[Senate Hearing 113-617]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 113-617
 
                      THE STATE OF VA HEALTH CARE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 16, 2014

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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                     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

                              ----------                              

                             July 16, 2014
                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
    Prepared statement...........................................     3
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     5
    Prepared statement...........................................     7
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     8
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     9
Tester, Hon. Jon, U.S. Senator from Montana......................    10
Moran, Hon. Jerry, U.S. Senator from Kansas......................    11
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................    13
Johanns, Hon. Mike, U.S. Senator from Nebraska...................    13
Begich, Hon. Mark, U.S. Senator from Alaska......................    39
    Submitted report in Appendix.................................    79
Heller, Hon. Dean, U.S. Senator from Nevada......................    43
    Prepared statement...........................................    43
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    47
Boozman, Hon. John, U.S. Senator from Arkansas...................    49

                               WITNESSES

Gibson, Hon. Sloan D., Acting Secretary, U.S. Department of 
  Veterans Affairs; accompanied by Philip Matkovsky, Assistant 
  Deputy Under Secretary for Health 
  for Administrative Operations, Veterans Health Administration..    15
    Prepared statement...........................................    18
    Response to request arising during the hearing by:
      Hon. Johnny Isakson........................................    28
      Hon. Mark Begich...........................................    42
      Hon. Dean Heller...........................................    46
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    52
      Hon. Richard Burr..........................................    58
      Hon. Jon Tester............................................    70
      Hon. Mark Begich...........................................    74
      Hon. Richard Blumenthal....................................    76
      Hon. John Boozman..........................................    76
      Hon. Dean Heller...........................................    78

                                APPENDIX

Begich, Hon. Mark, U.S. Senator from Alaska; report dated May 
  2003 from the President's Task Force to Improve Health Care 
  Delivery for Our Nation's Veterans.............................    79
Wounded Warrior Project; prepared statement......................   105


                      THE STATE OF VA HEALTH CARE

                              ----------                              


                        WEDNESDAY, JULY 16, 2014

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room SD-G50, Dirksen Senate Office Building, Hon. Bernard 
Sanders, Chairman of the Committee, presiding.
    Present: Senators Sanders, Murray, Tester, Begich, 
Blumenthal, Hirono, Burr, Isakson, Johanns, Moran, Boozman, and 
Heller.

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

    Chairman Sanders. Let us get to work. Good morning, and 
welcome to everyone to what I think will be a very important 
and productive hearing. We welcome Mr. Sloan Gibson, the Acting 
Secretary of the Department of Veterans Affairs, who will be 
discussing with us what he has been doing in what I perceive to 
be a very active 6 weeks on the job. We also look forward to 
hearing from him as to what he perceives are the problems 
facing the VA.
    I want to mention to the Members of the Committee that next 
week, on the 22nd, we will be holding a confirmation hearing 
for Bob McDonald, the President's nominee for Secretary of VA.
    Last week despite a very partisan environment here in 
Congress, 93 Senators put their differences aside to vote in 
favor of a significant piece of legislation which we hope will 
address many of the immediate problems facing the VA. It is an 
issue that Senator McCain and I and all of us in this room 
worked very hard on, and I want to thank everybody for their 
support. It is my hope that the conference we are having with 
the House will be completed by the time we leave here for the 
August break.
    It is clear to all of us that the VA faces many, many 
challenges, and they are well documented. It is well known that 
we have many, many, many veterans in this country who are 
unable to access VA care in a timely manner. We have 
significant problems in terms of accountability. All of us find 
it totally unacceptable that people have manipulated data in 
terms of waiting times; people have treated whistleblowers in a 
contemptuous way; people have lied. That is unacceptable. We 
want to hear from Mr. Gibson in terms of what he is doing to 
address those many problems.
    The issue that I want to focus on is that while we are 
determined to do everything that we can to make the VA--which 
is a huge institution, providing 6.5 million veterans a year 
with health care--efficient and accountable, there is another 
issue that we have got to address that is also part of our 
responsibility. That is, what are the legitimate needs, what 
are the real needs facing the 22 million veterans in this 
country, and how as a Congress are we responding to those 
needs?
    So, first, the VA has got to be accountable. It has got to 
be efficient. We have got to address many of the internal 
problems that we have all heard in the last several months.
    Second, we have also got to ascertain what the problems 
facing the veterans community and their families are and do 
everything we can to make sure that the VA is on the kind of 
position that it needs to be to address those problems. Let me 
just mention some of them.
    Of the 2 million men and women who served our country, put 
their lives on the line in Afghanistan and Iraq, studies 
suggest that 20 to 30 percent have come home with PTSD or TBI. 
Simply stated, that means those wars have created some 500,000 
mentally wounded American veterans, and as a result, very 
serious problems regarding suicide--and this Committee will be 
dealing with that issue in connection with PTSD--substance 
abuse, inability to hold onto a job, divorce, emotional 
problems for the kids. When you are dealing with PTSD, it is 
not just the veteran. It is the wife, it is the kids.
    Since fiscal year 2006, the number of veterans receiving 
specialized mental health treatment has risen from just over 
927,000 veterans to more than 1.4 million in fiscal year 2013. 
This means that in fiscal year 2013 over a quarter of those 
receiving care at VA were being treated for mental health 
conditions.
    In other words, VA currently provides 49,315 outpatient 
mental health appointments a day. A day. Forty-nine thousand 
mental health outpatient appointments a day. Imagine the scope 
of that. And imagine the challenge.
    If we had an endless supply of money, if we had an adequate 
number of psychologists and psychiatrists in this country--
which we do not have--this would be a very daunting tast. And 
yet we are where we are. That is the cost of war.
    Ensuring timely access to high-quality mental health care 
is critical for our veterans and for their loved ones, and the 
stakes are high. As I have said, we are all aware--and I know 
Johnny Isakson, among others, has taken a hard look at 
suicide--it is a tragedy beyond words, not easily dealt with, 
but it is one that we have got to address.
    Like most Americans, we are all concerned about these 
horrendous waiting periods, and I know that Mr. Gibson is going 
to be talking about that in his testimony. Let me just go 
through the numbers to understand the scope of the issue that 
we are dealing with.
    More than 46,000 veterans are on lists waiting to be 
scheduled for medical appointments. More than 8,000 of them 
have waited for more than 120 days. Now, we can have an 
argument about whether 14 days was an appropriate number. I 
think it was not and that it was overly ambitious. We do not 
have the resources to deal with it. But I do not think there is 
much argument that when you have more than 8,000 veterans 
waiting over 120 days to receive an appointment date. That is 
unacceptable.
    More than 600,000 veterans have an appointment that is more 
than 30 days from the date that the appointment was initially 
requested or from the date that was desired. That is not 
acceptable. The numbers are staggering, and that is an issue 
obviously that we are addressing right now, and we will hear 
from Mr. Gibson as to how he is going to go forward with that.
    I think the goal of every Member of this Committee--and I 
would hope and expect every Member of Congress and of the 
American people--is that the veterans of this country, people 
who have suffered so much, deserve quality health care and they 
deserve it in a timely manner. What I look forward to hearing 
from Mr. Gibson is some straight, honest talk about the needs 
of the VA in achieving that goal.
    If we are talking about a staggering number of veterans 
coming home with PTSD or TBI, how many mental health workers do 
you need? And how are you going to get them? Because that is 
tough. We do not have enough doctors in this country. How many 
primary care physicians does VA need? How many specialists does 
VA need?
    If the goal is to provide quality, timely health care in a 
cost-effective manner, we need some answers from the VA, and I 
hope we will begin to get some of them today from Mr. Gibson.
    Needless to say, the other issues that I know that Members 
of the Committee are going to be asking are: what actions the 
Department has taken to reprimand employees who have lied or 
manipulated data? That is something that nobody on this 
Committee tolerates. What has the Department done to ensure 
that such manipulation no longer occurs? What has the 
Department done to improve other areas of concern identified by 
the Inspector General, the GAO, and other auditing 
organizations?
    So with that, let me give the microphone over to the 
Ranking Member, Senator Burr.
    [The prepared statement of Chairman Sanders follows:]
         Prepared Statement of Hon. Bernard Sanders, Chairman, 
                       U.S. Senator from Vermont
    Good morning and welcome to what I think will be a very important 
and productive hearing. We look forward to hearing from Mr. Sloan 
Gibson, Acting Secretary of the Department of Veterans Affairs, who 
will discuss with us what he has been doing in the last six weeks since 
he assumed that position, and what he sees as the major challenges 
facing VA in the future.
    First, I would like to take a brief moment to discuss the status of 
the Conference Committee.
                          conference committee
    Last month, despite a very partisan environment here in Congress, 
93 Senators put their differences aside to vote in favor of a 
significant piece of legislation, which Senator McCain and I worked 
very hard to craft, to address the very serious problems currently 
facing VA.
    I am confident that my colleagues on the Conference Committee will 
also put their differences aside and come together to provide much 
needed access to health care for veterans in a timely manner, and give 
the Secretary the ability to hold dishonest or incompetent senior 
officials accountable and the resources needed to increase capacity at 
VA medical facilities around the country.
    I am pleased that, in reality, there are more similarities than 
differences between the House and Senate bills. We have been making 
significant progress in the last month and I believe that we can reach 
an agreement very soon. Millions of veterans are counting on us to do 
so. We can't afford to make them wait any longer for the care and 
services they have earned and deserve.
    With that said, I would like to discuss, what I believe, are the 
biggest issues facing VA health care.
                             va health care
    VA's challenges are well-documented. As any organization would, it 
faces significant challenges in providing timely and high-quality 
health care to millions of veterans all across this country. That's why 
it's important we have some context as we begin today's discussion. VA 
is the largest integrated health care system in America.

     VA operates over 1,700 points of care, which include 150 
hospitals, 820 CBOCS, and 300 Vet Centers.
     In fiscal year 2013, VA provided 89.7 million outpatient 
visits.
     VA conducts approximately 236,000 health care appointments 
per day.

    Overall, according to veterans that I talk to in Vermont and around 
the country, according to the national veterans' organizations that 
represent millions of veterans, and according to a number of 
independent studies, VA does a good job at providing quality health 
care to veterans--once they get into the system. In fact, they have 
been doing some cutting edge work in a number of areas--including tele-
health and CAM.
    But the simple reality is that the problems they face are 
staggering.
                             mental health
    Of the over 2 million men and women who served in Afghanistan and 
Iraq, studies suggest that 20 to 30 percent have come home with PTSD or 
TBI. Simply stated, that means the wars have created some five hundred 
thousand mentally wounded American veterans and, as a result, very 
serious problems regarding suicide, substance abuse, inability to hold 
on to a job, divorce and emotional problems for children and family 
members.
    Since FY 2006, the number of veterans receiving specialized mental 
health treatment has risen from just over 927,000 veterans to more than 
1.4 million in FY 2013. This means that in FY 2013, just over a quarter 
of those receiving care at VA were being treated for mental health 
conditions.
    In other words, VA currently provides 49,315 outpatient mental 
health appointments a day. During the last four years (FYs 2009-2013), 
VA outpatient mental health visits have increased from 14 million a 
year to more than 18 million.
    VA has noted on numerous occasions that it anticipates its need to 
provide mental health services will continue to grow for the next 
decade as current military operations come to an end.
    Ensuring timely access to high-quality mental health care is 
critical for our veterans and their loved ones. The stakes are high. 
Statistics show that on average 22 veterans a day commit suicide--
that's more than 8,000 veteran deaths a year. Even one veteran suicide 
is too many. 8,000 suicides are absolutely unacceptable.
    While many individuals with mental illnesses do not commit suicide, 
it is clear the consequences of failing to properly address and treat 
mental illness are serve.
                                 access
    I, like most Americans, have major concerns about the inability of 
veterans in various locations across this country to access care in a 
reasonable period of time. According to a recent VA audit:

     46,236 veterans are on lists waiting to be scheduled for 
medical appointments, 8,126 of them have waited over 120 days to 
receive an appointment--that's 120 days before they are told when they 
are going to be seen; and
     More than 636,000 veterans have an appointment that more 
than 30 days from the date that the appointment was initially requested 
or from the date that was desired by the patient. Of that amount, 
nearly 360,000 veterans are waiting between 31 and 60 days, nearly 
180,000 are waiting between 61 and 90 days, and more than 40,000 
veterans are waiting more than 120 days for their appointments. This 
doesn't account for how long new patients have been waiting on lists, 
so a new patient who waits for an appointment that is scheduled more 
than 30 days from when he or she asked for it may have also waited 120 
days, just to receive that appointment.

    This is unacceptable. VA must do much more to improve access to the 
VA Health Care System. We have a moral obligation to provide veterans 
with the timely access to the health care they need.
    A lot of attention has been given to the provision in the bill that 
allows veterans to access outside care. That provision in important 
because it will immediately bolster VA's capacity to address veterans' 
health care needs.
    However, the simple truth of the matter is that the VA needs more 
doctors, more nurses, more mental health providers and, in certain 
parts of the country, more space for a growing patient population. VA's 
ability to provide timely care both now and in the future must be 
strengthened by building capacity within the system. This is done by 
ensuring VA has the resources, including physical space and the health 
care providers and support staff necessary to provide such care.
    I think I speak for everyone on this Committee when I say we need 
more details on your current initiatives to address access issues, such 
as:

     How has the Department's Accelerated Access to Care 
Initiative improved the care and services VA provides veterans and how 
long does the Department intend to carry out expanded care options 
under this initiative, such as evening and weekend appointments;
     When does the Department estimate it will roll out its 
updated scheduling system; and
     Has VA completed all the recommendations in the IG's 
interim report on Phoenix.

    In order to address the issue of long wait times, the Department 
and Congress must work together. It is important that you keep us 
abreast of your initiatives and maintain close communication with the 
Members of this Committee.
                             accountability
    Further, it is beyond words that some employees have lied or 
manipulated data. These issues must be dealt with immediately. The 
Department must take swift action to hold those who may have 
manipulated data or failed to carry out their duties accountable for 
their actions.
    Today I would like to hear:

     What actions the Department has taken to reprimand 
employees who have lied and manipulated data;
     What has the Department done to ensure such manipulation 
no longer occurs; and
     What the Department has done to improve other areas of 
concern identified by the IG, GAO, OSC, and other auditing 
organizations?

    I believe it is important for the Department to create an 
accountable, safe, and, transparent culture for its employees. Only 
then would we be able to prevent these egregious actions.
                             whistleblowers
    Finally, I have been deeply troubled by the recent Office of 
Special Counsel reports that detail deliberate retaliation against the 
brave VA employees who seek to improve the care and services veterans 
receive by exposing deep flaws within VA's system.
    I will not accept honest whistleblowers--who want to improve the 
system--being silenced or having their concerns ignored. VA must have 
zero tolerance for the actions outlined by the Office of Special 
Counsel in recent weeks.
    During today's hearing, I would like to hear what the Department 
has done to prevent such retaliation from occurring.
                                closing
    With that, I look forward to hearing Acting Secretary Gibson's 
plans to address the critical issues I have highlighted.

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

    Senator Burr. Thank you, Mr. Chairman; and Acting Secretary 
Gibson, welcome.
    Since our last hearing, there have been several 
developments related to the scheduling irregularities across 
the VA and its negative impact on patient care. The VA has 
begun to take the necessary steps to address the systemic 
problems and the corrosive culture that have been identified 
and substantiated by several independent sources. However, 
these changes will not happen overnight, and this Committee 
must provide the critical oversight to ensure those changes 
occur and are effective.
    Even with the steps VA has taken to improve access for many 
veterans, there will continue to be reports and allegations 
regarding VA health care facilities and workers. These reports 
will not only highlight critical areas of needed reform, but 
identify the magnitude and the breadth of the systemic issues 
facing the VA. The ongoing internal evaluation by VA as well as 
investigations currently being conducted by the Office of 
Special Counsel and the VA's Office of Inspector General are 
essential to eliminate employees and rebuild not only veterans' 
trust but also the trust of stakeholders.
    To undertake the needed reforms within VA, the role of the 
Office of Special Counsel and the Inspector General are even 
more crucial now than ever before. Both offices have been 
essential in identifying systemic issues facing the VA. I would 
like to highlight a few critical reports that have been 
released since the last hearing.
    At the time of the May 15th hearing, there were several 
stakeholders who did not want to rush to judgment until the 
allegations surrounding Phoenix had been substantiated. Since 
that hearing the IG released an interim report regarding the 
allegations of scheduling irregularities and a secret wait list 
at the Phoenix VA health care system. Not only did the IG 
substantiate scheduling irregularities and a secret wait list 
at Phoenix, but the IG identified roughly 1,700 veterans who 
were waiting for appointments and were not included on an 
appropriate electronic waiting list.
    The IG found that scheduling irregularities are a systemic 
issue across VA's health care system and that this was not an 
isolated event. Additionally, the IG has received numerous 
allegations regarding, ``mismanagement, inappropriate hiring 
decisions, sexual harassment, and bullying behavior by mid- and 
senior-level managers at this facility.'' These allegations 
speak to the corrosive culture that has taken deep root 
throughout the entire Department.
    Within a 3-week period, the Office of Special Counsel 
released a statement on VA whistleblower reprisals and sent a 
letter to the President regarding VA's lack of responsiveness 
to OSC requests. In this letter, the Office of Special Counsel 
described the Office of Medical Inspector's, or OMI's, 
consistent use of, ``harmless errors.'' This is their defense, 
where the Department acknowledges the problem but claims 
patients were not--their cases were unaffected.
    The letter details ten cases of egregious patient care 
provided by VA facilities in which the OMI substantiates errors 
in patient care but dismisses potential patient harm. In one 
case, two veterans were admitted to an inpatient mental health 
ward at the Brockton VA facility and did not receive 
comprehensive evaluations for more than 7 years after being 
admitted to the facility.
    Another case in the letter describes how a pulmonologist 
copied previous provider notes in more than 1,200 patient 
medical records instead of recording current readings for these 
patients.
    I want to be crystal clear. The culture that has developed 
at VA and the lack of management and accountability is simply 
reprehensible, and it will no longer be tolerated.
    Secretary Gibson, you have taken several actionable steps 
in the last month and a half, and I commend the work that you 
have done. However, what has happened over the course of years 
is a horrendous blemish on the VA's reputation, and much more 
work will be needed to repair that damage.
    As VA continues to move forward in improving veterans' 
access to care and changing the culture that has taken deep 
root within the Department, this Committee has a lot of work to 
do. The Committee needs to take an active, vigorous oversight 
role to ensure that the problems that have been identified over 
the last several months--and, I might say, over the next 
several months as a host of IG reports come out--are 
effectively and appropriately addressed and they are not 
allowed to happen again.
    Again, Secretary Gibson, thank you for being here. Mr. 
Chairman, I thank you and I yield.
    [The prepared statement of Senator Burr follows:]
        Prepared Statement of Hon. Richard Burr, Ranking Member
    Good morning, Mr. Chairman. I would like to welcome and thank 
Acting Secretary Gibson for being here. Today, the Committee is holding 
a second hearing on the state of VA healthcare.
    Since our last hearing, there have been several developments 
related to the scheduling irregularities across the Veterans Health 
Administration and its negative impact on patient care. VA has begun to 
take the necessary steps to address the systemic problems and the 
``corrosive culture'' that has been identified and substantiated by 
several independent sources. However, these changes will not happen 
overnight and this Committee must provide the critical oversight to 
ensure these changes occur and are effective.
    Even with the steps VA has taken to improve access for many 
veterans, there will continue to be reports and allegations regarding 
VA healthcare. These reports will not only to highlight critical areas 
of needed reform, but identify the magnitude and breadth of the 
systemic issues facing VA. The ongoing internal evaluation by VA, as 
well as investigations currently being conducted by the Office of 
Special Counsel and VA's Office of Inspector General, are essential to 
rebuilding not only veterans' trust, but also the trust of stakeholders 
and employees.
    To undertake the needed reforms within VA, the role of the Office 
of Special Counsel and the IG are even more crucial now than ever 
before. Both offices have been essential in identifying systemic issues 
facing VA; I would like to highlight a few critical reports that have 
been released since the last hearing.
    At the time of the May 15th hearing, there were several 
stakeholders who did not want to rush to judgment until the allegations 
surrounding Phoenix had been substantiated. Since that hearing, the IG 
released an interim report regarding the allegations of scheduling 
irregularities and a secret wait list at the Phoenix VA Healthcare 
System.
    Not only did the IG substantiate scheduling irregularities and a 
secret wait list at Phoenix, but the IG identified roughly 1,700 
veterans that were waiting for appointments and were not included on 
appropriate electronic wait lists. The IG found that scheduling 
irregularities are a systemic issue across VA's healthcare system and 
this was not an isolated event.
    Additionally, the IG has received numerous allegations regarding 
(quote) ``mismanagement, inappropriate hiring decisions, sexual 
harassment, and bullying behavior by mid- and senior- level managers at 
this facility.'' These allegations speak to the corrosive culture that 
has taken deep roots throughout the entire Department.
    Within a 3 week period, the Office of Special Counsel released a 
statement on VA whistleblower reprisals and sent a letter to the 
President regarding VA's lack of responsiveness to OSC requests. In 
this letter, the OSC describes the Office of Medical Inspector's 
consistent use of (quote) ``a `harmless error' defense, where the 
Department acknowledges problems but claims patient care is 
unaffected.''
    The letter details ten cases of egregious patient care provided by 
VA facilities in which the OMI substantiates error in patient care but 
dismisses potential patient harm. In one case, two veterans who were 
admitted to an inpatient mental health ward at the Brockton VA facility 
didn't receive comprehensive evaluations for more than seven years 
after being admitted to the facility. Another case in the letter 
describes how a pulmonologist copied previous provider notes in more 
than 1,200 patient medical records instead of recording current 
readings for these patients.
    I want to be crystal clear; the culture that has developed at VA 
and the lack of management and accountability is simply reprehensible. 
And it will no longer be tolerated. Secretary Gibson, you have taken 
several actionable steps in the last month and a half. I commend the 
work you have done; however, what has happened over the course of years 
is a horrendous blemish on VA's reputation. And much more work will be 
needed to repair the damage.
    As VA continues to move forward in improving veterans' access to 
care and changing the culture that has taken deep roots within the 
Department, this Committee has a lot of work to do. The Committee needs 
to take an active, vigorous oversight role to ensure the problems that 
have been identified over the last several months are effectively and 
appropriately addressed, and they aren't allowed to happen again.

    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. Mr. Chairman, thank you so much for holding 
this hearing. As we all know, this is really a critical time 
for the Department. The VA is still struggling with major 
systemic problems. There are many vacancies in key leadership 
positions, and most importantly, veterans are still waiting too 
long for care.
    Secretary Gibson, as we talked about yesterday, I really 
appreciate your stepping up during this crisis. The Department 
needs strong leadership right now because the VA is facing 
serious challenges. Rob Nabors' review identified several of 
these issues which we have also been discussing here for some 
amount of time. A corrosive culture has developed in the 
Department, one that is unworthy of VA's many dedicated and 
talented medical providers who only want to help veterans. 
Management failures and lack of communication is a problem at 
all levels of the VHA, and VA needs more providers, more space, 
and modern IT systems.
    As we continue to work in the conference committee to craft 
a final bill, I hope an agreement will be reached so we can 
send it to the President and start making the changes needed at 
VA so veterans get into care, we create transparency, and hold 
people accountable.
    The compromise bill will be an important first step. As 
more reviews are done and more problems found, we will need to 
take additional steps.
    And while we continue working on these problems, we cannot 
lose sight of many other pressing issues. Too many veterans 
still die by suicide each day. Sexual assault survivors still 
need help. The VA has to continue to make progress toward the 
commendable and even more challenging goals of eliminating 
veterans' homelessness and reducing the claims backlog.
    On a positive note, Secretary Gibson, I really appreciate 
your help in finally getting the money to build the Walla Walla 
State Veterans Home. We have been working on this, as you know, 
for a very long time, and now hundreds of veterans in that area 
will be able to access the long-term care that they need.
    As I have said repeatedly here in this room, when the 
Nation goes to war, it also commits to taking care of the 
veterans when they return home. Their needs are a cost of war, 
and we will provide for them no matter what. We know many 
veterans will need VA care for several decades to come. Others 
will come to the VA for the first time many years after their 
service has ended. So today I am hoping to hear about solutions 
to these systemic problems and smart ways to strengthen the VA 
for the long term, because the VA does need to be there for our 
veterans, ready to help right away every time.
    Thank you, Mr. Chairman, and I yield to Senator Isakson.

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

    Senator Isakson. Thank you, Senator Murray.
    Secretary Gibson, thank you very much for accepting this 
interim responsibility. You are a brave and courageous man. And 
while I am encouraged by some of the serious steps you have 
taken, I am still not satisfied. We have tremendous problems as 
indicated by the letter from Special Counsel Lerner to the 
President of the United States, from which I want to quote one 
paragraph, ``I remain concerned about the Department's 
willingness to acknowledge and address the impact of these 
problems''--meaning the whistleblowers' problems--``may have 
had on the health and safety of veterans. In particular, the VA 
Office of Medical Inspector has consistently used the term 
`harmless error' as a defense where the Department acknowledges 
the problem but claims patients have been unaffected. This 
approach has prevented VA from acknowledging the severity of 
systematic problems and from taking necessary steps to provide 
quality care to veterans.''
    The letter goes on to delineate specific cases where 
veterans' health suffered because of the agency looking the 
other way.
    I have become personally convinced that this begins and 
ends with the failure of senior leadership in VA for years to 
overlook or to look over the manipulation of numbers, to make 
things look better than they really were, to hope that Congress 
would not come look. I think Congress is partially to blame for 
not coming and looking enough.
    You know, I learned when I was raising my children that if 
parents come every now and then, open the bedroom door and look 
inside, you have a better behaved kid than if you never look 
inside. I think some of the departments of the VA are exactly 
the same; and the pervasive culture of cooking the books for 
personal benefit, such as pay raises, is absolutely 
inexcusable.
    Last, I hope in your remarks, which I am looking forward 
to, you will address how the memo that was written by Mr. 
Schoenhard on August 26, 2010, that delineated specifically 
many of the problems we are now discovering--this was 4 years 
ago. I don't know how a memo to senior VISN leaders across the 
network and to senior management could have gone totally 
without follow-up by anybody in the VA. The problems that we 
are now trying to fix lasted 4 more years within the VA because 
there was a culture of just looking the other way when there 
was a criticism or accountability in place.
    So, while I appreciate very much your willingness to come 
forward as a citizen and take on this interim responsibility, 
and I appreciate the steps that you have made, I am not 
satisfied yet that the VA's culture is any different than it 
has been. We are going to have to see to it that the culture of 
the VA changes and we have accountability from top to bottom, 
but in particular, in the senior leadership and management of 
the Veterans Administration and Veterans Health Care.
    I will now yield to----
    Senator Murray [presiding]. I will just say that a vote has 
been called, so a number of Senators are going to be leaving. 
We will go to Senators Tester, Moran, Hirono, and Johanns, and 
by then the Chairman will return.

