[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]







  A CONTINUED ASSESSMENT OF DELAYS IN VETERANS' ACCESS TO HEALTH CARE

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

                                HEARING

                               before the

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        TUESDAY, APRIL 19, 2016

                               __________

                           Serial No. 114-65

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

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                            C O N T E N T S

                              ----------                              

                        Tuesday, April 19, 2016

                                                                   Page

A Continued Assessment Of Delays In Veterans' Access To Health 
  Care...........................................................     1

                           OPENING STATEMENTS

Honorable Jeff Miller, Chairman..................................     1
    Prepared Statement...........................................    40
Honorable Corrine Brown, Ranking Member..........................     3
    Prepared Statement...........................................    41

                               WITNESSES

Honorable David J. Shulkin,, M.D., Under Secretary for Health, 
  U.S. Department of Veterans Affairs............................     4
    Prepared Statement...........................................    42

        Accompanied by:

    Thomas Lynch, M.D., Assistant Deputy Under Secretary for 
        Health for Clinical Operations, U.S. Department of 
        Veterans Affairs

Mr. Larry Reinkemeyer, Director, Kansas City Office of Audits and 
  Evaluations, Office of Inspector General, U.S. Department of 
  Veterans Affairs...............................................     6
    Prepared Statement...........................................    44

        Accompanied by:

    Mr. Gary Abe, Acting Assistant Inspector General for Audits 
        and Evaluations, Office of Inspector General, U.S. 
        Department of Veterans Affairs

Ms. Debra Draper, Director, Health Care Team, U.S. Government 
  Accountability Office..........................................     8
    Prepared Statement...........................................    49

                       STATEMENTS FOR THE RECORD

The American Legion..............................................    55

                         QUESTIONS AND ANSWERS

Submitted by Chairman Jeff Miller................................    57
From Congresswoman Jackie Walorski...............................    66
Letter From Michael J. Missal to Chairman Jeff Miller............    69
Additional Questions and Answers.................................    69
 
  A CONTINUED ASSESSMENT OF DELAYS IN VETERANS' ACCESS TO HEALTH CARE

                              ----------                              


                        Tuesday, April 19, 2016

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:30 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Lamborn, Bilirakis, Roe, 
Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham, 
Zeldin, Costello, Bost, Brown, Takano, Brownley, Ruiz, 
O'Rourke, Walz, and McNerney.

           OPENING STATEMENT OF JEFF MILLER, CHAIRMAN

    The Chairman. The hearing will come to order. I would like 
to welcome everyone to today's hearing entitled ``A Continued 
Assessment of Delays in Veterans' Access to Health Care.'' This 
hearing marks two years since this Committee exposed the wait 
time scandal that has gripped the Department since 2014.
    I am proud of the work that we have done in those two 
years, particularly digging into the actions of bureaucrats 
whose self-interest was put ahead of the veterans that they 
were charged with assisting. The purpose of this hearing is to 
examine the efforts that VA has taken to improve access to care 
for veterans and to identify where serious issues still exist.
    Based on the bipartisan work of this Committee, GAO has 
undertaken an audit of new patient primary care wait times at 
six facilities across the Veteran Health Administration. GAO's 
review found that veterans at those facilities waited between 
22 and 71 days, which is significantly more than the 5-day 
average that Secretary McDonald has declared to this Committee 
earlier this month. Now, this discrepancy can probably be 
easily explained.
    First, VA only tracks and monitors a portion, a portion, of 
a veteran's actual wait time when tracking access data. Instead 
of considering a veteran's wait time to be from the date when 
the veteran first contacts VA to request an appointment to when 
the appointment takes place, VA actually considers a veteran's 
wait time to be from the date when the veteran wants an 
appointment and the date when the appointment actually occurs.
    This is problematic because it doesn't take into account 
the following. Doesn't take into account the time it takes the 
VA scheduler to contact the veteran to schedule the 
appointment; the fact that it is a regular practice for 
schedulers to negotiate a desired date with a veteran; or the 
fact that outright manipulation of desired dates to zero out 
wait times is still one of the most prevalent types of data 
manipulation that occurs within the Department today.
    In effect, VA continues to ignore the main forms of data 
manipulation while it continues to come to Congress, to this 
Committee, saying there is no data manipulation. To this point, 
you will not find what you do not seek. The obvious result of 
VA reporting only a portion of a veteran's actual wait time is 
artificially low results.
    I still don't understand how a culture could persist in 
presenting inaccurate data to this Committee, or more 
importantly to the veterans of this country. A true picture of 
wait times, or more importantly, the veteran experience the 
Secretary speaks about quite frequently, can help us ensure an 
adequate allocation of the resources that we are asked to 
provide. But when this Committee only hears requests for more 
manpower, more space, and more flexibility, it is hard to 
reconcile the additional resources with a reported wait time of 
only five days.
    This discrepancy between reality and VA claims was captured 
by GAO in its report where VA data shows that wait times were, 
at best, underestimated by two-and-a-half times, and, at worst, 
11 times the full wait time that the veteran experienced.
    Another tactic that VA uses to make its wait time appear 
lower is to combine shorter wait times for the large pool of 
established patients with the longer wait times of the smaller 
pool of new patients. This dilutes the wait time data, making 
new patients waits appear shorter since they have been co-
mingled with data from the other cohort.
    For years VA has blamed incorrect appointment scheduling 
and long wait times on training issues, largely because it was 
warned about those issues as far back as 2005 when the 
Inspector General's office published a report highlighting the 
improper scheduling practices and poor training process.
    Many OIG and GAO reports since that time have found that 
the same scheduling problems continue to exist. Yet, in the 11 
years since VA continues to blame wait time manipulation on the 
very same cause, a control over which a VA has complete 
control. Secretary McDonald has repeatedly asked that we allow 
him to run VA like a business. But I can assure you that if an 
executive running a company used the same excuse to explain 
away 11 years of problems in a row with no change to show for 
it, that individual would be out of a job. But not at VA.
    Despite years of reports of confirming systemic issues, the 
Department has successfully fired just four people for wait 
time manipulation while letting the bulk of those behind its 
nationwide delays in care scandal off with no discipline or 
very weak slaps on the wrist. Another issue regarding 
accountability is how VA continues to ignore retaliation 
against the whistleblowers that we have relied on for some of 
the information that our Committee has acted on.
    The Committee has asked VA for all adverse actions where an 
employee was disciplined for retaliation against a 
whistleblower. VA provided our Committee a list showing that as 
of March 15th, 2016, only six individuals were disciplined for 
whistleblower retaliation. However, looking deeper at the 
report, one of the listed employees is Sharon Helman, who the 
Committee has already shown was not successfully disciplined 
for whistleblower retaliation, was, in fact, successfully 
disciplined for failing to report accepting gifts.
    Two of the other disciplined employees were listed as 
housekeeping aide supervisors who are clearly not high-level 
supervisors. That leaves three employees. Two received 
reprimands and one received a less than 14-day suspension. To 
be clear, according to VA-provided documentation no employee 
has been removed for whistleblower retaliation. This is 
representative of the fact that, contrary to public statements 
by VA senior officials, whistleblower retaliation appears to 
most certainly be tolerated within the Department.
    So now, two years after what was and is a systemic crisis 
in care being brought to light, it is time for VA to stop using 
misleading data to tout wait time successes that simply do not 
show the real wait time experienced by our veterans.
    I want to hear what concrete actions have been taken, what 
fundamental changes have been made, and what tangible cultural 
shifts are occurring within the Department. Advertising 
artificially lowered numbers does nothing to stimulate the 
change that is needed to improve veterans' access to care.
    And with that, I yield to the Ranking Member, Ms. Brown, 
for any opening remarks that she may have.

    [The prepared statement of Chairman Miller appears in the 
Appendix]

       OPENING STATEMENT OF CORRINE BROWN, RANKING MEMBER

    Ms. Brown. Thank you, Mr. Chairman, for calling this 
hearing today. Following the wait time scandal of Phoenix, 
Congress passed, and President Obama signed, the Veterans 
Access, Choice and Accountability Act of 2014. In it, we 
mandated that there be an Independent Assessment of veterans' 
health care.
    The Assessment Highlighted many of the things we hear from 
our veterans. We hear that VA provides excellent health care, 
especially health care related to the special needs of our 
veterans. We also hear that in certain areas, VA is at the 
forefront of health care in this country. We also hear from our 
veterans that VA care is often fragmented, and that it can be 
difficult to navigate and arrange non-VA care. We hear of long 
wait times and limited access.
    Following the assessment in the Surface Transportation in 
Veterans Health Care Choice Improvement Act of 2015, we 
mandated a report by the VA regarding a plan for how VA could 
consolidate all purchased care programs into one New Veterans 
Choice Program. We received that report last year and this 
Committee is currently working with the VA on the best way to 
implement the legislative request.
    The VA is on track to see 6,277,360 unique patients, and 
9,247,803 unique enrollees. In Fiscal Year 2015, VA completed 
56.7 million appointments, nearly 2 million more than Fiscal 
Year 2014. That is roughly 226 appointments per day. Let me 
repeat that. That's 226,000 appointments per day.
    The number of patients that the VA sees would put any other 
health care system to shame.
    I am pleased the GAO study newly enrolled veterans and 
their access to primary care. In my conversations with 
veterans, time and time again they say that once you get into 
the VA system, the care is the best in the world. Let me repeat 
that. Once you get into the system, the care is the best in the 
world. It is this initial appointment that is so hard to get. I 
am troubled by the GAO finding that nearly half was unable to 
access primary care because VA medical center staff did not 
schedule appointments for these veterans in a quick timeframe.
    The GAO report goes on to say that veterans' access to 
primary care is hindered in part by data weaknesses and by the 
lack of a comprehensive scheduling policy.
    We are at a tipping point right now as to what the VA would 
look like and the services it would provide for veterans in the 
coming decades. I look forward to hearing from witnesses today 
as to what this aspect of the VA would look like in the future.
    With that, Mr. Chairman, I yield back the balance of my 
time.

    [The prepared statement of Corrine Brown appears in the 
Appendix]

    The Chairman. Thank you very much, Ms. Brown.
    As a custom with this Committee, I would ask that all 
Members waive their opening statement to allow me the 
opportunity to introduce the witnesses at the table today.
    From VA, we are going to hear from Dr. David Shulkin, the 
Under Secretary for Health in the Department of Veterans 
Affairs, and he is accompanied by Dr. Lynch, Assistant Deputy 
Under Secretary for Health and Clinical Operations. From the 
office of Inspector General we have Mr. Larry Reinkemeyer, 
Director of OIG's Kansas City office of Audits and Evaluation, 
he is accompanied by Mr. Gary Abe, Acting Assistant Inspector. 
Finally, we will hear from Ms. Debra Draper, Director of the 
Health Care Team at the Government Accountability Office.
    And I would ask if all the witnesses would please stand so 
we can swear you in.
    [Witnesses sworn.]
    The Chairman. Thank you. Please be seated.
    Let the record reflect that all witnesses did answer in the 
affirmative.
    Dr. Shulkin, you are recognized for your opening statement 
of five minutes.

