to patient incidents.
    At both Miami and Atlanta, as the reports indicate, standard steps 
to ensure veterans were kept safe while under VA control were not taken 
and two veterans died. In each instance, VA managers did not ensure 
that hospital staff performed their jobs.
    The OIG reported on poor management of contracted mental health 
care at the Atlanta VAMC, where between 4,000-5,000 veterans who were 
referred for non-VA mental health care at a public non-profit Community 
Service Board (CSB), were not followed or managed.\5\ In a sample of 85 
cases, 21 percent of the referred veterans did not receive mental 
health care and, outside of the sample, several veterans were found to 
have died with a history of inadequate mental health care support from 
VA or non-VA sources. Mental Health Service Line managers did not 
adequately oversee or monitor contracted patient care services to 
ensure safe and effective treatment. This lack of effective patient 
care management and program oversight by the facility contributed to 
problems with access to mental health care and as a VA employee told 
the OIG ``may have contributed to patients falling through the 
cracks.'' The facility's contract program lacked an integrated and 
effective Quality Assurance (QA) program and did not have a CSB QA 
process. For example, VA facility program managers did not track and 
trend patient complaints or conduct oversight visits to the CSB sites, 
as required by VA directives and the contract.
---------------------------------------------------------------------------
    \5\ Healthcare Inspection--Patient Care Issues and Contract Mental 
Health Program Mismanagement, Atlanta VA Medical Center, Decatur, 
Georgia (4/17/2013).
---------------------------------------------------------------------------
    Our review also confirmed that facility managers did not provide 
adequate staff, training, resources, support, or guidance for effective 
oversight of the contracted mental health program. Managers and staff 
voiced numerous concerns including challenges in program oversight, 
inadequate clinical monitoring, staff burnout, and compromised patient 
safety. Furthermore, other administrative issues contributed to the 
delay because the facility managers did not pay invoices promptly. 
These delays affected the CSBs' ability to accept new patients and plan 
their patient census.
    The Atlanta VAMC was overwhelmed by the demand for mental health 
services over a multiyear period. VA leadership's response to this 
crisis was fragmented, ineffective, and resulted in poor care, and may 
have contributed to the death of some of the veterans among the 4,000 
to 5,000 patients referred for non-VA care.
                      emergency department issues
    In October 2013, we issued a report detailing three deaths in the 
Emergency Department (ED) at the Memphis VAMC in Memphis, Tennessee.\6\ 
We received allegations that three patients died subsequent to care 
they received in the Memphis VAMC ED. We found the following:
---------------------------------------------------------------------------
    \6\ Healthcare Inspection--Emergency Department Patient Deaths 
Memphis VAMC, Memphis, Tennessee (10/23/2013).

     A patient was administered a medication in spite of a 
documented drug allergy and had a fatal reaction. Handwritten orders 
for this patient did not comply with the facility's requirement that 
all provider orders and patient care be documented in the electronic 
medical record. Since the orders were not entered into the electronic 
medical record, systems in place to notify the provider of a drug 
allergy conflict with ordered medications were bypassed. The patient 
died of a reaction to a medication allergy that was identified in the 
electronic medical record.
     Another patient was found unresponsive after being 
administered multiple sedating medications without being properly 
observed.
     A third patient had a critically high blood pressure that 
was not aggressively monitored and experienced bleeding in the brain.

    The facility did complete protected peer reviews of the care for 
all three patients. Two of the deaths were also evaluated through root 
cause analyses (RCA), which are quality reviews designed to identify 
and correct systemic factors and conditions that may pose a threat to 
patient safety. However, we found that the implementation of the RCA 
action plan was delayed and incomplete. Additionally, the RCA 
documentation we reviewed contained several errors of fact, such as how 
long Patient 1 was monitored in the emergency room before discharge and 
the number of intravenous medications given to Patient 2.
    Decisions were made which permitted the electronic medical record 
and its safeguards to be bypassed and to have patients on multiple 
sedating medications to be located in places difficult to monitor. 
Furthermore, when issues were identified through the RCA process, 
actions to prevent a recurrence were not taken seriously.
                     introduction of new technology
    Several VAMCs including the medical centers in Buffalo, New York, 
and Salisbury, North Carolina, failed to introduce new technology 
properly into the hospital environment.\7\ This resulted in 700 
patients at Buffalo and 260 patients at Salisbury being exposed to the 
risk of blood borne viral infections when insulin pens, designed to be 
used with one pen per patient, were instead used improperly such that 
one pen was used on multiple patients.
---------------------------------------------------------------------------
    \7\ Healthcare Inspection--Inappropriate Use of Insulin Pens, VA 
Western New York Healthcare System, Buffalo, New York (5/9/2013); 
Healthcare Inspection--Review of VHA Follow-Up on Inappropriate Use of 
Insulin Pens at Medical Facilities (8/1/2013).
---------------------------------------------------------------------------
    In late October 2012, the Buffalo Chief of Pharmacy discovered 
three insulin pens, which were designed for single-patient use only, 
with no patient labels in a supply drawer of a medication cart. 
Facility officials subsequently found three more pens without patient 
labels in medication carts on three other inpatient units, and, when 
queried, several nurses reportedly acknowledged using the pens on 
multiple patients. Inappropriately using single-patient use insulin 
pens on multiple patients may potentially expose patients to blood 
borne pathogens.
    We identified six factors that contributed to the misuse of insulin 
pens at Buffalo. We also found that misuse of the insulin pens went 
undetected for 2 years because even though facility staff often 
observed pens with no patient labels on the medication carts, they did 
not report it because they either did not fully comprehend the clinical 
risks of sharing pens, or they accepted the unlabeled pens as standard 
practice believing they were both multi-dose and multi-patient devices. 
We found that VHA did not notify Members of Congress or at-risk 
patients until January 2013 because of the time required for multiple 
levels of coordination between VA and VHA and inefficiencies in VHA's 
internal review process for large-scale adverse event disclosures.
    In addition to the Buffalo incident, nurses at two other facilities 
were found to have inappropriately used insulin pens on multiple 
patients. In January 2013, the Salisbury VAMC reported that two nurses 
had inappropriately used insulin pens on multiple patients. VHA 
instituted a large-scale adverse event disclosure to notify 266 at-risk 
patients. At another facility, a nurse acknowledged using a pen on two 
patients on one occasion. We identified two contributing factors to 
explain why some nurses misused the insulin pens:

     Facilities did not fully evaluate the risks of using 
insulin pens on inpatient units, specifically in regards to the impact 
on nursing procedures.
     Facilities did not provide comprehensive nurse education 
on the pens.