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

    Senator Tester. All right. Thank you, Senator Murray, and I 
want to thank Senators Sanders and Burr, even though they are 
not here, for their work on this Committee.
    Access to health care for our veterans did not pop up 
overnight. This is a topic that many of us have been working on 
for years. Solutions must be based on good information. You 
cannot make good decisions without good information. And 
hopefully the conversation today will be straightforward and 
frank so we can get down to some solutions.
    It is going to require tough decisions. It is going to 
require some creativity. It will require focus and engagement 
from folks on the ground and in Washington that lasts well 
beyond the media span. Veterans deserve better than to have 
folks jump on the latest crisis or two and then you never hear 
about it again. They want answers. They want solutions. They 
want the benefits that they have earned, not press releases.
    I am approached by veterans every time I go home, whether 
it is in the grocery store or at the service station. They are 
direct, they are straightforward, and they give me the best 
view of what is happening on the ground with the VA. In fact, 
this Friday I am going to be holding another roundtable, this 
time in the capital city of Helena, MT, to hear from veterans 
about the VA and the services that they are getting and the 
difficulties they are having, along with the successes.
    Since our last hearing on VA health care, the VA conducted 
a nationwide audit. They found that the biggest obstacle to 
timely medical care at the VA is the lack of service providers. 
It is a lack of service providers. I am looking forward to 
hearing from the VA on this audit and the follow-up actions 
moving forward.
    Since our last meeting, the White House has also completed 
a review on issues impacting access to care. This review echoed 
what we have already heard, that the VA provides high-quality 
health care once the veterans get in the door. The review also 
learned that the VA's scheduling technology is outdated--I 
believe 30 years old. It is secondary to the need for 
additional resources such as doctors, nurses, and other health 
care professionals, physical space, and appropriately-trained 
administrative support personnel.
    Since our last hearing, the Senate also passed a 
comprehensive bipartisan bill that would address some major 
issues impacting access to timely medical care at the VA. It 
passed by an overwhelming 93 votes. We seldom get 93 votes for 
anything in the U.S. Senate.
    Right now we are conferencing that bill. We are in the 
fourth week. There is not much to show for it. Those questions 
would be good to get answered today, too, because I think some 
members of the conference committee are balking at the cost. 
Look, we just shipped 800 folks off to Iraq. I did not hear one 
person talk about cost.
    Back in 2003, when we invaded Iraq, I was not here, but I 
certainly never heard anybody talk about the cost and making 
sure that there were offsets for that cost.
    Look, these folks went to war. They performed incredibly 
well. Some of them came back missing arms and legs. Some of 
them came back with mental health conditions that they did not 
have when they left or health problems they did not have when 
they left.
    It is very frustrating from my perspective coming from a 
State where we are about 22 doctors short to hear folks on the 
conference committee a few weeks back say, ``What we need to do 
is we need to schedule more patients for the doctors. That will 
solve the problem.'' That will not solve the problem. We need 
more health care professionals on the ground.
    And, Sloan, I hope to hear from you today on those issues 
about what those deficiencies are, because I think it is 
critically important that we get our arms around that as a 
Committee so that we can move forward, so that we can provide 
the kind of accountability that needs to happen within the VA 
to make sure that ultimately the veterans get the care they 
deserve.
    I will tell you something right now. I am very concerned 
that this conference committee will end up taking a step 
backward for veterans' health care in this country. That cannot 
happen. Veterans deserve better. They have earned the health 
care. We need to make sure we step up to the plate, give VA the 
resources they need, and then hold them accountable for the job 
that they do. Veterans deserve our best. They have demonstrated 
their best in the field. We need to demonstrate our best as 
policymakers and you folks as leaders of the VA.
    With that, I would yield the floor to my friend, Senator 
Moran.

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

    Senator Moran. Thank you very much.
    Mr. Secretary, thank you for joining us. Thank you very 
much for having a conversation with me by phone several weeks 
ago. I appreciate that outreach. It has been one of the 
experiences that I have had in recent years with the VA that 
leaves me feeling that I have no ability to convey the concerns 
of Kansas veterans. We have the ability to convey that 
information to the Department, but receive virtually no 
response time and time again. So, I appreciate the fact that 
you took the time to have a telephone conversation with me.
    I am going to present to you today, or shortly, a letter 
that I have compiled addressed to you. I heard the testimony 
from the House Veterans' Affairs Committee last week in which 
some of the topic was about whistleblowers and the apology that 
the Department made. What I have discovered as a result of what 
has transpired over the last several months is that many 
Kansans, veterans in particular, but also many employees of the 
Department of Veterans Affairs, are presenting me now with 
stories of problems within the VA, and they are reluctant, in 
fact, disinclined, to present that information as a 
whistleblower in a formal way because of fear of retribution 
and concern about their future and their employment.
    So, Mr. Secretary, we will be providing you an outline of 
things that we still consider significant challenges and 
problems in my homestate of Kansas.
    I indicated several months ago that I had been a member of 
the Veterans Committee since I came to Congress, 14 years in 
the House, 4 years in the Senate, and there have always been 
challenges at the VA. There are always challenges in health 
care. What seems to me to be different today, Mr. Secretary, 
and it has occurred over time, is the recognition that the VA, 
in a sense, was just shrugging its shoulders, no real attention 
to problems, and what that resulted in, then, were veterans 
telling me that they no longer had faith in the Department of 
Veterans Affairs to provide the services that they are entitled 
to as military men and women of our country.
    So, I thought a change in leadership at the Department of 
Veterans Affairs was required. It is now taking place. I look 
forward to meeting Mr. McDonald this afternoon in my office. 
But, what I know is that only changing the Secretary, only 
changing the top leadership is insufficient to solve the 
problems that exist.
    So, I look forward to working with you during your time at 
the Department of Veterans Affairs to see that the results are 
things that we all can be proud of and that the commitments 
that we have made to our veterans are kept.
    Most of my conversations with Secretaries of Veterans 
Affairs--I think there have been nine of them in my time--have 
dealt with rural issues, and I want to explore that with you 
today in your testimony. First, I am very anxious to hear about 
the steps that you are taking to change the nature--so it does 
not matter whether you are an urban, suburban, or rural 
veteran--that the Veterans Affairs Department is something 
different than it has been over the last several years. Then I 
will be happy to get to the issues that we face in a rural 
State like ours.
    Mr. Secretary, as we know, change is necessary. I want to 
do everything I can to make certain that the Department of 
Veterans Affairs has the tools necessary. It has been my 
commitment since I came to Congress, but I need the commitment 
from the Department of Veterans Affairs that those resources 
that they are provided, the tools they are given, are going to 
be used in a cost effective, compassionate, and caring way, and 
that there is an attitude at the Department of Veterans Affairs 
that there is no higher calling than to take care of the men 
and women who served our country.
    Thank you, sir.
    Chairman Sanders [presiding]. Thank you, Senator Moran.
    Senator Hirono.

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

    Senator Hirono. Thank you, Acting Secretary Gibson, for 
being here, and thank you, Chairman Sanders and Ranking Member 
Burr, for our continuing focus on the issues and challenges 
facing the VA.
    When the issues relating to wait times first arose over a 
month ago, the situation was described as an emergency. There 
was a sense of urgency. And, I want this Committee and this 
Congress to continue to be motivated by the sense of urgency 
and to continue to recognize that this emergency needs to be 
addressed, because there is every potential for other issues to 
come to the fore and for Congress to be distracted, important 
as these other issues may be. We owe it to the veterans to stay 
the course.
    I share the sentiments of the Chairman and many of the 
Members' statements this morning that we need to hear from you 
your short-term solutions for addressing the issues at hand and 
over the long term to address the systemic problems and 
challenges facing VA.
    I, like so many of my colleagues, have been visiting with 
the veterans in my State, frankly, long before the particular 
crisis arose. And, of course, they have shared with me their 
concerns about the lack of doctors, the changeover of doctors, 
and those are some of the practical considerations that they 
have raised with me.
    So, most of us--I think all of us--have had the opportunity 
to talk with veterans in our communities one-on-one and we have 
a commitment to make sure that we continue to stay the course. 
That, to me, is the most important thing that this Committee 
can do, and I thank the Chairman for not allowing us to move on 
to other matters that may be pressing, but what could be more 
pressing than to make sure that our veterans receive the care 
that they need and deserve.
    Thank you, Mr. Chairman.
    Chairman Sanders. Other members will be filtering back, but 
I would like to hear from the Acting Secretary now. 
Customarily, we give 5 minutes, but you will have more time. 
This is a serious discussion and we want you to have the time 
you need to make your case and we want the Members here to have 
the time they need to ask you their questions.
    All right. Senator Burr suggests that we should wait a few 
minutes to make sure that other Members get back here, so let 
us take a very quick recess. [Recess.]
    Let us reconvene, and Senator Johanns, I think we are ready 
for you and your opening statement.

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

    Senator Johanns. Thank you, Chairman Sanders and Ranking 
Member Burr, for convening another very important hearing to 
address issues at the VA. It is critical that we continue to 
have these oversight hearings to do everything we can to hold 
VA's feet to the fire and make sure that accountability is 
there.
    We know some things now that we did not know at the last 
hearing. We know for a fact that VA's wait list manipulation 
and access to care issues is, in fact, systemic. Report after 
report has confirmed this. In fact, 77 facilities are currently 
under investigation by the VA Inspector General. That is an 
astounding number. And, I believe the scheduling problems are 
the tip of the iceberg. Now we have allegations of 
whistleblower retaliation and improper payment of claims. The 
cancer does not seem to stop, but it must be stopped.
    While I appreciate your efforts, Secretary Gibson--I think 
you have done some things and they are recognized and 
acknowledged--but I think we would all acknowledge there is so 
much more to be done.
    There has to be accountability for wrongdoing or these 
issues will continue and the Senate will have more hearings, 
not only next week or the week after, but in 5, 10, 20 years 
from now.
    There is a serious lack of leadership from the top. The 
White House needs to have a more visible role in addressing the 
crisis. We, collectively, have the ability to fix this agency. 
We just have to find the will and the common ground to do it. 
All of us have to be a part of the solution.
    In May, during our last committee hearing, I encouraged the 
expanded use of non-VA care to get urgent treatment to those 
veterans that were languishing on both secret and official 
waiting lists. The bill recently passed by the Senate gives 
greater flexibility and treatment options for veterans faced 
with long wait times or lengthy travel. The ``choice card'' 
injects much-needed competition, in my opinion, into the 
process, and it demands of the VA that they get their act 
together.
    The accountability and transparency pieces of the 
legislation are not only important, they are critical. The 
notion that employment should be tied to performance might seem 
elementary to most people, but this has not been happening at 
the VA. There have been several instances in which senior VA 
executives who were involved in mismanagement or negligence 
were not reprimanded, but instead received bonuses and positive 
performance reviews. Shameful.
    And, while Senior Executive Service employees can be 
disciplined and fired under current law, it is a very long and 
very drawn-out process. Again, that does not work.
    The Secretary needs the authority this bill provides to cut 
through bureaucratic red tape and, most importantly, to hold 
individuals responsible. We have to root out the culture of 
corruption that is contributing to nearly all of VA's most 
pressing issues.
    It is a huge challenge, but we can and must get the VA back 
on track and focused on their core mission of providing quality 
health care to our veterans. They deserve nothing less.
    Thank you, Mr. Chairman. I yield back.
    Chairman Sanders. Thank you, Senator Johanns.
    Now, I want to take this opportunity to welcome Mr. Sloan 
Gibson, Acting Secretary of the VA. Thank you very much for 
joining us to give us an update on the state of health care at 
the Department of Veterans Affairs. We look forward to hearing 
your testimony.
    Secretary Gibson is accompanied by Mr. Philip Matkovsky, 
the Assistant Deputy Under Secretary for Health for 
Administrative Operations.
    Your prepared remarks will be submitted for the record.
    Secretary Gibson, please begin.

STATEMENT OF SLOAN GIBSON, ACTING SECRETARY, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; ACCOMPANIED BY PHILIP MATKOVSKY, ASSISTANT 
     DEPUTY UNDER SECRETARY FOR HEALTH FOR ADMINISTRATIVE 
           OPERATIONS, VETERANS HEALTH ADMINISTRATION

    Mr. Gibson. Mr. Chairman, forgive me if I dispense with the 
traditional niceties and get straight to business. As has been 
recounted this morning, we have serious problems. Here is how I 
see the issues.
    First and foremost, veterans are waiting too long for care.
    Second, scheduling improprieties were widespread, including 
deliberate acts to falsify scheduling data.
    Third, an environment exists where many staff members are 
afraid to raise concerns or offer suggestions for fear of 
retaliation.
    Fourth, in an attempt to manage performance, a vast number 
of metrics have become the focal point for staff instead of 
focusing on the veterans we are here to serve.
    Fifth, VA has failed to hold people accountable for 
wrongdoing and negligence.
    And, last, we lack sufficient clinicians, direct patient 
support staff, space, information technology resources, and 
purchased care funding to meet the current demand for timely, 
high-quality health care. Furthermore, we do not have the 
refined capacity to accurately quantify our staffing 
requirements because, historically, we have not built our 
resource requirements from the bottom up. We have instead 
managed to a budget number.
    As a consequence of all these failures, the trust that is 
the foundation of all we do, the trust of the veterans we serve 
and the trust of the American people and their elected 
representatives, has eroded. We will have to earn that trust 
back through deliberate and decisive action and by creating an 
open, transparent approach for dealing with our stakeholders to 
better serve veterans.
    To begin restoring trust, we focused on six key priorities. 
Get veterans off wait lists and into clinics. Fix systemic 
scheduling problems. Address cultural issues. Hold people 
accountable where willful misconduct or management negligence 
are documented. Establish regular and ongoing disclosures of 
information. And, finally, quantify the resources needed to 
consistently deliver timely, high-quality health care.
    Here is what we are doing now. VHA has reached out to over 
160,000 veterans to get them off wait lists and into clinics 
and made over 543,000 referrals for veterans to receive care in 
the private sector, 91,000 more than in the comparable period a 
year ago. This is in the last 2-month period. And, I would 
point out here that for each of those referrals, on average, 
they result in seven visits to a clinician.
    VHA facilities are adding more clinic hours, aggressively 
recruiting to fill physician vacancies, deploying mobile 
medical units, using temporary staffing resources, and 
expanding the use of private sector care. We are moving rapidly 
to augment and improve our existing scheduling system while 
simultaneously pursuing the purchase of a commercial off-the-
shelf, state-of-the-art scheduling system.
    I have directed medical center and VISN directors to 
conduct monthly inspections in person of their clinics to 
assess the state of scheduling practices and to identify any 
related obstacles to timely care for veterans. To date, over 
1,100 of these visits have been conducted.
    We are putting in place a comprehensive external audit of 
scheduling practices across the entire VHA system. We are 
building a more robust continuous system for measuring patient 
satisfaction, which I believe will be central to our 
measurement processes in the future.
    I have personally visited ten VA medical centers in the 
last 6 weeks to hear directly from the field on the actions 
being taken to get veterans off wait lists and into clinics. I 
leave later today for Albuquerque and El Paso.
    The inappropriate 14-day access measure has been removed 
from all individual employee performance plans to eliminate any 
motive for inappropriate scheduling practices. In the course of 
completing this task, over 13,000 performance plans were 
amended.
    Where willful misconduct or management negligence is 
documented, appropriate personnel actions will be taken. This 
also applies to whistleblower retaliation. I am sure we will 
talk about that further.
    I have frozen VHA central office and VISN office 
headquarters hiring as a first step to ensure that we are all 
working to support those delivering care directly to veterans.
    VHA has dispatched teams to provide direct assistance to 
facilities requiring the most improvement, including a large 
team on the ground right now in Phoenix.
    All VHA Senior Executive Performance Awards for fiscal year 
2014 have been suspended.
    VHA is expanding our use of private sector health care to 
improve access.
    I sent a message to all 341,000 VA employees and have 
reiterated during every single visit to VA facilities that 
whistleblowers will be protected. We will not tolerate 
retaliation against whistleblowers.
    I have conducted over a dozen meetings and calls with 
senior representatives of VSOs and other stakeholder groups to 
solicit their ideas for improving access and restoring trust.
    I have named Dr. Carolyn Clancy Interim Under Secretary for 
Health. She will spearhead our immediate efforts to accelerate 
veterans' access to care and restore the trust of veterans.
    Dr. Jonathan Perlin, a former Under Secretary for Health at 
VA, currently on leave of absence from his duties as Chief 
Medical Officer and President of Clinical Services for Hospital 
Corporation of America, has begun his 2-month assignment at VA 
as Senior Advisor to the Secretary. Dr. Perlin's expertise, 
judgment, and professional advice will help bridge the gap 
until VA has a confirmed Under Secretary for Health.
    Dr. Gerald Cox has agreed to serve as Interim Director of 
the Office of Medical Inspector, a Navy Medical Officer for 
more than 30 years and the former Assistant Inspector General 
of the Navy for Medical Matters. Dr. Cox will provide new 
leadership and a fresh perspective to help restructure OMI and 
ensure a strong internal audit function.
    As we complete reviews, fact finding, and other 
investigations, we are beginning to initiate personnel actions 
to hold those accountable who committed wrongdoing or were 
negligent in discharging their management responsibilities. To 
support this critical work, Ms. Leigh Bradley has begun a 4-
month assignment as Special Counsel to the Secretary. Ms. 
Bradley is a former General Counsel at VA and most recently a 
senior member of the General Counsel team at the Department of 
Defense, where she had direct responsibility for the ethics 
portfolio for DOD.
    Before I conclude, let me briefly address the need for 
additional resources.
    I believe that the greatest risk to veterans over the 
immediate-to-long-term future is that additional resources are 
provided only to support increased purchased care in the 
community and not to materially remedy the historic shortfall 
in internal VA capacity. Such an outcome would leave VA even 
more poorly positioned to meet future demand.
    We have been working closely with the Office of Management 
and Budget for several weeks to develop the request for 
funding. While the amounts under consideration are large in the 
context of VA's size, scope, and existing budget, they 
represent moderate percentage increases in annual expenditures. 
Furthermore, a substantial portion of the funds required are 
non-recurring investments in space and information technology 
that would not be reflected in long-term run rates.
    Resources required to meet current demand, covering the 
remainder of fiscal year 2014 through fiscal year 2017, total 
$17.6 billion. These funds address only the current shortfalls 
in clinical staff, space, information technology, and purchased 
care necessary to provide timely, high-quality care.
    In closing, we understand the seriousness of the problems 
we face. We own them. We are taking decisive action to begin to 
resolve them. The President, Congress, veterans, VSOs, the 
American people, and VA staff all understand the need for 
change. We must, all of us, seize this opportunity. We can turn 
these challenges into the greatest opportunity for improvement 
in the history of this Department. I believe that in as little 
as 2 years, the conversation can change, that VA can be the 
trusted provider of choice for health care and for benefits.
    If we are successful, who wins? The growing number of 
veterans that turn to VA for health care each year. The 700,000 
veterans who are currently diagnosed with post-traumatic Stress 
Disorder. The million Iraq and Afghanistan veterans that have 
turned to VA for health care since 2002. And, the average 
veteran who turns to VA for health care who is older, sicker, 
and poorer than average patients in the private sector. These 
are the veterans who will win when VA becomes the trusted 
provider of care and benefits.
    That is what and where we want to be in the shortest time 
possible. Our ability to get there depends on our will to seize 
the opportunity, to challenge the status quo, and to drive 
positive change.
    I appreciate the hard work and dedication of VA employees, 
the vast majority of whom I continue to believe care deeply 
about the mission, want to do the right thing, and work hard 
every day to take care of veterans. As well, I appreciate our 
partners from the veterans service organizations, our community 
stakeholders, and dedicated VA volunteers.
    Last, I deeply respect the important role that Congress and 
the Members of this Committee play in serving veterans, and I 
am grateful to you for your long-term support. I am prepared to 
take your questions.
    [The prepared statement of Mr. Gibson follows:]
     Prepared Statement of Hon. Sloan D. Gibson, Acting 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) 
health care 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.
    As the Chairman noted in May 2014, the Veterans Health 
Administration (VHA) operates the largest integrated health care 
delivery system in the United States. VHA has over 1,700 sites 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 every day and 
approximately 85 million appointments each year. Over 300,000 VHA 
leaders and health care employees--many who also are Veterans--strive 
to provide exceptional care to nearly 6.5 million Veterans and other 
beneficiaries annually.
    The Chairman also noted in May 2014 that there are things that VA 
does very well, and there are areas that need improvement. My testimony 
today will provide some updates on a number of actions that the 
Department has taken since the last hearing in May 2014.
    We know that unacceptable, systemic problems and cultural issues 
within our health care system prevented some Veterans from receiving 
timely care. That breach of trust--which involved inaccurate reporting 
of patient wait times for appointments--is irresponsible, indefensible, 
and unacceptable to the Department. We apologize to our Veterans, their 
families and loved ones, Members of Congress, Veterans Service 
Organizations (VSO), and to the American people. We can and must solve 
these problems as we work to earn back the trust of Veterans.
           nationwide data on access to veterans health care
    At VA, our most important mission is to provide the high quality 
health care and benefits Veterans have earned and deserve--when and 
where they need it. In mid-April, VA began a nationwide Access Audit to 
assess the integrity of our scheduling practices, the adequacy of 
training, compliance with policy, and proper use of systems. As a 
result of the audit, we now know that in many communities across the 
country Veterans wait too long to receive care.
    As of July 8, 2014, VHA has reached out to over 160,000 Veterans to 
get them off wait lists and into clinics sooner. Also, between May 15 
and June 30, 2014, we have made over 430,000 referrals for Veterans to 
receive their care in the private sector. VA made roughly 351,000 
referrals during this same time period last year in 2013, an increase 
of roughly 79,000. As we continue to address systemic challenges in 
accessing care, we are providing regular data updates\1\ to enhance 
transparency and provide the immediate information to Veterans and the 
public on improvements to Veterans' access to care. We are fully 
committed to fixing the problems we face in order to serve Veterans 
better. We know that we must not only restore the public's trust in VA, 
but more importantly, we also must restore the trust of our Veterans 
who depend on us for care.
---------------------------------------------------------------------------
    \1\ http://www.va.gov/health/access-audit.asp
---------------------------------------------------------------------------
    Following the release of results from VA's nationwide Access Audit, 
along with facility level patient access data, I personally visited VA 
medical centers in Fayetteville, NC; Gainesville, FL; Baltimore, MD; 
Washington, DC; Columbia, SC; Philadelphia, PA; Augusta, GA; and 
Jackson, MS, to gain a clearer understanding of the extent of the 
problems that we face.
    The following actions have been taken in response to the nationwide 
Access Audit findings and data:

     Removing 14-Day Scheduling Goal
          VA has eliminated the unrealistic 14-day access measure from 
        all employees' performance plans. This action will eliminate 
        incentives to engage in inappropriate scheduling practices or 
        behaviors. As of July 3, over 87,000 performance plans have 
        been reviewed and over 13,000 performance plans have been 
        amended, including over 3,500 front line schedulers.
     Mandated Site Inspections
          Medical Center Directors and VISN Directors are responsible 
        for ensuring Veterans receive timely, high quality healthcare. 
        As of June 17, every Medical Center Director has been 
        conducting in person visits to every clinic. Site inspections 
        include observing daily scheduling processes and interacting 
        with scheduling staff to ensure all policies are being 
        followed. In addition to monthly reviews of VHA facilities 
        nationwide, VISN Directors will also conduct similar visits to 
        at least one medical center within their area of responsibility 
        every 30 days, completing visits to all medical centers in 
        their network every 90 days. This action ensures leadership 
        knowingly accepts accountability for the integrity of 
        scheduling practices. As of July 9, 683 site inspections have 
        been completed.
     Establishing New Patient Satisfaction Measurement Program
          VHA immediately began developing a new patient satisfaction 
        measurement program to provide real-time, robust, site specific 
        information on patient satisfaction, including satisfaction 
        measurements of those Veterans attempting to access VA health 
        care for the first time. This program will include input from 
        VSOs, outside health care organizations, and other entities.
     Holding Senior Leaders Accountable
          Where audits identify concerns within a medical center 
        clinic, VA will trigger administrative procedures to ascertain 
        the appropriate follow-on personnel actions for specific 
        individuals. We will hold people accountable where misconduct 
        is found.
     Ordering an Immediate VHA Central Office and Veterans 
Integrated Service Network (VISN) Office Hiring Freeze
          VA has redirected its focus and resources to staffing at the 
        facility level to increase personnel who can directly serve 
        Veterans.
     Increasing Transparency by Posting Access and Patient Wait 
Time Data Twice-Monthly
          VHA is now posting regular updates to the access data 
        released at the middle and end of each month at VA.gov. The 
        first one of these was on June 9, 2014. These twice-monthly 
        data updates will enhance transparency and provide the 
        immediate information to Veterans and the public on Veterans 
        access to VA health care.
     Initiating an Independent, External Audit of Scheduling 
Practices
          I directed that an independent, external audit of system-wide 
        VHA scheduling practices be performed. We are working with an 
        outside private entity to conduct the audit and anticipate 
        initiating these audits early next fiscal year.
     Utilizing High Performing Facilities to Help Those That 
Need Improvement
          VHA will formalize a process in which high performing 
        facilities provide direct assistance and share best practices 
        with facilities that require improvement on particular medical 
        center quality and efficiency performance measures.
     Suspending Performance Awards
          VA has suspended all VHA senior executive performance awards 
        for fiscal year 2014.
     Enhancing Non-VA Care
          VHA is employing guidelines for using private sector care to 
        improve access to health care for Veterans who are or who may 
        experience excessive wait times for primary, specialty and 
        mental health care. VHA is now operationally monitoring the 
        effectiveness of our sites use of non-VA care to ensure 
        Veterans are receiving their timely care.
     Quickly Bringing in Veterans for Care
          VHA facilities are improving access to health care for 
        Veterans by: adding more clinic hours to evenings and weekends, 
        recruiting to fill physician vacancies, deploying mobile 
        medical units, using temporary staffing resources and expanding 
        the use of private sector care.
                       scheduling system updates
    VA recognizes that its medical appointment scheduling system is 
antiquated and we are replacing it through an acquisition process. VA 
hosted pre-solicitation ``Industry Day'' meetings with technology 
vendors on June 18 of this year to discuss the Department's upcoming 
scheduling system acquisition. This Industry Day presented an important 
opportunity for VA to communicate directly with potential vendors on 
all aspects of the upcoming scheduling system acquisition. The Industry 
Day served as a face-to-face platform for exchanging information about 
business needs, industry best practices, and challenges specific to 
VA's scheduling system. We recognize the need to develop lasting, long-
term reforms, including a complete overhaul to replace the outdated 
technology for our scheduling system. Bringing an innovative scheduling 
product into our world-class electronic health record system is a 
crucial part of providing the scheduling staff in our facilities with 
the necessary tools to succeed.
    VA's scheduling technical requirements are complex and require 
clear, well-articulated communication to ensure comprehensive 
understanding by industry and potential vendors. VA conducted a live 
scheduling system architecture question-and-answer session to ensure 
potential solutions seamlessly interface with VA's Veterans Health 
Information Systems and Technology Architecture electronic health 
record. The information shared during the Industry Day will provide VA 
with a better understanding of what needs to be included in the 
upcoming scheduling system solicitation, with the ultimate goals of 
receiving solid proposals and reducing time to field new technologies.
                       whistleblower protections
    At VA, we depend on the service of VA employees and leaders who 
place the interests of Veterans above and beyond self-interest, and who 
live by VA's core values of Integrity, Commitment, Advocacy, Respect, 
and Excellence. On June 13, 2014, I sent a message to all VA employees 
regarding the importance of whistleblower protection and met with 
employees at VA medical centers across the country to reemphasize that 
message. I reminded all 341,000 of our employees in messages and during 
site visits to VA facilities around the country that we must protect 
whistleblowers and create workplace environments that enable full 
employee participation. Intimidation or retaliation--not just against 
whistleblowers, but against any employee who raises a hand to identify 
a problem, make a suggestion, or report what may be a violation in law, 
policy, or our core values--is absolutely unacceptable.
    Following the recent release of the Office of Special Counsel's 
(OSC) recommendations to President Obama, I directed an immediate 
review of the Office of the Medical Inspector's (OMI) operation, 
process, and structure. After I was briefed on this review, I 
determined a clear need to revise the policies, procedures, and 
personnel structure by which OMI operates, and I directed a 
restructuring of the organization. As long-term restructuring moves 
forward, I have appointed an interim Director of OMI from outside the 
current office to assist with transition, and VA has suspended OMI's 
hotline and is currently referring all hotline calls to Office of 
Inspector General (OIG). On July 2, 2014, I met with Carolyn Lerner, 
Special Counsel of the United States Office of Special Counsel. VA has 
begun the process of completing the OSC 2302(c) Certification Program 
and is focused on ensuring protection from retaliation for employees 
who identify or report problems. Special Counsel Lerner and I 
identified ways to streamline the organizations' work together to 
ensure whistleblower protection during the course of an OSC 
investigation.
                                summary
    VA has also recently initiated the process of selecting the next 
Under Secretary for Health of VHA--one of the most important jobs in 
government today. VHA's new leader will be a change agent and deliver 
necessary reforms to provide our Veterans timely access to the world-
class health care that they have earned through their service and 
sacrifice.
    These are just a few of VA's actions to improve Veteran's access to 
high quality health care. 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 VSOs--important advocates for Veterans and 
their families--our community stakeholders, and our dedicated VA 
volunteers. Just two weeks ago, I met with the leadership of 26 
Military and Veterans Service Organizations (MSOs and VSOs) to reaffirm 
VA's commitment to work together to address the unacceptable, systemic 
problems in accessing VA health care. During this meeting, I updated 
the organizations' representatives on VA's work to restore Veterans' 
trust in the system and on VA's progress in reaching out to get 
Veterans into clinics and off of waiting lists. I appreciate MSOs and 
VSOs for being VA's valuable partners in serving Veterans and 
continuing to improve the Department, and I solicited their ideas on 
how VA can improve Veterans' access to care and services.
    I also respect the important role Congress and the dedicated 
Members of this Committee play in serving our Veterans. I look forward 
to continuing our work with Congress to ensure Veterans have timely 
access to the quality health care they have earned.

    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.

    Chairman Sanders. Well, Mr. Acting Secretary, thank you 
very much for not dealing with niceties, for dealing with 
realities.
    As I understand it, we are talking, in a broad sense, about 
two very serious problem areas. Number 1, I trust that every 
Member of this Committee understands that we have an immediate 
crisis, that we have hundreds of thousands of veterans on wait 
lists, that those folks must get the medical care they need in 
a timely manner. I am pleased to see, Mr. Acting Secretary, 
that you have moved aggressively in that area.
    But, if I understand you correctly, the second point you 
made is that while it is important we put out the current fire, 
unless we effectively deal with the long-term capacity issues 
facing the VA, we are going to be back here year after year 
with similar types of problems.
    You mentioned the number, and I want you to get into some 
detail. What are we talking about?
    Let us just start off with personnel. How many doctors, how 
many nurses, how many other types of medical personnel do you 
need to achieve that goal? Be as specific as you possibly can--
and, how much is that going to cost?
    Mr. Gibson. Mr. Chairman, of the $17.6 billion, 
approximately $10 billion is allocated for a combination of 
purchased care and hiring additional clinical staff. The blend 
of that will change over time as we ramp up that capacity, as 
we are successful in hiring people, yes----
    Chairman Sanders. Is it fair to say that to the degree that 
we strengthen the VA, we become less dependent on expensive 
contract care? Is that a fair statement?
    Mr. Gibson. It is absolutely a fair statement, Mr. 
Chairman.
    Chairman Sanders. OK. Please continue. I interrupted you.
    Mr. Gibson. So, over the 3-plus-year period of time that 
$10 billion gets allocated--a portion to purchased care, 
probably more on the front end than on the back end as we are 
successful in hiring.
    As I mentioned in my opening statement, you know, our 
ability to develop highly-refined bottom-up estimates of 
specific physician and clinician requirements is pretty 
limited. Our best estimates at this time is that this would--
that closing this gap would require hiring approximately 10,000 
additional clinical staff. Those are divided among primary 
care, specialty care, and mental health care. And, of the 
10,000, roughly 1,500 of those are actually physicians. Others 
are nurses and nurse practitioners and other direct patient 
support staff.
    Chairman Sanders. You talked about space.
    Mr. Gibson. Yes, sir.
    Chairman Sanders. I trust that you are not talking about 
building some Las Vegas-type expensive buildings. What is the 
relationship between space and the emergency that we currently 
have in terms of waiting periods?
    Mr. Gibson. I will tell you, Mr. Chairman, in every medical 
center I visited except one, and that is in Augusta, the number 
1 constraint that they are operating under right now is space. 
Fayetteville, NC, for example, is growing their patient 
population at a 7-percent annual rate. And, when it takes us 5 
or more years to get a building out of the ground, it does not 
take long to fall behind.
    So, where we are today as a Department is we are behind in 
terms of the space required today to serve patients, that there 
are $6 billion included in the $17.6 billion total that is 
designed for infrastructure.
    Chairman Sanders. And, can you tell us what are those 
projects? Do you have them?
    Mr. Gibson. There are--I am going to ask Philip to go into 
some of the details--there are eight major projects there. 
There are 77 lease projects for outpatient clinics that would 
add about two million square feet and roughly four million 
appointment slots. And then there are both minor construction 
and non-recurring maintenance that would add several million--
roughly four million, in round numbers--additional outpatient 
visit slots there.
    Chairman Sanders. We have heard time and time again that 
the dysfunctionality in terms of appointments for the VA has 
something to do with a significantly outdated scheduling 
system. Can you say a word on that?
    Mr. Gibson. There are actually four parallel tracks 
underway right now dealing with the scheduling system. There 
are 11 existing defects in the system that are being patched as 
we speak.
    There are four different interfaces that are in the process 
of being developed to make it easier for schedulers to access 
and to actually provide the opportunity for veterans to be able 
to directly access their schedule.
    On the 11th of July, we let a contract for major 
enhancements to the existing scheduling system that will remedy 
many of the most egregious problems that we have right now that 
make it hard to deal with.
    Then, parallel with all of that, as I mentioned in my 
statement, we are pursuing the acquisition of a commercial off-
the-shelf, state-of-the-art system. That is probably 2 years 
down the road in terms of actually having that functionality in 
place, which is why we are pursuing these other tracks in 
parallel.
    Chairman Sanders. All right. Let me conclude. I have gone 
over my time. If we do not have the resources at the VA to 
address issues like hundreds of thousands of folks coming home 
with PTSD and TBI, space issues, what happens in years to come?
    Mr. Gibson. The wait times just get longer. We do not--meet 
any acceptable standard of timely and consistent quality health 
care. It is--you know, I have committed to the President, I 
have committed to veterans, I have committed to the staff at 
VA, I will not hold back asking for resources because we have 
not been managing to requirements as a Department.
    This would never happen in the private sector. You would 
never stand for it. You would fail as a business if you did 
this. It makes no sense and I will not--I am not holding back 
now and will not hold back in the future.
    But, I have also told these folks that have worked on these 
numbers, I do not want a penny in there that we cannot justify, 
not one cent.
    Chairman Sanders. OK. I have gone over my time.
    Senator Burr.
    Senator Burr. Mr. Chairman, thank you.
    Secretary Gibson, again, I commend you. You have made all 
of us go back and sort of ask about numbers because it was not 
that long ago that we wrote off $127 million for that new 
software program to do scheduling, and I think that was the 
second time.
    And the $14 billion-plus that we have got currently in the 
construction and maintenance account, that means that projects 
are on a 7, 8, 10-year timeline.
    So, it is good to see, one, that VA has a sense of urgency; 
two, that OMB is recognizing the realities of what the needs 
are.
    I have got a set of questions for you, but I intend to send 
those to you and ask you to respond to them.
    I would ask unanimous consent that all Members have an 
opportunity to do that, Mr. Chairman.
    Chairman Sanders. Without objection.
    Senator Burr. Sloan, I want to focus for just a few moments 
on data integrity specifically at VBA.
    I want to give you some examples of testimony provided by 
the Office of the Inspector General and the General Accounting 
Office in a House hearing on Monday night.
    The Inspector General made these statements; all 
quotations:

          ``We have concerns that VBA's performance goals are 
        not realistic and comprised by data integrity issues.''
          ``We are receiving numbers of serious allegations 
        regarding mail mismanagement, manipulation of dates of 
        claims and other data integrity issues in the 
        Baltimore, Philadelphia, Los Angeles, Oakland, and 
        Houston VA Regional Offices, and today, we received an 
        additional allegation regarding the Little Rock VA 
        Regional Office. We are concerned at how quickly the 
        number of regional offices with allegations is 
        growing.''
          ``VBA removed all provisional rated claims from its 
        pending inventory. VBA's process misrepresented the 
        actual workload of pending claims and its progress 
        toward eliminating the overall claims backlog.''
          ``An Office of Inspector General team sent to 
        Philadelphia Regional Office on June 19, 2014, 
        determined that there were significant opportunities 
        for regional offices to manipulate and input incorrect 
        dates of claims in the electronic record. Incorrect 
        application of date of claim comprises data integrity 
        related to timeliness of claims processing.''

    Then there is this exchange that took place between 
Congressman Bilirakis and the Assistant IG, Linda Halliday.
    Mr. Bilirakis said, ``You remarked in your opening 
statement that VBA has self-reported a decrease in the national 
backlog by more than 50 percent since March 2013. Do you trust 
those numbers?''
    Ms. Halliday's response was, ``At this point, I would say 
no; I cannot trust those numbers. I think we have a lot of work 
ahead of us to address the allegations we have just received. 
They all seem to focus on data integrity, and they need to be 
looked at very carefully. So, I do not want to say I trust 
them.''
    Near the end of the hearing, Congressman O'Rourke asked Ms. 
Halliday, ``One of the things you said in your opening comment 
that struck me was that some of the success may be comprised by 
data integrity issues. [Is there] anything that Secretary 
Hickey has said tonight that alleviates those concerns that you 
raised in your opening statement?''
    Ms. Halliday simply responded, ``No.''
    Also, on the issue of whether VBA's quality metrics are 
reliable, the General Accounting Office provided this 
testimony:

          ``In prior work, we have documented shortcomings in 
        VA's quality assurance activities; and more recently, 
        concerns have been raised about the lack of 
        transparency related to the changes in the Agency's 
        national accuracy rate for disability claims.''
          ``In several basic areas, they are not following 
        general statistical procedures. That looseness in their 
        methodology translates to numbers that are not accurate 
        and are not very helpful in terms of looking at trends 
        over time, in terms of performance accuracy rates and/
        or comparing offices in terms of relative performance. 
        That is not good metrics.''

    Simply, the Inspector General's Office testified that they, 
``continued to identify a high rate of errors in regional 
offices' processing of claims decisions.''
    Now, Under Secretary Hickey was the one that testified for 
the VA. And, despite her testimony, which was refuted by the 
Inspector General, the GAO, VA put out a press release the very 
next day, entitled ``VA Takes Action to Ensure Data Integrity 
of Disability Claims,'' in which the VA touts that it has 
reduced the backlog by 55 percent and has reduced the number of 
days it takes to process claims and has improved their accuracy 
rate to over 90 percent.
    Now, listen; you have said that you have got to gain the 
trust of the Committee, of the veteran, of the country, and I 
think we agree with you.
    Let me ask you, how smart was that press release? Did you 
sign off on that press release?
    And how can numbers that were refuted by the people that 
are actually doing the investigations of VA facilities, how can 
they refute the numbers and the next day VA come out with the 
same numbers and tout them?
    Mr. Gibson. Senator, I think, as you have noted, trust is 
the foundation of everything that we do, and where there are 
questions about data integrity I think we have got to bore into 
those very deeply.
    There are a number of issues that have been raised there. I 
could sit and go through and pick at an item or two, but the 
fundamental issue remains that there are questions about 
whether or not we have got good data integrity there. And just 
as we are undertaking independent reviews in the VHA side, we 
will undertake those in the VBA side.
    Senator Burr. But, Mr. Secretary, they have been underway, 
much of it initiated by Members of this Committee, with the 
Inspector General, with the General Accounting Office.
    And you have acknowledged the shortcomings on the VHA side.
    This is fresh. This is this week. And, still, that press 
release stresses that the VA will continue to post these 
performance data on its Web site.
    How does publicizing suspect data increase the integrity 
and the trust that you----
    Mr. Gibson. Senator Burr, I would tell you I come into this 
organization from the private sector. I look at the 
transformation that has been wrought in VBA over the last 2 to 
3 years, and I defy anybody to show me any major part of the 
Federal Government anywhere that has transformed that much in 
that period of time. I think it is amazing, looking at it from 
a private sector perspective, much less doing it in the context 
of a Federal Government agency.
    There is room to improve there. I got it.
    We have got to restore trust there. I got it.
    They pulled the 100 percent provisional ratings out, and 
those did not get counted in the backlog. I got it.
    My recollection, round numbers, is it was about 12,000. I 
may not have that exactly right.
    The backlog is down 350,000 in round numbers.
    So, I get it. We need to make sure that the data integrity 
is there, but I am not going to pull back from standing by that 
Department and the good work that has been done.
    You know, we cannot have back and forth between IG. IG has 
findings, and we have got to embrace those findings.
    Senator Burr. Well, I appreciate the Chairman's leniency 
here.
    I am not sure you are embracing those findings, especially 
in comparison to how you have embraced the VHA findings.
    It concerns me because these are veterans that are waiting 
for their determinations to be made. In some cases, as the IG 
and GAO have pointed out, it involves overpayments--
overpayments that are due the American taxpayer, that are due 
back to the VA, to help fund other things.
    It just strikes me--and I realize this was a VHA hearing--
it strikes me that you could have testimony like we had on 
Monday night and yet turn around and put out a press release 
still stating the same numbers the next day when every one of 
the investigators found that those numbers could not be 
trusted.
    So I will work with you. It is an area of great concern. It 
is as big, if not bigger, a problem than the VHA because the 
budget is the biggest budget at the VA.
    I thank the Chair.
    Chairman Sanders. Senator Murray.
    Senator Murray. Thank you, Mr. Chairman.
    Mr. Secretary, the VA has removed wait time criteria from 
the performance contracts of network and medical center 
directors. And I do understand the need to be wary of creating 
incentives for people to game the numbers, but we also have a 
serious accountability problem.
    How will you still hold network and medical center 
directors accountable for wait times if it is not in their 
performance contract?
    Mr. Gibson. I think the first step that we have got to do 
is get integrity in the data, and so the idea behind pulling 
that out at this stage of the game was to eliminate any 
questionable motivation.
    Senator Murray. Understood.
    Mr. Gibson. I think as we move forward what we are going to 
find is that average wait times are a very poor gauge for 
timeliness of care for a large integrated health system. You do 
not really find that out in the private sector.
    That is one of the reasons we are boosting our patient 
satisfaction measurement activities because I think patient 
satisfaction is going to become central. Even at a 14-day 
standard, if the veteran needs to be seen today, we have failed 
that veteran.
    Senator Murray. So you are looking for different ways to--
--
    Mr. Gibson. So I think we are going to be looking at 
different ways to evaluate timeliness of care. It will be a 
combination of patient satisfaction. It will be a combination 
of veterans that are waiting too long and seeing that number 
coming down steadily; and then, as we have the system 
capability to do things like you see over in the private 
sector, metrics like the third next available appointment, 
which gives you some gauge of the capacity of the system to be 
able to handle that veteran as they come in.
    Today, at least, we are able to look at same-day 
appointments. Roughly, in the primary care area, we see about 
100,000 veterans on a same-day basis every single month in 
primary care. That, to me, suggests that there is capacity that 
is being maintained to take care of that veteran who cannot 
wait 14 days or 21 days or 30 days.
    Senator Murray. OK. Health care from the private sector 
does play a critical role in making sure that veterans get 
their care in a timely fashion, but there are some drawbacks to 
that care that VA has been trying to overcome, like not being 
able to get medical records returned to the Department and very 
little ability to see the quality of care that is provided.
    If Congress were to expand the authority for non-VA health 
care, what steps would be necessary to address those kinds of 
problems?
    Mr. Gibson. I am going to ask Philip to jump in here in a 
moment.
    One of the biggest challenges we have with purchased care 
in the community is maintaining continuity of care for the 
veteran. So, the ability to get information, medical 
information, medical record information, back and forth is a 
vital part of this--ensuring the quality of care.
    I would tell you if the floodgates open it will present the 
Department with challenges.
    But the fact remains, right now we are referring out 
roughly a quarter of a million referrals every month to 
purchased care. And, as I mentioned before, every one of those 
referrals, on average, will result in roughly seven 
appointments. That is an awful lot of activity.
    Last year, 15 million visits to non-VA providers over the 
course of the year plus the 85 million outpatient clinic visits 
that we have is 100 million outpatient visits a year that we 
are managing.
    So, it is already a very large number and a challenge for 
us, but it would be--if we open the floodgates, it would be an 
even bigger challenge.
    Anything to add there, Philip?
    Mr. Matkovsky. No, sir.
    Senator Murray, the one thing I would add is purchasing 
care in the community does not absolve us of the requirement, 
the responsibility, to coordinate that care.
    In addition to the assurance that we can both send and 
receive clinical data, there is just the hands-on coordination 
required to make sure that an appointment has occurred, that 
the veteran knows where to go----
    Senator Murray. Right.
    Mr. Matkovsky [continuing]. That their family is involved, 
all the rest of that.
    If we just look at the cost of the care alone, we are 
missing a big responsibility.
    Senator Murray. So when we look at how we do this and 
expand that, we have to look at all those issues as well and 
get them right, or we are just going to create a bigger problem 
for the future. OK.
    Finally, VA has had a lot of difficulty hiring providers 
for a number of reasons, including pay that is lower than the 
private sector and, as you mentioned, a very long, cumbersome 
hiring process plus the challenge itself of hiring in shortage 
areas in health care anyway because we know there are national 
shortages, as well.
    Now VA does a lot of training for doctors and nurses and 
works very closely with a lot of our universities.
    What more can the VA do to help build the health care 
workforce that is necessary to meet the needs of the Department 
and our country?
    Mr. Gibson. That is a great question, ma'am.
    I think one of the significant opportunities--and the 
Chairman and I have talked about this before--are opportunities 
where we can work collaboratively there, maybe tuition payment 
programs or tuition reimbursement programs, ways that we can 
encourage that.
    We certainly rely very heavily on our academic affiliations 
as a source for new clinicians, and we are doing some things 
from a compensation standpoint as well, where we have got some 
flexibility to be able to meet local market----
    Senator Murray. OK. I am very interested in that because I 
think that that is part of the reason for a backlog as well.
    Mr. Gibson. Yes, ma'am.
    Senator Murray. I mean, there is a variety of reasons, but 
we cannot ignore that side of it. So I am interested in hearing 
more of that.
    Mr. Gibson. Yes, ma'am.
    Senator Murray. Thank you very much, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Murray.
    Senator Isakson.
    Senator Isakson. Following up on Senator Murray's question 
about referrals, in particular to the private sector, I wrote 
down this from your statement. You said you all had recently 
made 543,000 referrals for veterans for private care.
    What percentage of those would you guess were mental health 
referrals?
    Mr. Matkovsky. I am sorry. I could hasten a guess, but I 
would take that one for the record.
 Response to Request Arising During the Hearing by Hon. Johnny Isakson 
                 to U.S. Department of Veterans Affairs
    Response. From May 15, 2014 to July 30, 2014, VHA made 
approximately 541,000 outpatient referrals. Based on the identified 
category of care, there were 8,454 referrals that were for mental 
health services.

    Question 2.  What is VA doing to ensure coordination of care for 
mental health patients?
    Response. It is the responsibility of the Veteran's treating 
clinician(s) to lead coordination of care for a Veteran receiving 
mental health care in the community, in coordination with clinic 
administrative staff, Health Information Management Service, and the 
facility staff responsible for the business (clinical and 
administrative) processes related to Non-VA Medical Care Coordination 
(NVCC).
    The NVCC model is a system of business processes that standardize 
front-end business processes and improve patient care coordination VA-
wide.
    In the NVCC model, the Veteran is notified of the approval of non-
VA medical care and contacted to identify availability, preferences, 
and needs. Once this information has been obtained, the non-VA medical 
care provider is contacted 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, 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 their 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.
    At the Atlanta VAMC, in particular, since 2013, VHA has greatly 
consolidated the number of contract providers it utilizes for mental 
health services, from 26 to 5, to ensure there is greater coordination 
of patient care.