                   STATEMENT OF DAVID SHULKIN

    Dr. Shulkin. Good morning, Chairman Miller, Ranking Member 
Brown, Members of the Committee. As the Chairman said, I'm 
accompanied by my right here by Dr. Thomas Lynch, who is the 
Assistant Deputy Under Secretary for Clinical Operations, and 
seated behind me, Dr. Poonam Alaigh, who is the Senior Advisor 
to the Under Secretary.
    I arrived at VA approximately nine months ago, and I 
understood when I came here that this access crisis was a 
national priority and the status quo simply wasn't acceptable. 
It's not my objective today to tell you that we fixed all the 
problems or that we don't have issues, rather it's my objective 
today to tell you that we are focused on this, this is my 
number one priority, that this is VHA's number one priority, 
and we're going to stick at this 'til we get this problem 
resolved.
    The first thing I did when I arrived as the Under Secretary 
was to assess all the data on wait times. There were literally 
file cabinets full of reports and bookshelves filled with data. 
And I have to tell you, I made it through medical school okay, 
but I had a really hard time understanding all this data; very, 
very confusing.
    What I didn't see was the ability to clinically prioritize 
which veterans needed care first, and I didn't know how to run 
a health care system unless I understood that you needed to see 
the patients that were sickest the first.
    So that's the first thing we did, we changed it so we could 
clinically prioritize the veterans. And that led to two 
national stand-downs where we opened up every VA medical center 
across the country and saw those veterans who needed the care 
that day on the day of the stand-down. And that led to real 
significant sustainable improvements.
    We had 57,000 urgent consults in what we call Level 1 at 
the first stand-down, today it's a 77 percent reduction, there 
were 12,000 urgent Level 1 consults. On our second stand-down, 
we addressed 81,000 urgent appointments and we got 93 percent 
of those gone through and resolved.
    This month, we're launching what we call our Declaration of 
Independence, which is called the Declaration of Access, which 
are nine core principles that are going to fundamentally 
redesign the way that we provide access to veterans. They 
include some pretty bold moves like same-day access in primary 
care, and same-day access in mental health.
    Now I will tell you these are aspirational goals to be done 
by the end of 2016, but I've never been part of a change effort 
that started with low expectations. And I'm confident we can 
get these bold goals done because today we have 34 medical 
centers in the VA system that are currently doing same-day 
access in primary care. So we can do this, we have to spread 
these best practices throughout the system.
    We also have to make the wait times more understandable. 
Mr. Chairman, as you said, it is very, very difficult to 
understand. And I will tell you that I am--my academic studies 
are in patient safety. I teach my students that there are bad 
systems, not bad people. And so I've already said we have to 
change our systems, but when we do identify bad people in the 
VA, and people who have lost their ways not following out 
values, we will hold them accountable.
    We have held 29 individuals so far accountable with 
disciplinary actions on the VA wait crisis. As the Chairman 
said, four of them have been fired. We've trained 32,067 
schedulers. We've done 11,500 individual visits auditing these 
schedulers. The Joint Commission has been invited and visited 
every single one of our medical facilities. We have a new 
training program for schedules to launch this spring, beginning 
in May. But our measurement system's too complex. And where I 
want to move this to is the veteran experience: asking veterans 
are they satisfied with access.
    And, in fact, in every medical center today, we have a 
system called VetLink. When you come in, you go to a kiosk, you 
actually are asked whether you're satisfied with the access to 
care. Eighty-nine percent of veterans today are satisfied with 
the access to care throughout VAs. And I have all of your 
individual data by the way.
    But we have to do better. We hired 17,000 new employees in 
the last fiscal year, that's a net number. A ten percent 
increase in productivity through RVVs user over the last two 
years. Two point two million square feet we've added of 
clinical space. We have a new scheduling system being rolled 
out now called VSE, a new veterans application that they can 
schedule themselves.
    We've allowed direct scheduling in audiology and optometry. 
We have group practice managers now over all of our medical 
centers. We're sharing best practices and access across the 
entire system. And, of course, as you know, we're working much 
closer than ever with our community partners to provide care.
    Fifty-seven million appointments last year, as the Ranking 
Member said, 1.6 million more visits last year than the year 
before, 96 percent scheduled within 30 days. We're processing 
claims faster than ever before, 25 percent increase in claims 
processed last month. We're looking forward to the comments by 
the GAO and the IG. I have to tell you, we're not afraid of 
criticism, we welcome it, we want this type of transparency.
    In conclusion, I just want to tell you, the VA is making 
sweeping changes, we are making progress, but there's 
significant work that lies ahead. That's what I'm here to do. 
But recall, as the Ranking Member said, the VA provides 
excellent care everyday, in fact, this year alone four peer-
reviewed studies showing our care is equal or superior to 
what's happening in the private sector.
    We appreciate the support of all of you on this Committee 
and look forward to answering any questions. Thank you, Mr. 
Chairman.

    [The prepared statement of David Shulkin appears in the 
Appendix]

    The Chairman. Thank you very much, Dr. Shulkin.
    Mr. Reinkemeyer, you are now recognized for five minutes.

                 STATEMENT OF LARRY REINKEMEYER

    Mr. Reinkemeyer. Mr. Chairman and Members of the Committee, 
thank you for this opportunity to discuss the recent reports we 
have issued that have addressed various obstacles to veterans 
receiving timely access to health care. As you mentioned, I am 
accompanied by Mr. Gary Abe, the Deputy Assistant Inspector 
General Of Audits and Evaluations.
    Two years ago, VHA's ability to provide veterans timely 
access to care became an even larger national focus. In 2014, 
we published two reports detailing the serious conditions that 
existed at the Phoenix health care system and provided VA 
leadership with recommendations for immediate implementation. 
These reports brought much needed accountability over serious 
access issues.
    Since our August 2014 reports, we have initiated a series 
of audits and reviews evaluating the extent to which veterans 
receive timely care. We have published several comprehensive 
reports detailing veterans' experiences during their initial 
application and their enrollment for health care, VHA's 
effectiveness in its efforts to improve veterans' access to 
psychiatrists, and VHA's consult management.
    In addition, a number of more recent reviews are still in 
progress, including work which Members of Congress requested at 
the Phoenix health care system to evaluate hiring practices of 
medical support assistants, or the schedulers, and continued 
concerns about timely access to care.
    The national attention sparked by our reporting on the 
Phoenix health care system resulted in a dramatic increase in 
the number of contacts to the OIG hotline and the number of 
inquiries and requests sent to us by Members of Congress. A 
number of these hotline contacts continue to allege 
inappropriate practices by VHA staff that undermine the 
integrity and reliability of wait time metrics, as well as 
allege that VHA's initiatives to provide veterans care in the 
community are not working.
    Our audits, reviews, and health care inspections have 
reported challenges VA faces in administering all aspects of 
purchased care programs, authorizing, scheduling care, 
documenting the care in the veterans' VA medical records, and 
timely and accurate payments for care.
    Two reports we issued in February 2016 highlight some of 
the problems we see. In our review of alleged untimely care at 
the Colorado Springs community based outpatient clinic, we 
substantiated the allegation that some eligible Colorado 
Springs veterans did not receive timely care and non-VA care 
staff did not add veterans to the Veterans Choice list, or the 
VCL, in a timely manner, or in some cases not at all.
    Generally, this occurred because scheduling staff used 
incorrect dates that made it appear the appointment wait time 
was less than 30 days, which resulted in the veteran's 
exclusion from the VCL.
    In our review of alleged patient scheduling issues at the 
VA medical Center in Tampa, we again substantiated that the 
facility did not add all eligible veterans to the VCL when 
their scheduled appointment was greater than 30 days. But we 
also found that staff inappropriately removed veterans from the 
VCL, and the facility staff did not cancel veterans' existing 
VA appointments when they did receive an appointment in the 
community through the Veterans Choice Program, which blocked 
other veterans from taking that VA appointment.
    My office recently initiated a pilot project to audit one 
VISN and its facilities to evaluate three key components of 
access: data reliability of wait time metrics, access through 
the Veterans Choice Program, and consult management.
    Our objective for this pilot is to provide comprehensive 
and timely oversight at all facilities within a VISN in order 
to provide the facility directors within that VISN a report 
detailing their current data and scheduling practices. We hope 
that by focusing our resources on this issue, we can audit each 
VISN and its facilities every three years as we currently do 
with our VBA regional offices.
    We feel this work is important and will help provide a 
veteran centric view of what actions VISN management is taking 
to ensure situations like Phoenix do not occur in the future.
    In conclusion, our work has shown that VA faces challenges 
in providing adequate access to health care. We have a number 
of active projects involving VHA practices and procedures that 
ultimately affect veterans' access to the Veterans Choice 
Program. We will continue to work with VA to provide the 
independent oversight and objective recommendations to help 
move these programs and initiatives forward.
    Mr. Chairman, this concludes my statement. We would be 
happy to answer any questions you or Members of the Committee 
may have.

    [The prepared statement of Larry Reinkemeyer appears in the 
Appendix]

    The Chairman. Thank you, Mr. Reinkemeyer.
    Ms. Draper, you are recognized for five minutes.

                   STATEMENT OF DEBRA DRAPER

    Ms. Draper. Chairman Miller, Ranking Member Brown, and 
Members of the Committee, thank you for the opportunity to be 
here today to discuss veterans' access to VA health care. My 
testimony today is based on GAO's ongoing body of work in this 
area, including most recently a report publically released 
yesterday, ``A Newly Enrolled Veteran's Access to Primary 
Care.''
    I wish that I was here today to discuss better news, but, 
unfortunately, that's not the case. Since 2000, and in 
particular over the past five years, we have consistently 
reported on VA's failure to ensure veterans' timely access to 
health care. In 2012, we found that outpatient medical 
appointment wait time data were unreliable, implementation of 
the scheduling policy was inconsistent across medical 
facilities, telephone access was problematic, and scheduling 
resources were not effectively allocated.
    In 2014, we found that access to outpatient specialty care 
was problematic due to mismanagement of the consult process, 
including poor oversight and the lack of clear policies. In 
2015, we looked at veterans' access to mental health care and 
found that the way VA calculates wait times does not always 
reflect the overall time a veteran is waiting for care, the 
lack of clear policies precludes effective oversight, and 
access data may not be comparable over time or between medical 
facilities.
    Our most recent work focused on newly enrolled veterans' 
access to primary care, which is typically the entry point to 
VA's health care system, and critical to ensuring veterans 
obtain needed medical care, including specialty care. For this 
work, we found many of the same problems as we had previously 
reported.
    We reviewed a sample of 180 newly enrolled veterans' 
medical records across six VA medical centers and found, for 
example, for the 60 veterans in our review who requested VA 
contact them to schedule appointments, but had not been seen by 
primary care providers, 17 were not contacted at all because 
these veterans did not appear on the new enrollee appointment 
list, which is intended to help track newly enrolled veterans 
needing appointments. Medical center officials were not aware 
that this problem was occurring and could not tell us why these 
veterans did not appear on the list.
    Further, for 12 of these 60 newly enrolled veterans, 
medical centers did not follow VA policy for making contact to 
schedule an appointment, which states that there should be 
three documented attempts by phone, and if unsuccessful, a 
letter sent. For the 120 veterans who requested care and were 
seen by primary care providers, we found the average number of 
days between the initial request that they be contacted to 
schedule appointments and the dates they were actually seen 
ranged from 22 to 71 days. About half were seen in less than 30 
days.
    However, veterans' experiences varied widely with 12 
veterans, for example, waiting more than 90 days. Delays in 
care were due to issues such as appointments not being 
available when veterans wanted to be seen and medical centers' 
failure to follow VA scheduling policy.
    In this most recent work, we also continue to see data 
weaknesses due to errors such as schedulers incorrectly 
changing dates, as well as the lack of a comprehensive 
scheduling policy, which has created confusion and contributed 
to the errors seen.
    In 2015, veterans' health care was added to GAO's high risk 
list due to VA's problems providing timely access to care, 
among other reasons. This list identifies government operations 
that are vulnerable to fraud, waste, abuse and mismanagement, 
or need a major organizational transformation.
    In designating VA health care as high risk, we identified a 
number of concerns, all of which affect veterans' access to 
timely health care and includes, for example, ambiguous 
policies, and inconsistent processes, inadequate oversight and 
accountability, and poor training.
    It has now been over a year since the addition of VA Health 
Care to the high risk list, and to date, we have seen at best, 
little progress by VA in addressing the issues. We are very 
concerned about the lack of meaningful progress and our concern 
is heightened further because the window of opportunity for 
making progress under the current administration is rapidly 
closing, if not already closed.
    VA health care's access problems are significant, 
persistent, and not only a disservice to our Nation's veterans, 
but places them at risk for harm. The status quo is not 
appropriate, nor should it be accepted.
    Mr. Chairman, this concludes my opening remarks, I would be 
happy to answer any questions.