    We found that VHA has processes in place to identify important 
patient safety alerts, including product recalls, and disseminate this 
information to facility managers. VHA's National Center for Patient 
Safety and Pharmacy Benefits Management Service lead VHA's efforts to 
collect patient safety information and share this information with 
facilities. At the facility level, patient safety managers are 
responsible for disseminating alerts to appropriate administrative and 
clinical staff and tracking the facility's response through a national 
database. VHA has followed up and tested for evidence of infection in 
the patients identified in this report.
    The use of these insulin pens in this fashion violates the core 
principles of infection control. Multiple personnel in several 
hospitals over an extended period of time failed to comprehend the 
impact of the decision to introduce pens of this nature onto inpatient 
wards. The decision to introduce new technology into hospital use is 
one that occurs routinely and to be done safely requires facility 
leaders to coordinate their actions and understand the implications of 
their decisions. Facilities with a singular focus on delivering high 
quality medical care should have recognized the risk these devices 
bring to the inpatient environment and taken appropriate actions to 
mitigate that risk.
    lack of accurate quality management data and staffing standards
    The OIG and Government Accountability Office have been reporting 
for nearly a decade that VHA managers needed to improve efforts for 
collecting, trending, and analyzing quality management data. We have 
reported that inaccuracies in some of VHA's data sources hinder the 
usability of VHA decisionmakers to fully assess their current capacity, 
optimal resource distribution, productivity across the system, or to 
establish staffing and productivity standards. Since July 2005, we have 
reported on inaccurate wait times and lists, and expect to report on 
the results of multiple reviews that are underway to the Committee 
later this summer.\8\ As recently as December 2012, we identified the 
continuing need for VHA to improve their staffing methodology by 
implementing productivity standards for specialty care services.\9\ We 
determined VHA had not established productivity standards for 31 or 33 
specialty care services reviewed, and had not developed staffing plans 
that addressed facilities' mission, structure, workforce, recruitment, 
and retention issues to meet current or projected patient outcomes, 
clinical effectiveness, and efficiency. VA agreed to put staffing 
standards for specialty care in place by FY 2015.
---------------------------------------------------------------------------
    \8\ Audit of the Veterans Health Administration's Outpatient 
Scheduling Procedures (7/8/2005); Audit of the Veterans Health 
Administration's Outpatient Waiting Times (9/10/2007); Audit of Alleged 
Manipulation of Waiting Times in Veterans Integrated Service Network 3 
(5/19/2008); Review of Veterans' Access to Mental Health Care (4/23/
2012).
    \9\ Audit of VHA's Physician Staffing Levels for Specialty Care 
Services (12/27/2012).
---------------------------------------------------------------------------
                              observations
    OIG work routinely reports on clinical outcomes or performance that 
did not meet expectations. We routinely determine that there were 
opportunities by people and systems to prevent untoward outcomes. In 
addition to local issues at the facility, there are several 
organizational issues that impede the efficient and effective operation 
of VHA and place patients at risk of unexpected outcomes.
    Although health care delivery may be the first priority of many 
within the system, others are focused on research, training the next 
generation of health care providers, disaster preparedness, 
homelessness, support for compensation evaluation requirements, and 
other related missions. This lack of focus on health care delivery as 
priority one can be seen by the process commonly used at hospitals to 
fill vacant positions. A resource board reviews open positions and then 
determines which should be filled. Thus the position recently occupied 
by a nurse in the GI clinic, who is essential to the delivery of 
required care, may not be filled while a position that is important to 
the research or teaching community is filled. The decision by this 
board, to not fill a clinic position, may have far reaching 
consequences. The clinic that does not have the nurse may not function 
properly. The leadership of the clinic is left believing that hospital 
``leadership'' does not understand or does not care about the care 
provided in that clinic. All a provider can do is ask for clinical 
positions to be filled, and if they are not filled, either leave VA or 
agree to work in an environment that provides less than satisfactory 
care. There is no national process to establish a set of positions that 
are deemed ``essential'' to the delivery of health care and thus are 
priority one for the hospital administration to resource.\10\ The 
establishment of ``essential positions'' in the context of a standard 
hospital structure would enhance the delivery of quality patient care.
---------------------------------------------------------------------------
    \10\ Healthcare Inspection--Delayed Cancer Diagnosis, VA Greater 
Los Angeles Healthcare System, Los Angeles, California (7/24/2007).
---------------------------------------------------------------------------
    VA hospitals and clinics do not have a standard organizational 
chart. Some hospitals have a chief of surgery and a chief of 
anesthesia; others have a chief of the surgical care line. The lack of 
a common organizational chart for medical facilities results in 
confusion in assigning local responsibility for actions required by 
national directives. Variation in staff organization also creates 
difficulty in comparing the performance of clinical groups between 
hospitals and clinics.
    Leadership, teamwork, communication, and technical competence are 
among the most important factors in providing quality health care. 
However, organization, assignment of clear responsibility, and 
efficiency of operation all make important contributions to the process 
of improving the quality of health care delivered.
                               conclusion
    The unexpected deaths that the OIG continues to report on at VA 
facilities could be avoided if VA would focus first on its core mission 
to deliver quality health care. Its efforts would also be aided by 
discussion of the best organizational structure to consistently provide 
quality care. The network system of organization and the accompanying 
motto, `all health care is local,' served the VA well over the last 
several decades but does not standardize the organization of medical 
centers. It is difficult to implement national directives when there 
are no standard position descriptions or areas of responsibility across 
the system. VA has embraced the ``aircraft checklist'' approach to 
improve the chances that preventable medical errors will not occur in 
the operating room, but has taken the opposite approach to the 
assignment of duties and responsibilities in medical centers, where no 
two hospitals are alike. We believe it is time to review the 
organizational structure and business rules of VHA to determine if 
there are changes that would make the delivery of care the priority 
mission.

    Mr. Chairman, that concludes my statement and we would be pleased 
to answer any questions that you or other Members of the Committee may 
have.

    Chairman Sanders. Thank you very much, Mr. Griffin.
    Admiral Marsh.

   STATEMENT OF REAR ADMIRAL W. CLYDE MARSH, USN (RETIRED), 
PRESIDENT, NATIONAL ASSOCIATION OF STATE DIRECTORS OF VETERANS 
                            AFFAIRS