    Senator Isakson. The reason I ask that question is I got 
into the Atlanta VA starting in August of last year when we had 
two suicides and a drug overdose.
    When we dug down, they were using a community-based 
provider for mental health. VA would see the patient, refer 
them to the community-based provider, with no follow-up between 
the referral and the appointment. And, in that period of time, 
when the person was determined to be at risk for themselves and 
their own life, in two cases they took their own life because 
they did not get timely services on the referral.
    I think Mr. Matkovsky made an interesting observation about 
coordinated care.
    As we expand private sector options in veterans' health 
care, which we may or may not do--I hope we do in terms of the 
legislation going forward--care coordination is going to be one 
of the secrets to making that work, not just in reducing wait 
times but increasing the quality of care to the veterans, 
particularly with the number, as Chairman Sanders said, the 
number of veterans seeking mental health care coming forward.
    That is going to be an ongoing process. It is going to be 
one that is going to have to be coordinated and monitored.
    My question is, did you ever see the William Schoenhard 
memorandum?
    Mr. Matkovsky. Yes, Senator.
    Senator Isakson. In May, when Secretary Shinseki and Dr. 
Petzel were here to testify, I asked them both the question, 
had they seen it?
    Dr. Petzel said he had seen it and read it, and Secretary 
Shinseki said he had not.
    I think both of them told the truth. I do not think 
Secretary Shinseki ever saw it, and I do not think he ever saw 
it because the senior leadership of the VA did not let him see 
it.
    My experience of a lot of these problems lies at the 
highest levels of the veterans administration and veterans 
medical services that insulate the leadership of VA from the 
problems that they had. Why else would a memorandum written 4 
years ago, describing what we are all discovering now in 2014, 
not have been acted on?
    The last sentence of the third paragraph says, ``These 
practices will not be tolerated.'' It does not say, ``Look at 
this when you get a chance.''
    And it delineates each of the programs just like the 
testimony that the whistleblowers gave the other night in the 
House hearing.
    You are an interim secretary. You are going to be handing 
off, presumably, to Mr. McDonald, who I understand is a well-
qualified individual.
    Mr. Gibson. Yes.
    Senator Isakson. What are you doing to put in place--the 
type of information transfers and conduits--that will see to it 
Mr. McDonald does not become a rookie victim as a distinguished 
general did, in terms of Secretary Shinseki?
    Mr. Gibson. I am not going to let him. I am not going to 
let my old friend become a rookie victim of anything.
    More fundamentally----
    Senator Isakson. Let me interrupt. I am not being trite 
when I ask this question.
    Mr. Gibson. No, no, I understand.
    Senator Isakson. For 4 years the VA insulated its leader, 
in the case of Secretary Shinseki.
    Mr. Gibson. I would tell you from my own personal 
perspective I have learned to never have all my information 
filtered through a couple of people, and so from the first day 
that I got to VA I started reaching down in the organization to 
get additional information.
    I think your sense is a very accurate one. I think, 
historically, VHA has operated a fairly insular organization--
not fairly, a very insular organization; and I think part of 
what we have been doing is dismantling a lot of those barriers.
    Since my first day as Acting Secretary, every single 
morning at 9 a.m. we have something called Access Standup. We 
have senior leaders from across VHA as well as senior leaders 
from across the Department. We are up in our integrated 
operations center, and we are boring into data around access to 
care:
    What is the status?
    What are we doing?
    How many contacts?
    How many appointments?
    What are the wait times?
    What is the status on many of these different initiatives 
that I have alluded to in my opening statement?
    It is just part of what we are putting in place.
    I would have to say this young guy right here--I have said 
before, if I was half as smart as Philip, I would be darn 
smart--he has been doing an awful lot of the work to put in 
place the kind of management information that you are talking 
about so that we are not just relying on, by chance, that 
information filters up, that we have got dashboards in place 
that will help us identify where there is scheduling 
malpractice. That is in place right now, where there are 
productivity opportunities for us to wring more productivity 
out of a particular clinic, that we are able to identify those 
things, and then, in tandem, requiring medical center directors 
and VISN directors to get out in their clinics so that they 
take direct ownership for the consequences.
    The first sentence in the memo that provided that direction 
was, ``Medical center directors and VISN directors are directly 
accountable for the quality of care and the timeliness of care 
that is delivered by VA.''
    That was the first sentence, and it was in there because I 
wrote it.
    That is part of ensuring that we have got that kind of 
accountability, and frankly, it is part of the culture change 
for the organization. VHA is not used to operating that way.
    Senator Isakson. Well, my time is up, but with that 
endorsement of Philip, I have to ask this question; Philip, you 
are not leaving when Secretary Sloan leaves, are you?
    Mr. Gibson. I am not going anywhere either. I am going to 
stick around.
    Senator Isakson. I am talking about in the leadership. Make 
sure he is at the right hand of Mr. McDonald.
    Mr. Matkovsky. There are a lot of good people building a 
lot of good tools.
    One of the things that we have a team working on right now 
is to take that memo and actually develop tools that allow us 
to mine data to look for those patterns, to give us a risk 
score at the timeliness data that we are looking at.
    So, as we are looking at our timeliness data, Secretary 
Gibson has directed us to place an integrity score against it 
and rate it. Are there certain questions? And, if the questions 
persist, then have an audit come in, take a look at it, and 
manage it.
    Senator Isakson. Thank you both very much.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    You are right; there are a lot of good people in the VA 
building tools and there are also a lot of them delivering some 
damn good health care on the ground. We need more of them, and 
we need to get rid of the bad apples that are in that bunch.
    Mr. Sloan, you said that you have a concern about purchased 
care trumping VA capacity. I assume that is during this 
conference committee and other times, where we will put more 
emphasis on purchased care and not enough emphasis on VA 
capacity.
    Have you been able to do any sort of cost analysis on 
providing care for veterans outside the VA? Is it more 
expensive, less expensive, about the same?
    You can kick it over to Matkovsky if you would like.
    Mr. Matkovsky. There are instances where we have taken what 
we would consider to be the mix of patients that we would be 
serving--veteran patients--and the types of services we would 
provide, and we compare them to a private sector model. 
Sometimes we do it for a community-based outpatient clinic, 
sometimes larger.
    As a general rule, it tends to be more expensive.
    And there are two different types of contract actions that 
we have used: capitated models and fee-for-service models. They 
both have their problems.
    Senator Tester. OK. I come from a State where, quite 
frankly, it is a frontier in a lot of areas. And the private 
care may or may not solve the problems, but it looks pretty 
attractive.
    If it breaks the budget of the VA, though, and we do not 
get better health care in the private sector, which I think 
both of those are up for debate, it can be a problem. That is 
why I agree with your capacity issue with the VA.
    In the meantime, I want to talk about an issue that Senator 
Moran worked on, and that is Project ARCH. I think it has 
worked well. It has not been perfect, but it has worked well.
    Can I get any assurance from you that ARCH will not be 
prematurely shut down before it is reauthorized?
    Mr. Gibson. The discussion that Senator Moran and I had the 
other day was exactly to that issue.
    My commitment is we will not, to the extent that I have got 
the authority--there is some question there--but we will not 
end a program that is providing access to veterans until we 
have the robust replacement in place so that there is no lapse 
in care for the veterans that are being served in Project ARCH.
    That is my commitment to Senator Moran. It is my commitment 
to you and the veterans that we serve.
    Senator Tester. That is good. I mean, I think the Project 
ARCH definitely works, and it definitely allows you to have 
control of those medical records too as you move forward, which 
is a big concern when we start going to the private sector.
    Could I ask you, what do you say to folks that say the VA's 
work shortages are a myth and that the real problem is the 
medical personnel are just not working hard enough or fast 
enough?
    Mr. Gibson. I will begin, then I will probably pass it over 
to Philip for a wrap-up.
    I think when you look--I mentioned earlier in my opening 
remarks, older, sicker and poorer, when you look at the typical 
VA patient.
    First, you start talking panel sizes or RVUs when you are 
looking at specialty care. You have to take into account the 
very different patient population that VA is dealing with. So 
the number of primary care patients that a clinician sees at VA 
is, in all likelihood, going to be different than what you see 
in the private sector.
    Second, there are oftentimes factors that bear on their 
ability to see. For example, space, as we talked about that 
earlier.
    I think the average in the private sector for primary care 
is two and a half treatment rooms for a primary care provider. 
And I do not think we have good data on what that looks like 
across VA, but I strongly suspect we do not have those 
resources.
    In the case of specialty care, I would tell you one of the 
places we are significantly underleveraged--and it is addressed 
in these numbers in this request--is, on average, we have one 
support person for every specialty care provider at VA. That 
compares to a goal, or a target, of three and a half to one in 
primary care. We are underleveraging our specialty care 
providers, and as a result they are not seeing as many patients 
as they ought to be able to see.
    So, we get these differences in comparison to the private 
sector.
    I am convinced we are going to see some productivity 
enhancement, but it also means that we have got some 
investments to make to be able to deliver those.
    Senator Tester. Will that productivity enhancement meet the 
needs of the veterans that do not have access to the VA?
    In other words, what I am saying is that I was told, for 
instance, VA-Montana has 22 slots short on docs and nurses are 
significantly higher than that. Productivity can probably take 
care of some of those docs--maybe, maybe not.
    But, my point is that if we are short 22 docs, it just 
means harder work for the doctors there, it becomes an issue of 
are they going to be as happy with the VA. Nine out of ten say 
they are happy with the service now--the ones that get through 
the door.
    Mr. Gibson. Let me ask Philip to take just a moment and 
summarize the process that we have been going through across 
VA.
    Senator Tester. Yes, that is fine.
    Mr. Matkovsky. When we did accelerated care, one of the 
things we pushed out was productivity data for specialty care. 
I may touch on panel size a little bit because I think there is 
some criticism there, but we sometimes miss the comparative 
patient populations when we do that.
    We are looking at productivity. We are comparing 
productivity internally. Where we have highly-productive 
facilities, we are looking at how they got there. Part of that 
is smart use of support staff, but part of it is actually just 
monitoring RVUs and productivity in our appointments that we 
have available.
    Some of that can be covered internally. Some of it will 
require additional resources. So when we pushed out 
accelerating care, we asked every facility to look at their 
productivity numbers as well as whether or not they could 
increase them; if they could not, to give us a requirement for 
some non-VA care resources. And we used that as the basis to 
accelerate care.
    Senator Tester. OK. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Sanders. Senator Moran.
    Senator Moran. Chairman, thank you very much. Again, 
Secretary Gibson, thank you for your presence today.
    Senator Burr and others, including you, have used the word 
``trust.'' I have never asked for a Cabinet Secretary's 
resignation. This is the first time I have ever done that in my 
time in Congress. And we were indicating at the time that there 
was a problem with the culture, systemic problems, lack of 
leadership. It was my sense that all that was true, or I would 
not have taken the steps that I took.
    I was--I do not know--somewhat comforted in the position, 
but actually, you know, very concerned but what I heard 
Secretary Shinseki say on the day that he announced his 
departure, which was something to the point that he had been 
surrounded by people whose views he trusted that he should not 
have trusted. The reason that there was some assurance to me is 
it seems to me that we were right, there is a culture and a 
systemic problem if the Secretary cannot trust the people that 
he or she must deal with on a day-to-day basis to provide 
information.
    I want my comments here today to be broad and not 
provincial just to Kansas. I appreciate the Senator from 
Montana raising this issue of ARCH, but I want to use that 
program as an example of why I, as a Member of Congress, have 
had difficulty trusting the Department of Veterans Affairs. I 
do not mean this in a personal way. I do not mean to suggest 
that I am personally offended by the circumstances that have 
developed over a period of time. What I mean is that my ability 
to assess what you are doing, to make decisions as a member of 
the Appropriations Committee, but most importantly, my ability 
to care for the veterans back home in Kansas is handicapped by 
the sense that I have had that the Department of Veterans 
Affairs does not trust us, does not share information with us, 
is not honest with us, and perhaps most importantly, has rarely 
responded to issues that we have raised.
    Again, this is not a personal concern of mine; it is not 
like I am personally offended. But when a veteran in Kansas 
brings an issue to me and I raise it with the Secretary or 
anyone else at the Department of Veterans Affairs, I think we 
should be able to expect an honest, fair, and timely response, 
and it has not occurred. So, my ability to trust the Department 
of Veterans Affairs has been significantly handicapped.
    An example of that is this ARCH program. I authored 
legislation that ultimately created a pilot program--it got 
narrowed down to be a pilot program--that says if you live long 
distances from a VA hospital outpatient facility, you can 
access that at home by the Veterans Department giving you the 
ability to do that paying for the service. That pilot program, 
five of them across the country in rural areas, was created in 
2011. I kept continually asking questions of the VA: how is it 
going? Some pride of authorship, but mostly, is it working? How 
are veterans--are they liking it? Is it cost-effective? Does 
the technology work? And we got virtually no answers over a 
long period of time.
    Finally, at the hearing with Secretary Shinseki--this 
program is about to end. Its 3-year pilot program is coming to 
a conclusion, although we are pleased to know that you have the 
authority to extend it. Secretary Shinseki in March of this 
year indicated to me that I would have an answer to my question 
by sunset. Those were his words, ``by sunset.'' I never got an 
answer.
    Then on March 20--and, incidentally, one of the things I 
have learned since then is that in the spring of 2012, a year 
after the pilot program gets started, the Wichita VA is 
interested in promoting this program to rural veterans, and 
they were instructed by folks in Washington, DC, that you 
cannot recruit veterans for ARCH and you cannot ``market'' 
ARCH.
    My concern is that we have created a program that somebody 
at the Department of Veterans Affairs does not like, so they 
are out and about trying to make certain they prove is does not 
work. For somebody at the VA to tell folks in Kansas, ``Do not 
market this, do not encourage veterans to participate,'' 
suggests that they wanted failure. So, I became more suspicious 
as I learned this.
    On March 26 of this year, the national program director 
directed the five pilot programs to notify veterans the program 
was coming to a conclusion. At the same time--in fact, in 
April, a week or so later--senior staff at the VA assures my 
staff and Committee staff that we are continuing to assess the 
program. Subsequently, we have learned that already the memo 
has gone out telling those five pilot programs to notify 
veterans the program will no longer exist, but 10 days later or 
2 weeks later, we are assured VA is continuing to assess. That 
again makes me suspicious about the inability to get the report 
promised by the Secretary of Veterans Affairs by sunset that I 
will know what is going on with ARCH.
    Then, in June of this year we discovered that there was an 
email ready to be sent terminating the program. I and several 
other Senators, including some on this Committee, asked that 
not to be the case, and we are told just in time the ``Send'' 
button was never pushed.
    So, there were a series of things that cause us to have 
great doubts about who is telling us what; what the truth is. 
And I guess in a more fundamental way, these programs 
authorized by Congress, can they be easily undermined by 
personnel at the Department of Veterans Affairs who apparently 
do not like the suggestions that we have made? This is not a 
suggestion; this is the law that we passed.
    Finally then, our telephone conversation of June 27, I 
appreciate you reiterating what you just said to Senator 
Tester. So, that is the circumstance that I find myself in as 
someone who is a supporter of veterans and, therefore, a 
supporter of the Department of Veterans Affairs whose mission 
it is to take care of veterans across our country and our 
States.
    Mr. Gibson. Just a quick comment. I alluded in my opening 
remarks to openness and transparency. I think that is central 
to maintaining trust. And the position that we are in right 
now, re-establishing trust, this is one of the central cultural 
issues that we have to deal with as an organization. I would 
tell you that there is a--I used the word ``insular'' earlier 
to describe particularly VHA. As I find it coming into the 
Department, I think that is the case. As you know, what I have 
been doing over the last 6 weeks is pushing information out the 
door as fast and as hard as I can push it out. I prod behind 
the scenes for responses to Congress, and we have got a lot of 
work to do in that regard. We have to earn the trust back.
    Chairman Sanders. Thank you.
    Senator Hirono?
    Senator Hirono. Thank you.
    We know there are capacity issues at the VA, and I would 
just like some clarification on some comments or statements 
that you made. Did you say that based on your assessment of the 
capacity issues that you would need 10,000 additional staff? I 
think you were talking about some $17.6 billion that----
    Mr. Gibson. That is correct.
    Senator Hirono [continuing]. You would be requesting.
    Mr. Gibson. That is correct, yes, ma'am. I know that sounds 
like a huge number. There are 300,000 people in VHA alone.
    Senator Hirono. So is that 10,000 additional staff--and I 
know you broke it down into how many doctors, et cetera, within 
the specialties, et cetera. So is that for the emergency 
situation we have now; or is this an assessment that reflects 
your long-term staffing needs?
    Mr. Gibson. There was a reference made in one of the 
opening statements earlier about the findings of the field 
audit, and the number 1 cause for scheduling difficulties was 
that there were not sufficient provider slots to be able to 
schedule patients into. So what we are talking about here, my 
comment earlier that we have not historically managed to 
requirements, we have managed to a budget number.
    So, basically, we took a budget number, and we did what 
folks thought they could do. And the veterans wound up being 
the shock absorber in that process----
    Senator Hirono. So meanwhile, if you are looking at what 
your true needs are, then you are saying that you would need to 
hire----
    Mr. Gibson. Yes, ma'am.
    Senator Hirono [continued]. 10,000 additional staff.
    Mr. Gibson. Yes, ma'am.
    Senator Hirono. And that would, of course, depend on the 
appropriations that we provide.
    Mr. Gibson. Yes, ma'am.
    Senator Hirono. So, if you were to have the appropriations 
to hire 10,000 people, how long do you think it would take for 
10,000 people to be hired? Because one of the things that I did 
hear about the hiring in VA is that it takes a long time to 
hire a doctor. So, I hope that in your review you are also 
looking at your hiring processes, because it should not take a 
long time, whatever that means. That is one question.
    Then to hire 10,000, do you have any sense of how long this 
would take should you get the funding from us?
    Mr. Gibson. A couple of comments. One, at every single 
medical facility I visit, I hear from rank-and-file staff that 
it takes too long to hire. Staffing practices is one of our 
areas of concentration. My guess is there are some of those 
things that we are going to find it just a function of being in 
the Federal Government, and that is the regulation and statute 
that we have got to follow. But my guess is that we are going 
to find a large portion of that is self-inflicted, and we have 
got to clear that stuff away so that we can hire more 
expeditiously.
    Second, round numbers, I would say in VHA we probably hire 
30,000 people every year anyway. So I know 10,000 sounds like a 
huge number. It is about 3 percent of staff, maybe a little bit 
less than that. But recognize that some of these are in places 
like primary care physicians and mental health providers, and 
we know and you all know that those are tough to find. So, it 
will take time for us to be able to hire them.
    Quite frankly, the other problem we have, even if we could 
go out and hire them all tomorrow, we do not have a place to 
put them all. So in some instances, what we are going to have 
to do is deal with some space issues in tandem with this. We 
may be able to do--there are actually some provisions in here 
for what are called Emergency Leases. I actually authorize some 
of these when I go out to the field where somebody has found 
some clinic space that is local, that can be occupied quickly--
10,000 square feet, something like that--they can go put three 
patient line care teams in there and take care of an 
additional----
    Senator Hirono. Excuse me. I do not want to interrupt you, 
but my time is running out.
    Mr. Gibson. Yes, ma'am.
    Senator Hirono. My concern is mainly that you are 
addressing the length of time it takes, and if you are hiring 
30,000 people every year, there are probably some retention 
issues that you are also probably addressing.
    Mr. Gibson. It is 10-percent turnover, which, in fact, is 
relatively low if you look at health care organizations.
    Senator Hirono. That is good. You had mentioned in response 
to a question that when the IG has findings, to quote you, ``we 
are embracing those findings.'' And since the problems and 
challenges at the VA have been longstanding, I wonder whether 
you have a process or someone in the VA who provides a response 
to the IG's findings. Should you be providing a report to 
Congress to respond to the IG's findings so that we also can 
provide the kind of oversight that Congress should provide as 
to what is happening at VA?
    Mr. Gibson. There are responses to those, and unless I am 
mistaken, I believe that those responses are shared. Is that 
correct, Philip?
    Mr. Matkovsky. Yes.
    Mr. Gibson. So, there are responses. What I would tell you 
is that I do not believe that those have always gotten 
visibility and attention. Some of the examples surrounding the 
Office of the Medical Inspector and some of those reports, 
quite frankly, I do not think those were getting the attention 
that they deserved. So, as we look at overhauling certain of 
our processes, part of what we have got to do is make sure that 
the issues that need to be elevated all the way to the Office 
of the Secretary are, in fact, being elevated.
    Senator Hirono. Yes.
    Mr. Gibson. And that is where somebody says, ``We have 
taken care of this issue,'' that we know what has been done and 
we have confirmed that.
    Senator Hirono. I have, Mr. Chairman, just one more item. I 
was told by the veterans that I have been talking with--many of 
them live on neighbor islands, so these are rural issues--I was 
told that even if they got vouchers to go out to get private 
care, the doctors on the Big Island and Maui would not take 
veterans so it would not help them. Have you heard that 
concern?
    Mr. Gibson. I would tell you there are issues around the 
PC3, Primary Care Close to the Community Contract, that we have 
got with two different national providers for specialty care, 
and we do find instances where I think we have got room for 
improvement. PC3 is a new program, just launched earlier this 
year, and I do not think we are executing it as well as it 
needs to be executed. There are discussions going on this week, 
today, with the leadership of those two programs to make sure 
that we address those issues.
    I get that feedback from staff and from veterans, as well, 
when I am out in the field.
    Senator Hirono. The main thing, you are addressing that 
issue also.
    Mr. Gibson. Yes, ma'am.
    Senator Hirono. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Hirono.
    Senator Johanns?
    Senator Johanns. Mr. Chairman, thank you.
    Mr. Secretary, in your request for more money, a lot more 
money, one of the things that you mentioned was new facilities, 
and the idea behind that is that new facilities may improve 
productivity and hopefully that results in better services to 
veterans, that sort of thing. You mentioned that there were 
eight facilities that would be construction projects. How did 
you pick those eight? I know of a list out there that if you 
have a need for a facility, a new hospital say, it makes its 
way up the list. Did you just pick the top eight? And if you 
want to toss it over to Philip, that is fine, too.
    Mr. Gibson. I am going to toss this one to Philip, if I 
could, please.
    Mr. Matkovsky. Sure. We have a backlog of major 
construction projects, and these are in major construction 
items, not in minor construction or non-recurring maintenance. 
There is a prioritized ranking system that typically--not 
typically--has rated safety and security issues as the highest. 
So seismic corrections where we have got seismic deficiencies 
where, if there were an earthquake, the building would crumble; 
those have to get fixed. So, there are a number of those.
    We also have longstanding space shortages. Every single one 
of our facilities has a space shortage in terms of meeting 
patient care needs. I think we need to understand that. These 
are not abstract numbers. There is not enough space.
    But the vast majority of these, the eight projects--they 
are St. Louis, Louisville, American Lake, San Francisco, Palo 
Alto, West L.A., Long Beach--for the most part are safety and 
security high prioritized items because of structural 
deficiencies. Some of them do have patient care for additional 
space.
    Senator Johanns. Would this top eight be the same top eight 
as the list of 20-some projects that are out there waiting to 
make their way?
    Mr. Matkovsky. It is from that list, yes, sir.
    Senator Johanns. OK. Would they match if I took that list 
and matched it with what you have just described for me?
    Mr. Matkovsky. Are you talking about the 26 or 27----
    Senator Johanns. Yes.
    Mr. Matkovsky [continuing]. Major leases, or are you 
talking about----
    Senator Johanns. No; it is not leases.
    Mr. Matkovsky. I think you are talking about the historical 
projects that were ranked and prioritized. It would match, and 
it would match against that list for the most part. Yes.
    Senator Johanns. OK. For the most part. What is the ``most 
part'' missing here?
    Mr. Matkovsky. So, ``for the most part,'' just to give you 
a direct answer, might be the ability to complete a project 
given the size of the required funding it would fit in, whereas 
somewhere else that might only be 20 percent of that project. 
That is what I mean.
    Senator Johanns. OK. At the Committee's hearing in May, one 
of the things I talked about--and other Members did, too--is 
the expanded use of non-VA care to deal with the urgent 
treatment issues. You know, this is not an academic issue. It 
never was. It very definitely is not today because we know 
people died on the VA waiting list. And we know that throughout 
the system the list was gamed, intentionally and dishonestly, 
to the detriment of veterans.
    Now, there are a lot of ways of handling that, and, Mr. 
Secretary, let me just be candid with you. I have sat on this 
Committee now nearly 6 years. Other members have sat on the 
Committee a lot longer. This Committee has been, I think, very, 
very generous to the VA. And I kind of find it remarkable--
Republicans, Democrats, liberals, conservatives, it has kind 
of--when General Shinseki would come in, it was like, ``What do 
you need, General?'' And it was almost like we would salute 
when he said what he needed, and out the door he would go with 
more money, and always made the promise that we were doing 
better.
    Here is my concern. This sounds so similar to what we have 
heard over the years: ``I need more money. I need to be bigger, 
faster, grander. I need a bigger bureaucracy. I need to hire 
more people,'' and on and on and on.
    Personally, I think what you need is competition. I think 
if somebody were biting at your backside because they were 
providing better care, faster care, honest waiting lists, et 
cetera, people would go, ``Holy smokes, if we do not put our 
act together, we are going to lose out on this. If we do not 
see more patients during the day, we are going to lose out on 
this.''
    Just let me ask you, what am I missing here?
    Mr. Gibson. I do not know what you are missing. I know that 
millions of veterans turn to VA for their health care. And as a 
number of folks have mentioned at various points this morning, 
an awful lot of veterans continue to believe they get great 
care.
    Access to care is a challenge for many, particularly for 
new patients, but there is a lot of great care that is being 
delivered every single day. The challenge is----
    Senator Johanns. Here is what I would offer, because I am 
out of time. You know, and I hear this. But at the end of the 
day, these veterans fight for our freedoms. Why don't they have 
the freedom to make their own choice about their health care? 
And maybe they would say, ``By golly, I love the VA. I will 
stay with the VA until the day I die.'' But maybe they would 
say, ``That hospital 20 minutes down the road from where I am 
at is just simply a better situation for me than the hospital 
that is 250 miles from where I am at, with a long waiting 
list.''
    I am totally out of time, and I do not want to impose upon 
the Chairman's patience, but I just think you guys need 
competition. And I feel very, very strongly about that. And if 
you cannot clean up your act, then guess what? You lose out. 
And that is what I think you need. I do not think you need more 
billions and billions of dollars.
    Thank you.
    Chairman Sanders. Thank you, Senator Johanns.
    Senator Begich did not make, as I recall, opening remarks, 
so we will give you a modest amount of additional time.

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

    Senator Begich. Thank you very much. I like the way you say 
that, Mr. Chairman.
    Let me, if I can, thank you both for being here. I 
appreciate it. But, you know, it is amazing to me. I have been 
here now just about 6 years, but I am looking at a 2003 report, 
``Improve Health Care Delivery for Our National Veterans.'' Are 
you familiar with this report?
    [Mr. Gibson nodding head.]
    Senator Begich. If not, you should all read it. But I am 
really doing this for my colleagues, because when I turn to one 
page here--and why I am saying this, this is really part of 
your point. It says, ``Although enrolled veterans technically 
have access to VA health care system, long waiting times for 
appointments with health care providers continue to be 
problematic for a significant number of veterans. As of January 
2003, at least 236,000 veterans were on a waiting list of 6 
months or more for a first appointment[...]--a clear indication 
of lack of sufficient capacity or, at a minimum, a lack of 
adequate resources to provide the required care.''
    This is not new. It is just they did not get the funding 
years ago, and now we are playing catch-up, because you have 
also had 1.4 million net new VA patients. We did not do it. And 
I say ``we.'' I was not here. Somehow people missed this 
report. I do not know. I would submit it for the record, Mr. 
Chairman. I think, you know, it is like somehow suddenly it is 
all a new problem, it just occurred yesterday. No. It is right 
here in this report. And because they were not funded properly, 
it built up and new patients were added to the list from the 
Afghanistan and Iraq wars. Maybe people missed that. I do not 
know. Pretty simple, third page of the report, not complicated. 
Done under a different administration.
    So, I want to put that to the record because the issues you 
are bringing up are relevant.

    [The report from May 2003 is in the Appendix under Senator 
Begich.]