    [The prepared statement of Debra Draper appears in the 
Appendix]

    The Chairman. Thank you very much.
    Dr. Shulkin, I know that you have been hard at it for nine 
months. And a simple question, does it irritate you that even 
after your nine months--and we are talking about two years from 
the exposure of the wait time problem--that there still is 
serious problems in manipulation of wait times?
    Dr. Shulkin. I am very, very impatient to get this problem 
resolved. I am concerned that we have data out there that is 
not necessarily understandable by people. I am concerned when I 
hear about mistakes being made. Wherever we do find that there 
is manipulation of data, that is unacceptable and we're taking 
action.
    So we're doing everything that we can, but am I impatient? 
Am I upset about it? Absolutely. We are--this is why it's our 
number one priority, Mr. Chairman.
    The Chairman. Expound on the action that you are taking, 
because it appears, you know, that folks have said for almost a 
decade that it has been lack of training or improper training. 
That is 10 years that this has been going on, or more. Give me 
some concrete steps as to what you are doing, and have you 
really analyzed what the root cause--
    Dr. Shulkin. Yep.
    The Chairman [continued]. --of this issue is?
    Dr. Shulkin. Well, let me first start. It's an excellent 
question, and very fair question. First of all, I want 
everybody to be clear, we do not have access or wait times in 
our performance measures. In other words, nobody's getting 
bonuses, there is no incentive whatsoever to be manipulating 
this financially as there was in the past. So, I think, thanks 
to your Committee's work, we make sure that that isn't 
existing.
    So I'm going to go back to the fact that, in general, we 
mostly, of our 340,000 employees, have very, very good, 
dedicated employees; we have bad systems in place. One of the 
things that we've talked to you about is this is our current 
scheduling system to the right. It is DOS black screen. To 
think that this is how we're having our 32,000 schedulers have 
to schedule appointments invites confusion; it invites the 
inability to do this accurately.
    So we are putting in now, currently being rolled out, the 
one to the left, which looks like a Microsoft Outlook calendar. 
That's important that we give our people the right tools. We're 
also evaluating a commercial system called MASS, which offers 
greater capabilities.
    Number three, we are insisting that our leadership do 
visits to the schedulers personally, and where they find that 
people aren't scheduling appropriately, they're pulling their 
scheduling keys, and we're doing that on a regular basis.
    We are talking about this and trying to do better training. 
We are taking disciplinary actions where we find that people 
have deviated. So we're just going to have to stick at this. I 
don't know any other faster magical way to make this happen, 
and I'm frustrated by it.
    The Chairman. I think it would surprise many of the Members 
to know, or maybe it wouldn't, you know, we just saw an example 
of the scheduling software that is being used $127 million 
later, and we are just now looking at something that could be 
purchased off the shelf.
    Quick question. GAO found that almost one-third of the 
veterans that it reviewed, 17 out of 60 did not get contacted 
for an appointment because they did not appear on the NEAR 
list, and one would assume that directors at these facilities 
neither knew this was occurring, nor they didn't know why a 
veteran would not appear on the NEAR list. And so the question 
is why would a hospital director not know?
    Dr. Shulkin. Yep. Well, when you read the GAO report, I 
think it's pretty clear that we didn't do the best that we 
could for veterans. So that's why we appreciate the spirit and 
the information 'cause it's going to help us do this better. So 
we are sunsetting the NEAR report, we are moving it towards an 
automatic system called Welcome My VA where we're contacting, 
reaching out to every veteran.
    Part of the problem that was in the GAO report they said is 
we had the wrong phone numbers for some of these veterans, we 
couldn't reach them. When we reached some veterans, they didn't 
want appointments, they wanted C&P exams, so we got them there. 
Other veterans said, no thank you, I know I originally said I 
wanted an appointment, but I no longer want an appointment.
    So we have to do a better job, but it wasn't that every 
veteran that Ms. Draper just mentioned we failed. We failed too 
many, but a lot of them, frankly, those facilities just weren't 
able to get in touch with or when they did, they didn't want 
the appointments.
    The Chairman. Okay. And my time is expired, but I got one 
more question that I want to ask you because a lot of folks 
have talked about accountability at the table and wanting to 
hold people accountable for things that they had done, but, you 
know, in the media, there have been examples including an 
employee who participated in an armed robbery, a chief of staff 
that was improperly prescribing drugs to a VISN director's 
wife, a nurse who is being charged with manslaughter in the 
death of a veteran patient, they are all still on the payroll.
    Similarly, according to the weekly list that VA provides to 
the Committee in the wake of the nationwide wait time 
manipulation scandal, VA has successfully fired only four 
people for wait time manipulation. How is any of this possible, 
especially those on the front end who have been--some of them 
have been convicted of crimes?
    Dr. Shulkin. Yep. Seems hard to believe, Mr. Chairman, so 
let me try to step through my understanding, and if I make any 
mistakes, I will commit to you that I will get back to you with 
that.
    You mentioned the VISN director, he is not on our payroll; 
he's retired from Federal service. It is my understanding that 
the person who--who was found with some of the criminal 
allegations, no longer at the VA. The person--one of them 
actually is going through a court hearing and we're following 
the court's procedures on that.
    But, look, somebody who does either violate the law or 
violate our principles does not belong at the VA, and we 
clearly take that seriously. We go through a very extensive 
process of, you know, due process to get them there, sometimes 
it takes a long time, but we do not want people that shouldn't 
be treating veterans treating veterans, and I take that very 
seriously. So if there are some of those cases that you've 
talked about that we haven't acted fast enough, we will go back 
and take a look at them.
    The Chairman. You talked about the VISN director having 
retired, it wasn't the VISN director, it was his wife that was 
receiving prescription drugs by the chief of staff of that 
particular hospital.
    And one other thing, something that hit the press a couple 
weeks ago and that was the doctor at Tomah that had his medical 
license suspended for emergency reasons by the state. I believe 
you took action, fired that individual, now a court or a--has 
been adjudicated that his license should not have been 
suspended on an emergency basis. So you have to, I assume, put 
that person back on the payroll--
    Dr. Shulkin. No.
    The Chairman. Not on the payroll?
    Dr. Shulkin. Not the payroll.
    The Chairman. Okay.
    Dr. Shulkin. No. No, you're correct about the court action, 
but that does not change our administrative action.
    The Chairman. Okay. Is that person appealing at this point, 
your firing of them?
    Dr. Shulkin. My understanding is they're looking at their 
options in that regard, yes, sir.
    The Chairman. Okay. Because my question would be, if that 
person is brought back on the payroll and subsequently the 
medical board goes through the normal process of suspending 
that person's license, how do you get that money back from that 
individual that comes back on your payroll?
    Dr. Shulkin. Well, you know, I think we have to let people 
have their due process, but right now we've made the decision, 
an administrative decision, not to have him on the payroll, and 
we are not planning on changing that decision unless there's 
new information that comes up that we would have to consider.
    The Chairman. Okay. Thank you, thank you very much.
    Ms. Brown?
    Ms. Brown. Thank you, Mr. Chairman. Mr. Secretary, it just 
seems like you have been here longer than nine months. This 
problem that we are having with the VA goes back more than ten 
years. I have been on this Committee for 23 years, and we have 
had problems with the VA over a long period of time, and it 
would be a misnomer to act like these things just occurred.
    I would like to ask, and I am very concerned about, is that 
the GAO report have once again, just a couple of days ago, put 
VA on the high risk list. Explain that to me, and what we are 
doing to take care of this problem? I want to address the 
stand-down, what you all have done, and all the positive things 
that you have done? I am real concerned.
    Dr. Shulkin. Yes. Well, I believe that VA was placed on the 
high risk list probably well over a year ago because it was 
prior to my confirmation, but the GAO has been very clear about 
the reasons they put the VA on the high risk list.
    We have inconsistent policies and procedures; we have not 
systematized best practices, or the best processes across the 
VA the way that a health care system should; and we have 102 
outstanding recommendations, or at least that was when we went 
on the GAO report, I think we've gotten some of them down, but 
there's still many outstanding recommendations.
    We work with the GAO now on a regular basis to show them 
how we're working to fix that, and in consultation with them. 
But look, the GAO was right in this regard. We have policies 
and procedures that were conflicting, and we're working to fix 
that 'cause you can't have that.
    The best practices across the system, that's what health 
care system should be doing, it's why it's one of my five 
priorities, and we are focused on learning from the best and 
putting it throughout the system.
    This is going to make VA a better system, and I thank GAO 
for that. I'm anxious to get off this list fast. I don't agree 
with Mr. Draper's assessment that we're not making progress. I 
know we're making progress. It may not be as fast as she wants 
us to, or as fast as I want us to, but we're heading in the 
right direction and we're addressing the right issues.
    Ms. Brown. The stand-downs?
    Dr. Shulkin. The stand-down--the stand-downs are part of 
it, but the stand-downs aren't a way that you sustain 
improvements; they are the declarations of emergencies. When 
you have urgent patients that aren't being seen, they are 
emergencies, and we have to act like that. But they've led to 
sustainable improvements, our nine core principles of how we're 
going to redesign accessing the system. So ten years from now, 
a year from now, we're not going to be talking about this in 
the same way.
    Ms. Brown. When you all had the stand-downs, how many 
people showed up in the various areas?
    Dr. Shulkin. One hundred percent of our medical centers 
were open on those Saturdays. No exceptions. People asked for 
exceptions; I denied them. So we acted as a system in the 
country. Thousands of people--Dr. Lynch, do you have a number 
of how many?
    Dr. Lynch. I think we had 5,000 employees that were 
actually involved in the stand-down. There were 10,000 patients 
or so that were actually seeing on the day of the stand-down. 
But make no mistake, the stand-down was only a symbol. 
Everything was going on prior to that stand-down. So we were 
actually evaluating open consults, evaluating pending 
appointments, scheduling appointments, and assessing patients 
prior to that.
    The stand-down was actually a way to really bring together 
the five points that are in Dr. Shulkin's priorities. We 
focused on access, we engaged our employees, we looked to the 
community for help where we needed it, we engaged best 
practices from across the networks, and we're working to 
basically restore trust with our veterans.
    Ms. Brown. I just want to say the next time that you all 
schedule a stand-down, it would be good to let the Members of 
this Committee know because we would like to attend, I know I 
would like to be at my center on a Saturday when this occurs.
    Dr. Shulkin. I know at the last stand-down, Congresswoman, 
I was in Orlando, Florida, and there were Members of the 
Congressional staff there. So we welcome your involvement.
    Ms. Brown. My last question. What policies, directives, 
have resulted from the stand-downs?
    Dr. Shulkin. What we've done as a result of the stand-down, 
we sequestered a team of people from the field, not from the 
central office, who have told us what needs to be done to 
redesign the system so we don't ever get long wait lists again 
of veterans who need care urgently.
    And that led to this Declaration of Access, the nine core 
principles that every VA medical center is now signing their 
name to, committing to these principles to fix access in 
calendar year 2016 with same-day access in primary care and 
mental health, eliminating our recall system, which we've been 
using for veterans for a long time, and in making sure that 
we're using telehealth and expanded opportunities to improve 
access.
    Ms. Brown. Thank you. And thank you, Mr. Chairman, I yield 
back the balance of my time.
    The Chairman. Thank you very much.
    I heard something I was unaware of just a second ago. You 
testified, I think, at a Subcommittee hearing on Thursday about 
the commercial scheduling software MASS that you just talked 
about, and I think your testimony was that it is on a strategic 
hold at this point. A hundred and fifty-two million dollars is 
what it would cost to do that? And the question is, how in the 
world could a pilot cost $152 million?
    Dr. Shulkin. Yep. So, again, the VSE, the VistA scheduling 
enhancement solution that's being rolled out now, total cost of 
the project, $6.4 million. MASS, which we do have a contract 
for--it's an IDIQ contract so we can implement this--the next 
step would be to do a pilot at three sites. It would be a ten-
month pilot where you have to build the interchanges between 
VistA and MASS, and the cost of it is $152 million. The total 
cost of the national rollout is $600 and something million.
    The Chairman. Okay. With that, Mr. Lamborn, you are 
recognized.
    Mr. Lamborn. Mr. Secretary, you paint a much too rosy 
picture. The system is broken. For those of us on the this side 
of the dais, we talk to the people, and we listen to the 
people, and the people in my district are very frustrated and 
angry that we have all of this dysfunction here in Washington, 
and more specifically with the bureaucracy that continues to 
fail our veterans.
    People want real reform, real change, and not just talking 
points about how everything is about to be fixed. And I have 