    Admiral Marsh. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of the Committee, my name is Clyde Marsh 
and I am the President of the National Association of State 
Directors of Veterans Affairs. I am honored to present the 
views of the State Directors from all 50 States, the District 
of Columbia, and five Territories.
    As State governmental agencies, we are charged with the 
duties to include assisting the processing of claims for 
disability compensation and pension, burial services in our 
State veterans' cemeteries, survivor benefits, coordinate 
access to health care, and provide over half of all VA-
authorized long-term care in our State nursing homes.
    From the NASDVA perspective, the state of VA health care is 
strong. The VA has medical centers located in the majority of 
major cities in America. The VA has expanded their community-
based outpatient clinics in recent years to many of the smaller 
cities and rural areas in our States. The VHA has moved out of 
the box, taken advantage of technology to provide telehealth, 
telemedicine, and rural consults in rural areas. They have also 
taken steps to provide transportation for those veterans in 
extremely rural areas to make their CBOC appointments.
    VA customer satisfaction has been trending higher in 
accordance with the American Consumer Satisfaction Index. The 
VA may not get everything perfectly every time. However, on a 
national level, VA has and still is one of the leading health 
care providers in the country in providing good, quality health 
care.
    Those of us in the health delivery business for VA, we 
constantly strive to get it right and we work on that every 
single day. In our experience, VBA, VHA, and NCA are on the 
same page.
    NASDVA does not endorse, nor do we agree with calling for 
Secretary Shinseki's resignation, along with his top VA 
administration officials. These leaders are crucial, not only 
to continuing to transform our Nation's second-largest Federal 
agency, but they will be needed to lead following actions to 
swiftly address or correct any health care or procedural issues 
that may be identified. It is premature to point fingers or 
rush to judgment, and it certainly is not in the best interests 
of our Nation's 22 million veterans to make premature decisions 
based on allegations before the IG investigations are concluded 
and the facts are determined.
    Under Secretary Shinseki's leadership, the U.S. Department 
of Veterans Affairs is transforming a pre-World War II 
antiquated claims process into a paperless claims system that 
has reduced compensation and pension claims backlog by 44 
percent, has reduced veterans' homelessness by 24 percent, and 
has enrolled more than two million veterans in the health care 
system since 2009, receiving some of the highest quality care 
ratings in decades.
    NASDVA is committed to supporting VHA in caring for over 
eight million veterans enrolled in the health care system. At 
the local level, State Directors are in constant coordination 
with medical center directors concerning the delivery of health 
care.
    To assist VA, NASDVA asks that the Senate gives full 
attention to confirming those individuals that have been 
nominated to fill VA key vacant leadership positions that VA 
could then become fully manned.
    NASDVA strongly emphasizes, again, that it is imperative 
that VA, and specifically VHA, receive the necessary support 
that is required to adequately care not only for the eight 
million veterans enrolled today, but the anticipated one 
million more veterans over the next several years that will 
require medical assistance, and those folks will be coming as a 
result of the war and military drawdown. The bottom line is 
that VA may require more in terms of the budgets. They may need 
more doctors, nurses, technicians, clinicians, and possibly 
even facility expansions or operations.
    As the IG inspection results are made available and VA 
implements corrective measures of improved procedures in the VA 
health care system, NASDVA looks forward to participating as 
co-partners or facilitators.
    In conclusion, NASDVA can help veterans become more 
informed about their benefits as well as how to be enrolled and 
receive the care that they have earned and need.
    Mr. Chairman and distinguished Members of the Committee, 
the State Directors of Veterans Affairs remain dedicated and 
committed to doing our part. We have the utmost confidence in 
Secretary Shinseki and firmly believe that he and his VA 
leaders will transform VA into a technology-based, more 
service-oriented and veteran-friendly 21st century agency. 
Thank you for including NASDVA in this very important hearing.
    [The prepared statement of Admiral Marsh follows:]
    prepared statement of rear admiral w. clyde marsh, usn (ret.), 
president, national association state directors of veterans affairs and 
          commissioner, alabama department of veterans affairs
                              introduction
    Chairman Sanders and distinguished members of the Senate Veterans' 
Affairs Committee, my name is Clyde Marsh, President of the National 
Association of State Directors of Veterans Affairs (NASDVA) and 
Director of the Alabama Department of Veterans Affairs. I am honored to 
present the collective views of the State Directors of Veterans Affairs 
for all 50 states, the District of Columbia, and five U.S. Territories.
    As state governmental agencies, our Governors, State Boards and/or 
Commissions task their respective State Departments of Veterans Affairs 
(SDVA) with the responsibility of addressing the needs of our veterans 
and their families particularly in our role as advocates. We are 
charged with a plethora of duties that include processing veterans' 
claims for disability compensation and pensions, burial services in 
state veterans cemeteries, survivor benefits, coordinate access to 
``healthcare,'' and provide over half of all VA authorized long term 
care in state veterans nursing homes.
                       the state of va healthcare
    From a NASDVA prospective, the state of VA Healthcare in our nation 
is strong. The VA has Medical Centers located in the majority of major 
cities in America. They have expanded their Community-Based Outpatient 
Clinics (CBOCs) over the past several years to many of the smaller 
cities and rural areas in our states. VHA has moved ``out of the box'' 
taking advantage of technology to provide Tele-health and Tele-medicine 
consults in rural areas. They have also taken steps to provide 
transportation for those veterans in extremely rural areas in order to 
make CBOC appointments.
    VA customer satisfaction has been trending higher. VA does not do 
everything perfectly nor do they have everything they need. However, on 
a national level, VA has and still is one of the leading health care 
providers in the country in providing top quality health care. Those of 
us involved in the delivery of VA benefits and services strive to get 
it right and constantly work toward making conditions better. In our 
experience, VHA, VBA and NCA are on the same page. Overall, VA provides 
good quality care and services to our Nation's veterans and their 
families.
    NASDVA, does not endorse, nor do we agree with those calling for 
Secretary Shinseki's resignation along with his top VA officials, Under 
Secretary for Health Honorable Robert Petzel and Under Secretary for 
Benefits Honorable Allison Hickey. These leaders are crucial not only 
for the continuing transformation of the Nation's second largest 
Federal agency. They will need to lead the follow-on actions to swiftly 
address or correct any health care or process issues that may be 
identified. It is premature to point fingers, rush to judgment and is 
certainly not in the best interest of the majority of veterans before 
the IG investigations are concluded.
    Under Secretary Shinseki's leadership, the U.S. Department of 
Veterans Affairs in transforming from a pre-WWII antiquated VA claims 
process into a paperless claims system that has reduced the 
compensation and pension claims backlog by 44 percent; has reduced 
veterans homelessness by 24 percent; and has enrolled more than 2 
million veterans in the health care system since 2009 receiving some of 
the highest quality of care ratings in decades.
               items critical to success of va healthcare
    NASDVA and its individual states appreciate and are committed to 
supporting the VHA in caring for the over 8 million veterans enrolled 
in the healthcare system. The States are also actively engaged in 
referring veterans to the VAMCs and CBOCs and we daily assist veterans 
in completing applications for medical care. At the local level, State 
Directors are in constant coordination with the VISN and VAMC Directors 
concerning the delivery of healthcare. Issues that arrive are handled 
personally with the leaders. We also conduct outreach events such as 
health-fares and ``stand downs'' to inform veterans about VA medical 
benefits and help them in obtaining them. To assist VA, we ask that the 
Senate give attention to confirming those individuals that have been 
nominated to fill key leadership positions.
    I would like to emphasize again that it is imperative that VA, and 
specifically VHA, receive the necessary support that is required to 
adequately care not only for the veterans enrolled today but also the 
anticipated million more veterans in the next year or two that will 
also require medical assistance. The bottom line is VA may require an 
increase in budget for more doctors, nurses, therapist, technicians and 
possibly facility expansion.
    Some outsourcing may be possible and or encouraged; however, we 
should not bank on sending veterans to outside doctors and facilities 
as the magic answer or cure. If overdone, we will be sending veterans 
out of a compassionate veteran centric environment and placing them in 
the ``for profit'' corporate medical system. Any outside provider would 
come with its own set of problems with not guarantees of significant 
appointment time reduction or better quality of care.
    As the IG inspection results are made available and VA recommends 
or implements corrective measures of improved procedures in the VA 
Health Care system, NASDVA looks forward to participating as co-
partners or facilitators. We can help veterans become more informed 
about their benefits as well as how to be enrolled and receive the care 
they have earned and need.
                               conclusion
    Mr. Chairman and distinguished Members of the VA Committee the 
State Directors of Veterans Affairs remain dedicated to doing our part. 
Thank you for including NASDVA in this very important hearing.

    Chairman Sanders. Admiral, thank you very much.
    We now have from the Government Accountability Office their 
Director of Health Care, Debra Draper. Thank you.

   STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, U.S. 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Draper. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, I appreciate the opportunity today to 
discuss access to care problems in VA that may delay needed 
medical care for our Nation's veterans.
    For over a decade, GAO and others, including VA's Inspector 
General, have reported that VA medical centers do not always 
provide timely care. In some cases, these delays have resulted 
in harm to veterans.
    Across our work on access to VA health care, several common 
themes have emerged: weak and ambiguous policies and processes, 
which are often subject to interpretation, resulting in 
significant variation and confusion at the local level; 
antiquated software system that do not facilitate good 
practices; inadequate training; unclear staffing needs and 
staffing allocation priorities; and inadequate oversight that 
relies largely on facility self-certification and use of 
unreliable data for monitoring.
    In 2012, we reported that VA's wait times were unreliable 
because scheduling staff did not always correctly record the 
required appointment desired date, the date on which the 
veteran or provider wants the veteran to be seen. This is due, 
in part, to lack of clarity in the scheduling policy on how to 
determine and record the desired date, a situation made worse 
by the large number of staff who can schedule appointments, 
more than 50,000 people at the time of our review.
    During our site visits to four medical centers, we found 
that more than half of the schedulers we observed did not 
record the desired date correctly, which may have resulted in 
reported wait times shorter than what veterans actually 
experience. Some staff also told us they changed appointment 
desired dates so that the wait times aligned with VA's related 
performance goals.
    We also identified other problems in how the scheduling 
policy was implemented. For example, we found follow-up 
appointments being scheduled without ever talking to the 
veteran, who would then receive notification of their 
appointment through the mail. In addition, we found that the 
scheduling system's electronic wait list was not always used to 
track new patients, putting these patients at risk for delayed 
care or not receiving care at all. We also found that the 
completion of required training was not always done, although 
officials stressed its importance.
    Additionally, we found a number of other factors that 
negatively impacted the scheduling process. For example, 
officials described the VISTA software system used for 
scheduling as antiquated, cumbersome, and error-prone. We also 
found shortages and turnover of scheduling staff, provider 
staffing shortages, and high telephone call volumes without 
sufficient staff dedicated to answering these calls.
    We recommended VA take actions to improve the reliability 
of its medical appointment wait time measures, ensure the 
consistent implementation of its scheduling policy, allocate 
scheduling resources based on needs, and improve telephone 
access for medical appointments. VA concurred with our 
recommendations and told us they are taking steps to address 
them. We are pleased that actions are being taken, but 
substantially more progress is needed to ensure timely access 
to care.
    We are currently conducting work examining VA's management 
of specialty care consults, which is a type of medical 
appointment. Our preliminary work has identified a number of 
problems, including delays in care or care not being provided 
at all at each of the five medical centers included in our 
review, unreliable specialty care consult data, and systemwide 
closure of 1.5 million consults older than 90 days with no 
documentation as to why they were closed. We expect to publish 
our findings related to this work this summer.
    As the demand for VA health care continues to escalate, it 
is imperative that VA address its access to care problems. 
Since 2005, the number of patients served by VA has increased 
nearly 20 percent, and the number of annual outpatient medical 
appointments has increased by approximately 45 percent. In 
light of this, the failure of VA to address its access to care 
problems, including the accurate tracking and reporting of wait 
times at specialty care consults, will considerably worsen an 
already untenable situation.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.
    [The prepared statement of Ms. Draper follows:]
  Prepared Statement of Debra A. Draper, Director, Health Care, U.S. 
                    Government Accountability Office