    Senator Begich. You know, do I think it is a lot of money? 
Yes. Is the money well deserved for our veterans? Absolutely. 
Because if they would have had it here, we might have been 
recruiting doctors back then, because the problem we are going 
to have, to Senator Hirono's question, is hiring 10,000 people. 
I agree. You have got a hiring system that is great. But to get 
mental health providers and primary care doctors? You do not 
just turn a switch. Every private hospital in this country is 
behind the curve getting doctors. Nurses are backed up. We do 
not have the capacity to fill these.
    So, I want to make this clear because I think there are a 
lot of good bumper stickers being talked about today, and I get 
it. But this is a systematic problem that has been around for a 
decade or more. And yet it is now suddenly--thanks to the VSOs 
and others who have come forward and said, look--they have been 
fighting for this for years. And now we are finally figuring 
this out.
    I will tell you--and I know the Chairman gets aggravated, 
not aggravated, but he knows I will bring it up all the time, 
and that is--what we are doing in Alaska. We have talked about 
this. We saw this problem. When I came into office in 2009, we 
said, ``What are we doing?'' We had 1,000 people on our waiting 
lists in Alaska with 120-day wait periods. So, what did we do? 
We did not go to the private sector because, honestly, all of 
us that go to the private sector get a doctor, it is hard 
enough to get appointments. Do you think we are going to add 
veterans to the system and clog it up some more? So what did we 
do? We looked at our current system of Federal tax dollars and 
how they are being used. Indian Health Services delivered by 
our tribes in Alaska, the federally qualified clinics, 
federally funded. So what did we do? We maximized the resources 
we have at our fingertips today.
    What is our wait time in Alaska in the Northwest Region? It 
is one of the lowest in the country, because we now have 
access. As a matter of fact, in Anchorage, when you use the 
qualified Federal clinic there and/or the South Central 
Clinic--and, again, you have got to be on the list. You sign 
up, you get through the system, you get on the list. For non-
major medical you get same-day care. That is pretty 
significant.
    That is competition that actually works with the tax 
dollars we are all paying. But if we shove it out only to the 
private sector, some magic will happen--and I agree, with the 
Closer to Care program, as you know, which uses private sector 
resources. But that does not mean it is the panacea, that every 
veteran is going to get care overnight. We have to look at the 
systematic problems here that I know you and I have talked 
about--this idea and what we are doing in Alaska, which I think 
has been successful. We have some problems still. We have some 
logistic problems, billing problems still. We have some 
scheduling issues and how to make sure the records are 
transferred properly between Federal agencies and so forth, but 
I know we are going to figure this out.
    Doesn't that seem like something we should be expanding and 
looking at around the country? I mean, federally-qualified 
clinics; the one reason you have certain pay levels for doctors 
so you have a controlled cost unit. In the private sector you 
are not going to have a controlled cost unit.
    Now, it does mean we will still use private sector 
resources as we are doing in Alaska, along with federally-
qualified clinics and our Indian Health Services, otherwise 
known as what we call it, the ``Nuka'' model, which is a very 
impressive model for the delivery of health care. Don't you 
think this is a model that we could use to actually go after 
some of this?
    Again, I did not mean to get so aggravated about this. It 
just aggravates me when people tell me it is suddenly a new-
found problem. People who have been here a lot longer than me 
should have read this report, not necessarily you two. I mean, 
Congressional people.
    Senator Begich. Go ahead. Sorry. There is my rant. There 
was a question there.
    Mr. Matkovsky. I will try to address it, sir. Very quickly, 
about the model in Anchorage, the Director there actually was a 
trailblazer for us. He actually established a number of the 
Tribal agreements with local Alaska Tribes----
    Senator Begich. There are 26 of them now.
    Mr. Matkovsky. Yes, phenomenal work that he did. I mean, he 
earned the trust. He literally extended the network of 
community providers into a seamless integrated system up there. 
It also allowed us to avoid folks having to travel long 
distances. I mean, the norm before used to be folks flying down 
to Washington State, if you recall----
    Senator Begich. Yes, in Seattle.
    Mr. Matkovsky [continuing]. So, they were able to stay 
local. So, it is remarkable work by the Director. Some of that 
has actually become sort of a pattern that we have used 
elsewhere in the country, with local Tribes and with IHS, 
signing the agreement with IHS to extend health care services. 
But most importantly, with the Tribes, in the Dakotas, in 
Oklahoma, across the country, we have Tribal agreements in 
place where we can reimburse for care. It is not perfectly 
seamless, but it is something that has really taken root for 
us.
    Senator Begich. And, you did not need new rules to do that?
    Mr. Matkovsky. No, we did not. We used our sharing 
agreement authority.
    Senator Begich. Right.
    Mr. Matkovsky. We have certain authorities in Title 38 that 
we use, you know----
    Senator Begich. And you can do that, also, with federally-
qualified clinics.
    Mr. Matkovsky. We can----
    Senator Begich. Yes.
    Mr. Matkovsky [continuing]. Under sharing authority.
    Senator Begich. Right. In Alaska, we are doing that with a 
couple which--one just went from a private to a federally-
qualified clinic to deliver care in Seward, AK, because there 
is no veteran care down there, which is a great example of how 
you can do this with your existing rules.
    Let me ask you, on having the VA utilize--and we talked 
about this or I may have sent a letter to General Shinseki on 
this--regarding positions that the Indian Health Services use, 
which are some of the Corps being used for their medical 
delivery system, and seeing if the VA can do the same thing. It 
is actually in the bill of how to fund some of these folks. In 
other words with the Health Care Corps, can you tell me if your 
regulations allow you--I know we talked about this briefly; I 
do not know if you had time to check on that. I think this is a 
resource of over 5,000 medical professionals sitting there, 
ready to go.
    Chairman Sanders. Mark, are you talking about the National 
Health Service Corps?
    Senator Begich. Yes. I am.
    Chairman Sanders. Yes. The National Health Service Corps.
    Mr. Matkovsky. Yes. I mean, I think we would have to look 
at some credentialing and privileging issues that would allow 
us to credential and privilege and share those authorities to 
treat in our system, as well. I would have to take that back 
and look at it to tell----
    Senator Begich. Can you do that for me?
    Mr. Matkovsky. I will.
 Response to Request Arising During the Hearing by Hon. Mark Begich to 
                  U.S. Department of Veterans Affairs
    Response. VHA has the ability to enter into agreements with other 
government agencies to temporarily assign professionals with critical 
skills. Inter-Governmental Personnel Act (IPA) agreements are one 
method endorsed by the Office of Personnel Management. To date, VHA has 
not pursued an IPA with the Public Health Service as VHA has been 
engaged in ongoing discussions with them regarding detailing medical 
professionals, particularly for mental health care, to VHA. The 
discussions presently are exploring the creation of an Interagency 
Agreement (IAA), which would define the terms, costs and skills of 
assigning 100 mental health professionals from PHS to VHA temporarily.

    Senator Begich. And then the last thing is on--I have a 
bill which Senator Murray talked about, and that is 
reimbursements for doctors in the sense of serving our VA 
system, and I have a bill on mental health providers, 
psychiatric care, which is a huge gap, and doing loan 
forgiveness. Have you had a chance to look at that bill, and if 
not, can you give us some feedback on that at an appropriate 
time?
    Chairman Sanders. Mark, if you will yield to me for a 
second----
    Senator Begich. Yes.
    Chairman Sanders. The issues that Senator Begich is raising 
are very important, and that has to do with how we not raid 
other facilities and steal doctors and psychiatrists, but 
develop more.
    Mr. Matkovsky. Right.
    Chairman Sanders. And, the issues are that you guys have a 
Health Education Assistance Program, which: (A) needs to be 
reauthorized; and (B) needs to be significantly increased. 
Right now, the maximum you can provide is only $60,000, which 
does not do anything for somebody graduating $200,000 in debt. 
That is what you are talking about, right, Mark?
    Senator Begich. Exactly. As a matter of fact, under ACA, 
the Affordable Care Act, for other professions, it is up to 
$100,000 for 2 years' service. So, the question is, have you 
had a chance to look at that bill, and do you support this 
concept?
    Mr. Matkovsky. I think we support the concept. We just have 
to look at the funding requirements associated with it. But, in 
practice, it is something that would allow us to recruit and 
retain highly qualified staff.
    Senator Begich. Very good.
    Mr. Chairman, I have some other questions. I will submit 
them for the record. But, I appreciate you allowing me to ask 
questions. It is just very frustrating when I see a report like 
this and people suddenly think it is a newfound problem when it 
has been around for 10 years. We just need to get after it and 
deal with it, and it is going to take years to change it.
    Thank you, Mr. Chairman.
    Chairman Sanders. OK. Thank you, Senator Begich.
    Senator Heller, you will have additional time, as well, 
because you did not make opening remarks.

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

    Senator Heller. You know, what I may want to do, Mr. 
Chairman, is just submit my opening remarks for the record. 
That way, I will go back to having 5 minutes and keep this 
hearing timely.
    [The prepared statement of Senator Heller follows:]
                 Prepared Statement of Hon. Dean Heller
    Thank you Chairman Sanders and Ranking Member Burr for holding this 
hearing today. I believe this Committee must continue conducting this 
vigorous oversight at a very troubling time in the Department's 
history. It is also important that the Conference Committee works 
quickly to reach an agreement so Congress can pass a bill to help 
Veterans get the care they need immediately.
    In a short number of months, Congress, Veterans, and the American 
public have had a glimpse into the failure of the VA to provide quality 
care to Veterans across the Nation, and it is disturbing to say the 
least that many of our Veterans went without health care because a few 
employees decided to cheat the system.
    Every time I am home, I repeatedly hear from Nevada veterans about 
their individual stories and difficulties they've faced with the VA, 
and many of them are doubtful it will ever improve.
    I share their frustration. Our veterans are entitled to a VA system 
that delivers the benefits and care they have earned in a timely 
manner. But today, the VA is not meeting that standard.
    I have a timeline here showing the progression of this scandal, and 
every week there has been a new revelation about failure to provide 
quality care, another VA official resigning due to a lack of 
accountability, or whistleblowers being punished for doing the right 
thing.
    It is unfathomable so many problems existed at the VA for years and 
management at some level allowed it to continue.
    That's not going to be the case anymore, and I expect the nominee 
for VA Secretary to prove to this Committee that he will bring a 
dedicated and unrelenting approach to fixing this broken agency.
    Veterans in my home state of Nevada are also facing significant 
problems that I expect to be resolved.
    At the Las Vegas VA Hospital, more than 6,700 Veterans were forced 
to wait more than 30 days for an appointment.
    And just last year, a blind female veteran waited nearly 6 hours in 
the Emergency Room before being seen by a nurse or doctor.
    I have spoken with the VA Hospital Director Duff about improving 
these wait times and better meeting the demand of Veterans in the area, 
and I expect this hospital to provide the best care possible moving 
forward.
    Over in Pahrump, 6,000 Veterans have waited more than two years for 
a clinic to be built. Despite promises of progress, construction of 
this facility has not started, and VA officials have not even provided 
a timeline for final approval of this facility.
    Pahrump Veterans have waited too long for this clinic to be built, 
and I would like to see the VA break ground on this facility before the 
fall so construction can begin and Pahrump Veterans can finally receive 
the care they waited for.
    In Northern Nevada, the Reno VA Hospital is still waiting for a 
director to be hired. As the VA works to bring greater accountability 
and transparency to its health system, I want to ensure any new 
director is committed to this goal.
    Unfortunately, the challenge with the VA health care system is not 
the only issue facing Nevada Veterans. These same problems with 
management and accountability are also an issue in the Veterans 
Benefits Administration, which processes the disability claims for 
veterans.
    The VBA continues to struggle to eliminate the veterans' disability 
claims backlog as it operates under a 1940s system in the 21st century.
    On a local level, Nevada's Veterans are facing the worst of the 
claims backlog. Not only does Nevada have the longest wait in the 
Nation at 340 days for a claim to be processed, but the VA Regional 
Office in my state was recently audited by the Inspector General with 
less than satisfactory results.
    The IG found that 51 percent of disability claims they reviewed 
were inaccurately processed, and many of the problems at this VARO 
persisted due to poor management.
    The VA has been given enough chances to fix the backlog for 
Nevada's Veterans, but has failed to produce adequate results. What 
Veterans need now is for Congress to take action to reform the outdated 
claims processing system. That is why Senator Casey and I introduced 
the bipartisan 21st Century Veterans Benefits Delivery Act to address 
three areas of the claims process: Claims submission, VARO practices, 
and Federal agency responses to VA requests.
    Just as Congress needs to address the quality and timeliness of our 
veterans' health care, Congress must also work to improve the delivery 
of their benefits, which is why I have continued to encourage Chairman 
Sanders to re-schedule a legislative hearing so the Committee can 
consider this important bill.
    Again, thank you Acting Secretary Gibson for testifying today. I 
look forward to hearing about what the VA is doing to improve care and 
benefits for Nevada and our Nation's veterans.

    Thank you, Mr. Chairman.

    Chairman Sanders. One of the few Senators who wants less 
time than being offered.
    Senator Heller. Yes. But, having said that, if I go over, 
please do not cut me off. [Laughter.]
    Having said that, thank you very much for holding this 
hearing, for both the Chairman and the Ranking Member.
    At risk of irritating you, like Senator Begich claimed, you 
know that I will be talking about backlog statistics. I would 
certainly appreciate a rescheduling of the hearing on the 
backlog information, and I will talk about that in just a 
minute.
    But, I am looking at the latest statistics; and I want to 
thank both of you for being here, Secretary, and the smartest 
guy in the room, Philip here, for taking some time. But, I am 
looking at the latest average days of completion in the VARO in 
Reno, which I bring up because Reno has the worst VA Regional 
Office in the country. I have been hitting on this and hitting 
on this, and I think it is a management problem. I do not think 
the rank and file in that office are at fault. I truly do 
believe it is a management problem and I am certainly hoping 
and have called for changes in that particular office.
    The average days to complete now a pending claim is about 
340 days. I have been harping on this for 5 years, and they are 
making slow progress. In 5 years they have reduced it by 10 
days. That is it. We have gone from 350-351 days down to 340 
days over 5 years--5 years! You have got to imagine, it is 
pretty frustrating. And, I am not frustrated for myself. I am 
frustrated for every veteran in the State of Nevada that truly 
needs the help, the benefits, and the health care that they 
deserve.
    On top of that, we had an Inspector General report that 
found that 51 percent--51 percent of the disability claims that 
were reviewed in this VARO were inaccurate.
    I have to tell you, I appreciate your opening statement, 
your openness and concern for openness. I think that is 
important. Transparency is important.
    Senator Bob Casey and I, because he has similar problems in 
Pennsylvania, worked together. Our staffs worked very, very 
hard. We came up with this VA Claims Backlog Working Group, 
submitted legislation on that. Are you familiar with the 
information in this----
    Mr. Gibson. I would tell you that I am aware of it. It 
would be a stretch for me to say that I am familiar with it.
    Senator Heller. OK. OK. Fortunately, I will be able to meet 
with the nominee tomorrow----
    Mr. Gibson. Good.
    Senator Heller [continuing]. And get an opportunity for him 
to also address or take a look at it, because I think it is 
very clear, the concerns, the problems that we have. I think 
this legislation does address some of those problems. 
Legislation is available.
    What is good news is Senator Moran and Senator Tester from 
this Committee are also cosponsors of this legislation. I think 
it would go a long way so that we do not, in 5 years, have a 
10-day improvement, that, hopefully, in less than a year, we 
could see perhaps a much greater improvement.
    I want to get on another topic real quickly, if you do not 
mind, and that is an issue that we have in the State of Nevada. 
There is a small city in Southern Nevada called Pahrump. 
Pahrump has about 6,000 veterans down there, and you are 
shaking your head, Philip. I am glad to see that. They have 
been waiting for a VA clinic for several years now. The 
Director in Las Vegas, Director Duff has approved it. They are 
now waiting for the national VA officials here in DC to get 
this done. What is the status?
    Mr. Matkovsky. I have to get back on the detailed status. 
We have had some issues with, if I may, our lease authorities 
that we have been trying to work through, and I think some 
folks here may be familiar with that, that have resulted in 
some delays in getting leases enacted. We had some challenges 
on the procurement side of that, as I think your staff has been 
briefed over the years. Right now we are working through trying 
to make sure that we can exercise our lease authority in the 
current environment. That is the challenge we have, sir.
    Senator Heller. Do you have any timeline for approval of 
this clinic?
    Mr. Matkovsky. I do not right now. It is not an issue of 
approval. It is an issue of actually effecting a lease 
agreement.
    Senator Heller. Do you think we can get an answer perhaps 
by this fall or something to----
    Mr. Matkovsky. I will get it to you sooner than fall, sir.
    Senator Heller. If you would, please----
    Mr. Matkovsky. I will personally go in and look at it.
 Response to Request Arising During the Hearing by Hon. Dean Heller to 
                  U.S. Department of Veterans Affairs
    Response. VA Southern Nevada Healthcare System (VASNHS) has 
developed plans to expand the clinic, which is too small for the 
Veteran workload in this area.
     The current clinic is in a modular building which is not 
feasible for expansion.
     In May 2013, an Out-of-Cycle SCIP proposal was approved 
for a new expanded Pahrump CBOC.
     VASNHS has solicited proposals for a larger clinic, which 
would be built to VA specifications and leased back.
     There are viable proposals which are currently under 
review in VA's contracting process, with final approval expected in the 
next few months.
     The costs of the proposals exceeded the threshold for 
local approval and will require Secretary Veteran Affairs approval.
     Once a bid is approved and funds are obligated, the 
estimated construction timeframe is between 12 to 18 months.
     The current Pahrump CBOC provides primary care, women's 
health, mental health, telehealth and social work services. The new 
clinic will expand these services and add space for radiology and 
pharmacy services.

    Senator Heller. I want to talk about--I have got just 
another minute here--about the face-to-face audits, reviews, 
and the problems. We have scheduling. We had an audit. The 
first phase was released on June 9, and this is with the Las 
Vegas VA Hospital, Southwest VA Clinic in Nevada, and they said 
that it needs further review. Do you know if those reviews have 
been completed?
    Mr. Matkovsky. We have referred all of those cases to the 
Inspector General, and we have prepared a detailed set of 
briefings. I think we are trying to schedule it now with the 
Committees and with Delegations to walk through the audit 
findings as well as why someone would have wound up on a 
further review list.
    Senator Heller. OK.
    Mr. Matkovsky. I know it has taken us a while to do that. I 
want to apologize for the amount of time.
    Senator Heller. I just want to make sure there is not a--we 
don't miss the follow-up. I would not anticipate that you 
would. But, do we have any timeline into when those----
    Mr. Gibson. I would tell you, the question there--somebody 
mentioned earlier that the IG is in over 70 different 
locations----
    Senator Heller. Sure. I am sure.
    Mr. Gibson. Any location where the IG is working, we are 
not able to go in and do any additional review. We have created 
Accountability Audit Teams to go into all of those where the IG 
is not, and those are scheduled to be completed, I think, by 
mid-August. But, in the meantime, we are going to provide some 
briefings on what the findings were and what we know.
    Senator Heller. Thank you very much.
    Mr. Gibson. I am going to be in Reno in August. I have to 
go out there to speak. We will get you the dates.
    Senator Heller. If you would, please.
    Mr. Gibson. I will make sure these guys get you the dates 
when I am going to be there and I will go visit the RO while I 
am there.
    Senator Heller. If you would. Thank you very much.
    Mr. Chairman, thank you.
    Mr. Gibson. And, last, we appreciate the opportunity to 
provide some technical input on the leasing issue.
    Senator Heller. Great.
    Mr. Gibson. I think we have furnished some of that 
information to the staff, Mr. Chairman, which would be very 
helpful for us to be able to move forward.
    Chairman Sanders. Thank you.
    Senator Blumenthal, you have 8 minutes, and I alert the 
members that there will be a vote, as I understand it, at 
12:20. Senator Blumenthal, 8 minutes.

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

    Senator Blumenthal. Thank you very much, Mr. Chairman. I 
really appreciate your holding this hearing and your 
leadership, along with Ranking Member Burr; and thank you, Mr. 
Gibson and Mr. Matkovsky, for your service to our Nation.
    I think you folks are in a difficult, if not impossible, 
position, because you are temporarily before us without the 
head of an agency, and my hope is that there will soon be a 
Secretary of the VA. But, right now, in effect, there is an 
empty desk where the buck should stop and I think that 
situation has to be remedied as soon as possible, and that is 
on us, not on you.
    Leadership has to include an overhaul, top to bottom, of 
the people who run the agency. Very simply, my view is that 
there has to be accountability for what is done in the past, 
but also a change in leadership which you are commendably 
seeking, as well, top to bottom, across the country.
    My experience over the last few months has been that the 
failure of the agency to be more responsive and accurate in 
some of what it is saying to the public is actually aggravating 
its credibility and trust problems. Senator Burr raised one 
instance earlier with the press release that he mentioned. I 
have found that there simply have been no answers to some of 
the questions that I have posed in letters to the agency, 
letters asking for site-specific information about the audits 
that were performed.
    The VA officials locally, and the audits seem to confirm 
that there have been no problems in Connecticut with these 
delays and destruction of documents and manipulation of waiting 
lists, and yet we have found in recent data released by the VA 
that, in fact, wait times have increased over the May-to-July 
period. In fact, those wait times have tripled. What is the 
meaning of that data?
    So, I have asked not only for the site-specific information 
resulting from the audit that was performed as a result of 
General Shinseki's order, but also for an explanation of those 
wait times, and I have yet to receive responses from the 
agencies that are really complete and satisfactory, in writing, 
to the questions that I have posed.
    Now, I understand you have a lot going on, but I would 
suggest that that kind of responsiveness in providing 
information is part of the mission that is all the more 
important. It has always existed, but it is all the more 
important now. So, I would like a commitment from you that the 
agency will respond to my inquiries in writing as soon as you 
are able to do so, and that you will respond in the future to 
the inquiries that I pose.
    Mr. Gibson. Two quick comments. First of all, the answer 
is, we absolutely will. It might even be more effective for us 
to arrange to come in and deliver a briefing, walk through the 
wait time data, also walk through, as Philip just mentioned a 
second ago, briefing material around the access audits that is 
being provided. You have not had the opportunity to hear other 
comments, but we have been pushing information out the door as 
fast and as hard as we can over the last 6 weeks. That openness 
and transparency, to your very point, is an essential part of 
earning back trust.
    Last thing. I told the President of the United States when 
he tapped me to be the Acting Secretary, I said, do not expect 
me to behave like the word ``acting'' is in front of my title. 
So, if anybody has seen any behavior out of me that looked like 
I was serving as a caretaker, please let me know what it was so 
that I can try to explain what maybe you were looking at.
    Senator Blumenthal. Well, I welcome that comment and I 
second it and support it.
    Can you tell us anything about the ongoing inquiry 
internally, what its status is, when you expect it to be 
completed, and second, about the Department of Justice 
investigation. I called for a criminal investigation by the 
Department of Justice with great reluctance and regret, but I 
do think that criminal responsibility has to be applied if 
there was obstruction of justice, destruction of documents, 
fraud in reporting, because those crimes, even with an agency 
as important as the VA, or perhaps especially because of its 
very important mission, has to be implemented where necessary.
    Mr. Gibson. There was a mention earlier of the fact that 
the IG has reviews underway at 70-some locations across the 
organization. I should explain more here. Before the IG goes 
into any location to do any kind of a review for any purpose, 
they inform the FBI. And, at any point during the course of 
their review of activities they uncover evidence of criminal 
wrongdoing, those routinely get referred to the Department of 
Justice. In fact, there is a Criminal Investigation Division of 
VA's IG. So, routinely, there are criminal investigations 
undertaken and completed and prosecutions that occur as a 
result of IG investigations. So, it is a routine matter.
    I would tell you, of the 70-some-odd locations that the IG 
has been reviewing, at the end of June I got the first set of 
reports on the first location, so, we have been working. With 
more than a thousand pages of transcripts of sworn testimony, 
it turned out that we actually needed some additional 
information, so we dispatched an official fact-finding group to 
go to that particular location. We have reviewed hundreds, if 
not thousands, of e-mail traffic. And, I expect by the end of 
this week to have proposed personnel actions on my desk for 
that--for a number of individuals at that one particular 
location.
    There is nobody that wants to see this process move 
faster--move forward faster than I do. It is painstaking.
    You know, I would say the other general category here of 
issues have to do with the referrals coming from the Office of 
Special Counsel. I have met directly with Carolyn Lerner. We 
are expecting a substantial number of those to come to us very 
quickly, and we have agreed on some expedited processes that we 
will work through to ensure that the whistleblowers are 
properly protected, and then to launch the appropriate 
personnel actions in the wake of that.
    Senator Blumenthal. My time is about to expire, so I 
apologize. I am not going to have more questions in this 
setting. I would like to follow up on the Department of Justice 
investigation--I know you cannot really comment in this setting 
about it--and, most important, about protection for 
whistleblowers. I think one of the unexplored areas here has 
been the potential for retaliation against whistleblowers. I 
would like to know from you, in the form of a future briefing, 
what has been done to protect them.
    Just one last comment. There is nothing routine about what 
happened here. You said that, routinely, the FBI is involved. 
There is nothing routine about what happened here and I think 
the FBI should be fully engaged and the Department of Justice 
involved. Thank you.
    Thanks, Mr. Chairman.
    Chairman Sanders. Senator Boozman, you will also have 
additional time.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Chairman Sanders and Ranking 
Member Burr, for having this very, very important meeting. And 
I want to thank you all for being here. I know that you are 
working very, very hard to try to resolve these things.
    I also want to commend you, Mr. Gibson, for getting out to 
the places that are really struggling, and also the places that 
are doing well, trying to figure out best practices and then, 
again, why others are struggling so much.
    Dr. Perlin, I think, is important in the situation of 
bringing him on as an advisor. I think that was really a very 
good move.
    In regard to your request as far as additional personnel 
and things like that, is that based on current practice or is 
that based on reforms in the future that are going to 
significantly change things, hopefully?
    Mr. Matkovsky. The methodology we used is largely framed in 
the current context, Senator Boozman. So, what we looked at is 
looking at our current appointment volume, looking at our 
current delays in care, forecasting those through the years, 
and trying to attenuate them year on year. So, it is not any 
subsequent reform. It is in our current context.
    Senator Boozman. Right. You know, I had the opportunity to 
serve with Tom Osborne over in the House, the great coach from 
Nebraska. People used to talk to him about winning and he would 
say, ``We did not ever talk about winning. What we talked about 
was doing the little things.'' And, one of the little things 
that has to be done--which I am a little bit concerned, because 
you said it would take 2 years, though in terms of VA, that is 
probably more like 4 or 5--is the scheduling.
    That is one of the little things. My understanding is they 
do not call people the day before and tell them they have got 
an appointment. You could cut your ``no show'' rate 
significantly just by doing that and then taking somebody that 
is on a backlog and sticking them into those slots. That is 
just common sense practice that is done throughout the country 
with anybody in the private sector. So, you have to get the 
scheduling under control, and there is no reason not to do that 
rapidly, particularly targeting the areas that are having 
problems. You know your facilities that are doing OK right now 
by whatever standards you are measuring. But, it does seem like 
you could put that in place right away.
    Mr. Gibson. You may have mentioned--missed the comments 
earlier. There are actually four different major initiatives 
underway on scheduling. One has to do with fixing existing 
issues. There are 11 of those fixes in process right now. There 
are four separate applications under development to make it 
easier for schedulers to interface with the system as well as 
to give veterans the ability to directly request schedules.
    There is a contract that has already been let that will 
make major modifications to the existing scheduling system--was 
let on the July 11--and we expect that to bear fruit in the May 
through August time period next year, to deal with some of the 
toughest, some of the most difficult issues associated with the 
existing scheduling system.
    All of that is in parallel while we are working to acquire 
a commercial, off-the-shelf----
    Senator Boozman. If there are good over-the-counter systems 
right now in place that major medical centers are using without 
any problem at all--that is the basis of medical practice.
    Mr. Gibson. Do you want to answer this one?
    Mr. Matkovsky. Sure. I would agree with you, sir. I think 
that you have two comments. One of them is the underlying 
system, and I think there was a reference made to a prior 
system effort. I do not think we are looking to go build 
something from scratch this time. I think----
    Senator Boozman. No. I mean----
    Mr. Matkovsky. Right.
    Senator Boozman [continuing]. I would hope not.
    Mr. Matkovsky. We are not, no.
    Senator Boozman. I would say that that is something that 
people have been doing for years. I am an optometrist by 
training, so, again, that is the basis of your practice, 
scheduling.
    You mentioned that you have one assistant per specialist 
right now in the VA system. I think you said two-and-a-half or 
whatever, which might even be a little bit low. What I would 
like to know is what is the relationship between--if you take a 
major VA medical center and you look at total staffing, you 
look at the staffing that it takes to support that medical 
center, what is the comparison with a major private entity as 
far as numbers?
    Mr. Matkovsky. I do not have the exact percentages, but if 
you look at the overhead rate in the VA or the indirect rate in 
the VA for support staff, it is considerably lower in each one 
of our major areas: primary, specialty, and mental health. I do 
not have the specific counts.
    Senator Boozman. As far as the total numbers. I am talking 
about administration, the whole bit.
    Mr. Matkovsky. I am looking just at the field costs, not 
looking at everything else for a blended overhead rate. I think 
we could come up with something like that, which would look at 
a blended rate and see where the different overhead and G&A 
charges come in. But, in terms of what we have in our 
facilities, the labor share is lower in the VA for support than 
it is in the private.
    Senator Boozman. Not as dollars, but people.
    Mr. Matkovsky. In terms of people, it is lower in the VA 
than it is in the private sector. What you may be asking, as 
well, would be, could we construct a blended rate that looked 
at the overall cost factors. We could. We have not done that.
    Senator Boozman. OK. I would like to see that. I think that 
would be interesting.
    The other thing is that right now if you go to your 
Medicare doctor, if you are a veteran and you have a physical 
with a Medicare doctor who decides that you need high blood 
pressure medicine, then you go to the VA, instead of filling 
that prescription--which is a pretty good deal for the 
veteran--they have to have a physical in order for it to be 
filled.
    Mr. Matkovsky. I understand----
    Senator Boozman. Why is that? I mean, is there any logical 
reason for that, as well? How many slots would that free up if 
you made that one change? How much money would that save?
    Mr. Matkovsky. I am not a clinician, so I cannot in a 
learned way describe why that is the case, but there are 
certain reasons why that would be appropriate and why that does 
make sense. But, I will tell you that we are looking at things 
like referrals to audiology and where that could obviate--where 
we could bypass the primary care step as an additional item. 
But, we need to look at that carefully, and I think folks are 
looking at that now, audiology, optometry, ophthalmology, maybe 
some pharmacy, not all pharmacy. We need to be careful. But, we 
are looking at that, to your point.
    Senator Boozman. Now, I can see the scheduled drugs and 
things like that, but to me, it makes no sense at all that if a 
guy that is licensed and taking Medicare dollars, another 
entity that is licensed by the government, why a prescription 
cannot be filled for diabetes, high blood pressure, the vast 
majority of stuff that actually comes across. Could you look 
and see how many slots that would save----
    Mr. Matkovsky. We will look at that. But, the one thing--
just one point of caution would be not to over-correct in that 
direction. But, we do have folks looking at the pattern between 
primary care and certain specialty, the pattern between primary 
and pharmacy----
    Senator Boozman. How do you mean, over-correct?
    Mr. Matkovsky. Just to not be vigilant for pharmacy-filled 
requests that would be coming in from the private sector. That 
is the only thing that I mean, just to make sure that we are 
determining the appropriateness of certain prescription fills. 
And, the examples that you have given, they seem pretty 
straightforward, but we just need to make sure that those are 
the only examples.
    Mr. Gibson. There is a large percentage of veterans that 
are served by both VA and Medicare.
    Senator Boozman. Yes.
    Mr. Gibson. And, so, part of this is understanding what the 
second and third order effects are of the kind of change that 
you are talking about. Clearly, one of the impacts would be 
that it would free up primary care slots. Got it. That is a 
good thing. What are the second and third order effects, and 
that is, I think, Philip's point, about being thoughtful----
    Senator Boozman. Well, it probably would decrease the 
backlog.
    Mr. Gibson. Yes.
    Senator Boozman. I am sorry to run over Mr. Chairman. Thank 
you.
    Chairman Sanders. We have reached the end of what I think 
has been an important and productive hearing.
    Mr. Acting Secretary, I want to thank you very much for 
stepping in, clearly unexpectedly, into a very important 
position in a very difficult moment in the history of the VA, 
and thank you very much for the work that you are doing.
    And, Mr. Matkovsky, thank you very much for what you are 
doing. We look forward to working with you in the days, weeks, 
and months to come.
    Thank you very much. The hearing is adjourned.
    [Whereupon, at 12:20 p.m., the Committee was adjourned.]
                                ------                                

Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
                  U.S. Department of Veterans Affairs
                    va resources requirement access
    Question 1. What will be the impact on veterans if VA does not 
receive the funding that is being requested?
    Response. 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; however, VACAA also directs VA to accomplish several tasks 
that will incur costs but were not funded by the Act, which will have 
the impact of further decreasing VA funds available to provide health 
care to Veterans. These provisions include:

          Sec. 201. Independent assessment of the health care delivery 
        systems and management processes.
          Sec. 202. Commission on Care.
          Sec. 203. Technology task force on review of scheduling 
        system and software.
          Sec. 303. Clinic management training for employees at medical 
        facilities of the Department of Veterans Affairs.
          Sec. 402. Provision of counseling and treatment for sexual 
        trauma by the VA to members of the Armed Forces.
          Sec. 403. Reports on military sexual trauma.
          Sec. 501. Extension of pilot program on assisted living 
        services for veterans with Traumatic Brain Injury.

    In addition, VA requested funds for increased costs above the 
budget request for Caregivers stipends and new Hepatitis C treatments. 
VA also requested a $368 million increase above the FY 2015 Advance 
Appropriation level for Veterans Health Care programs, but neither H.R. 
4486 nor Senate Report 113-174 have provided the requested increase.

    Question 2. What barriers does VA face when hiring additional 
health care professionals, especially primary care doctors--given our 
nationwide shortage of primary care doctors? What is VA doing to 
address such barriers?
    Response. The barriers VA faces in hiring healthcare professionals 
include both systematic and local issues. On a macro scale, shortages 
specific to role (e.g. primary care, psychiatry) reflect national 
staffing challenges. There are also geographic considerations, in 
particular in rural and other underserved areas. To be successful VA 
must provide competitive salaries and benefits along with an 
environment that is conducive to a productive and rewarding work 
experience including work-life balance.
    VA employs an aggressive, multifaceted strategy to recruit and hire 
physicians, Executive and clinical leaders at 150 medical centers 
assess physician staffing needs. Physician shortages or deficits at 
specific locations are addressed by increased marketing and recruitment 
efforts on a case-by-case basis. Marketing is also targeted to academic 
affiliates, professional health care associations, the Department of 
Defense (DOD), Health and Human Services (HHS) and Office of Personnel 
Management (OPM).
    VA's support of additional training positions and partnership with 
academic affiliates (who manage these residency positions), will help 
to increase the workforce in areas of high demand and limited capacity. 
Further, VA is in the early exploratory stage of examining novel 
programs and partnerships to expand training capacity, including the 
schools of Osteopathic Medicine and the Family Practice programs, as 
well as through the Federal Teaching Center model with Health Resources 
and Services Administration (HRSA).
    Veterans Health Administration's (VHA) National Recruitment Program 
(NRP) provides an in-house team of skilled professional recruiters 
employing private sector best practices to the agency's most critical 
clinical and executive positions. The NRP has increased its targeted 
recruitment efforts for mission critical clinical vacancies that 
directly impact and, once filled, will improve access to care. These 
specialties include primary care, mental health, and critical medical 
subspecialties.
    The national recruiters are attending conferences to showcase 
clinical practice opportunities to potential candidates. These include 
American College of Physicians; American Psychiatric Association and 
American Psychological Association. The team will also attend 
additional conferences through the end of 2014, targeting specialties 
such as Anesthesia, Gastroenterology, Family Medicine, Emergency 
Medicine, and Pharmacy.
    VHA, in partnership with the Office of Academic Affiliations (OAA), 
pioneered the agency's first-ever recruitment outreach program 
targeting health professions trainees. The Take a Closer Look 
Initiative provides VHA with a standardized outreach strategy to 
recruit health professions trainees from VHA affiliate programs for 
employment upon completion of training. Residents and fellows receive 
attractive marketing throughout their programs with information on 
careers at VHA, as well as guidance on contacting and facilitating 
employment with a National Recruiter.
    In addition to actively recruiting physicians, increasing and 
further incorporating nurse practitioners and physician assistants with 
specialized training and experience in primary care into care teams 
will increase Veterans access to care. Additionally, VA continues to 
recruit for a variety of administrative, technical and professional 
occupations to ensure the right mix of staff are available to provide 
safe, quality care to Veterans.
    The national recruiters, all of whom are Veterans, work directly 
with Veterans Integrated Service Network (VISN) Directors, Medical 
Center Directors, and clinical leadership in the development of 
comprehensive, client-centered recruitment strategies that address both 
current and future critical needs. Since its founding in April 2009, 
VHA's NRP efforts resulted in filling 1,286 mission-critical vacant 
positions, as of 8/21/14, which increased access to care in rural 
communities and contributed to Title 38 Veteran hiring goals. In fiscal 
year (FY) 2014, as of 8/21/14, the recruiters have placed 482 health 
care providers:

     91.49 percent are physicians;
     30.91 percent are primary care physicians;
     26.55 percent will go to rural/highly rural facilities; 
and
     16.18 percent are Veterans

    Sixteen of these Veteran hires will fill clinical and executive 
leadership roles at VA hospitals.
    By filling long-standing vacancies, VHA's NRP is able to eliminate 
several multi-million dollar contracts for temporary provider staff. In 
one case, the team staffed a full anesthesiology department in the 
Northern California Health Care System, and in another, a full surgical 
team at the Texas VA Medical Center, translating into improved patient 
care and cost savings to VHA.
                             mental health
    Question 3. Would any of the funding VA is requesting be targeted 
toward VA's capacity to treat veterans who need mental health 
treatment?
    Response. Yes, there is funding available through the FY 2015 
budget request and the Veterans Access, Choice, and Accountability Act 
to expand mental health provider capacity. The additional staffing 
under consideration for mental health (MH) would help to achieve the 
proposed overall staffing ratio of 7.72 MH providers per 1,000 MH 
patients.
                              construction
    Question 4. What are the infrastructure needs envisioned by the 
additional $6 billion and how would they impact VA's capacity to 
provide care to veterans?
    Response. VA is in the process of developing a spend plan for the 
$5 billion provided in Section 801 of the Veterans Choice Act and will 
submit it to the Committees as soon as it is finalized.
    As specified in the law, these funds will be used to increase the 
access of veterans to care and to improve the physical infrastructure 
of the Department. This mixture of investments will help ensure VA is 
increasing its capacity to meet the current and projected future demand 
for services.

    Question 5. What is the specific importance of leasing to VA's 
ability to deliver medical care?
    Response. Leasing is an essential vehicle that allows VA to provide 
care to Veterans at the right place at the right time. Leasing allows 
flexibility in that VA can reassess local Veterans' needs as they exist 
at the end of the lease term. As the needs and demographics of Veterans 
change and develop over time, VA is able to adapt and respond in a more 
agile manner than if VA owned the facilities. Additionally, VA can 
vacate aging facilities at the end of the lease term.

    Question 6. Why does VA need its own leasing authority for medical 
facilities?
    Response. VA continues to work to respond to this question and will 
follow up with the Committee as soon as possible.
                              data quality
    Question 7. What steps has VA taken to address criticisms to 
trustworthiness of data produced by the Department in order to ensure 
Congress and the public can have faith in information provided by VA?
    Response. VA has taken several first-steps to ensure data integrity 
and transparency, and restore the trust of Veterans, of our elected 
representatives, and all Americans:

     Suspended all VHA senior executive performance awards for 
FY 2014.
     Removed the 14-day access measure from all individual 
employee performance plans to eliminate motives for inappropriate 
scheduling practices or behaviors. In the course of completing this 
task, over 13,000 performance plans were amended.
     Updating the antiquated appointment scheduling system--in 
the short-term, enhancing existing systems. Working toward a 
comprehensive, state-of-the-art, ``commercial, off-the-shelf'' 
scheduling system. Expanding digital technology to free-up more people 
to care for Veterans. Adding more clinic hours in facilities.
     Contracting with an outside organization to conduct a 
comprehensive, independent audit of scheduling practices across the 
entire VHA system, beginning early fiscal year 2015.
     Every medical center and VISN Director are now conducting 
monthly, in-person inspections of all their clinics, including 
interacting with scheduling staff to assess scheduling practices and 
identify obstacles to timely care for Veterans. So far, over 2,450 of 
these visits have been conducted.
     Taken action on all of the IG's recommendations in the 
May 2014 Interim Report on Phoenix and responded to OIG's 
recommendations in the final report with action plans to be implemented 
during FY 2015.
     VA has set a goal to improve forecasting to better align 
available resources with identified demands.
     Building a more robust, continuous system for measuring 
patient experiences, to provide real-time, site-specific information on 
patient satisfaction.
     Improving communications between the field and the central 
office, between employees and leadership, and between VA and Veterans 
Service Organizations and stakeholders.
                           addressing culture
    Question 8. Outline the actions VA has taken to ensure employees 
who take the courageous step of coming forward to expose wrongdoing, 
waste, fraud or abuse are not intimidated, punished, or face retaliated 
against for such action?
    Response. VA recognizes the dedication and courage shown by 
employees who report violations of law, wrongdoing, waste, fraud, and 
abuse. VA is committed to protecting whistleblowers from retaliation. 
VA is working collaboratively with the U.S. Office of Special Counsel 
(OSC) to review allegations of retaliation, and VA will make a 
whistleblower whole where there has been a finding of retaliation. This 
may include, but is not limited to, placing the whistleblower back into 
his or her position, or assigning the whistleblower to a new supervisor 
or position. In addition, VA will, as appropriate, take disciplinary 
action against employees who have committed substantiated acts of 
retaliation.
    On July 11, 2014, VA registered for the OSC Section 2302(c) 
Certification Program. This Program will allow VA to meet its statutory 
obligation to inform its employees about the rights and remedies 
available to them under the Whistleblower Protection Act, the 
Whistleblower Protection Enhancement Act, and related civil service 
laws.
    On October 7, 2014, VA received that certification from the OSC. 
This is an acknowledgement of the seriousness, commitment, and 
resources the VA is directing toward fundamental change in VA's systems 
and culture.
    Under the OSC certification process, VA:

    1. placed informational posters regarding prohibited personnel 
practices (PPP), whistleblowing, and whistleblower retaliation in a 
public setting at VA facilities and VA personnel and equal employment 
opportunity offices;
    2. provided and will continue to provide new hires with written 
materials on PPP, whistleblowing, and whistleblower retaliation;
    3. developed a Web site on PPP and whistleblower rights and 
protections; and
    4. developed, in cooperation with the OSC, supervisory training on 
PPP and whistleblower rights and protections. VA executives, managers, 
and supervisors must complete this training on a biennial basis.

    One of the requirements of the Program is that all supervisors in 
the agency complete training on whistleblower rights and protections 
and prohibited personnel practices. To that extent, VA has worked 
closely with the OSC to develop specialized training for VA executives, 
managers, and supervisors on whistleblower rights and protections and 
prohibited personnel practices. VA executives, managers, and 
supervisors were required to complete this training by September 30, 
2014, and biennially thereafter.
    To reinforce the above, VA leadership sent a message to all VA 
employees regarding the importance of whistleblower protection, 
emphasizing that managers and supervisors bear a special responsibility 
for enforcing whistleblower protection laws. VA Leadership meets with 
employees at VA facilities across the country to reemphasize that 
message.
    VA's Office of Diversity and Inclusion (ODI) is also conducting on-
site and virtual training for facility leadership on workplace 
inclusion, prevention of workplace harassment, and whistleblower 
protections. ODI also recently issued communications on whistleblower 
rights and protections through its Diversity@Work Newsletter and 
Diversity News Broadcast, accessible on ODI's Webpage, http://
www.diversity.va.gov.
    As part of VA's commitment to whistleblower rights and protections, 
VA has established a whistleblower Webpage, http://
www.diversity.va.gov/whistleblower.aspx, accessible from VA's internet 
home page, http://www.va.gov. VA's whistleblower Webpage outlines 
employee and supervisor rights and responsibilities, including avenues 
of redress for complaints, informational posters and materials, and 
whistleblower training resources.
    Additionally, VA has established the Office of Accountability 
Review (OAR) to ensure leadership accountability for improprieties 
related to patient scheduling and access to care, whistleblower 
retaliation and related matters that impact public trust in VA. As of 
September 26, VA has announced the proposed removal of four senior 
executives following investigations by the OAR and the VA Office of 
Inspector General.
    VA will continue to take additional steps in creating a cultural 
shift within the organization and ensure its employees have a safe 
channel for disclosing whistleblower information.

    Question 9. Following the release of Acting Secretary Gibson's 
June 13, 2014, letter to staff regarding whistleblower protections, has 
there been a distinct increase in employees who have raised concerns or 
suggestions with individuals in leadership positions across the system?
    Response. Given that whistleblower disclosures may be made to any 
employee in VA or to OSC, we are unable to determine whether there was 
an increase in the number of employees who raised concerns or 
suggestions following Deputy Secretary Gibson's message to all 
employees on June 13, 2014, regarding the importance of whistleblower 
rights and protections. We continue to encourage employees to disclose 
wrongdoing, violations of law, fraud, waste, or abuse.

    Question 10. How doe VA intend to create an accountable, safe, and 
transparent department focused on caring for veterans?
    Response. VA is conducting multiple simultaneous investigations on 
patient scheduling issues, questions of record manipulation, 
appointment delays, patient deaths, and whistleblower retaliation. 
Based on the findings of those investigations, VA will take corrective 
and/or disciplinary action. 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 
transparently share information as appropriate and 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.
    As discussed in response to question eight, VA has mandated online 
training for all VA executives, managers and supervisors on 
whistleblower rights and protections and prohibited personnel 
practices. This training, along with existing mandatory training on 
equal employment opportunity, diversity and inclusion, and prevention 
of workplace harassment, conflict management training for supervisors, 
and mandatory Workplace Harassment/No FEAR training helps to create an 
atmosphere that welcomes accountability, safety, and transparency.
    As Secretary McDonald described in a message to all employees sent 
on August 28, 2014, sustainable accountability in a high performing 
customer service organization is more complex than just firing 
employees. It includes a productive discussion of accountability, 
ensuring all employees, from top to bottom, understand how their daily 
work supports VA's mission, values, and strategic goals. VA has strong, 
institutional values--mission-critical ideals that must profoundly 
influence our day-to-day behavior and performance: Integrity, 
Commitment, Advocacy, Respect, and Excellence. On his first day in 
office, Secretary McDonald asked all VA employees to join him in 
reaffirming their commitment to these core values.

    Question 11. Further, what steps has VA taken to ensure problems, 
investigations, and recommendations are elevated to the appropriate 
level of leadership for thorough evaluation and immediate corrective 
action?
    Response. Employees are encouraged to disclose wrongdoing, 
violations of law, fraud, waste, or abuse. If the information being 
disclosed pertains to a possible or actual criminal violation, 
employees must report the information to VA's OIG.
    In VA's training for executives, managers, and supervisors on 
whistleblower rights and protections and prohibited personnel 
practices, VA reemphasizes the importance of investigating disclosures 
of wrongdoing, violations of law, fraud, waste or abuse. VA also 
emphasizes that all executives, managers, and supervisors who receive 
these disclosures should notify a senior executive (an employee in the 
Senior Executive Service (SES) or a Title 38 SES-equivalent employee) 
supervisor about the disclosure.
                           personnel actions
    Question 12. How many personnel actions were issued under Acting 
Secretary Gibson of Veteran's Affairs Department?
    Response. The term ``personnel actions'' within the VA describes a 
variety of actions. These actions include, but are not limited to, 
reassignments, conversions in career status, realignments, and 
transfers. Between the time period of May 30, 2014, and July 29, 2014, 
when Deputy Secretary Gibson served as VA's Acting Secretary, a total 
of 104,009 personnel actions were issued. Of those 104,009 actions, 
1,062 were adverse personnel actions.

    Question 13. If firing does not send a clear message regarding 
accountability regarding the care and management of veterans, how does 
VA intend to hold individuals accountable for wrong doing?
    Response. Secretary McDonald has demonstrated his commitment to 
serving Veterans by directing focus on VA's core values: Integrity, 
Commitment, Advocacy, Respect, and Excellence. VA will continue to use 
all tools available to correct misconduct and improve performance in 
accordance with applicable laws, rules, and regulations.
                   holding senior leaders accountable
    Question 14. VA announced new administrative procedures would be 
triggered when concerns are identified during an audit. This is a bit 
vague and the Committee in its oversight capacity would like to 
understand these procedures in detail. Please describe in detail the 
triggers that are used to employ these new administrative procedures?
    Response. The Department's OAR has initiated a series of leadership 
interviews designed to elicit testimony regarding the actions VHA 
facility leaders took, and are continuing to take, to ensure that 
scheduling and wait list protocols are being followed throughout their 
facilities. If those interviews unearth senior leader misconduct or 
serious failure of oversight, disciplinary procedures may be triggered. 
If the interviews demonstrate that a facility's leaders exercised 
appropriate oversight with respect to scheduling and wait lists, the 
audit process will be closed out with respect to that facility.

    Question 15. Who is involved in activating these so-called 
``triggers'' and what is the line of communication from audit staff to 
work center?
    Response. VHA leaders are working collaboratively with the 
Department's OAR--an interdisciplinary team of attorneys, employee 
relations specialists, and other subject matter experts--to identify 
facilities requiring review and to carry out interviews and any 
necessary disciplinary actions.

    Question 16. Have these new ``triggering procedures'' been rolled 
out and how have the procedures been utilized to hold leaders and 
managers accountable to date?
    Response. Leaders of approximately eight VHA facilities have been 
interviewed, with several dozen additional interviews in the works. The 
team will likely interview leaders at all VHA facilities when the VA 
OIG completes its ongoing investigations into scheduling and wait list-
related misconduct.

    Question 17. What are some of the ways you are refocusing your 
leaders and managers on the mission of veteran's health and well-being?
    Response. Veteran's health and well-being has always been a focus 
for the vast majority of VA's leaders and managers. In any cases where 
this is found not to have been true, appropriate fact-findings and/or 
administrative investigations are taking place and for any 
substantiated findings, disciplinary measures will be taken.
    Additionally, Secretary McDonald recently sent out a mandate for 
all of VA to reaffirm commitment to mission and core values. The 
Secretary directed that by August 22, 2014, all Under Secretaries and 
Assistant Secretaries confirm that they and their employees have 
reaffirmed their commitment to the ICARE core values.
                              non-va care
    Question 18. In the written testimony submitted to the Committee it 
was indicated that between May 15 and June 30, VA had made over 430,000 
referrals for veterans to receive care in the private sector. Is VA 
tracking the average wait time for these veterans to receive care? If 
not, what are the challenges preventing VA from doing this?
    Response. VA does not have specific data on the timeliness of the 
430,000 referrals. However, VA has recently developed a management 
report that will assist in the reporting of non-VA care appointment 
timeliness. The field will be expected to adhere to specific referral 
procedures in order for VA to accurately track wait times. The 
reliability of the tracking will be dependent on the procedural input 
from the field. All sites were provided training on the procedures 
during the national roll-out of the Non-VA Coordination model. The 
challenge remains to ensure that the facilities are properly following 
the procedures.
    Since January 2014, VA has tracked appointment timeliness for 
Patient Centered Community Care referrals using a combination of VA 
data and contract data. The following average appointment metrics are 
reported:

 
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
Consult request to Authorization Created...........................................................      16.2
Authorization sent to Contractor to Authorization Accepted.........................................       5.6
Accepted Authorization to Appointment Scheduled....................................................       3.3
Days to Scheduled Appointment......................................................................      12.5
----------------------------------------------------------------------------------------------------------------

Nationally, the average days from Consult to Scheduled Appointment is 
37.6 days.
                          scheduling practices
    Question 19. In VA's efforts to better understand issues 
surrounding scheduling, it has directed an independent external audit 
of VHA's scheduling practices. Can you please provide further detail 
regarding VA's expectations of this audit and any details of the 
project's timeline?
    Response. The Joint Commission is VA's accreditation vendor and 
provides accreditation services for all VHA medical facilities, 
Community Based Clinics and Consolidated Mail Outpatient Pharmacies. 
VHA has requested that The Joint Commission (TJC) provide special 
focused reviews of internal VHA scheduling and other processes that 
could cause delays in care. Specifically, TJC will review the standards 
for regulatory compliance that align with how VHA schedules 
appointments, and if the scheduling is timely, accurate, and results in 
the prevention of delays in care for Veterans. Additional reviews may 
also be conducted if TJC becomes aware of newly provided services at 
facilities or for other reasons for which TJC believes that the safety 
and quality of patient care is vulnerable.
    TJC does not perform audits, but instead examines standards and 
reviews the connected processes. The Joint Commission will perform 
reviews at all VHA facilities. The reviews began on September 18, 2014 
and will continue through FY 2015 until all visits are completed.
                             best practices
    Question 20. Acting Secretary Gibson noted in his written testimony 
that VHA is looking to develop a process to share best practices from 
high performing facilities in order to offer suggestions those 
facilities that require improvement. Please provide additional detail 
regarding this effort. In particular, what high performing facilities 
have you identified.
    Response. A VHA Steering Group has begun the process of determining 
how to measure the performance of facilities to find those that achieve 
excellent performance in their particular environment. This may allow 
for example, a small facility in a highly rural area to be paired with 
a like-facility with better performance. Specific facilities in each 
domain have not yet been identified by the Steering Group.