even been told to my face, well, the problems were already 
fixed at the beginning of the study and what the GAO documented 
was--or, the Office of Inspector General documented was after 
the beginning of the study and everything is okay. We can't 
have a real conversation if you won't even admit that there is 
a problem in places like Colorado Springs.
    I want to share with you a brief excerpt from a letter I 
recently received from a constituent who found it impossible to 
navigate the VA system to get health care. His case is 
important as an individual, but I think there are thousands 
like him. He wrote a respectful letter, but he is simply beyond 
being fed up. Here is an excerpt.
    ``Sir, I speak for myself and thousands of veterans when I 
tell you enough is enough.'' He says, ``Stop the tough talk and 
for once act on the corruption and deceit going on at the 
clinics.'' And he is talking about the CBOC in Colorado 
Springs. He ends up with his letter describing a 14-month 
runaround with the clinic and says, ``When will it stop?''
    So when will it stop, Mr. Secretary? Veterans take way too 
much time to get their care, and they are not being able to 
really have access to the Veterans Choice Program, which is 
especially frustrating because that was implemented by Congress 
to try to stem the tide of some of this dysfunction.
    So the first question, Mr. Secretary, according to the OIG, 
in places like Colorado Springs, VA staff did not add some 
veterans to the Choice list or did not add others in a timely 
manner. What we see clearly is that besides the VA altering the 
times for VA care, like Phoenix and other places all over the 
country, it now does the same thing by acting as a gatekeeper 
for veterans who should have access to Choice. Why aren't 
veterans really being given the opportunity to use the Choice 
Program?
    Dr. Shulkin. Okay. Congressman, if you think I've painted a 
rosy picture, I've failed because I'm telling you right now I 
am acknowledging that we still have significant issues, and we 
have a lot of work to do. That's why it's my top priority, and 
I'm not going to rest until we do get this fixed. It's why I 
came here, and I am focused on it, and you and I sound similar 
when I'm with my staff because I'm hearing directly from the 
veterans just like you. So I'm with you.
    What I am saying, and maybe this is where you thought I was 
painting a rosy picture, I know we're headed in the right 
direction. Where we had 57,000 urgent veterans waiting more 
than 30 days for care, today that's 12,000. Our electronic wait 
list for our Level 1, our most important clinics, down 32 
percent in the past couple months. Our veterans themselves are 
telling us on these kiosks--we can't manipulate this data, it's 
our veterans--that 89 percent are satisfied with their care.
    The Choice Program isn't working for veterans, there's no 
question. We've told you that, and we need to make this system 
work better, and that's why we have legislation before you to 
try to simplify and streamline the care in the community to 
make this work better. So we have significant problems. I'm 
hearing the same things you are. We're headed in the right 
direction, but we are a long way from declaring that we've got 
this problem solved.
    Mr. Lamborn. Mr. Secretary, your own metrics from February 
of this year showed that 29 percent of veterans received 
appointments in excess of 30 days, 5 percent of those waited 
longer than 120 days, worst of all, over 2,400 veterans are 
still waiting on a wait list to receive an appointment, and 708 
of those have been waiting longer than 120 days.
    These metrics made the clinic in my district the eighth 
worst in the United States. So, and I know of at least three 
people who have died, and it could have been because of this 
waiting problem. It could have been directly a result of these 
delays.
    So I do not see the VA fixing it. I don't really see them 
being held accountable. And I just have to agree with the man 
who wrote the letter to my office, enough is enough. Thank you, 
Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Lamborn.
    Mr. Takano, you are recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman. Dr. Shulkin, I am very 
concerned that the VHA has been placed on the GAO's high risk 
list and that veterans are still struggling to get timely 
access to care. The VA has undergone significant change in the 
past year, and it will take continued commitment from those in 
this room and Members on the Committee to work together to make 
sure the VA is functioning the best it can to care for our 
veterans. But I want to move on to some other questions I have, 
Dr. Shulkin.
    In your testimony you mentioned that one of the VA's top 
priorities remains legislation to streamline the process for VA 
to work with outside providers. Now I am concerned that the 
provider agreement legislation this Committee considered throws 
out crucial workplace protections in the name of expediency.
    I offered an amendment when we marked up the provider 
agreement bill to ensure that the Office of Federal Contract 
Compliance Programs retained the authority to enforce workplace 
nondiscrimination protections. The OFCCP is the only Federal 
office that protects LGBT employees from discrimination in the 
workplace, and notably protects veterans from being 
discriminated against for their veteran status.
    Your testimony seemed to imply that we can improve provider 
agreements without undermining workplace protections. Do you 
agree?
    Dr. Shulkin. What I agree with is, is that I know that we 
desperately need provider agreements to make this program work 
better for veterans. It's not working well and we need them 
desperately to be able to do that. I certainly don't know if 
there's an unintended consequence that you're talking about, 
and so I haven't looked at your legislation, but we have no 
intent of wanting to impose discrimination or to take away 
protections from people in putting in place provider 
agreements.
    What provider agreements do is, too many small providers, 
the doctors and the small practices that are today caring for 
veterans, can't deal with the Federal contracting process. It's 
way too complex. They simply drop out, especially our nursing 
homes and our skilled nursing facilities. So we need provider 
agreements to be able to do a easy to do contract with our 
providers to care for our veterans. We certainly have no intent 
to discriminate against our employees.
    Mr. Takano. I realize there is a need to get these 
providers on board as quickly as possible, I am concerned that 
in the spirit of quickly as possible that on two counts, the 
possibility of the LGBT people could be discriminated against, 
and our own veterans could be discriminated against, that we 
need to make sure we balance--
    Dr. Shulkin. Yeah.
    Mr. Takano [continued]. --the desire to bring the providers 
on, but make sure those provider agreements are not 
discriminatory.
    Dr. Shulkin. Yeah. Yeah, Congressman, I have to tell you, I 
don't understand the linkage between what a provider agreement 
does and how it could potentially discriminate, but I will get 
back to you and have our legislative people help me understand 
that, because that's not our intent.
    Mr. Takano. Well, thank you. Part of providing timely 
access to care requires having a sufficient workforce. 
Leveraging community providers can benefit veterans, but we 
must be mindful of the fact there are many areas across the 
country that face health workforce shortages in the private 
market as well.
    And that is why I was supportive of increasing the number 
of graduate medical school education residencies in the Choice 
Act. Can you keep--give us a brief update on how that rollout 
is going?
    Dr. Shulkin. Well, I think it is one of the most important 
things that you authorized as part of the Choice Act; we need 
to train more health care professionals. There are actually 
more medical students now than residency spots, and so the VA 
expanding these spots is important. You authorized 5,000, to 
date we've only--we've only implemented more than about 380 of 
those spots.
    So we're continuing to work with your academic partners in 
your districts to look to expand these. There are a couple 
issues, one is the funding, as you know, goes away with the end 
of the Choice Program. So when an academic center--'cause we do 
this in partnership with academic centers, VA doesn't, with the 
exception of Puerto Rico, run its own GME programs.
    So we say to our academic partners in California, would you 
like to expand your psychiatry program, and they say of course 
we would, but the funding's going to be eliminated when Choice 
is sunset. Then they say, well, what happens then? So that's 
one of the problems we'd like to work with you on.
    Mr. Takano. I think there are Members on both sides of the 
aisle that are working with you on that--
    Dr. Shulkin. Yes, actually.
    Mr. Takano [continued]. --as well as the Medicare cap 
issue.
    Dr. Shulkin. Yes. That's an important issue too, the 
Medicare cap issue. But we believe this is part of the 
solution: training more health care professionals in areas of 
need. I know, for example, in El Paso we're just working, 
thanks to the Congressman, to work with tech--with Texas Tech 
on the new agreement.
    Mr. Takano. Well, I certainly appreciate my colleagues Mr. 
O'Rourke and Ms. Titus, and my colleagues on the other side of 
the aisle, for working together in a bipartisan way to deal 
with this germane issue.
    Dr. Shulkin. Yes, thank you.
    The Chairman. Dr. Shulkin, there were two pots of money in 
the Choice, the 10 billion and then there was 5 billion. So the 
5 billion doesn't sunset, the Choice Program sunsets, but the 5 
billion is there until the 5 billion goes away.
    Dr. Shulkin. Yeah. My understanding is on the GME program, 
it has a five-year--it has a five-year length of time that you 
can use the funding for. If I have a correct understanding of 
that, that would be good news. So I'll look at that.
    The Chairman. So it is your testimony today that the part 
of the reason you cannot get more slots is because of the 
sunset, and that needs to change?
    Dr. Shulkin. The reason we're not going faster, and we want 
to desperately go faster, is our academic partners need to 
agree to do this with us. They're telling us that there are two 
things in general that are preventing them from going faster. 
One is the Medicare cap issue. The Medicare cap says that if 
you go above your number, you can't get additional Medicare 
reimbursement, direct and indirect graduate medical education 
funding. Many hospitals, every hospital I've worked for, has 
been at their cap or above.
    The second is the length of time that it takes to start a 
program. When you start a program from ground zero to starting 
it, it often takes two years or so. If your money's going to 
expire before you graduate your first group of residents, the 
administrators at those hospitals say I'm not so sure this is a 
great deal for us.
    So those are the two issues I'm hearing. If I have it 
incorrect about the money running out after five years, that 
would be good news and I will look into that.
    The Chairman. Well, if we are just now talking about 
setting up the program, somebody is way behind the curve. The 
other thing is, I would tend to believe that the bigger issue 
is the Medicare cap issue and the reimbursement rates.
    But, Mr. Bilirakis, you are recognized.
    Dr. Shulkin. Yeah.
    Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it. 
Dr. Shulkin, you mentioned in your testimony about direct 
scheduling. I want you to elaborate on direct scheduling--
    Dr. Shulkin. Yes.
    Mr. Bilirakis [continued]. --that is available to certain 
veterans for certain specialties, you mentioned ophthalmology 
and I believe one more.
    Dr. Shulkin. Yes.
    Mr. Bilirakis. Elaborate, for the benefit of our veterans 
out there, who can direct schedule and why is it only limited 
to a couple specialties?
    Dr. Shulkin. Right. Right. The way the VA has done this for 
a long time is you go through a primary care physician, a 
gatekeeper. So you have to be able to get an appointment with a 
primary care doctor just to be authorized to get a consult.
    I have to tell you, I practice now, I'm a primary care 
physician in the VA, my first appointment was just to get a 
pair of shoes. I had to actually approve a consult to get a 
pair of shoes. It makes no sense. So we've started piloting a 
program where veterans can now directly schedule, without going 
through a primary care doctor, in audiology and optometry. It 
worked terrifically.
    We're expanding that now across the system. I think that 
was done in Florida. We're expanding that across the system. 
Then I want to look at, exactly as you're saying, other 
specialties: podiatry, social work, nutrition, you know, all 
sorts of things that, frankly, veterans can make the decisions 
themselves, they don't need primary care doctors' time to do 
it.
    Mr. Bilirakis. Very good. Another question has to do with 
walk-in clinics. How many walk-in clinics are out there? Where 
you mention about access, same-day access--
    Dr. Shulkin. Yes.
    Mr. Bilirakis [continued]. --is that widespread? Because we 
do have a walk-in clinic in our outpatient center in Newport 
Ridge, and I think it works very well.
    Dr. Shulkin. Yeah.
    Mr. Bilirakis. How many walk-in clinics are out there? How 
long--what is the average time where a veteran would have to 
wait to get the same-day access?
    Dr. Shulkin. Yeah. Actually, where I practice in New York 
City at the VA, that's where I practice, in the walk-in clinic, 
so we're there--if anybody needs to be seen, we see them that 
day. Not all of our VA's have walk-in clinics. Of the sample I 
looked at, for example, of the six in the GAO report, three had 
walk-in clinics, three didn't. But what many--
    Mr. Bilirakis. Why don't they?
    Dr. Shulkin. Well, because many, 34 actually have same-day 
access in their primary care centers. So if you can see your 
patients through your primary care center, you don't need walk-
ins, the other ones do need some type of urgent care visits.
    We do know that in areas that are challenged, they've 
actually begun some pilots with commercial urgent care clinics 
as well too. So this is part of our Declaration of Access. 
Everybody needs to get to same-day access for primary care by 
the end of 2016. Walk-in clinics are certainly a strategy to 
get there.
    Mr. Bilirakis. So do veterans who need same-day access, do 
they all qualify, if they qualify for VA care, to go to a walk-
in clinic?
    Dr. Shulkin. We don't have walk-in clinics in every one of 
our medical centers, but--
    Mr. Bilirakis. Well, the ones that do?
    Dr. Shulkin. Yep.
    Mr. Bilirakis. That the centers that do?
    Dr. Shulkin. The ones that do, I can tell you that if 