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman Sanders. Thank you very much, Ms. Draper.
    Phillip Longman is a Senior Research Fellow at the New 
America Foundation. Mr. Longman, thanks so much for being with 
us.

   STATEMENT OF PHILLIP LONGMAN, SENIOR RESEARCH FELLOW, NEW 
                       AMERICA FOUNDATION

    Mr. Longman. Thank you, Chairman Sanders and the other 
Members of the Committee, for giving me this opportunity.
    I am a little different from the other panelists you have 
heard today in that I am not a veteran. I am not affiliated 
with VA in any way. I am not affiliated with Veterans Service 
Organizations. I am here because I wrote a book, now in its 
third edition, called Best Care Anywhere: Why VA Care Would Be 
Better for Everyone. I think the title pretty much speaks for 
itself and I stick by it today.
    The inspiration for my book came from losing my wife, 
Robin, to breast cancer in 1999. Robin was treated in one very 
prestigious corner of the American health care system right 
here in Washington, DC. Suffice it to say that what I saw 
during the 6 months between her diagnosis and demise caused me 
to become radically interested in the questions of medical 
quality and safety.
    Now, shortly after Robin died, the Institute of Medicine 
issued a report that has been alluded to here already today 
showing that up to 98,000 people a year in the American health 
care system are killed by medical errors. That is equivalent to 
a jumbo jet falling out of the sky and killing everybody on 
board every third day. It goes on year in and year out. More 
recently, the Chairman has alluded to other estimates showing 
that as many as a quarter-million people a year are killed by 
various forms of over-treatment, mistreatment, maltreatment, 
under-treatment in the American health care system, making 
contact with the U.S. health care system the third leading 
cause of death in the United States, after all cancers and all 
heart disease.
    So, I set out at some point to find out who is doing a 
better job, and I was very surprised to find, after reviewing 
the literature on health care quality and talking to many 
experts, talking to many veterans and such, that the VA Health 
Care System, by many, many metrics, outperforms the rest of the 
U.S. health care system as a whole, and the proceedings today 
seem to have come to a broad consensus that VA health care in 
itself has exceptionally high quality. The problems we are 
dealing with here are access.
    So, I will not really belabor the point. I will want to 
say, though, that I would have welcomed Robin's being treated 
in a hospital that had an Inspector General. Would that not 
have been wonderful? Would it not have been wonderful if there 
had been a committee of Congress, or maybe even two committees 
of Congress that exercised oversight of that hospital? Would it 
not have been great if there were various broad-based, 
effective citizens' organizations akin to the American Legion 
that have applied scrutiny to that corner of the American 
health care system? So, we have to bear in mind what the 
context here is.
    I also would want to draw attention to the fact that when 
we have a problem of someone gaming a metric on wait times or 
gaming some other metric that VA applies, that is because there 
is a metric, right. I mean, in the rest of the health care 
system, by and large, there are no quality metrics that are 
exercised, let alone wait times. It took me 2\1/2\ years to 
find a primary care physician in Northwest Washington who is 
still taking patients. Robin waited for a mammogram long enough 
for her tumor to grow from this size to this size [indicating], 
right. Many people in the United States today--most people in 
the United States--live in places where there are acute primary 
care shortages, right. We have a tremendous problem of access 
to begin with.
    My final point, I will just say, too, is that on the 
waiting times so much of what we are doing is trying to 
determine whether somebody has a service-related disability or 
not, right. Is the reason you are losing your hearing because 
of the artillery fire that you heard in Vietnam or because of 
all The Who concerts you went to in the 1960s? We have just a 
tremendous administrative machine that adjudicates that kind of 
question, and that is where most of these veterans are getting 
ground down, waiting to get into the VA. How much smarter would 
it be if we just opened up VA to all veterans and said, thank 
you for your service. Come on in.
    Thank you very much.
    [The prepared statement of Mr. Longman follows:]
   Prepared Statement of Phillip Longman, Senior Fellow, New America 
  Foundation, Author: Best Care Anywhere: Why VA Health Care Would Be 
                          Better for Everyone
    Chairman Sanders, Ranking Member Burr and distinguished Members of 
the Committee. I greatly appreciate the opportunity to testify in these 
critical hearings.
    I am not a veteran nor a VA employee. I am also not affiliated with 
any veterans service organization. Instead, the perspective I bring 
comes from my having written a book about the transformation of the VA 
health care system. The book, now in its third edition, is called Best 
Care Anywhere: Why VA Health Care Would be Better for Everyone.
    The inspiration for the book came from my experience in losing my 
first wife, Robin, to breast cancer, in 1999.
    Robin was treated at a highly renowned cancer center here in 
Washington DC. I never blamed her doctors for her death. But suffice it 
to say that what I saw of this one prestigious corner of the American 
health-care system caused me to become extremely alarmed the problem of 
medical errors and poorly coordinated care.
    Shortly after Robin's death, the Institute of Medicine issued a 
landmark report in which it estimated that up to 98,000 Americans are 
killed every year in hospitals as a result of medical errors . That's 
like three jumbo jets crashing every other day and killing all on 
board.\1\
---------------------------------------------------------------------------
    \1\ Corrigan J, et al, eds. To Err Is Human: Building a Safer 
Health System. Washington, DC: Institute of Medicine, the National 
Academies Press; 2000; and editorial, Preventing fatal medicl errors, 
New York Times, December 1, 1999, p. 22a.
---------------------------------------------------------------------------
    Then came another report published in the Journal of the American 
Medical Association, which looked not just at hospitals, but at the 
American health care system as a whole. It estimated that through a 
combination of under-treatment, over-treatment, and mistreatment, the 
U.S. health care system is killing 225,000 Americans per year. To put 
that in perspective, it means that contact with the U.S. health system 
is the third-largest cause of death in the United States, following all 
heart disease and all cancers.\2\
---------------------------------------------------------------------------
    \2\ Starfield B. Is US health really the best in the world? Journal 
of the American Medical Association 2000; 284(4): 483-485.
---------------------------------------------------------------------------
    These reports, combined with my personal experience, put me on a 
quest to find out who had the best workable solutions to America's 
dysfunctional and dangerous health care delivery system.
    The answer that emerged was not one I expected. But as study after 
after study now confirms, the VA system as a whole outperforms the rest 
of the health care system on just about every metric that health care 
quality experts can devise. These include adherence to the protocols of 
evidence-based medicine, investment in prevention and effective disease 
management, use of integrated electronic medical records, and, 
importantly, patient satisfaction.
    Just how the VA transformed itself is an inspiring story, involving 
front-line employees bringing about a revolution from below, as well as 
courageous leadership at the top, particularly during the period when 
Dr. Kenneth Kizer headed the Veterans Health Administration.
    As I also explain in my book, important structural factors were at 
work as well. For example, the VA has a nearly lifelong relationship 
with most of its patients and does not profit from from their 
illnesses. This gives it incentives to keep its patients well--
incentives that are sorely lacking in most of the rest of the health 
care system. If the VA doesn't teach its patient how to effectively 
manage their diabetes, for example, it becomes liable down the line for 
the cost of their amputations, renal failures, and all the other long-
term complications of the disease.
    Now, of course, bad medicine does happen at the VA, and when it 
does those who may be responsible need to be throughly investigated. 
But when such breakdowns occur, we should always put them in context by 
asking: ``Compared to what?''
    As we've seen, U.S. health care system outside of the VA is 
exceptionally dangerous. It would have been great,for example, if the 
private hospital that treated my wife had been been under the scrutiny 
of an Inspector General, whose full-time job it was to look out for 
failures in patient care. But of course, private hospitals don't have 
I.G.s.
    Similarly, if a committee of Congress such as this one was 
specifically focused on the quality of care provided by that hospital, 
that oversight would have likely helped the institution to become more 
accountable. Or again, more mistakes would undoubtedly have come to 
light at that hospital and many others if effective watchdogs group 
akin the American Legion looked out for the interest of non-VA 
patients.
    But, of course, that kind of scrutiny does not occur. And this 
asymmetry creates a perverse result. For the average news consumer it 
can lead to the impression that the VA is limping along from one 
scandal to the next, even as its patients and health-care quality 
experts applaud its superior quality, safety, and cost-effectiveness.
    Finally, I'll close by pointing out another way in which context is 
often missing in discussion of VA health care. Overwhelmingly, the 
failures of the VA in recent years haven't been about the quality of 
health care for those who get covered. Instead, they've mostly been 
about the excessive waiting times, and excessive red tape that our vets 
must go through to establish eligibility.
    Here, the Veterans Benefits Administration must accept blame for 
not doing a better job of streamlining administrative procedures. But 
in all fairness, it is Congress, and by extension the American people 
as a whole, who have established the laws that require most vets to 
prove that they have service-related disabilities before becoming 
eligible for VA care.
    This is the perverse root cause of the waiting time and other 
problems of access. Who can say if a Vietnam vet is losing his hearing 
due to expose to too much artillery fire, or exposure to too many Who 
concerts?
    We need to open up the VA and grow it, extending no-questions-asked 
eligibility not only to all vets but to their family members as well. 
This not only makes clinical sense, it also makes economic sense. So 
long as the VA remains one of, if not the most, cost-effective, 
scientifically driven, integrated health care delivery systems in the 
country, the more patients it treats, the better for everyone.