    Question 21. How do you intend to share these best practices across 
the VHA system; and 3) what is the project's timeline?
    Response. VA has a variety of models in which best practices have 
been spread across the larger health system. The VA Health Services 
Research and Development's (HSR&D) Quality Enhancement Research 
Initiative (QUERI) program's mission is to implement best practices 
into routine care. HSR&D/QUERI also identifies best practices through 
the Evidence Synthesis Program (ESP) Centers, including a recent rapid 
review of VHA wait times. A strategic goal of the QUERI program is to 
also identify which systems-level models work best, especially in high-
performing facilities, to spread clinical best practices across 
different settings. A key program (Blended Facilitation) has been 
adopted by VHA national program offices to enhance the uptake of PTSD 
and related treatments. QUERI has applied innovative models to promote 
the uptake of primary care-mental health integration, e-health, 
anticoagulation treatment, and population management strategies 
especially for vulnerable Veteran populations, and is currently 
developing a Lean evaluation center in collaboration with the QSV 
Veterans Engineering Resource Center to promote best practices across a 
variety of facilities. HSRD is also leading a series of studies focused 
on best practices in disclosing adverse events to Veterans in a way 
that lessens Veterans' anxiety and distress and increases their 
confidence and trust in VA.
    HSR&D also shares lessons learned from research through various 
dissemination efforts such as its Cyberseminars program. For example, 
recent sessions included: ``Telemental Health in VA: Opportunities for 
Improving Access to Cognitive Behavioral Therapy for Pain'' and ``Using 
Lessons for VA to Improve Primary Care for Women With Mental Health and 
Trauma Histories.''
    The National Center for Patient Safety (NCPS) uses ``Lesson 
Learned'' as well as Patient Safety Alerts to improve system-wide 
performance. VA also uses a bundle approach to improve performance on 
certain common hospital acquired conditions. Bundles are developed to 
make it easy for common and standard approaches to be used to combat 
hospital infections. These bundles are paired with measurement of 
performance and feedback on that performance to drive down infection 
rates. Subject matter experts in infectious diseases, critical care, 
and others also provide consultation to facilities. To further enhance 
updates NCPS uses Breakthrough Series to encourage facilities to 
enhance uptake of best practices. Using these techniques, VA has seen 
dramatic decreases in rates of catheter-associated urinary tract 
infection, ventilator associated pneumonia, methicillin-resistant 
staphylococcus aureus (MRSA) infections, and other hospital-acquired 
conditions. It is anticipated that these and other models will be used 
to share best practices between facilities.
    A Steering Group has been chartered and we anticipate a more 
detailed strategy will be developed to better assess facility 
performance, determine areas requiring attention within some 
facilities, create an action plan for improvement, and then matching 
facilities to enhance and sustain improvements.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
                  U.S. Department of Veterans Affairs
    Question 22. According to a study published in the Annals of Family 
Medicine, the average non-VA primary care provider has an average panel 
size of 2,300 patients compared to VA's current target of 1,200 
patients per primary care provider.
    A. What steps has VA taken to evaluate the appropriateness and 
effectiveness of the primary care panel size?
    Response. The Department of Veterans Affairs (VA) has taken several 
steps to evaluate the appropriateness of primary care panel size:

     Comparison with external agencies and review of relevant 
medical literature using capitated models (Department of Defense (DOD), 
Kaiser Permanente, etc.) show comparable panel sizes;
     Evaluation of the range of VA panel sizes to ensure that 
outcomes, such as Ambulatory Care Sensitive Conditions admissions and 
Emergency Department visits do not deteriorate as panel sizes reach the 
top decile for VA; and
     An evaluation of primary care team burn-out and stress as 
a function of rising panel size is currently underway.

    B. In July 2004, VA issued a directive on primary care panel size, 
which expired on May 31, 2008; has VA updated this guidance?
    Response. The Guidance on Primary Care Panel Size Directive was 
replaced by the Primary Care Management Module Handbook, published on 
April 21, 2009. This is currently undergoing revision and is expected 
to be published in FY 2015. The guidance regarding panel size is 
currently unchanged from the earlier Directive.

    Question 23. In a recent House Committee on Veterans' Affairs 
hearing, Dr. Lynch stated that, on average, VA primary care physicians 
see 10 patients each day compared to non-VA primary care physicians who 
see an average of 22 patients each day. He further stated that the 
number of patients seen daily by VA primary care physicians may range 
from 6-22 patients.
    A. Why do VA primary care physicians see roughly half the amount of 
patients per day as those outside VA?
    Response. The number of patients that VA physicians see per day 
varies from clinic to clinic and from facility to facility depending on 
the physician's specialty, the age and complexity of the patients they 
treat, and factors such as the number of available examination rooms 
and clinic support staff. VA patients tend to be elderly (mean age 63) 
with complex comorbidities compared to many health care organizations 
in the private sector and private practices. It is important to note 
that not all clinical encounters are equal--more complex patients 
require more time. This universally-recognized variation in the 
complexity of clinical encounters is accounted for by the use of 
``relative value units'' (RVUs) that consider the time and intensity of 
the service delivered by the provider during a given encounter. Within 
Veterans Health Administration (VHA), we calculate and monitor the RVU-
based productivity of our providers.
    The largest component of VHA's physician workforce is the Internal 
Medicine specialty (largely primary care), representing over 5,000 
full-time equivalent employees or approximately 25 percent of our total 
physician workforce. Internal medicine physicians tend to be assigned 
older Veterans and those with multiple medical problems in their 
patient panels. The average number of appointments a typical internal 
medicine specialist sees ranges from 7 to 22 patients per day across 
all VHA sites, with the overall average being about 10 patients per 
day. A survey conducted by the nonprofit group Physicians Foundation 
and reported in the Washington Post indicates that 39.8 percent of U.S. 
doctors see between 11 and 20 patients per day.
    In addition, the re-organization of primary care into Patient 
Aligned Care Teams (PACT) featuring more comprehensive and coordinated 
health care requires more face-to-face time with the provider at each 
visit. With the advent of PACT, primary care teams were encouraged to 
offer different venues of care to meet the preferences, convenience, 
and specific health care needs of Veterans. A greater reliance on 
health care via telephone, group visits, and secure messaging is 
encouraged, allowing a reduction in face-to-face clinic visits with a 
commensurate increase in virtual patient encounters.
    B. What steps has VA taken to evaluate the number of patient 
appointment slots to ensure that VA is maximizing their resources?
    Response. VistA Scheduling, the software tool currently used to 
schedule appointments with providers, is not adequate to maximize 
resources because of the design of the nearly 30 year old software. A 
report called the Clinic Utilization Statistical Summary is available 
to each site, but can be very difficult to understand and interpret. To 
improve the situation, VA has produced a report nationally called the 
Access Index. The Access Index, available for every VA Clinic Profile, 
allows users to measure and understand the relationship between patient 
appointments and clinic slots. This report measures both the 
utilization of the schedule (how much of the available schedule was 
booked) and utilization of slots (how many available slots were used) 
for that individual profile. It also allows clinicians to understand 
the relationship between appointment length and slot length, which can 
be different. In addition, VA clinicians commonly have multiple 
profiles, (for example Mental Health providers have an average of 7 
profiles), which makes overall assessment of evaluation the 
maximization of resources more challenging. To resolve this situation, 
VA is pursuing acquisition of a modern commercial off-the-shelf package 
that will enable better resource management.

    Question 24. Mr. Secretary, in your testimony, you state that, in 
facilities identified during the Nationwide Access Audit as having 
problems, VA will begin administrative procedures to determine the 
appropriate personnel actions needed.
    A. What personnel actions has VA taken either at the facility, 
VISN, or Central Office?
    Response. We are in the midst of a nationwide accountability audit, 
in follow--up to the access audit, to determine which supervisors, 
managers and employees may have intentionally directed or carried out 
inappropriate scheduling practices. Nine scheduling-related personnel 
actions have been proposed to date and we expect others may be 
necessary as our accountability investigations continue.
    B. Has anybody directly related to the improper scheduling 
practices been fired?
    Response. All proposed disciplinary actions are still in progress. 
Some of the proposals do involve termination of employment.

    Question 25. On June 18, 2014, Secretary Gibson, you announced that 
VA medical facilities Directors would conduct monthly in-person reviews 
of scheduling practices. While this is an important step to ensuring 
that correcting inappropriate scheduling practices remains a top 
priority, I am concerned that the ``corrosive culture'' and 
whistleblower retaliation will make it unlikely that VA employees will 
accurately portray additional barriers to access.
    A. Secretary Gibson, do you share my concerns, and if so, how does 
the organization overcome these issues?
    Response. VA recognizes the dedication and courage shown by 
employees who report violations of law, wrongdoing, waste, fraud, and 
abuse. VA is committed to protecting whistleblowers from retaliation. 
VA is working closely with the U.S. Office of Special Counsel (OSC) to 
investigate allegations of retaliation, and VA will take corrective 
action where there has been a finding of retaliation. This may include, 
but is not limited to, placing the whistleblower back into his or her 
position, or assigning the whistleblower to a new supervisor or 
position. In addition, when substantiated, VA will, as appropriate, 
take disciplinary action against employees who have committed acts of 
retaliation.
    On July 11, 2014, VA registered for the OSC Section 2302(c) 
Certification Program. This Program will allow VA to meet its statutory 
obligation to inform its employees about the rights and remedies 
available to them under the Whistleblower Protection Act, the 
Whistleblower Protection Enhancement Act, and related civil service 
laws.
    On October 7, 2014, VA received that certification from the OSC. 
This is an acknowledgement of the seriousness, commitment, and 
resources the VA is directing toward fundamental change in VA's systems 
and culture.
    Under the OSC certification process, VA:

    1. placed informational posters regarding prohibited personnel 
practices (PPP), whistleblowing, and whistleblower retaliation in a 
public setting at VA facilities and VA personnel and equal employment 
opportunity offices;
    2. provided and will continue to provide new hires with written 
materials on PPP, whistleblowing, and whistleblower retaliation;
    3. developed a Web site on PPP and whistleblower rights and 
protections; and
    4. developed, in cooperation with the OSC, supervisory training on 
PPP and whistleblower rights and protections. VA executives, managers, 
and supervisors must complete this training on a biennial basis.

    One of the requirements of the Program is that all supervisors in 
the agency complete training on whistleblower rights and protections 
and prohibited personnel practices. To that extent, VA has worked 
closely with the OSC to develop specialized training for VA executives, 
managers, and supervisors on whistleblower rights and protections and 
prohibited personnel practices. VA executives, managers, and 
supervisors were required to complete this training by September 30, 
2014, and biennially thereafter.
    To reinforce the above, VA leadership sent a message to all VA 
employees regarding the importance of whistleblower protection 
emphasizing that managers and supervisors bear a special responsibility 
for enforcing whistleblower protection laws, and meets with employees 
at VA facilities across the country to reemphasize that message.
    VA's Office of Diversity and Inclusion (ODI) is also conducting on-
site and virtual training for facility leadership on workplace 
inclusion, prevention of workplace harassment, and whistleblower 
protections. ODI also recently issued communications on whistleblower 
rights and protections through its Diversity@Work Newsletter and 
Diversity News Broadcast, accessible on ODI's Webpage, http://
www.diversity.va.gov.
    As part of VA's commitment to whistleblower rights and protections, 
VA has established a whistleblower Webpage, http://
www.diversity.va.gov/whistleblower.aspx, accessible from VA's internet 
home page, http://www.va.gov. VA's whistleblower Webpage outlines 
employee and supervisor rights and responsibilities, including avenues 
of redress for complaints, informational posters and materials, and 
whistleblower training resources.
    Additionally, VA has established the Office of Accountability 
Review (OAR) to ensure leadership accountability for improprieties 
related to patient scheduling and access to care, whistleblower 
retaliation and related matters that impact public trust in VA. Since 
September 26, VA has announced the proposed removal of four senior 
executives following investigations by the OAR and the VA Office of 
Inspector General.
    Other actions include a memo to all employees from Secretary 
McDonald reaffirming the importance of VA's Core Values (Integrity, 
Commitment, Advocacy, Respect, and Excellence or I CARE).
    VA will continue to take additional steps in creating a cultural 
shift within the organization and ensure its employees have a safe 
channel for disclosing whistleblower information.

    Question 26. On June 23, 2014, the Office of Special Counsel sent a 
letter to the President regarding the ``Continued Deficiencies at 
Department of Veterans Affairs' Facilities.'' This letter confirms the 
well-known cultural problems within the Department and VA's lack of 
responsiveness to problems that have been identified by independent 
investigative agencies. Secretary Gibson, you took immediate steps 
after receiving this letter, calling for a review of the Office of 
Medical Inspector and referring all hotline cases to the Office of 
Inspector General.
    A. Has the comprehensive review of the Office of Medical Inspector 
been completed? Please provide the Committee with the results of this 
internal review.
    Response. In response to the OSC's June 23, 2014, letter to the 
President that included criticisms of the Office of the Medical 
Inspector (OMI), the Acting Secretary of Veterans Affairs directed an 
immediate review and subsequent restructuring of OMI to better serve 
Veterans. He announced that this restructuring would create a strong 
internal audit function to ensure that health care quality and patient 
safety remain a primary and constant focus. On July 10, 2014, an 
Interim Director of OMI was appointed from outside the office to 
spearhead the restructuring effort. The Acting Secretary determined a 
clear need to revise the policies, procedures, and personnel structure 
by which OMI operates, and has directed a restructuring of the 
organization.
    VA reviewed and is in the process of restructuring OMI to better 
serve Veterans. This restructuring creates a strong internal audit 
function to include risk assessment capabilities to ensure that health 
care quality and patient safety remain a primary and constant focus.

    B. Would you please provide the Committee with a timeline for a 
path forward with respect to the restructuring of the Office of Medical 
Inspector?
    Response. Since July 2014, OMI has made significant progress in 
restructuring the policies and procedures by which it operates. OMI's 
status as an independent, objective advisor to the Under Secretary for 
Health (USH) was reaffirmed in a memorandum signed by the USH in 
September 2014. After a two-month hiatus on accepting new cases, OMI 
resumed conducting OSC whistleblower investigations in September with a 
renewed focus on both health care quality and accountability. OMI's 
investigators have likewise adopted a revised standard for judging 
whether substantiated whistleblower allegations represent a threat to 
public health and safety.
    OMI is working closely with VA's new Office of Accountability 
Review (OAR) as well as the Office of General Counsel before, during, 
and after its investigative site visits to VA medical facilities. 
Because of these closer working relationships and increased leadership 
oversight within both VHA and VA, a shared understanding has developed 
that VA's responses to OSC referrals represent the work of the entire 
Agency, not just OMI. In addition, OMI has established a more 
collaborative working relationship with OSC. More frequent 
communication allows OMI to clarify whistleblower allegations, 
encourage whistleblower cooperation (where necessary) with 
investigations, and share preliminary findings with OSC weeks before 
OSC receives VA's official written report.
    Among other procedural changes, OMI provides a ``Notice of Witness 
Obligations and Protections'' to each witness to inform them of their 
responsibilities and rights, including protection from reprisal. In the 
area of personnel restructuring, each team of OMI investigators is now 
augmented by a human resources (HR) expert identified by OAR. This H.R. 
expert becomes an integral team member, in most cases traveling with 
other investigators to each site, where they are able to address 
instances of potential individual wrongdoing and advise the lead 
investigator on personnel matters, including disciplinary procedures. 
OMI is also hiring three additional senior, experienced Title 38, Nurse 
V program managers to expand its ability to manage the growing number 
of case investigations.
    In addition, OMI conducted benchmarking activities in recent weeks 
with several external organizations within both the Federal Government 
and the private sector. This benchmarking has served to inform VA about 
internal audit procedures and standards used elsewhere in the health 
care industry, and provided new ideas and helpful reference materials. 
As a first step toward developing the desired internal audit function, 
VHA is realigning the Office of Compliance and Business Integrity 
(CBI), which performs financial audit, compliance, and business 
oversight activities, with OMI. By working together, these two offices 
can leverage CBI's auditing capability and OMI's clinical expertise to 
create the synergy needed to audit both business and clinical 
processes.
    Further restructuring will continue in the coming months. VA would 
be happy to provide periodic updates.

    C. How does the Department plan to ensure that all oversight 
offices, including the Office of Special Counsel and VA's Inspector 
General, are cooperating with VA's internal offices and working 
collaboratively to address systemic issues and potential patient harm?
    Response. The mandate to review OMI's current environment served as 
a catalyst for a broader organizational assessment of VHA's capacity 
for maintaining effective oversight. In conjunction with OIG, VHA has 
implemented multiple processes that facilitate open, collaborative, and 
regular communications about systemic issues and potential patient 
harm. VHA and OIG use both informal and formal methods of 
communication: phone calls are common, frequent emails, and structured 
entrance/exit conferences and briefings.
    VHA program office leadership meets monthly with Assistant 
Inspectors General (AIG) for Audit and Evaluation, Health Care 
Inspections, and Criminal Investigations. The purpose of the monthly 
meeting is to candidly exchange information about concerns by either 
party regarding upcoming or ongoing audits or inspections, hotline 
allegations of care deficiencies, early notification on significant 
findings from active reviews, VHA internal information about health 
care issues, and process improvements.
    OMI also meets monthly with the AIG for Health Care Inspections to 
review cases and health care issues both groups are addressing to 
better inform future investigations. The two organizations also share 
information about planned inspections in an effort to avoid duplication 
and overlap and to benefit from any investigative activity that has 
already occurred.
    In addition, OMI meets regularly with OSC to review the status of 
whistleblower investigations, and to discuss schedules for reports and 
other deliverables. These meetings should go a long way toward 
improving communication between OSC and VA on investigative findings, 
ensuring complaints are thoroughly examined and that whistleblower's 
receive the protections they are entitled to under the law.
    The VA has also established an accountability review office, 
located within the Office of the Secretary and independent of VHA, to 
ensure that appropriate leadership accountability actions are taken 
when facility leaders are implicated in findings by OIG, OMI, or other 
investigative bodies. The accountability review office functions 
collaboratively with OIG, OSC and OMI to improve Departmental leaders' 
visibility over issues raised by various oversight entities.
    This improved cooperation will help overcome some of the 
organization's current challenges in providing effective health care 
oversight, and should support efforts to restore Veterans' and the 
public's trust.

    Question 27. At the hearing, Acting Secretary Gibson indicated that 
VA processes a quarter million non-VA care referrals per month and each 
referral includes, on average, seven appointments. For fiscal year 2013 
and fiscal year 2014 to date, please provide a breakdown of the 
referrals by specialty and the average number of appointments per 
unique veteran by specialty.
    Response. Attached in the Excel spreadsheet are authorizations per 
Category of Care (COC), as of 8-22-14, for Fee Basis Claims Systems 
authorizations by COC and noted is the arithmetic mean and median for 
each category.














                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
                  U.S. Department of Veterans Affairs
    Question 28. What is your response to those who say the VA's 
workforce shortages are a myth, and that the real problem is VA medical 
personnel who are not working hard or fast enough? Why is it 
unproductive to point to the number of patients seen in a day or year 
by doctors in the private sector, and demand the VA meet those same 
numbers? Would establishing such benchmarks help veterans?
    Response. Veterans Health Administration (VHA) has a physician 
workforce of more than 18,000 full-time equivalent employees 
representing over 30 sub-specialties. The largest proportion of VHA's 
physician workforce is composed of Internal Medicine (largely primary 
care) and Mental Health (psychiatrists), representing nearly half of 
the physician workforce. The majority of VHA's physicians are salaried, 
with approximately 10 percent of the physician workforce working in a 
VA facility on a fee-basis or under another contractual type 
arrangement. Primary Care (PC), the largest component of the Department 
of Veterans Affairs (VA) physician workforce (34 percent), has been 
employing a panel model for standardizing productivity and staffing in 
PC since 2004. Mental Health, the second largest component of VA's 
physician workforce (14 percent) has developed a productivity model 
that was implemented in June 2013. As of July 2014, 91 percent of all 
specialties have productivity and staffing standards in place and the 
remaining specialties will be completed by September 30, 2014.
    It is unproductive to point to the number of patients seen by 
doctors in the private sector and demand the VA meet those same numbers 
because some private sector doctors tend to be financially rewarded for 
the number of patients they see in a day. However, not all patients 
need face-to-face visits with a physician in order to meet their needs. 
By contrast, VA doctors are encouraged to have flexible schedules to 
meet urgent needs. As well, since 2010, VA primary care workforce has 
embraced the patient centered medical home model that uses a 
diversified approach to providing patient care. Patient Aligned Care 
Teams utilize multiple diverse interdisciplinary team members to 
provide care to each patient. This allows the team to efficiently 
customize patient care to meet the individual and unique needs of our 
Veterans. Although some Veterans require frequent face-to-face visits 
with their provider, many benefit more from telephone interactions, 
secure messaging, or care from other team members including nurses, 
behavioral therapists, clinical pharmacists, and social workers. 
Following PACT implementation, providers often see a decrease in 
scheduled face-to-face visits with their patients, but patients will 
have an increased number of contacts (face-to-face and non-face-to-
face) with their entire provider team. Providers are able to use this 
time to manage their panel of patients by processing clinical 
reminders, managing clinical computer alerts, performing telephone and 
virtual visits and interacting with their primary care team members. 
Providers are actually encouraged to keep 10-20 percent of their daily 
visit slots unscheduled to allow flexibility to manage urgent needs for 
their patients, with a goal toward reducing reliance on urgent care and 
emergency department utilization. Therefore, approximating provider 
workload by monitoring number of face-to-face visits alone ignores the 
complexity of managing all of the ``ways in'' that are visible to a 
patient: face-to-face, telephone, secure messaging, team member visits, 
etc. The overall team effort adds value to our Veterans' health and 
well-being.

    Question 29. I understand that the VA just enacted a hiring freeze 
for the VHA Central Office and VISN offices in order to put more 
emphasis on increasing personnel at medical facilities. Can you 
elaborate on this decision--why was it made and what are the early 
results? Has the VA seen any gains in personnel? Moving forward, are 
the VHA Central Office and VISN offices improperly staffed?
    Response. Per the attached June 9, 2014, press release, bullet #3 
cites the specific language then-Acting Secretary Gibson used to 
announce and explain the hiring freeze. The hiring freeze enables Human 
Resources staff to focus on hiring for mission critical positions which 
directly support Veterans' access and care. The Department is assessing 
the organization and staffing of VHA Central Office and VISN HQs. The 
hiring freeze ensures we retain our focus on operational hiring in the 
field, while the evaluation of a more streamlined headquarters 
management structure continues.


FOR IMMEDIATE RELEASE

June 9, 2014

       VA Releases Data on Quality, Access to Veterans Healthcare

       1Acting Secretary Gibson Provides Transparency, Announces 
              Further Actions on Timely Healthcare Access
    WASHINGTON--Today, the Department of Veterans Affairs (VA) released 
the results from its Nationwide Access Audit, along with facility level 
patient access data, medical center quality and efficiency data, and 
mental health provider survey data, for all Veterans health facilities.
    Full details made public at VA.gov follow Acting Secretary of 
Veterans Affairs Sloan Gibson's commitment last week in Phoenix, 
Arizona and San Antonio, Texas to provide timely access to quality 
healthcare Veterans have earned and deserved.
    ``It is our duty and our privilege to provide Veterans the care 
they have earned through their service and sacrifice,'' said Acting 
Secretary Gibson. ``As the President has said, as Secretary Shinseki 
said, and as I stated plainly last week, we must work together to fix 
the unacceptable, systemic problems in accessing VA healthcare.
    ``Today, we're providing the details to offer transparency into the 
scale of our challenges, and of our system itself. I'll repeat--this 
data shows the extent of the systemic problems we face, problems that 
demand immediate actions. As of today, VA has contacted 50,000 Veterans 
across the country to get them off of wait lists and into clinics. 
Veterans deserve to have full faith in their VA, and they will keep 
hearing from us until all our Veterans receive the care they've 
earned.''
    Acting Secretary Gibson announced a series of additional actions in 
response to today's audit findings and data, including:

 Establishing New Patient Satisfaction Measurement Program
     Acting Secretary Gibson has directed VHA to immediately begin 
developing a new patient satisfaction measurement program to provide 
real-time, robust, location-by-location information on patient 
satisfaction, to include satisfaction data of those Veterans attempting 
to access VA healthcare for the first time. This program will be 
developed with input from Veterans Service Organizations, outside 
health care organizations, and other entities. This will ensure VA 
collects an additional set of data--directly from the Veteran's 
perspective--to understand how VA is doing throughout the system.

 Holding Senior Leaders Accountable
     Where audited sites identify concerns within the parent facility 
or its affiliated clinics, VA will trigger administrative procedures to 
ascertain the appropriate follow-on personnel actions for specific 
individuals.

 Ordering an Immediate VHA Central Office and VISN Office 
    Hiring Freeze
     Acting Secretary Gibson has ordered an immediate hiring freeze at 
the Veterans Health Administration (VHA) central office in Washington 
D.C. and the 21 VHA Veterans Integrated Service Network (VISN) regional 
offices, except for critical positions to be approved by the Secretary 
on a case-by-case basis. This action will begin to remove bureaucratic 
obstacles and establish responsive, forward leaning leadership.

 Removing 14-Day Scheduling Goal
     VA is eliminating the 14-day scheduling goal from employee 
performance contracts. This action will eliminate incentives to engage 
in inappropriate scheduling practices or behaviors.

 Increasing Transparency by Posting Data Twice-Monthly
     At the direction of the Acting Secretary, VHA will post regular 
updates to the access data released today at the middle and end of each 
month at VA.gov. Twice-monthly data updates will enhance transparency 
and provide the most immediate information to Veterans and the public 
on Veterans access to quality healthcare.
 Initiating an Independent, External Audit of Scheduling 
    Practices
     Acting Secretary Gibson has also directed that an independent, 
external audit of system-wide VHA scheduling practices be performed.

 Sending Additional Frontline Team to Address Phoenix
     Following his trip to Phoenix VA Medical Center last week, Acting 
Secretary Gibson directed a VHA frontline team to travel to Phoenix to 
immediately address scheduling, access, and resource requirements 
needed to provide Veterans the timely, quality healthcare they deserve.

 Utilizing High Performing Facilities to Help Those That Need 
    Improvement
     VA will formalize a process in which high performing facilities 
provide direct assistance and share best practices with facilities that 
require improvement on particular medical center quality and 
efficiency, also known as SAIL, performance measures.

 Applying Immediate Access Reforms Announced in Phoenix to Most 
    Challenged VA Facilities
     Last week, Acting Secretary Gibson announced a series of measures 
to address healthcare access problems in Phoenix. Today, Acting 
Secretary Gibson announced he'll apply the same reforms to facilities 
with the most access problems from the results of the audit, including:

   Hiring Additional Clinical and Patient Support Staff
        VA will deploy teams of dedicated human resource employees to 
        accelerate the hiring of additional, needed staff.

   Employing New Staffing Measures
        VA's first goal is to get Veterans off wait lists and into 
        clinics. VA is using temporary staffing measures, along with 
        clinical and administrative support, to ensure these Veterans 
        receive the care they have earned through their service.

   Deploying Mobile Medical Units
        VA will send mobile medical units to facilities to immediately 
        provide services to patients and Veterans awaiting care.

   Providing More Care by Modifying Local Contract Operations
        VA will modify local contract operations to be able to offer 
        more community-based care to Veterans waiting to be seen by a 
        doctor.

   Removing Senior Leadership Where Appropriate
        Where appropriate, VA will initiate the process of removing 
        senior leaders. Acting Secretary Gibson is committed to using 
        all authority at VA's disposal to enforce accountability among 
        senior leaders.

   Suspending Performance Awards
        VA has suspended all VHA senior executive performance awards 
        for FY 2014.