there's a walk-in clinic and they are eligible for VA care, 
they can walk in and be seen that day, yes.
    Mr. Bilirakis. Thank you. Next question, again for Dr. 
Shulkin. One of the VA's legislative asks is to have 
flexibility and budget authority to avoid artificial 
restrictions that impeded delivery of care and benefits to 
veterans. However, the VA has experienced many issues in which 
they attribute to lack of training and education. Not too long 
ago, the VA encountered a budget shortfall for the same fiscal 
year, as you know. The VA did not submit to Congress a formal 
request for emergency funds until months after the VA had 
already identified a potential budget shortfall as early as 
March of that year.
    This was in part due to the fact that the VA employees were 
not utilizing the $10 billion appropriated for community care 
through the Choice program, and utilizing the traditional non-
VA care account. The VA's only solution was a potential 
shutting down of VA medical facilities throughout the country; 
that's unacceptable. The question is, should Congress allow 
such flexibility, what assurances do veterans and taxpayers 
have that employees will be trained this time around properly 
so that another budget shortfall, nor threats of medical 
facilities being closed, does not happen again? So give me some 
assurances, please.
    Dr. Shulkin. Yep. Well, Congressman, I think you got it 
exactly right, which is what we had was, we had spent all the 
money in one checking account so it got down to zero, and we 
had lots of money in the other checking account. In order to be 
able to give veterans care in the community, we had to come and 
ask you for authorization at the last minute.
    What we're saying is, we don't ever want to do that again. 
That's not acceptable, it's not the right way to run a system, 
so we want the flexibility to use care in the community funds 
to support veterans who get care in the community.
    That means when we train our people in the system how to 
use it, we can train them that there's one pot of money and now 
focus on doing the right thing for veterans instead of 
following rules for seven to eight or nine different pots of 
money that, frankly, are too complex, and we've shown doesn't 
work for veterans. So that's why we really do need this type of 
legislation and we need your support in getting that passed.
    Mr. Bilirakis. Thank you very much. I yield back. Thank 
you.
    The Chairman. Thank you very much.
    Dr. Ruiz, you are recognized for five minutes.
    Mr. Ruiz. Thank you, Mr. Chairman, for holding this 
hearing. The issues that we are discussing are wrong in so many 
different levels, and I am going to talk about three. One, are 
your goals; two, are your data integrity; and, three, is the 
veterans' experience.
    So goals are important because it defines your success, it 
helps you achieve your objectives. Setting a goal of 30 days is 
arbitrary, there is no clinical data to suggest that is the 
best practice anywhere in the health care literature. And you 
had mentioned a term which earlier in the beginning of your 
presentation about trying to match scheduling with the clinical 
practice. Right?
    So we know that some illnesses are urgent, and emergent, 
and we need to really take care of them right away, and some 
others could be scheduled maybe more than 30 days, like your 
routine colonoscopies that you get once a year. Right?
    So I think that you need to start perhaps changing your 
premise in getting more towards a clinical approach so that you 
can take care of your high priorities first and--not 
necessarily rush--take up a spot for your high priorities with 
things that can be done in a routine basis.
    The second thing is setting up of goals of urgent care 
appointments within 30 days, which I recently heard of, is 
nonsensical. Then why are they urgent if you are going to wait 
30 days? Usually an urgent is what you call your walk-ins or 
maybe even within 48 days when you want to match your clinical 
practice with your scheduling goals.
    The third thing that I am concerned about in terms of your 
goals is the use of the word ``same-day access for all primary 
care and mental health.'' You are setting yourself up for more 
controversy by not clearly defining to the veteran what access 
is. Is it going into--picking up the phone and having--speaking 
with a scheduler, is that what access means? Is it receiving 
the appropriate care, is that what access means?
    So the second part is your data integrity. Now, we use 
population studies to reduce the chance that errors are done by 
chance, so that we can get a statistical significant accounting 
of whether this is a true problem and whether this is systemic. 
But the only way that we can really rely on those population 
studies is if your data is accurate, if your data has 
integrity, and the GAO is continuing to find faults in the way 
that you collect data and how you are reporting it. So you can 
understand why we are still skeptical when you tout the number 
that 96 percent of all appointments have been seen within this 
arbitrary goal of 30 days.
    The other thing is the way you report data. So you are 
telling me that by veterans who use VetLink inside the 
hospitals are telling you that 89 percent of them rate their 
access good, what--you are giving me data with a very high 
reporting bias. Of course they are going to rate it good 
because they are already on the inside of the hospital. How 
about asking those that don't get access, that are not inside 
the hospital, to tell us what their access is going to look 
like?
    So for those of us who know statistics and know 
methodologies, you know, we are skeptical when you report some 
of these reports to us that may not be as accurate as possible.
    And lastly, when we can't rely on the population data, when 
we can't rely on the integrity, then we go by case studies. And 
case studies, depending on the accuracy, and the write up, and 
the details is what oftentimes we are left to look at. So let 
me tell you about a case of a wounded warrior who actually 
works in my office, who is a hero in my book, who went for his 
yearly checkup for the VA.
    He is service-connected disabled, manages well, he is 
prescribed medication through the VA. After waiting 30 minutes 
on hold, 30 minutes on hold, the veteran was notified that 
because he had not had an appointment in over a year, he would 
have to schedule a new patient appointment, even though he was 
not a new patient.
    He agreed to the appointment, asked to schedule that 
appointment as well. They couldn't fit him in until 134 days 
later. Again, arbitrary, right? As a result, this veteran 
elected Choice, but they still said you have to come in and do 
your new patient appointment before you get to your Choice 
appointment.
    So, one, what does same-day access mean? And, two, why do 
these arbitrary numbers exist in the first place? And, three, 
why do they need to have--why do veterans need to have a new 
patient appointment after a certain amount of time, even though 
they have been getting prescribed medications, you know, as 
recent as a month?
    Dr. Shulkin. Okay. Thank you. I appreciate your skepticism. 
I think most doctors and politicians generally are skeptical of 
data and I think that's a good thing.
    So let me very briefly tell you. First of all, you said it 
absolutely perfectly, the VA needs to clinically prioritize its 
appointments. That is exactly what I brought into the system. 
We used to have 31 ways of ordering a consult, today we have 2. 
It's either urgent or it's not. There is no 30-day rule for 
urgent care, I don't know where you got that. That does not 
exist. Urgent patients have to be seen now, that's why we did 
the stand-downs. I've never had a patient who has a urgent care 
need that I wasn't working to get them to be seen right away. 
That's our goal; get them seen right away when they have an 
urgent care problem. So I completely agree, and you said it 
perfectly.
    Secondly, same-day access, what does it mean? It means 
resolving the veteran's needs that day. If they need a 
prescription refill, they don't have to come in, we can do that 
on the phone or electronically. If they need to talk about how 
to understand how to use their treatments, we can do that over 
the phone or from telehealth. But patients who are sick and 
need to be seen, should be seen that day, that's what we're 
working to get implemented. So I agree with you, we have to set 
expectations and explain it in a way quicker than we can do 
today.
    The last thing about the veteran's experience. Look, the 
only thing that matters, are we meeting the needs of veterans? 
The VetLink system that you talked about asks them when they're 
in the system, you're exactly right. So we have a second survey 
called CAHPS, it's what's used by the industry, the private 
sector industry too.
    That asks whether you've been able to get in to see your 
doctors when you needed, both for routine and urgent care. So 
we compare ourselves to the private sector using CAHPS, 
internally we use the VetLink system because that's a point-of-
care system. So all of your points are absolutely right, 
Congressman, and we take them to heart.
    Mr. Ruiz. Thank you.
    The Chairman. Dr. Roe?
    Mr. Roe. Thank you, Mr. Chairman. And, Dr. Shulkin, you 
know I have great respect for you and one of the things I don't 
think I would have said if I were you is, at one year from now 
things will be different. I am not sure they will be. I hope 
they will be, but I am not convinced.
    Just a couple, three, quick points I would like to have 
your answer on. One is if the VA is doing its job, why did we 
need a stand-down? What was that need to be done?
    Dr. Shulkin. Believe me, stand-downs are not the way you 
run a system. Dr. Roe, absolutely right. If we have to continue 
to do stand-downs, something's really wrong. The reason why you 
do a stand-down is because you've reached an unacceptable 
situation. The day I learned, literally the day I learned, we 
had 57,000 patients who had urgent consults greater than 30 
days, I said there is nothing to do but to declare it an 
emergency. That's why two weeks from then we had our first 
stand-down, because it's unacceptable. But that can't be the 
way that you run the system. You have to put in sustainable 
fixes, that's what we're doing now.
    Mr. Roe. And I looked at the number of schedulers you've 
got, you've got 32,000 schedulers, that is plenty of 
schedulers. Because I did the math right quickly in my head, 
and they scheduled ten people a day which shouldn't overwork 
anybody. That is way past 70 million schedules--I mean, 
appointments in a year. So you got that fixed.
    If the system works--and I would like to have you guys 
define what an appointment is. And what I finally figured out 
through all this is, look, if the day I called you, if you are 
my doctor and I called, treed, that is the day I want--I am 
calling to get the appointment. What I would see happening was 
that you would tell the veteran, well, you don't have--we don't 
have an appointment the day you want it, but we have got one 
six, would that be okay? When the veteran says that is okay, 
that is their desired date, according to you guys.
    Just look, the numbers are what they are, just go ahead and 
say we don't have it until then and if it is a problem, if you 
prioritize, as Dr. Ruiz said, the sicker patients, then see 
them early. Why is that hard? Why have we made this so 
difficult?
    Dr. Shulkin. No. So, Dr. Roe, a couple things, 32,067 
schedulers seems like a lot. The only issue I would add to that 
is it's got a 25 percent turnover rate every year, you know, 
GS5s, and so you're constantly circulating people in and out.
    Mr. Roe. Food restaurant, sounds like.
    Dr. Shulkin. Right. Secondly, seeing the urgent patients 
first, that's what health care systems need to do, that's what 
doctors do, absolutely. That was missing from the VA. That's 
what we're focused on now, I absolutely agree.
    I think when you talked about how, you know, we assign 
clinically indicated dates, preferred dates, that's what the 
Chairman was talking about when he said there's this 
negotiation going on, that's where we're confusing people.
    So look, we need to do better with that. We can't have it 
be an arbitrary way of assigning appointments and that's where 
I think we really need to move towards this veteran experience 
and seeing if we're meeting the veterans' needs because you 
can't manipulate data there, right? That's--you're listening to 
your patients, your customers, the data is what it is, and 
that's where we need to get to.
    Mr. Roe. Yeah. And then if you--if everybody is speaking 
from the same--singing from the same song book, then you can 
make some changes, but you--when Ms. Draper comes in with 
completely different information, we hear from you all, how are 
we up here on this dais supposed to make any sense out of it?
    And, Ms. Draper, a question to you. What would you be 
recommending to the VA after your analysis? Because, clearly, 
this is not what the VA is telling us is happening, this 
investigation that you did.
    Ms. Draper. Yes. In that report, this recent report, we 
made three recommendations to VA. One was that we think the 
entire period that a veteran waits from the time that they 
first request care to when they actually receive care, that 
entire wait time should be monitored. There's a lot that can 
happen between the period a veteran requests care to when that 
preferred date is set.
    So we made a recommendation with which VA concurred that 
that whole period of time should be monitored. The preferred 
date is really an artificial measure for the veteran. They 
really don't understand what that means. And so the veteran's 
wait time experience is from when they actually request care to 
when they actually receive it.
    Mr. Roe. Got it.
    Ms. Draper. So that's one. The second piece is that VHA has 
been without a scheduling policy since 2014. And what they've 
done, they implemented a scheduling policy in 2010; it was 
rescinded in 2014 after Phoenix.
    And the way that they've provided guidance to the field has 
been through memos, and that's really not the way to do it; 
it's been a really piecemeal effort. The field will tell us 
that it's very confusing because they get memos, they don't 
know what they're supposed to be doing.
    And so you need a really good policy which sets the stage 
for also really being able to do effective oversight because if 
you don't have a very clear policy or you don't have steps that 
you should be looking at in the scheduling process, it's really 
hard to evaluate whether people are doing the right things or 
not. And we've heard a lot of confusion about that.
    So those are some of the things. And VA, again, concurred 
with our recommendations. So there's a lot that needs to be 
done. I would say the other thing related to training is that I 