    Chairman Sanders. Thank you very much, Mr. Longman.
    I thought all the testimony was excellent. Thank you all 
for the high-quality testimony.
    Mr. Griffin, a few questions. Thank you very much for 
plunging into this investigation, in a sense, on short notice. 
Briefly, let me reiterate--you and I have chatted on the 
phone--do you have the necessary resources to undertake the 
kind of thorough investigation that needs to be done regarding 
Phoenix?
    Mr. Griffin. Yes, sir. [Off microphone.]
    Chairman Sanders. Please use your microphone.
    Mr. Griffin. Yes, we do. We have, under Dr. Daigh's 
direction, 120 medical clinicians, who, for a number of years, 
have been doing reviews of VA medical centers, a 1974 West 
Point graduate, 26 years as an Army doctor, and 10 years with 
us.
    Chairman Sanders. OK.
    Mr. Griffin. The reason the IG system was set up the way it 
was is so that you will have people who have knowledge of the 
Department, and that is why we are the right group to do this 
review.
    Chairman Sanders. Let me ask you this. I think you have 
heard from almost all of the Members here the desire for you to 
do a thorough examination and investigation, and also to do it 
in a timely manner. Now, when you told us a few moments ago 
that you do not think you can do that until August, is there 
any way you can give us some preliminary information before 
that, maybe a preliminary report, because I think many of the 
Members would like to get a sense of what you have found out 
there.
    Mr. Griffin. As the review progresses, if there appears to 
be a seam where it would be appropriate for that to happen, we 
would do that. But, remember, part of this review could lead to 
criminal charges being brought and we do not want to do 
anything to jeopardize the ultimate outcome of the facts in the 
case.
    Chairman Sanders. Let me ask you this, and maybe it is 
premature, but if you could answer, I would appreciate it. You 
know, what we have been reading in the media, and I will quote 
from one media report, ``At least 40 U.S. veterans died waiting 
for appointments at the Phoenix Veterans Affairs Health Care 
System, many of whom were placed on a secret waiting list.'' At 
this particular point, can you tell us how many people you have 
identified who died while waiting on a secret waiting list?
    Mr. Griffin. I cannot give you that number because the 
number 40 that has been wildly quoted in the press does not 
represent the total number of veterans that we are looking at. 
That was one list that was created by the facility. We need to 
do an analysis of that list, both death records and VISTA 
records, by Dr. Daigh's clinicians. But, there are also other 
people who have come through the Congress, who have come 
through the media, who have come through our hotline. So, we 
have multiple lists, none of them identical.
    We have begun to process on a preliminary basis of going 
through those lists. And the initial list that we were given, 
we have gone through, and there were only 17 names on that 
list. Our review to-date--we have more work to do on this 
because we want to have more than one set of eye look at all of 
the records--but on those 17, we did not conclude so far that 
the delay caused the death. It is one thing to be on a waiting 
list and it is another thing to conclude that as a result of 
being on the waiting list, that is the cause of death, 
depending on what the illness might have been at the beginning.
    Chairman Sanders. So, at this point, the one list of 17 
names that you have looked at has not, at this point, 
identified anybody who has died as a result of being on a 
waiting list and not getting----
    Mr. Griffin. That is right, for our initial review. And I 
want to ask Dr. Daigh to expand upon that so you can understand 
the nature of these lists.
    Chairman Sanders. Right. This is complicated stuff. I do 
understand that.
    Dr. Daigh, did you want to add.
    Dr. Daigh. Well, sir, let me try. So, we have been provided 
names of people who are on various lists, and it is true that 
those veterans whose names were on the list have died. We have 
looked at a substantial number of cases, and we have in looking 
at those cases determined that, yes, there was a delay in care 
frequently, as has been expressed. We have, in several cases, 
found that the quality standards were not met. In a subset of 
that, we found some patient harm. But, to draw the conclusion 
between patient harm and death has so far been a tenuous 
connection.
    The records that we have looked at to date are mostly VA's 
medical records. So, to the extent that a patient died, we are 
in the process of getting death certificates and autopsy 
reports, if they were in another hospital then there are 
procedures we need to go through to get the rest of those 
records. We may need to interview people who are knowledgeable 
about the events surrounding the death.
    So, it is a serious problem and it is going to just take my 
staff a little time to work through so that what we say, we can 
stand by, and that you are happy with the result.
    Chairman Sanders. OK. Thank you very much.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Ms. Draper, in the GAO report regarding outpatient 
appointment and wait times and scheduling, the conclusion 
states, ``Unreliable wait time measurements has resulted in a 
discrepancy between the positive wait time performance VA has 
reported and veterans' actual experience.'' Now, this VA report 
that you are talking about was the report that was presented to 
the VA in December 2012.
    Ms. Draper. That is correct.
    Senator Burr. It became a public document in January 2013, 
correct?
    Ms. Draper. That is correct.
    Senator Burr. And, what I have said so far about your 
comments on it are accurate. Am I right?
    Ms. Draper. That is correct.
    Senator Burr. OK. In this report, GAO recommended, ``The 
Secretary of VA direct the Under Secretary of Health to take 
actions to improve the reliability of wait time measures,'' and 
it went on to suggest, ``The Secretary of VA direct the Under 
Secretary of Health to take actions to ensure the VAMCs 
consistently and accurately implement VA's scheduling policy.'' 
That is accurate?
    Ms. Draper. That is correct.
    Senator Burr. Ms. Draper, for the two recommendations, VA 
specified in their comments that these recommendations had a 
targeted completion date of November 1, 2013. Let me ask you, 
based upon the knowledge that you have today, has this process 
at VA been completed as it relates to those two actions in your 
report from December 2012?
    Ms. Draper. It has not been fully completed.
    Senator Burr. And, is this an ongoing conversation with VA 
about the completion of----
    Ms. Draper. It is. I mean, they have told us they have 
taken steps, and we provided that in our written testimony, 
about the update on where they say the recommendations are. You 
know, to be quite frank, it has been almost a year and one-
half. We would have expected more progress to have been made.
    Senator Burr. I think most of the Members of this Committee 
would probably say that they associate with that statement.
    Mr. Griffin, thank you for serving in an acting capacity. 
You are a stand-up guy and I just want you to know this Member, 
and I think I can speak for all Members, we have got great 
confidence in what you and your team will do, can produce, the 
accuracy of it, and the reliability of it. I want you to 
understand that and please share that with the folks that are 
working so hard.
    Mr. Griffin. Thank you, Mr. Burr.
    Senator Burr. Do you, or did your predecessor, have a 
regular scheduled meeting with the Secretary?
    Mr. Griffin. We have meetings with the entire leadership 
team every 2 weeks. My predecessor went to one; I went to the 
other one. And we have had occasional meetings with the 
Secretary at different times during the year.
    Senator Burr. So, how many meetings have you had with the 
Secretary since the issue of Phoenix arose and you mobilized 
this IG review there?
    Mr. Griffin. Well, we had one meeting that was unconnected 
to the review. It was a budget-related meeting. And we had a 
second meeting when I went over to request that certain 
individuals be put on admin leave.
    Senator Burr. But, from a standpoint of the actual 
investigation, the scope of it, all of that, who has handled 
that from a standpoint of----
    Mr. Griffin. During the course of the admin leave 
discussion, I gave an overview, not unsimilar to the seven 
bullets that I mentioned here, as to what we were going to be 
looking at. I would expect to be asked what is your basis for 
requesting that I put someone on admin leave. I think that was 
completely appropriate. But, I think, in the Secretary's words, 
we are independent and we cannot be told to do or not do 
something because it would violate our independence.
    Senator Burr. I understand that. So, when the Phoenix 
report is finished, if it happens like every other IG report, 
will you or your staff physically sit down with the Secretary 
and brief him on the findings of that IG report?
    Mr. Griffin. Not on every report, but certainly, a report 
of this magnitude. We issue probably 300 reports a year----
    Senator Burr. And how many----
    Mr. Griffin. Not all of them would rise to that level. But 
we do--at the Assistant Inspector General level, Dr. Daigh 
meets with the VHA senior staff on a recurring basis to discuss 
these things. As we just heard about the process of getting 
closure on reports, there is an ongoing follow-up process that 
our personnel do until we are satisfied that they have taken 
corrective action.
    Senator Burr. How many years have you been in VA at some 
capacity in the IG's Office?
    Mr. Griffin. About 13 out of the last 16 years.
    Senator Burr. And, how many times have you sat down with a 
Secretary and briefed them on an IG report?