 Future Travel
     Over the course of the next several weeks, Acting Secretary Gibson 
will travel to a series of VA facilities across the country. He will 
hear directly from Veterans and employees about obstacles to providing 
timely, quality care and how VA can immediately address them.

National audit and patient access data available at www.va.gov/health/
    access-audit.asp.
Medical center quality and efficiency (SAIL) and mental health data 
    available at http://www.hospitalcompare.va.gov/.
                              #    #    #

    Question 30. Is there a national standard for how long patients 
should wait to get primary care or mental health care? What is that 
standard? How frequently are those standards met? To what extent does 
the VA hold itself to those standards?
    Response. There is no U.S. national standard within primary care in 
regard to wait times. At VA, patient needs often can be met via non-
face-to-face communication or by visits with members of the Patient 
Aligned Care Team (Primary Care team), as well as Primary Care Provider 
appointments. The goal is to meet the patient's need in the most timely 
and clinically appropriate way possible.
    Though there is not one U.S. national standard for mental health 
access, VA has attempted to measure mental health access based on 
Veteran preference and need for the initial appointment and provider/
Veteran agreed upon next visit date for follow-up visits.
    VA's long-term goal for mental health oversight and metrics is the 
development of a finite number of composite measures that can help to 
``signal'' when an organization is at risk of departing from a stated 
patient care or access goal, with recommended actions to address a 
given signal. However, short-term, VA is monitoring the number of new 
Veteran appointments seen in mental health, the number of Veterans 
departing inpatient mental treatment (including residential care) who 
are seen in outpatient care after discharge from such care, and 
aggressive monitoring of the Electronic Wait List as an indicator for 
delays in care.
    Individual health care systems create their own goals and have a 
variety of methods to measure progress toward their goals. Merritt 
Hawkins, a physician staffing firm, polled five types of offices across 
the country about several types of non-emergency care wait times for 
new patient appointments. They found patients waited an average of 29-
days nationally to see a dermatologist for a skin exam, 66-days to have 
a physical in Boston and 32-days for a heart evaluation by a 
cardiologist in Washington. The New York Times recently published an 
article on the issue: The Health Care Waiting Game: Long Waits for 
Doctors' Appointments Have Become the Norm (5 July, Elisabeth 
Rosenthal, New York, NY)
    Because of recent experience with manipulation of wait-time 
measures at certain sites of care, VA is exploring ways to ensure 
validity and reliability in its access standards, including how to 
appropriately measure timely access to care, and is working to report 
patient ratings of access to care. See question 42 below.

    Question 31. We are all well aware that the VA's scheduling system 
is outdated, far too easily manipulated and inadequate for both VA 
employees and veterans. I recently chaired a hearing of my Federal 
workforce subcommittee at which Stephen Warren testified that the VA is 
now moving forward quickly to solicit a new system. What is the latest 
update in obtaining the new system? When would such a system be 
operational and deployed?
    Response. On August 25, 2014, VA announced its plan to issue a 
Request for Proposal (RFP) for a new Medical Appointment Scheduling 
System, which will replace the legacy scheduling system. The new system 
will improve access to care for Veterans by providing medical 
schedulers with cutting-edge, management-based scheduling software. A 
draft RFP was made public on September 17, 2014, and eligible vendors 
have a window to provide feedback. A final RFP is expected to be 
released by the end of October and vendors will have 30 days to respond 
from the day of issuance. Even as the VA issues an RFP to replace the 
existing system, efforts are underway to enhance the current scheduling 
system. Some of the enhancements include:

     VA recently awarded a contract to improve the existing 
scheduling interface, providing schedulers a calendar view of resources 
instead of the current text-based, multiple-screen view. This update is 
scheduled to begin roll out beginning in January 2015;
     VA is also developing mobile applications to allow 
Veterans to directly request certain types of primary care and mental 
health appointments (scheduled to begin deployment December 2014). 
Another application under development will give VA schedulers an 
easier-to-use interface to schedule medical appointments (scheduled to 
begin deployment December 2014); and
     VA is also rolling out new clinical video tele-Health 
capabilities in October 2014 to further enhance access to care.

    As part of the current RFP preparation process, VA is working with 
Veterans Service Organizations (VSO) to incorporate the groups' 
feedback on requirements important to Veterans focusing on user 
experience and business process documentation. Additionally, the VA's 
acquisition process will comply with recently established legislative 
requirements related to the Department's scheduling software.

    Question 32. To what extent does the VA currently offer evening and 
weekend appointments? Does the VA currently have sufficient staffing to 
expand this option to more veterans?
    Response. Primary Care--VHA Directive 2013-001, Extended Hours 
Access for Veterans Requiring Primary Care Including Women's Health and 
Mental Health Services at Department of Veterans Affairs Medical 
Centers and Selected Community Based Outpatient Clinics, explains in 
detail extended hour requirements for Primary Care and Mental Health 
Clinics. Weekly, extended hours for Primary Care Clinics must be 
available no less than one weekday and one weekend day per facility; 
these clinics must also cover the full range of general mental health 
services as defined in the Directive. Very large Community Based 
Outpatient Clinics are required to have extended hours at least one day 
per week. Extended-hour clinics are defined as anytime outside of 
8:00am-4:30pm Monday through Friday.
    In FY 2013, VA primary care providers (PCP) conducted 119,573 in-
person encounters during extended hours (23,253 week-end and 96,320 
week-day). In FY 2014, VA PCPs conducted 195,039 in-person encounters 
during extended hours (67,167 weekend and 127,872 weekday).
    Mental Health--VA is committed to providing mental health services 
to Veterans in a manner that may mitigate time of appointment as a 
barrier to such care. In FY 2013, VA delivered 121,096 in-person mental 
health encounters during extended hours on weekdays and 21,651 
encounters during extended hours on weekends. The corresponding numbers 
for FY 2014 to date are 115,707 and 34,644.

    Question 33. Last month, the VA announced plans to reorganize the 
Office of the Medical Inspector (OMI). Can you elaborate on the 
proposed changes? What is the expected completion of this 
reorganization? What led to the proposed changes?
    Response. Please refer to the response to questions 26A and 26B.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
                  U.S. Department of Veterans Affairs
    Question 34. The twice-monthly data updates will enhance 
transparency and provide the immediate information to Veterans and the 
public on Veterans access to VA health care. According to the 3 July 
version Alaska has some of the shortest New Patient wait times in 
America. In fact our new patient average for Mental Health counseling 
is the 2nd fastest in the Nation. I believe this is a testament to the 
partnerships that our VA has established with Indian Health Services. 
What is the VA's plan to expand the Tribal Agreements?
    Response. Based on the geographical and rural status of Alaska and 
because of the limited Department of Veterans Affairs (VA) presence in 
Alaska, VA's reimbursement agreements with Alaska Tribal Health 
Programs (THP) cover reimbursement for direct care services provided to 
eligible Alaska Native American Indian (AN/AI) Veterans as well as non-
AN/AI Veterans. This along with the number of Veterans in Alaska in 
comparison to areas with a higher Veteran population may have indeed 
contributed to the shorter wait times for new patients. Currently, VA's 
national reimbursement agreement with the Indian Health Service (IHS) 
and reimbursement agreements with THP in the continental United States 
cover only eligible AN/AI Veterans. For Native Veterans, VA is 
expanding the number of agreements with tribal health care facilities. 
There are currently 59 signed agreements with another 63 in progress, 
as of August 6, 2014. In accordance with section 102(c)(2) of Public 
Law 113-146, the Veterans Access, Choice, and Accountability Act of 
2014, VA and IHS will assess the feasibility and advisability of 
expanding VA's agreements with IHS and THP (outside of Alaska) to cover 
Non-Native Veterans.

    Question 35. VA has suspended all VHA senior executive performance 
awards for fiscal year 2014 and increased accountability for senior 
leaders. Do you expect to bring back these awards in 2015? If not, what 
is the plan to attract and retain superior executive leadership in the 
future?
    Response. The Secretary is the final deciding official for senior 
executive performance ratings and awards. At this time, it is too early 
to determine the process for fiscal year 2015. However, VA's Senior 
Executive Service performance appraisal system is certified by the U.S. 
Office of Personnel Management, which allows VA to be competitive with 
other Federal agencies that are certified regarding individual pay and 
aggregate total compensation limits. In addition, VA still has the 
ability to offer incentives, such as retention incentives when 
competing for top talent.

    Question 36. As you know in order for non-VA providers to provide 
care and services to veterans they need to have the right credentials, 
how will the VA work with non-VA providers to facilitate the delivery 
of telemedicine services across state lines?
    Response. In 2006, the Office of General Counsel provided an 
opinion on Federal Supremacy and State medical licensing issues in 
Telemedicine contracts. In this opinion it states that, ``VA can 
determine that contractors who are licensed in `a' State are qualified 
to provide VA with teleradiology services in any State. Such 
contractors do not need to be licensed in the State(s) where the 
services are performed, including the State(s) they enter 
electronically using telemedicine.'' VHA Handbook 1100.19, 
Credentialing and Privileging was modified accordingly to state:

    (a) Contracts for telemedicine and/or teleconsultation services 
need to require that these services be performed by appropriately-
licensed individuals. Unless otherwise required by the specific 
contract or Federal law (such as the Federal Controlled Substances 
Act), contract healthcare professionals must meet the same licensure 
requirements imposed on VA employees in the same profession whether 
they are on VA (Federal) property or not when providing telemedicine or 
teleconsultation services.
    (b) Some states do not allow telemedicine and/or teleconsultation 
across state lines, unless the provider is licensed in the state where 
the patient is physically located. In these states, the clinical 
indemnity coverage of contract practitioners may be void, even if they 
are credentialed and privileged by VA. Prior to the commencement of 
services by the contract practitioners providing telemedicine and/or 
teleconsultation or remotely monitoring physiology data from Veteran 
patients, the State regulatory agency in the state in which the 
practitioner is physically located as well as the state where the 
patient is physically located, must be consulted. When dealing with 
Federal entities, additional licenses that authorize the provision of 
telemedicine and/or teleconsultation services in the relevant states 
may not be required. The opinion of the Regional Counsel needs to be 
sought in these matters.
    The burden is on the contractor to address any issues that may be 
identified by the State regulatory agency in the state where the 
contractor is located as well as the State where the Veteran patient is 
located as well as the contractor's medical malpractice carrier. VA 
accepts any appropriately licensed health care provider.

    Question 37. In the Veterans Access to Care thorough Choice, 
Accountability, and Transparency Act included is increased care to vets 
by non-VA providers, what policies are you implementing to increase 
sharing of electronic medical records between these providers and the 
VA?
    Response. The Veterans Health Administration (VHA) has established 
a Virtual Lifetime Electronic Record (VLER) Program for electronic 
health information exchange (HIE) in accordance with national standards 
and specifications as described by the Department of Health and Human 
Services, Office of the National Coordinator for Health Information 
Technology. Through VLER HIE, VHA now has the capability to exchange 
Veteran health data with private sector hospitals and clinics.
    VLER provides secure and seamless access between Electronic Health 
Records in structured, standardized formats using national 
specifications. This Exchange is accomplished through several push and 
pull programmatic mechanisms, known as Direct and Exchange. Sharing of 
these records ensures that enrolled Veterans receive coordinated care 
between their VA clinicians and Non-VA health care providers.
    There are many other health information sharing platforms that may 
be used by the HIE community in information sharing. VA is in the 
process of developing a VHA Directive that will provide guidance to VA 
health care facilities considering participating in local community HIE 
organizations. This same Directive will give guidance about using 
community HIE portals to view non-VA health information for Veterans.
    Section 101(l)(2) of the Veterans Access, Choice, and 
Accountability Act provides that to the extent possible, medical 
records submitted by non-Department providers shall be submitted 
electronically. Furthermore, subsection 101(n) of the act requires that 
the Secretary prescribe interim final regulations on the implementation 
of subsection 101 of the Act; the sharing of electronic medical records 
will be considered in the drafting of such regulations.

    Question 38. Given the Veterans Administration's need to increase 
access to high quality health care, how would implementation of the VHA 
Nursing handbook, and recognition of the Full Practice Authority of 
APRNs working in the VHA, help increase capacity and improve access for 
Veterans?
    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. All VA program 
offices provided input in 2012 utilizing the internal concurrence 
process. Since that time, the VHA Under Secretary for Health has 
conducted meetings with several internal and external stakeholders 
including a variety of professional organizations, as well as Veterans 
Service Organizations. The proposed change is being driven by the 
efficacious use of resources and to decrease variability in care 
provided by Advanced Practice Registered Nurses (APRN) throughout the 
VA system.
    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, training and certification. This evidenced-
based recommendation by the IOM prompted VHA to propose Full Practice 
Authority (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 VHA's proposed policy is consistent with the National Council 
of State Boards of Nursing Consensus Model and includes all APRN roles. 
Model APRN regulation is aimed at public protection by ensuring 
uniformity across all jurisdictions. Uniformity of national standards 
and regulation not only allows for the mobility of nurses, it also 
serves the public by increasing access to care. Within the nursing 
handbook, VHA is proposing the authorization of FPA for 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. As an integrated Federal health care system, 
the proposed policy parallels current policy in the Department of 
Defense (DOD). Implementation of FPA in VHA would enable Servicemen and 
women transitioning from DOD to VA, to receive the same level of care 
from APRNs in both systems.
    A significant number of states have approved full practice 
authority for APRNs, with many VA medical centers successfully 
utilizing APRNs to the full extent of their education and training. The 
proposed nursing policy would not authorize APRNs to replace or act as 
physicians; the proposed nursing policy would authorize FPA within the 
field of nursing. Implementation of FPA for APRNs 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 VA released an audit in early June 2014 showing that more than 
57,000 Veterans have had to wait at least 3-months for initial 
appointments. There has been a large influx of new enrollees in the VA 
Health Care System and VA statistics demonstrate a consistent upward 
trend in enrollment numbers since 2000. Over the past 3 years, primary 
care appointments have increased by 50 percent, yet the primary care 
physician staff has increased by
    9 percent. Many nurse practitioners are working in these clinics, 
but are not able to function to the full extent of their education and 
training, due to barriers created by disparate state regulations.
    Implementation of FPA would allow APRNs to function at the top of 
their education, training and certification, resulting in increased 
access to VA primary care services in states where scope of practice 
barriers currently limit an APRN's ability to practice. VHA would be 
able to utilize APRN providers to improve patient access for Veterans 
in need of timely Primary Care services and to decrease waiting time 
for new patient appointments. FPA may also result in cost savings to VA 
by decreasing the need to outsource care to the community.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
                 to U.S. Department of Veterans Affairs
    Question 39. Given the Veterans Administration's need to increase 
access to high quality health care, how would implementation of the VHA 
Nursing handbook, and recognition of the Full Practice Authority of 
Advanced Practice RNs working in the VHA help increase capacity and 
improve access for Veterans?
    Response. Please see response to Question 38 above.

    Question 40. Given the need to hire more clinicians and in the 
spirit of exploring all options, have you considered reaching out to 
former employees who recently retired or those who left the VA in the 
last year or two to see if they would be able to help assist to 
increase the capacity at the VA? Because they already know the system 
they could become fully productive faster than someone not familiar 
with the VA.
    Response. As staffing needs vary across the Veterans Health 
Administration (VHA) system, facilities are encouraged to pursue the 
hiring of critical staff utilizing whatever means that would yield the 
most success (considering local labor markets and hiring trends). This 
includes hiring re-employed annuitants (retired Federal employees) and 
hiring former staff to perform work on a fee basis (per procedure).
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. John Boozman to 
                  U.S. Department of Veterans Affairs
    Question 41. Acting Secretary Gibson, in your prepared testimony 
you speak to removing the 14-day scheduling goal from VA policy. Do you 
anticipate another numeric goal being put in its place? If so, any 
thoughts on what it will be; did current VA health schedulers have any 
ideas for a better target? I know you have met with private sector 
health providers; did these private providers have any thoughts on 
scheduling metrics or suggestions for a new system?
    Response. The Department of Veterans Affairs (VA) is building a 
more robust, continuous system for measuring access and patient 
satisfaction, to provide real-time, robust, site-specific information 
on patient satisfaction. VA will augment our existing Survey of Health 
Experiences of Patients (SHEP) survey with new questions and larger 
sample size in the coming year, to capture more Veteran experience data 
using telephone, social media, and on-line means. Our effort includes 
close collaboration with the Veterans Service Organizations (VSO), with 
whom we have already met to begin planning our efforts. VA is also 
contracting for an independent assessment of the ``current state'' of 
clinic management infrastructure in addition to establishing a 
benchmark for access levels from the body of evidence and from other 
healthcare organizations.
    The 14-day access measure has been removed from all individual 
employee performance plans to eliminate any motive for inappropriate 
scheduling practices or behaviors. In the course of completing this 
task, over 13,000 performance plans were amended--from then-Acting 
Secretary Gibson's prepared remarks before the Veterans of Foreign Wars 
Annual Convention July 22, 2014. VHA Schedulers have many comments on 
ways to improve the current process for scheduling including entering 
required time-stamp information, including Desired Date (DD). These 
ideas are in the process of being consolidated in a memo that will 
clarify existing policy and practice. Private sector practices tend to 
use capacity measures (such as the time to the third open slot) to 
measure access. VA has limited capability to use capacity measures 
because of legacy VistA scheduling software limitations. However, the 
Choice Act requires VA measure individual patient waiting times rather 
than capacity measures. VA has therefore proposed using the Veterans 
Preferred Date (formerly called the Desired Date) to meet the intent of 
the law. In order to improve the reliability of this measure, VHA 
anticipates adopting many elements of the new procedures suggested by 
schedulers, defining the clinic management role better, and 
standardizing the training of the clinic manager, including schedulers. 
While the waiting time goals have been removed from performance 
standards, the timeliness information will be need to comply with 
elements of the Choice Act. VA is exploring ways to ensure validity and 
reliability in its access standards, including how to appropriately 
measure timely access to care.

    Question 42. Has the new patient satisfaction measurement program 
been put in place? Who will oversee that program? Will there be 
outreach to veterans to ensure they know their input is appreciated and 
crucial to future success of the system?
    Response. The Department of Veterans Affairs (VA) is building a 
more robust, continuous system for measuring access and patient 
satisfaction, to provide real-time, robust, site-specific information 
on patient satisfaction. VA will augment our existing Survey of Health 
Experiences of Patients (SHEP) survey with new questions and larger 
sample size in the coming year, to capture more Veteran experience data 
using telephone, social media, and on-line means. Our effort includes 
close collaboration with the Veterans Service Organizations (VSO), with 
whom we have already met to begin planning our efforts. VA is also 
contracting for an independent assessment of the ``current state'' of 
clinic management infrastructure in addition to establishing a 
benchmark for access levels from the body of evidence and from other 
healthcare organizations.
    The 14-day access measure has been removed from all individual 
employee performance plans to eliminate any motive for inappropriate 
scheduling practices or behaviors. In the course of completing this 
task, over 13,000 performance plans were amended--from then-Acting 
Secretary Gibson's prepared remarks before the Veterans of Foreign Wars 
Annual Convention July 22, 2014. VHA Schedulers have many comments on 
ways to improve the current process for scheduling including entering 
required time-stamp information, including Desired Date (DD). These 
ideas are in the process of being consolidated in a memo that will 
clarify existing policy and practice. Private sector practices tend to 
use capacity measures (such as the time to the third open slot) to 
measure access. VA has limited capability to use capacity measures 
because of legacy VistA scheduling software limitations. However, the 
Choice Act requires VA measure individual patient waiting times rather 
than capacity measures. VA has therefore proposed using the Veterans 
Preferred Date (formerly called the Desired Date) to meet the intent of 
the law. In order to improve the reliability of this measure, VHA 
anticipates adopting many elements of the new procedures suggested by 
schedulers, defining the clinic management role better, and 
standardizing the training of the clinic manager, including schedulers. 
While the waiting time goals have been removed from performance 
standards, the timeliness information will be need to comply with 
elements of the Choice Act. VA is exploring ways to ensure validity and 
reliability in its access standards, including how to appropriately 
measure timely access to care.

    Question 43. I certainly appreciate the approach of looking at well 
performing medical centers and taking those best practices and using 
them at those places that need help and improvement to provide timely, 
quality care to our veterans. Are you able to say which VAMCs are the 
high performing facilities you will be looking at and some examples of 
the best practices you will try to spread from these places?
    Response. VHA has formed a Steering Group to begin the process of 
determining how to measure the performance of facilities to find those 
that achieve excellent performance in their particular environment. 
This may allow for example, a small facility in a highly rural area to 
be paired with a like facility with better performance. Specific 
facilities in each domain have not yet been identified, nor which 
specific areas of vulnerability will need to be targeted. Further, best 
practices should be informed by the medical or business literature 
which may require additional research to ensure the validity of some 
practices.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Dean Heller to 
                  U.S. Department of Veterans Affairs
    Question 44. It is my understanding the VA has not yet authorized 
construction for a new Community Based Outpatient Clinic (CBOC) in 
Pahrump, Nevada. The Director of the VA Southern Nevada Healthcare 
System, Isabel Duff, has indicated this proposal is awaiting approval 
by VA Central Office. To date, a timeline or any indication for 
approving this project has not been released. I respectfully request 
the VA provide a timeline for approving this clinic's construction so 
that the facility can break ground before Fall 2014.
    Response. The lease package for the Pahrump, Nevada Community Based 
Outpatient Clinic was approved by the Under Secretary for Health on 
August 8, 2014, and subsequently by the Secretary on August 22, 2014. A 
copy of the signed approval memorandum was provided to the Veterans 
Integrated Services Network Capital Assets Manager on August 22, 2014. 
The Department of Veterans Affairs (VA) began the acquisition process, 
to include working with the General Services Administration (GSA), for 
this lease on August 22, 2014. VA anticipates a lease award for this 
site by the end of the calendar year.

    Question 45. I respectfully request a timeline for expected 
completion of the second phase of the VA's face-to-face audits.
    Response. The second phase of VA's face-to-face access audit 
concluded on June 4, 2014.

    Question 46. During the hearing, you informed me that you would be 
visiting Reno, NV, in August 2014, and assured me that you would visit 
the Reno VA Regional Office during the trip. I respectfully ask for the 
dates of this trip and a complete list of the VA facilities in Nevada 
that you will visit.
    Response. On Tuesday, August 19, 2014, Secretary McDonald conducted 
site visits to the Reno Nevada VA Regional Office and the Reno Nevada 
VA Medical Center.
                            A P P E N D I X

                              ----------                              


     Report Submitted by Hon. Mark Begich dated May 2003 from the 
President's Task Force to Improve Health Care Delivery for Our Nation's 
                                Veterans




















































                                ------                                


             Prepared Statement by Wounded Warrior Project

    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee: Recent scandals marked by widespread inability among 
VA medical facilities to provide initial treatment promptly, by 
cover-ups of problems in health care scheduling and delivery, 
and by recriminations against VA employee ``whistleblowers,'' 
underscore the importance of this Committee's examining the 
state of VA health care.
    These are grave problems that must not be dismissed. 
Problems of care-delivery in this system, however, are not 
insoluble. What is more challenging are practices that suggest 
that instead of a culture of caring for veterans, too many 
facilities have seemed caught up in a culture of cover-up. For 
too long, VA leaders over-emphasized a narrative of Department 
successes and relied heavily on performance ``data'' to measure 
those successes. Perverse incentives led some to falsify or 
skew data to meet required metrics. Yet even as this complex 
health care system is described as infected by a ``toxic 
culture,'' we learn of clinicians at VA facilities who have 
long been working overtime and on weekends, voluntarily, to 
help the veterans under their care. This duality underscores 
that VA operates a complex system, one that--while marred by 
scandal--employs many very dedicated, compassionate health care 
professionals.
    Many of the veterans we serve rely on that system for some 
or all of their care. We owe it to them to improve VA health 
care, not to dismantle the system or impose sweeping untested 
solutions. In that regard, with VA's problems in providing 
veterans an initial appointment within a then-required 14-day 
rule, it should be noted that lack of timeliness in providing 
care is not unique to VA. As reported earlier this month by the 
New York Times, ``there is emerging evidence that lengthy waits 
to get a doctor's appointment have become the norm in many 
parts of American medicine, particularly among general doctors, 
but also for specialists.'' \1\ While describing VA as reeling 
from revelations of long wait times, the Times reported that VA 
is one of the only health care systems in the Nation that 
openly tracks waiting times and has standards for what they 
should be.\2\
---------------------------------------------------------------------------
    \1\ Elisabeth Rosenthal, ``The Health Care Waiting Game,'' New York 
Times (July 6, 2014).
    \2\ Id.
---------------------------------------------------------------------------
    Wounded Warrior Project has not been hesitant over the 
years to critique VA timeliness of care, the effectiveness of 
certain VA services, its adherence to law and its own policies, 
and the consistency of its practices. That criticism and 
expectation has been directed to the high obligation the 
Department owes to those wounded, ill and injured in service--
obligations reflected in laws the Department is charged to 
administer.
    We commend to the Committee's attention a recent 
perspective co-authored by former VA Under Secretary of Health 
Ken Kizer, ``Restoring Trust in VA Health Care.'' \3\ The 
authors ask rhetorically, how ``[a]fter the VA had gained a 
hard-won reputation for providing superior quality care 15 
years ago, * * * did cracks appear in its delivery of safe, 
effective, patient-centered care?'' They offer three main 
causes:
---------------------------------------------------------------------------
    \3\ Kenneth W. Kizer and Ashish K. Jha, ``Restoring Trust in VA 
Health Care,'' NEJM (June 5, 2014).

        `` * * * an unfocused performance-measurement program, 
        increasingly centralized control of care delivery and 
        associated increased bureaucracy, and increasing 
        organizational insularity.'' \4\
---------------------------------------------------------------------------
    \4\ Id.

    While each is a critical flaw, an important starting point 
for this Committee would be to press VA to revisit its 
performance measures. As Kizer writes, the use of ``hundreds of 
[performance] measures with varying degrees of clinical 
salience * * * not only encourages gaming but also precludes 
focusing on, or even knowing, what's truly important.'' Kizer's 
---------------------------------------------------------------------------
prescription in terms of first steps is sound:

        ``First, after ensuring that all veterans on wait lists 
        are screened and triaged for care, the VA should 
        refocus its performance-management system on fewer 
        measures that directly address what is most important 
        to veteran patients and clinicians--especially outcome 
        measures.'' \5\
---------------------------------------------------------------------------
    \5\ Id.

    This would represent a good initial step toward restoring 
trust. We urge the Committee to continue its oversight in that 
effort.
      

                                 [all]