know that they have said that they trained over 32,000 
schedulers--I don't know if they're all schedulers, but people 
with scheduling keys which could be other people as well.
    But have they evaluated the effectiveness of that training? 
One of things that we saw when we went into some facilities, we 
saw schedulers, the same scheduler making multiple mistakes. We 
didn't see intentional manipulation, but the question to me is 
how effective is that training? Where's the oversight? And, you 
know, maybe there's some people that lack the capability or the 
skills to be able to do this job, and that needs to be 
accounted for. So there's just a lot of things that go into 
this whole process.
    Mr. Roe. Mr. Chairman, I am going to yield back because I 
am over time, but there is one other subject that Mr. Takano 
brought up that we've discussed in the docs caucus, and maybe 
one of my colleagues will bring it up, is the GME 
implementation. It may be worth a hearing because what Dr. 
Shulkin is saying is correct.
    We had the VA come over and talk to the entire docs caucus 
and we walked through that, and I have been walking through 
that in my local medical center trying to get this done. So I 
think it would be worthwhile in doing that, because 300, we 
would like to get them out there, get these young doctors in 
these training positions. I yield back. Thank you for--
    The Chairman. Thank you very much. And we will. Let's go 
ahead and take care of that because the issues that you brought 
up are really the first time that I have heard that, and I 
think it is something that we need to go ahead and address as 
quickly as we possibly can. It is an easy fix from a 
legislative standpoint.
    Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman. Secretary Shulkin, 
shortly after I arrived in Congress in 2013, I noticed a gross 
discrepancy between what the VA was reporting on wait times in 
the district that I represent, El Paso, Texas, and what 
veterans themselves were telling me.
    In 2014, because we couldn't resolve that based on the data 
we were given by the VA and the assurances from one of your 
predecessors, Dr. Petzel, we commissioned a third-party 
independent survey of El Paso veterans that returned results 
with a margin of error under 5 percent, that showed that 
instead of waiting eight or nine days for primary or mental 
health care, veterans were waiting over 70 days, over 80 days, 
for those two respectively.
    The conclusion I arrived at, and I still insist upon, is 
that the only way to find out how long veterans are waiting for 
care is to ask veterans directly. And so we will continue to 
survey. We surveyed in 2015; we will survey again this year.
    I am glad to hear that you agree with Ms. Draper's 
conclusion that the VA must measure from the date that the 
veteran first requested help to the day that that appointment 
was delivered. And for anyone who hasn't read this GAO report, 
this is illustrated graphically on the first page in a way that 
anyone can understand.
    So I have a question about that. When will we receive those 
numbers, and when will that be standardized as the way that VA 
measures wait times so that we don't have preferred wait times 
with multiple points of potential failure and manipulation, and 
we just have you asked for an appointment on this day, you 
received it on this day, number one?
    And number two, you gave a great presentation in October on 
the way forward for VHA that acknowledges that today we have 
43,000 authorized, funded, but unhired positions within the VA. 
We will never hire all of them. We are going to leverage 
capacity in the community. We are going to specialize within 
the VA on what the VA should be doing best. That is something 
that needs to happen if we are going to resolve the fact that 
there is more demand than there is capacity within the VA.
    Where are we on that? So those are my two questions, the 
standardizing of wait time reporting, and where are we on the 
October plan that you announced at the end of last year?
    Dr. Shulkin. Well, Congressman, I've already acknowledged 
that our systems for measuring wait times are overly complex 
and very difficult to understand. Where I believe that we need 
to go is to simplify this by looking at the veteran experience, 
by asking our veterans, are we meeting the needs of the 
veterans in the El Paso community?
    That's the way that it's done in the private sector, they 
don't have these complex wait times. Remember we went out, we 
asked the Institute on Medicine, we've asked so many consulting 
companies, I can't even imagine, tell us the right way to do 
this, the way the private sector's doing it, and they've come 
back and they said there is no standard.
    So I think what VA is doing is, we're measuring so much 
right now and trying to report everything, we're confusing the 
picture. So we have to get better at this, and we have to 
simplify it, and we are going to do that. I think what the GAO 
report is talking about is the new enrollees and that's where 
we've concurred that we will measure the full wait time. But 
I'm not anxious to start redefining wait times and getting even 
more data and more confusing; I actually want to simplify this.
    On the issue of what do we need to do to go forward to work 
with care in the community, we need the legislation to 
streamline the care in the community, we need the provider 
agreement legislation passed because we need to fix this 
program for veterans, and we do need to work with the private 
sector.
    We are committed to that as well as our Federal partners 
like DoD, the Indian Health Service, federally qualified health 
centers. So we think we did present a plan, we know that you're 
looking very hard at that, and we'd appreciate your support.
    Mr. O'Rourke. So on both of these issues, I would love to 
follow up with you to get written specifics on just when we'll 
have wait times reported in the way recommended by GAO. And, 
two, I want to know specifically what is on our plate that we 
have to finish in order to allow you to implement what I 
thought was a very ambitious proposal to make VA work for every 
veteran and get to what you describe, which is outstanding 
care, and that should be the ultimate focus.
    When it comes from my colleagues, when it comes to 
measuring wait times, we have introduced a bill the Ask 
Veterans Act, which would standardize throughout the country in 
each of our districts the ability to get objective third-party 
confirmed wait times, the actual wait times. The VA reports for 
April of 2016 that veterans are waiting 13 days in my district 
for primary care, 10 days for mental health care. When I say 
that in my town halls, I almost get laughed out of the room.
    When we report back what veterans have told us in the 
surveys, they all nod their heads. This confirms the experience 
that they have had. So we welcome the support and collaboration 
of my colleagues on this, and I thank you for your commitment 
for making sure that we report more honest wait times for 
veterans in our communities.
    Dr. Shulkin. Thank you.
    Mr. O'Rourke. With that. I yield back.
    The Chairman. Mr. Huelskamp, you are recognized for five 
minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman. I think the keyword 
I have been looking for in my time on here is accountability 
from the VA employees and leadership. And I want to drill down 
on a couple situations that I think are pretty striking 
examples and perhaps, Dr. Shulkin, you can clarify what has 
occurred here.
    But apparently, what I understand is the VA in Puerto Rico 
has refused to fire a medical center employee who was convicted 
of crimes related to armed robbery, and apparently in comments 
to the media a VA spokesman apparently suggested it was okay 
for VA's employees to participate as long as it was on their 
free time.
    Now, I am sure you don't agree with that. What is the VA 
doing to take care of this situation in Puerto Rico?
    Dr. Shulkin. Congressman, I am aware of that situation and 
I don't--it is my understanding, and, you know, I'm very 
careful, I want to give you accurate information. So if I 
misspeak on this, I will commit I will get back to you by the 
end of the day. But it is my understanding that that person is 
not currently working at the VA in San Juan.
    Mr. Huelskamp. Is he on paid leave?
    Dr. Shulkin. No. That's not my understanding. Again, I 
will--I will personally make sure that we confirm that with 
you. But, no, that is not my understanding, that they are not 
an employee of the VA.
    Mr. Huelskamp. Okay. I look forward to that. Second one, VA 
apparently, as I understand it, still has not disciplined the 
chief of staff at the Cincinnati VA Medical Center who was 
found had improperly prescribed controlled substances. What is 
the status of that particular employee at the VA?
    Dr. Shulkin. That situation, I'm a little bit closer to. If 
you will recall, I made a administrative decision to suspend 
their clinical privileges of the chief of staff, and she was 
actually in a acting chief of staff role, and also to remove 
her from that role. She is following her due process, which 
means that the medical staff is looking at the clinical 
privileges and there's a due process going on, on the 
administrative decision I made. So there was both a 
administrative and clinical decision. But currently she's 
certainly not in that role, and she is not--
    Mr. Huelskamp. And I appreciate the follow up on that. So 
no access to veterans as it stands today? No access?
    Dr. Shulkin. She's not in a clinical role and not in that 
leadership role, no.
    Mr. Huelskamp. Okay. And what role is she in?
    Dr. Shulkin. My understanding is she's doing administrative 
reviews, like quality reviews.
    Mr. Huelskamp. And has been found improperly prescribed 
controlled substances and is still doing quality reviews?
    Dr. Shulkin. We had concerns, that's why we took actions. 
We invited the Inspector General, that was my first request, to 
come in to take a look at this. I know that the DEA has also 
come in to take a look at this. We are waiting for their final 
reports on this before we can make a additional determination 
about that.
    Mr. Huelskamp. And thirdly, going back two years, and I am 
looking at a statement from Mr. Sloan Gibson, it is in June 5th 
of 2014, and here is the statement. ``In Phoenix, we initiated 
a process to remove senior leaders.'' And as I understand 
today, a number of those senior leaders are either still on 
paid leave or have not been removed, or are still working 
through the process, in particular, the Chief of Staff Darren 
Deering. Is that the case that it has taken two years, and Mr. 
Gibson has yet to fulfill that process and in that process to 
remove these folks that were covering up secret waiting lists 
that harmed up to 20 veterans?
    Dr. Shulkin. Yeah. I believe approximately 30 days ago Mr. 
Gibson did make a disciplinary decision on all three 
individuals. That decision was removal. They are each in their 
own process of due--of due process. Dr. Deering is a Title 38 
employee, so he has a shorter period of time in which to do 
that. The other two are Title 5 employees, which is, we know 
we've talked about as part of the Accountability Act, takes a 
little bit longer.
    Mr. Huelskamp. And I am out of time. So that is what I 
understand about that situation. So June 5th of 2014, the 
promise is made public, CNN, we are going to take care of this. 
As we sit here today, April 19th, still not completed the 
process to take care of someone and get them out of harming our 
veterans.
    You know, Mr. Shulkin, I would ask you to pass on to your 
superiors, and I appreciate the work you are doing. We have got 
a VA Accountability Act to take care of this, for some reason 
the Senate is still sitting on it, they are talking about 
spending more money instead of taking care of these folks. This 
is absolutely outrageous, whether it is Puerto Rico, 
Cincinnati, or Phoenix, still almost two years later and we 
can't get rid of the folks that have harmed our veterans.
    And just like Mr. O'Rourke, I go in town halls and say we 
have got a VA Accountability Act, they are really working for 
us, and they all laugh. They have lost all respect within the 
veterans community. And so we hear these numbers and I 
appreciate it, and I didn't get a time to ask questions because 
I have gone over, but I understand, you know, we had 58 cases 
referred to the Department of Justice for possible criminal 
charges.
    That would be my thought from the Committee if we could 
find out what the response has been from those Justice 
Department to those 58 criminal cases and the disposition of 
those. So with that, Mr. Chairman, I appreciate letting me go 
over a few seconds. I yield back.
    The Chairman. Thank you.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman. Secretary, Shulkin, 
I appreciate your testimony today to say that your intention in 
your testimony, both written and your earlier testimony, was 
not to paint, you know, an extraordinarily positive picture, 
but to say that it paints a picture that we are on track, so I 
appreciate that.
    I have to say, though, in your testimony, when you ``That 
in April 1st, 30"--or ``the wait time for VA overall is 
completed 96 percent of the time within 30 days overall,'' and 
that is data, I think, from February. When I was reading your 
testimony last night, I said to myself, oh, gee, it must be my 
district that is causing the four percent that is not there.
    So I went back to look at the--I went back to look at the 
data, and as of April 1st, almost 30 percent of our veterans 
that I represent in the Oxnard CBOC in Ventura County have 
primary care appointments pending over 30 days. And, actually, 
I asked my staff for the data this morning and I think based on 
the data in that one metric, we are the second highest CBOC in 
the country with Dover, Tennessee, being the highest at 48 days 
for a pending appointment within 30 days.
    So we have a problem, and we have had a problem, and I am 
extraordinarily excited that the VA Greater Los Angeles health 
care system has finally hired a medical center director who is 
permanent. We have had interims now for a year and a half to 
two years, I have sort of lost count.
    But we are working very, very closely with Ann Brown, who 
was, I believe, is doing a very good job, and is very aware of 
what is going on in Oxnard. And, clearly, we have had trouble 
hiring and keeping teams there within the CBOC. I think we have 
a contracted out facility that plays a role. The Choice Program 
is not really working too terribly much in our district, so 
that is not as large a option as that we would like it to be.
    So we know these things are happening. I guess, you know, 
my question is that if I was not watching this closely, my 
question is, is the VA watching this closely and would you 