    Mr. Griffin. Oh, I would say a report of this magnitude, I 
would brief him on maybe a couple times a year, depending on--
again, there are 300 reports--I would say, maybe, at most, 
quarterly.
    Senator Burr. On a report, or on multiple----
    Mr. Griffin. On a report, but the door is open. It is just 
the issues typically are resolved at the Under Secretary level.
    Senator Burr. Have you ever requested a meeting with a 
Secretary while you have been there and the meeting was not 
made available to you?
    Mr. Griffin. No.
    Senator Burr. OK. I thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Burr.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I want to thank, 
as with this panel, I want to thank you for your testimony.
    Mr. Griffin, you said you have 120 medical investigators. 
Are there more investigators than that?
    Mr. Griffin. We have about 615 personnel in the IG 
organization. One hundred twenty of them work for David and 
they are health care inspectors. They are doctors. They are 
nurses. They are psychiatrists, psychologists, clinicians----
    Senator Tester. How many people----
    Mr. Griffin [continuing]. Physical therapists. We have 
about 150 criminal investigators. We have people in 39 cities 
around the country.
    Senator Tester. Got you.
    Mr. Griffin. We have over 200 auditors.
    Senator Tester. Let me cut to the chase.
    Mr. Griffin. OK.
    Senator Tester. How many people are working on this 
investigation----
    Mr. Griffin. So far----
    Senator Tester [continuing]. Total?
    Mr. Griffin. So far, 185 people have touched this 
investigation.
    Senator Tester. You have been working on it for how many 
weeks so far?
    Mr. Griffin. This is the third week.
    Senator Tester. Your testimony said you anticipate a final 
by August?
    Mr. Griffin. That is correct.
    Senator Tester. Do you anticipate a preliminary report 
before that?
    Mr. Griffin. To the extent that it will not impact----
    Senator Tester. Got you.
    Mr. Griffin [continuing]. The outcome of the work, to 
include the fact that we are working with two different groups 
from the Department of Justice, looking at possible criminal 
violations.
    Senator Tester. OK. I want to talk a little bit about 
senior management staff, including the Secretary in the VA. 
Have you--in this investigation, have you asked those folks for 
information?
    Mr. Griffin. No, we have not.
    Senator Tester. OK.
    Mr. Griffin. I mean, we----
    Senator Tester. Go ahead.
    Mr. Griffin. We did ask them for a list that they suggested 
to us that they had of veterans who died on an electronic list, 
but----
    Senator Tester. Have--let me put it this way.
    Mr. Griffin. OK.
    Senator Tester. This is where I want to get to. Have they 
been open and transparent and--what is the other word I am 
trying to think of--helpful in your investigation?
    Mr. Griffin. Yes, they have, and they have offered 
resources, but we do not want to give anyone the impression 
that our independence is in question, so we have not received 
any resources, nor do I intend to.
    Senator Tester. But, as far as up to this point, being 
fully transparent with what you need, when you ask, they 
deliver?
    Mr. Griffin. That is correct.
    Senator Tester. OK. Has there been any--maybe you can say 
this, maybe you cannot, if you cannot, do not--but, has there 
been any sign that, up to this point, that there has been two 
sets of books run on appointments?
    Mr. Griffin. I think that over the past 8 or 9 years--there 
are a list of reports that were mentioned earlier where we 
found that waiting times were not being accurately reported, 
most recently, on mental health, where it was reported at a 95 
percent level. We looked at the exact same data and concluded 
it was 49 percent. So, it is not a new issue and I am confident 
that when we finish our work in Phoenix, it will be the same 
outcome as these previous reports.
    Senator Tester. OK. That is all, Mr. Chairman. I would just 
say, we look forward to the investigation. I know you need the 
time to do it right. Of course, in the society we live in, this 
case is already being litigated and convicted every day in the 
news media by some. So, it will be great to get the facts out 
there so that we can help VA do their job better to serve the 
veterans who served this country so well. Thank you all for 
being here.
    Mr. Griffin. Understood, and the only thing I can say about 
the rush is we are not going to rush to judgment at the 
sacrifice of quality. I know you are not suggesting that.
    Senator Tester. No.
    Mr. Griffin. We are going to nail this thing, and at the 
end, we will have a good product for you.
    Senator Tester. Yes, and at the sacrifice of people who are 
innocent. Thank you.
    Mr. Griffin. Sure.
    Chairman Sanders. Thank you.
    Senator Moran.
    Senator Moran. Mr. Chairman, I understand there is only a 
minute or so left in the vote that has been called, so I will 
try to summarize very quickly.
    Ms. Draper, and then I will follow up with Mr. Griffin, the 
GAO reports, what is the process by which you have assurance 
that your report is acted on by the Department of Veterans 
Affairs? What is the follow-through, and what has been the 
result of GAO reports at the VA?
    Ms. Draper. Yes. For the report that we issued, it was 
publicly released in January 2013. We did a follow-up. They 
issue a 60-day letter on the status of the recommendations, so 
we do have that. Then we provided Congressional testimony for 
the House Committee in April. We followed up with VA to get an 
update on where the recommendations were. So, we have periodic 
updates with VA on the status of the recommendations.
    Senator Moran. You testified earlier about this particular 
report and its current status. About other GAO reports, do you 
have a sense that the VA is successful, or useful--that your 
report is useful and they are successful in implementing the 
proposals that you suggest?
    Ms. Draper. It varies. I think that we have quite a number 
of open recommendations at VA at this time across GAO.
    Senator Moran. Mr. Griffin, in regard to the IG's report, 
what--how are you able to determine whether or not your report 
and its suggestions, its recommendations, are followed through 
by the Department of Veterans Affairs?
    Mr. Griffin. We do it in two different ways. In some 
instances, we will review--if we say, you need a new policy on 
staffing, or you need a new policy on waiting times, or you 
need to train the schedulers and you need to create a 
methodology where you can audit the scheduling process to make 
sure someone is not cooking the books, if they can satisfy us 
that, here is the new policy and here is how we are going to 
make this work, we may close out at that time. More often, if 
we do not have a comfort level, we will send a team back 6 
months later and go to the same facilities to see if the fixes 
are in place.
    Senator Moran. What is your sense--in your time as Acting, 
or if you have information about your predecessor--what is your 
sense of the Department of Veterans Affairs following the 
recommendations and implementing them following an IG report?
    Mr. Griffin. The answer is mixed. I think, frequently, 
policies emanate from Washington. The policies look good on 
paper, but they are not always followed by the managers in the 
field. So, it is an accountability question for the field 
managers; when they do not follow it, something needs to 
happen.
    Senator Moran. One of the things that I do not think you 
have anything to do with, but is an important component of an 
investigation of the Department of Veterans Affairs, would be 
the Office of Medical Inspector reports, and one of the things 
that we have discovered is that those are not made public and 
not submitted to Congress, so we do not know the results of 
those types of audits, investigations, or reviews. I am 
pursuing legislation to change that so we can see what that 
report says. We can excise the names and keep the 
confidentiality of patients straight, but I think there is a 
whole set of other reports that there is no ability for us to 
gauge whether or not a recommendation is followed.
    Let me just ask, in conclusion, Mr. Griffin, are there IG 
investigations ongoing that involve facilities in Kansas?
    Mr. Griffin. I would like to take that for the record. I 
know that we have, in the past week and a half, our criminal 
investigators, who are located around the country, have had a 
rapid response to ten new allegations. And in the matter of 2 
days over the previous week, they went to 50 medical centers, 
unannounced, in order to see if what was being alleged was 
occurring at those facilities, so----
    Senator Moran. I would be happy to know that. I actually 
was referring to more--not necessarily a current investigation 
beginning as a result of the current circumstance, but over the 
last year or so. The reason I asked the question is that there 
have been allegations of incidents, circumstances, consequences 
within the VA in my State, and our effort to find out what is 
going on, what response has the Department taken as a result of 
at least these stories that are out there, we have never 
received a response from anyone at the Department of Veterans 
Affairs, either here in Washington from the Secretary in his 
testimony or with Kansas officials, individuals who work at VA 
within our State. And, I do not know whether or not any of 
those circumstances that are at least part of a conversation 
are being investigated by you. If you would follow up with me, 
that would be----
    Mr. Griffin. I will. The majority of our audit and health 
care reports go to the member whose district that facility is 
located in. Some of the criminal reports take longer because of 
the judicial process and privacy issues involved with the 
criminal cases. You may or may not see quickly----