have--nobody brought it to my attention, I just bring it to 
your attention. And so my concern is, you know, is the VA 
looking specifically at regional problems that is skewing your 
data perhaps, to really address these pockets within the 
country that aren't doing very well at all?
    Dr. Shulkin. Yes, we are tracking this. I think you have it 
correct, which is--which is that the--this is very different 
depending upon the geography of the country that you're in. So 
that we have some VAs that actually don't have backlogs at all, 
and others, like in your district, that have significant 
backlogs in primary care.
    So we are paying attention to that, we're actually focused 
on those top 10 to 15 percent. We're sending our veterans 
engineering resource center teams out now to work with those 
most distressed facilities to help them redesign their systems. 
We're focused on recruitment in areas that really are 
struggling with recruitment. So we absolutely are focused on 
that, but I think that it's a relatively new direction for us 
to focus on those areas that have been so--that really are 
struggling the way that yours is.
    Ms. Brownley. So when did you start working, you know, 
with--teamed up with the Oxnard facility to help facilitate 
some of the issues?
    Dr. Shulkin. Well, I think you identified it correctly in 
your district. You need permanent leadership in place and you 
need experienced leadership. Ann Brown, which, of course, as 
you know came from Jesse Brown in Chicago, is one of those 
experienced leaders. We knew Greater Los Angeles was one of our 
most challenged facilities, so we brought an experienced leader 
there. I think you're seeing that makes a big difference. But 
without having permanent experienced leadership in place, it's 
very hard to address this in a system as large as we are.
    Ms. Brownley. All right, but I can rest assured that the 
Washington team is working directly with Ann Brown to help 
facilitate this issue in Oxnard?
    Dr. Shulkin. I've recently been out there to visit with 
Ann--
    Ms. Brownley. Okay.
    Dr. Shulkin [continued].--and the Secretary, some people 
think he lives in Los Angeles, he goes there so often, so--
    Ms. Brownley. And I just want to, you know, say publicly 
that I believe that Ann is working very, very hard on this and 
I appreciate her leadership, and she is now giving my district 
office regular updates. But it is an eyesore compared to, you 
know, the rest of the country and needs that attention.
    So Ms. Draper talked about--or you spoke actually, Mr. 
Shulkin, about working directly with the GAO now in a team to 
recognize where some of this--some of these improvements have 
come from, and I guess I just would ask Ms. Draper, you know, 
to ask you your feedback in terms of are those meetings 
productive, and are you meeting on a regular basis with 
specific agendas?
    Ms. Draper. Yeah. So there are five criteria for removal 
from the high risk list. One is leadership commitment, one is 
capacity, and that's having the necessary resources, people and 
otherwise; a third piece is the action plan, fourth is 
monitoring, and then the fifth is demonstrated progress.
    So what's happened thus far is that VA provided us a draft 
action plan in January, and it really addressed one of the five 
areas, and we felt that the action plan was not sufficient. So 
we met with them, provided them comments, and then we referred 
them to an agency we felt has done a really good job making 
progress on their high-risk status.
    So they have gotten that action plan, and we have committed 
to VA that we will begin meeting with them starting the end of 
this month and then monthly. I think they are trying to get it 
on target to get us an action plan, a reliable or feasible 
action plan by August.
    And that includes having metrics that we both can agree 
that show there's progress made. The first plan did not include 
that. So there's a lot of work to be done, and we are going to 
work with them to provide feedback. It's a little difficult for 
us because we have to straddle the line of independence, but we 
can provide them feedback and direct them to other agencies 
that we feel have made good progress, improving their high-risk 
status.
    Ms. Brownley. Thank you. I apologize for going over. I 
yield back.
    The Chairman. That is all right.
    Dr. Abraham, you are recognized.
    Mr. Abraham. Thank you, Mr. Chairman. Like Dr. Roe, Dr. 
Shulkin, my respect for you personally is great, and I know in 
my heart of hearts you want to get this right. My concern is, 
like Ranking Member Brown said, this is way before your time, 
goes back ten years plus. So, you know, my concern is the 
culture of the VA, this may be a bridge too far to actually fix 
this problem within the VA system itself. And, you know, it may 
be time to look outwardly to a private sector to just do simply 
the scheduling.
    If 89 percent of the veterans are satisfied with their care 
once they get there, we certainly want to enhance your ability 
to treat those veterans with the expert care that we know the 
VA gives our veterans' population. But we are talking today 
mostly about the scheduling issue where either VA has the 
inability or they lack resolve to actually get rid of these 
poor scheduling employees. And it is certainly in the private 
sector they can fire at will, and they are gone, and they 
replace them with somebody that does.
    And your turnover rate you said 25 percent. You know, that 
is hard to keep any quality employee on task, on target, with 
that going on. And certainly, with the $152 million and 
extrapolate to the $600 million to implement the software 
program, you dangle that carrot in front of private enterprise, 
they are going to be knocking your door down to do this. And 
you know there are businesses that do this for a living, that 
is all they do is schedule patients.
    So, again, just a thought and maybe a pilot program or 
something could be on the agenda, just to compare how the 
private sector does. On just the scheduling, I am not talking 
about health care for the veteran, but just the scheduling the 
veteran to get the appointment, and, you know, compare it 
against the VA's track record. So, again, just a thought.
    Mr. Reinkemeyer, couple of questions to you. You had said 
that you guys are hopefully go to each VISN every three years 
and you look at data reliability, the Veterans Choice Program 
implementation, and the consult management if I remember the 
three tagged right. And I guess the first question on the data 
reliability that you guys are getting from the VA, because the 
old adage, garbage in garbage out.
    If you don't get the data that you need, and if you don't 
trust the data that you get, then it is hard to make informed 
decisions. So the question is are you satisfied, are you 
comfortable to date, with the data that you are receiving from 
the VA on this issue of scheduling?
    Mr. Reinkemeyer. No. We continue to see the data is 
unreliable, which is one of the reasons why we're going to try 
to implement this VISN approach. National reviews are great, 
where we sample so many facilities throughout the country. But 
we think if we can push this down to a more local level and 
feed this information to the VISN management, and give them an 
opportunity to take control of their VISN and make changes, we 
think that's going to be more helpful. But the 96 percent, and 
the data that has been discussed today, we don't see it. I 
mean, every facility we go to, it's not accurate.
    Mr. Abraham. Okay. And my next question to you too, and it 
has a quote so I want to make sure I get it right. It says in a 
February 25, 2016, letter to the President of the Office of 
Special Counsel, said that the VA OIG investigations of 
whistleblower disclosures regarding wait times in Hines, 
Illinois''--it is Freeport, Louisiana, which is in my state--
``were inadequate.''
    OCS found that, ``The OIG investigations found evidence to 
support the allegations that employees were using separate 
spreadsheets outside of the VA's electronic scheduling and 
patient record systems. However, the OIG largely limited its 
review to determine whether the separate spreadsheets were 
'secret'.'' Please explain why the OIG limited its review?
    Mr. Reinkemeyer. So that review was conducted by our 
investigative staff, so I was not directly involved with that. 
I am aware of the concerns and I know Ms. Halliday, my boss, 
has made sure that we try not to interpret the allegations too 
strictly. And, you know, I can ask the Office of Investigations 
to get back to you on their response.
    Mr. Abraham. I guess my follow-up question, were there any 
criminal charges that were sent up to the DOJ for prosecution 
that you know of?
    Mr. Reinkemeyer. So I would say, no, I don't know of them. 
I know that there were some and there's been discussions, but 
that's outside of our office.
    Mr. Abraham. Okay. Thank you, Mr. Chairman, I yield back.
    The Chairman. Thanks.
    Mr. Zeldin, you are recognized.
    Mr. Zeldin. Thank you, Mr. Chairman. Dr. Shulkin, April 7th 
USA Today story starts with, ``Supervisors instructed employees 
to falsify patient wait times at Veterans Affairs medical 
facilities in at least seven states.'' Was that accurate?
    Dr. Shulkin. I've reviewed 72 IG reports, 11 of them were 
found to have intentional manipulation. So that would be 
accurate, but it's not representative of the majority of their 
findings.
    Mr. Zeldin. And of these supervisors, how many of them have 
been fired?
    Dr. Shulkin. We have for a total of all of those IG 
reports, when I add up going across that, we have 29 
individuals that have been disciplined. I think Chairman Miller 
before had said four have been fired, I'm aware of five who 
retired under investigation. So rather than letting the 
investigation go forward, they decided to retire from Federal 
service.
    Mr. Zeldin. When you referenced the number 29 disciplined, 
that is from this USA Today story?
    Dr. Shulkin. From the 72 IG reports that I've reviewed. I 
sort of--I manually counted them up as we went through each of 
the accountability actions.
    Mr. Zeldin. Have any supervisors who instructed employees 
to falsify patient wait times, have any not been disciplined?
    Dr. Shulkin. Oh, I suspect that of people investigated, 
many--there were many, many more than 29. Probably lots more 
that were investigated and the evidence did not suggest that 
there was discipline that needed to be imposed.
    Mr. Zeldin. Okay. Are you saying that there were 
supervisors who instructed employees to falsify patient wait 
times who have not been disciplined?
    Dr. Shulkin. Of the investigations that we've done that 
found intentional manipulation, we then would send in our 
office of accountability review to do to these investigations. 
Everybody that was found to have a action or found to have a 
behavior that required disciplinary action, we have imposed or 
they have retired.
    Mr. Zeldin. So no one has not been disciplined?
    Dr. Shulkin. Oh, I wouldn't say that.
    Mr. Zeldin. We are going in circles right now.
    Dr. Shulkin. Yep.
    Mr. Zeldin. I am asking about the people who of the 
supervisors who instructed employees to falsify patient wait 
times, have any not been disciplined?
    Dr. Shulkin. You know, I don't know the--I don't know what 
your denominator is. Anybody that has been accused of a 
manipulation, we have investigated. When we have found that 
there's evidence that they did do the manipulation, we have 
implemented disciplinary action.
    Mr. Zeldin. None of those people haven't been disciplined?
    Dr. Shulkin. I am not aware of anybody that we found that 
was supervising a manipulation that we haven't implemented 
disciplinary action. Now sometimes after the action, they've 
appealed and those actions have been overturned.
    Mr. Zeldin. But no supervisor who you have investigated who 
has instructed employees to falsify patient wait times has not 
been disciplined?
    Dr. Shulkin. You know, Congressman, I feel like--I feel 
like I'm being asked some questions about--you have to ask me 
individuals, you'd have to say--
    Mr. Zeldin. I am asking about anyone.
    Dr. Shulkin [continued]. Well, look--
    Mr. Zeldin. Has anyone not been disciplined?
    Dr. Shulkin. These disciplinary actions have been going on 
well before I got here. What I--all the information I have, and 
this is not my responsibility to implement these disciplinary 
actions, we have an office of accountability review. What I'm 
telling you is, is that when I've reviewed these reports, when 
I find that other people have taken disciplinary action against 
29 individuals, I'm sure there are many more that have been 
accused of supervising. So I don't know how to answer your 
question.
    Mr. Zeldin. Right. Okay. Well, I mean, it is a simple 
question. There was a USA Today story that says, ``Supervisors 
instructed employees to falsify patient wait times in at least 
seven states.'' You are then saying that you investigate it, 
and if you have evidence to back that up, then the person is 
disciplined. I am asking if through that process has anyone not 
been disciplined, and then we start going around in circles.
    We are talking about patient wait times while we are here, 
we have issues with patient advocates, where I have 
constituents who will call a patient advocate, they will not 
get someone on the phone, they will leave a message, sometimes, 
many times they will not get a call back. Reports about calling 
a suicide hotline and getting a voicemail, in some cases not 
getting a call back.
    A backlog of appeals this Committee is concerned about, 
greatly concerning numbers, the Denver VA hospital construction 
project. I have a constituent, John Mitchell, in an aid and 
attendance case with over 20 years of service, an Army Ranger 
in Vietnam with over 16 years in service with special ops. He 
suffers from traumatic brain injury that's directly connected 
to his service. One was from an accident in a military vehicle, 
another one was from a parachute fall.
    And because the VA lost his file, he is being denied his 
benefits. Twenty-year veteran, Vietnam veteran, special ops, 
and he is unable to take care of himself. And we are getting 
all these different cases, but the only time that it comes to 
light for this Committee is when the Committee brings it up to 
the VA. The VA needs to be bringing these issues up to the 
Committee beforehand.
    When one example after another doesn't come to light until 
this Committee brings it to light, or the USA Today does, or 
the Inspector General, or GAO, if it is not initiated by the 
Department of Veterans Affairs, it looks like a cover-up.
    So you say that someone who violates the law, or violates 
our principles doesn't belong at the VA, well, I would argue 
that that goes straight up to the top of people who are 
violating the principles of the VA. And it is greatly 