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Mr. Griffin, I apologize for interrupting 
you. I think there are 95 Senators waiting for us to vote.
    This was a great panel and I very much appreciate the 
wonderful testimony. Thank you all very much.
    The hearing is adjourned.
    [Whereupon, at 2:07 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


          Prepared Statement of Hon. John D. Rockefeller IV, 
                    U.S. Senator from West Virginia
    Thank you, Chairman Sanders and Ranking Member Burr, for holding 
this important hearing. And thank you, Secretary Shinseki, for coming 
to speak with us today.
    Secretary Shinseki, I think your record speaks for itself. You and 
your leadership have been working tirelessly on behalf of veterans has 
helped improve the VA health care system by leaps and bounds.
    I will be honest with you, I am deeply troubled by the increasing 
reports of employee misconduct in VA facilities around the country. 
Stories like these, with the worst allegations coming from the VA 
facilities in Phoenix, are incredibly worrisome. They call into 
question our country's ability to address the needs of our veterans, 
and they damage the reputation of a system that has made great strides 
over the past few years.
    If these reports are true, then appropriate action must be taken. 
Our veterans and their loved ones deserve nothing less.
    Amidst stories of alleged secret waiting lists and falsified 
records, however, I do believe that it is important for everyone to 
remember one key fact: the VA treats millions of veterans every year, 
and it treats them exceptionally well. I know that the men and women 
employed by the VA--from the doctors to the nursing staff to the people 
who work in admission--are working day and night to improve the health 
of our veterans and honor their service. It is important not to forget 
this.
    Currently, the VA faces major challenges. More people are enrolling 
in the VA than ever, and many of them have complex injuries. If the VA 
does not have enough doctors to see these patients, then these problems 
are a result of a lack of funding. And that is something that we in 
Congress can blame no one for but ourselves.
    I applaud this Administration for its continued commitment to 
providing funding for veterans. The request for a three percent 
increase reflects the largest increase for any agency in the 
President's budget request. But if we're being honest about the needs 
of the VA, a three percent budget increase is not enough. As tens of 
thousands of our troops continue to come home--some with mental health 
problems or severe, debilitating wounds--we're funding an agency with 
incredible demands and health care costs at only half of our entire 
military budget.
    We have a moral obligation to take care of our veterans. However, 
this Congress has been falling short of its obligations to care for our 
veterans when they return. And recently, it seems that it's only during 
crisis situations that we are forced to look at how we are prioritizing 
the care and long-term health of those who have fought for our country.
    That is not to say that swift action must not be taken if the 
Inspector General determines there has been misconduct at the VA. But 
for as long as we continue to underfund the VA, I firmly believe 
problems will continue to arise.

    Thank you.
                                 ______
                                 
               Prepared Statement of Hon. Sherrod Brown, 
                         U.S. Senator from Ohio
    Thank you, Mr. Chairman, for holding this important hearing and for 
your leadership of this Committee.
    I want to thank the VSO leaders who are testifying today and 
Secretary Shinseki for your continued commitment to serving our 
Nation's veterans.
    We've heard some very serious allegations made against the VA. And, 
like any allegation, we are investigating the claims so we can ensure 
VA healthcare is the best possible care for our veterans.
    The Inspector General said it would take a few months, perhaps as 
late as August, to do a tough, fair, independent investigation. But 
three months is too long when it comes to honoring our veterans. That 
is why this hearing is so important.
    VA and this Committee are not sitting idly by until we hear from 
the IG.
    The Secretary has taken these allegations very seriously. He 
requested the IG investigation. He removed employees accused from 
patient care responsibilities, placed several more on administrative 
leave, and ordered the Veterans Health Administration to complete a 
Nation-wide access review.
    And, this Committee is performing its constitutional duties that 
include rigorous oversight, of which this hearing is a part.
    So many of us admire the work done by Veterans Service 
Organizations. Their commitment to veterans cannot be questioned.
    I was extremely troubled when I heard the allegations of wait lists 
leading to patient deaths and of employees allegedly cooking the books. 
These are serious claims.
    If true, there must be reforms and serious consequences. And if 
true, this Committee will act swiftly and decisively.
    But we should be cautious not paint the entire VA system with a 
broad brush--many VA workers serve our veterans honorably every day.
    The Veterans Health Administration operates more than 1,700 sites, 
and conducts approximately 236,000 health care appointments each day. 
This amounts to approximately 85 million appointments each year.
    We also know that Secretary Shinseki has a strong commitment to our 
veterans and our Nation as well.
    We are short on time, so I will conclude my remarks and look 
forward to hearing from you.

    Thank you Mr. Chairman.
                                 ______
                                 
             Memorandum Submitted by Hon. Johnny Isakson, 
          U.S. Senator from Georgia, Memorandum for the Record

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
  Prepared Statement of Hon. John Boozman, U.S. Senator from Arkansas
    Chairman Sanders and Ranking Member Burr, thank you for this 
opportunity and the dedicated work of the Veterans' Affairs Committee. 
I enjoy serving with you both and all the Members of this Committee, 
and I look forward to reviewing the testimony from today's hearing with 
Secretary Shinseki on the state of VA health care. Regretfully, I am 
unable to attend, as I am in Arkansas, recovering from a recent 
surgery. I appreciate Secretary Shinseki's willingness to come before 
our committee and address our questions and deep concerns so we are 
able to move forward and better serve our veterans.
    Last week I sent a letter to Secretary Shinseki expressing my 
disappointment regarding recent allegations of ``secret'' wait lists 
and preventable veteran deaths. I have asked Secretary Shinseki for 
assurances that none of these deplorable practices are happening at VA 
medical centers (VAMCs) used by Arkansas veterans, and have yet to 
receive an acknowledgement that he even received my letter. I anxiously 
await its arrival, and a response.
    I understand that in most respects VA does provide good care, when 
and where it is actually available. Additionally, I know that employees 
in various roles at VA, like me, strongly support those who have served 
our Nation in uniform and believe the Federal Government should uphold 
all of its promises to our veterans and extend the best timely care to 
them. However, as recent reports indicate, this is not happening. This 
is a clear access problem, and warrants a full analysis of the future 
of VA health care as part of our effort at solving immediate problems. 
I have reservations about the ability of VA's ``face to face'' audits 
to produce meaningful reform that will increase access for veterans and 
bring accountability to the process. I am supportive of rigorous 
oversight by this Committee and I look forward to working with all of 
my colleagues on both the House and Senate Veterans' Committees, in 
consultation with the Department of Veterans Affairs, to ensure that 
these systemic problems are fixed.
    In conclusion, we need to be thoughtful about our responsibilities 
and cautious about our steps forward in regard to these very important 
issues. As always, I appreciate opportunities to work together and I 
will be reviewing the testimony and the record of today's hearing to 
begin that process.
                                 ______
                                 
  Letter from Diane M. Zumatto, National Legislative Director, AMVETS


      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                           ______
                                 
                Letter from Ronald E. Brown, President, 
                   National Gulf War Resource Center
                         National Gulf War Resource Center,
                                      Topeka, KS, October 10, 2014.
Hon. Bernard Sanders,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.

    Dear Chairman Sanders: My name is Ronald Brown, and I am president 
of the National Gulf War Resource Center (NGWRC). I would like to 
submit testimony concerning issues our Gulf War Veterans from 
Operations Desert Shield/Storm (ODS) face daily at the Department of 
Veterans Affairs hospitals.
    Numerous ODS Veterans experience long waits to see doctors--
particularly specialists--and have a hard time receiving compensation 
benefits. In general, they don't receive proper medical care compared 
with other groups of veterans. Many ODS Veterans have been fighting for 
23 years for benefits they earned from the honorable service they 
provided. Due to this honorable service, many are sick from exposures 
experienced on the most toxic battlefield in our Nation's history of 
warfare. NGWRC sent surveys to Veterans concerning their VA hospitals, 
and they responded to us that the issues exist and happen to Gulf War 
Veterans across the country. NGWRC wants to address problems and bring 
solutions to fix issues, ensuring that our veterans' health care is the 
best in the world.
    In January 2014, NGWRC suggested solutions to the VA during a 
meeting with Principal Deputy Under Secretary for Health, Dr. Robert L. 
Jesse. If implemented, these solutions--derived from surveys from our 
Veterans--would help them at VA hospitals across the country. Issues 
these Veterans brought forward were:

          1. Primary Care Providers (PCP) must be better trained on 
        illnesses due to toxic exposures during Desert Storm. Many PCP 
        doctors are not properly trained to provide care Veterans need 
        for illnesses they suffer from due to environmental exposures. 
        Many ODS Veterans feel their PCP does not believe them when 
        they tell medical professionals their problems, yet science 
        shows that Gulf War Illness is a physiological condition and 
        not a psychological issue. Many Veterans, however, are still 
        treated like it is a psychological issue. An ill Veteran should 
        not have to educate the PCP on research that has been done on 
        Gulf War Illness. This type of treatment must change, and the 
        NGWRC must work with the VA to help our Veterans.
          2. Veterans face long wait times for PCP visits and 
        specialist, sometimes 6 months or longer. In our surveys, one 
        Veteran responded that for clinics such as the sleep study, he 
        encountered an 8-month backlog. Other veterans reported waits 
        of 6 month or longer to referred specialty clinics like 
        Rheumatologist for Fibromyalgia or Chronic Fatigue Syndrome. 
        Some of these veterans were told they would not be seen in such 
        clinics due to a current backlog. They were also told that they 
        would have to pay out of pocket to have care provided for 
        service connected illnesses. Accountability needs to be 
        established at the upper levels of the Central Office of the VA 
        and at the lower levels within our VA hospitals. It is 
        deplorable that bonuses are issued for stellar care when it is 
        far from stellar. Chronically ill Veterans should never have to 
        wait months to get into specialty clinics or PCP follow-up 
        visits.
          3. Sadly, many claims have been denied for years due to 
        medical professionals who are not properly trained to treat 
        illnesses from which many Veterans suffer. Many Veterans feel 
        they have been left to die, which is unacceptable. These 
        Veterans are your constituents, and their voices deserve to be 
        heard. Most of our chronically ill Desert Storm veterans have 
        been voicing their concerns for two decades to the VA. They 
        find their voices fall on deaf ears. How much science must show 
        that these veterans are suffering with real illnesses before 
        they are taken seriously? How many Veterans must die from 
        cancer? What is the acceptable number of deaths before these 
        cancers can be made presumptive to their service?

    In conclusion, we are aware of the burden our VA health care system 
has on it. That will most likely get worse before it gets better, with 
the current war in Afghanistan winding down. There will be an influx of 
Veterans coming into an already overcrowded, understaffed, and 
underfunded health care system. The NGWRC feels that steps must be 
taken to relieve some of the burden on our VA health care system. This 
includes allowing Veterans to access care outside the VA with care paid 
by the VA. Another possible solution is stopping Veterans with no 
service connected disabilities who have private insurance from 
accessing VA hospital care. Most of these veterans have jobs and 
private insurance, so they can go to outside doctors for care. 
Something must be done to fix issues with the VA to ensure veterans get 
proper care and services. Our expertise, obviously, is on the 
conditions suffered by Gulf War veterans and evolving treatments. The 
NGWRC is willing to work with anyone to come up with viable solutions 
to fix these issues.
            Respectfully,
                                           Ronald E. Brown,
                                                         President.
      

                                  [all]