concerning that it is this Committee responsible, and it is the 
GAO responsible, it is the Inspector General, it is the media 
responsible for bringing this to light, and you don't do that 
for us.
    I yield back.
    The Chairman. Thank you.
    Mr. Coffman, you are recognized.
    Mr. Coffman. Thank you, Mr. Chairman. Just a question about 
the appointment wait times scandal because I think that we are 
getting kind of different summaries of it, if you will. And so 
wasn't the--you said that it wasn't about cash bonuses, but you 
didn't put a date on that, I guess that the policy had changed. 
But what was the policy in 2013 when this issue came to light?
    Dr. Shulkin. Congressman, I wasn't here then, so. But I 
believe that there was wait times as part of people's 
performance evaluations. And so, Dr. Lynch, am I correct in 
that?
    Dr. Lynch. Yes.
    Dr. Shulkin. So there was a potential of a financial bonus 
if people hit certain criteria.
    Mr. Coffman. Sure.
    Dr. Shulkin. Today, that doesn't exist. There is nobody.
    Mr. Coffman. So you allowed--people were allowed to retire 
who are under investigation, who were complicit in manipulating 
appointment wait times; is that correct? I think--
    Dr. Shulkin. I think I said the investigation didn't to 
conclude. Before the investigation was able to conclude, they 
retired from Federal service.
    Mr. Coffman. So, but this involves fraud and fraud is a 
criminal issue. How many criminal referrals occurred of people 
who were involved in this scandal?
    Dr. Shulkin. My understanding--I don't know whether the 
Inspector General can help us with this--was that we did ask, I 
think this was actually Senator Blumenthal who asked that the 
Department of Justice come in to take a look at this, and they 
ended up declining on looking at most of these cases. But I 
know that there are referrals that go from the IG to the 
criminal division.
    Mr. Coffman. Could someone comment on that?
    Mr. Reinkemeyer. There are referrals and I know in every 
case where we suspect something we will make that referral. I 
can tell you, and this is not my area of expertise, but I think 
a lot of the money that you're referring to, the bonuses, while 
inappropriate, is not necessarily a high dollar amount, and 
there's not a lot of traction.
    Mr. Coffman. So fraud is okay if it is a low dollar amount, 
is that what we are saying here today?
    Mr. Reinkemeyer. Not for me, but I'm just saying--
    Mr. Coffman. Really?
    Mr. Reinkemeyer. --the Department of Justice, I think 
there's not a lot of traction if it's a small dollar amount.
    Mr. Coffman. That is disappointing, under this 
administration, that that would occur. And let me state what is 
current law, and that is if somebody commits fraud, but is 
awarded a bonus, there is no clawback provision in current law; 
is that not correct? Who can answer that?
    Dr. Shulkin. I'm not aware of the answer.
    Mr. Coffman. There is no provision. And, in fact, there is 
legislation before the Congress, and the position of the VA is 
neutral on that, which I find is appalling, as a taxpayer and 
as a veteran, that when somebody gets a bonus that they clearly 
did not earn, should not have been given, that the only 
provision in which the VA is allowed to claw it back is if it 
is given administratively to the wrong person. But if it is 
given to the person that is the subject matter of the bonus, 
even if they didn't earn it, there is no provision for 
clawback. That law needs to change, and the Secretary needs to 
take a position affirmative for that legislation and not simply 
sit on the sidelines. This is about cleaning up the VA. And the 
Secretary was giving a speech in Denver last weekend--well, I 
think it is two weekends ago--
    Dr. Shulkin. Yes.
    Mr. Coffman [continued]. --that I was at where he said that 
the fundamental problem in terms of the appointment wait time 
scandal was a lack of training of VA personnel; is that 
correct? Was it due to a lack of training?
    Dr. Shulkin. I think what the Secretary most likely meant 
was that our system was complex and we weren't spending enough 
time training. But I don't think he would say that was the only 
factor. This was--there were many factors involved in this.
    Mr. Coffman. It really had nothing to do with a lack of 
training, it had everything to do with people that were fairly 
skilled at manipulating the system, because what, in fact, they 
did was to make the numbers look smaller to get these cash 
awards, is that they pushed veterans out on these secret 
waiting lists who did not get health care and, in fact, there 
are veterans who died on those secret waiting lists.
    And, you know, I don't know how we ever clean up problems 
in the VA if we really don't acknowledge their existence, and I 
really do not believe that the leadership of the VA has 
acknowledged the depth of the problems that exist here, and 
that's why they will never be cleaned up under current 
leadership. I yield back.
    Mr. Benishek. [Presiding.] Mr. Bost, you are recognized.
    Mr. Bost. Thank you, Mr. Chairman. Mr. Shulkin, I have to 
ask specifically. In the individual VA medical facilities, 
administrators and/or directors basically have the ability to 
monitor this with their own facilities, correct, so make sure 
they are the ones that are in charge of doing that; is that 
correct?
    Dr. Shulkin. Monitor this wait time?
    Mr. Bost. This wait time and all of these.
    Dr. Shulkin. Yes.
    Mr. Bost. They are the ones who do that?
    Dr. Shulkin. Yes, sir.
    Mr. Bost. Okay. The concern that I have, and I am going to 
express this--and I am going to tell you about a bill that we 
are working on that you may be aware of. The problem is I see 
right now--St. Louis is one of our facilities--in the last 34 
months, every 120 days or 280 days, depending on--or 240 days 
by your rule, we keep circulating directors in and out.
    I ran business for years, and if--in 120 days I couldn't 
get all of my employees' names down, I couldn't--definitely 
couldn't figure out where the problems were. And whenever--I 
thought this was only in the St. Louis facility, but our 
research has found out that there is 40 facilities that are 
actually in interim directors that are just kind of cycling 
through like this. It is very hard to have oversight if someone 
is not there for a long period of time and they understand that 
is their job. Is there anything being done right now to try to 
cure those problems?
    Dr. Shulkin. Yes. First of all, I couldn't agree more. You 
can't solve the problems in the VA unless you have the right 
leaders in place and they need to be permanent leaders. So 
we're on the same page. St. Louis, very unfortunate. We 
actually had named a permanent leader who was coming--
    Mr. Bost. He was no longer available.
    Dr. Shulkin [continued]. Yeah. He was coming from Hawaii, 
and because of personal issues he retired from Federal service. 
And so now we're back in a national search, and we have some 
candidates. So I am very focused on getting a leader in St. 
Louis.
    But I don't count 40, I count 34. That's 34 too many. So we 
have national recruitments out in place. It's one of the 
reasons why we've asked again for your support for Title 38 
legislation, because we need not only accountability in the VA, 
but we also need market rates that will help us attract the 
very best who will come to take these jobs. Right now, there 
aren't enough people who want to come and take these jobs.
    Mr. Bost. Because of salary?
    Dr. Shulkin. I think that the bad press that VA has been 
getting, our applications are down 78 percent from the date of 
the crisis. These are known to be very, very tough jobs and the 
salary is not anywhere near where what the market rates are for 
these jobs.
    Mr. Bost. I am pretty sure that nobody wants to jump on a 
ship that is sinking. And that is the problem is--or maybe it 
needs to be sealed up and then bailed out in the condition that 
it is right now. And I think this is a possible--this just 
causes a downward spiral and I think it needs to be cured.
    Now I am willing to work with you on that, and I understand 
the legislation we are going to be pushing forward gives the 
Secretary about 120 days to look over proposals on what it is 
that we can do and move forward to try to cure these problems.
    With that, Mr. Chairman, I yield back.
    Dr. Shulkin. Thank you.
    Mr. Benishek. Thank you, Mr. Bost.
    I am going to yield myself five minutes to ask a few 
questions. Dr. Shulkin, as you know, we have been aware of this 
problem with the training and the procedures for these 
schedulers since 2005 when the Inspector General first reported 
on it, and it has been 11 years since then. And the Inspector 
General stated in its August 14 Phoenix report, since July 
2005, the Inspector General has published 20 oversight reports 
on VA patient wait times and access to care, and that the VA 
has been resistant to change.
    I guess my question is about the procedure for responding 
to and dealing with Office of Inspector General reports. Okay? 
This is something that I have been working on for years in my 
position here. Is someone actually put in charge of responding 
to a specific Inspector General report?
    Dr. Shulkin. Yes. I did not do, when I came into office, a 
major reorganization of VA leadership because I wanted us 
focused on this problem, fixing the wait time crisis, not 
internal politics. But the one thing I did do, was, I 
established a new deputy undersecretary for organizational 
excellence, whose position it is to focus on this. That's Dr. 
Carolyn Clancy.
    Mr. Benishek. There is one person then--
    Dr. Shulkin. Yes.
    Mr. Benishek [continued]. --has the responsibility--
    Dr. Shulkin. One office, one person.
    Mr. Benishek [continued]. --to deal with this?
    Dr. Shulkin. Yes.
    Mr. Benishek. So then that person will be held responsible 
for making sure that the Inspector General reported deficiency 
as corrected?
    Dr. Shulkin. Well, I will be held responsible and the 
Secretary ultimately is held responsible--
    Mr. Benishek. Yeah, yeah. But it is difficult because--
    Dr. Shulkin. Yes.
    Mr. Benishek [continued]. --you know, we have had so many 
Inspector General reports where the VA Secretary has agreed 
with the report and agreed to change it.
    Dr. Shulkin. Yes.
    Mr. Benishek. The way things are going. But nothing has 
changed in 20, 30 years. You realize that, right? I mean, the 
Inspector General report--
    Dr. Shulkin. I do realize this.
    Mr. Benishek. For example, I will give you a good example, 
identified the fact there is no central hiring process for 
physicians at the VA. That was reported, I think, 8 times over 
30 years. That problem still exists.
    Dr. Shulkin. Yeah.
    Mr. Benishek. So no one seems to have fixed that problem. 
So I want to have us where one person is responsible for 
responding to the Inspector General reports. Let me ask of Mr. 
Reinkemeyer, has there ever been an accountable employee 
assigned to fix a problem in your history with the Inspector 
General?
    Mr. Reinkemeyer. So there's always someone assigned, but 
quite honestly, and I was involved with the first 2005 report, 
and we reported it. And until 2014, there was really no 
priority placed to it. We reported it in '05, we reported it in 
2007. The right words were said, changes were made, but when we 
came back two years later, we found that nothing had been put 
in place.
    Mr. Benishek. Right. Well, that is my experience as well. 
They say we are going to fix it, but then nobody is actually 
responsible, a name of an individual whose job it is, to 
actually make it happen, never seems to get fixed, you know. 
You think that legislation mandating that the VA assign a 
specific accountable employee to fix a problem would be an 
effective strategy?
    Mr. Reinkemeyer. I think Dr. Shulkin was right that 
ultimately he's responsible and the Secretary. We make our 
recommendations generally to the Under Secretary for Health 
assigning responsiblity. I wouldn't think legislation would be 
necessary, but that's certainly something you can explore.
    Mr. Benishek. I know, but that is what I mean by saying 
that, you know, there was this problem for 30 years with the IG 
telling the VA they need to have a central plan for hiring 
physicians. They said that to the VA six times over 30 years. 
The VA's agreed with them six times over 30 years. And, yet, 
nobody was ever assigned to fix that problem, and it still 
occurs today that there is no real central plan for hiring 
physicians within the VA.
    So, I mean, you see what I am talking about, Dr. Shulkin?
    Dr. Shulkin. Yeah.
    Mr. Benishek. That, you know, this is something that is a 
procedural, the way things are done. I mean, it is given to 
some Committee, it is given to some department, but then there 
is nobody actually who is in charge other than you. And then 
you say, well, you know, we are all working on it.
    Dr. Shulkin. But, Dr. Benishek, what I'm saying is, that is 
the organizational change I made. I have a brand new deputy 
undersecretary whose job it is to do that, and they've put 
together the Office of Medical Inspector, all of the compliance 
officers, the regulatory officers, the ethics people.
    Mr. Benishek. What is his name?
    Dr. Shulkin. Well, Dr. Carolyn Clancy. You know Dr. Clancy.
    Mr. Benishek. Okay. Okay.
    Dr. Shulkin. Yep.
    Mr. Benishek. So then how many Inspector General reports 
has he looked at so far in that position?
    Dr. Shulkin. They've been keeping us pretty busy this year. 
We've looked at at least 72 on the wait times alone, and you've 
probably sent over a bunch of others on top of that. So I would 
say--
    Mr. Benishek. Well, I would like to see--
    Dr. Shulkin [continued]. --probably over 100.
    Mr. Benishek. I would like to see the Inspector General 
reports that he has looked at and what exactly he has done to 
respond to those Inspector General reports.
    Dr. Shulkin. Absolutely.
    Mr. Benishek. All right. Thank you. I am out of time. And I 
think everybody has asked their questions. So we are just about 
ready for the closing.
    Ms. Brown has a closing statement she would like to talk 
about.
    Ms. Brown. Yes. I want to ask Ms. Draper a question.
    You mentioned the scheduler and that perhaps they are not 
getting an adequate training. We all know that a scheduler is 
an entry-level job. Do you think that the VA needs to do more 
to upgrade, because once a person is trained in that position, 
if they see another opening, they want to move up?
    Ms. Draper. Yeah. Let me just back up a little bit because 
I think training is an issue, but I think it's much more 
complicated than that. I think there's oversight issues, the 
VistA scheduling system is really prone to user error. There's 
a lot of things that factor into the errors that we've seen.
    As far as the schedulers, it is an entry-level position, 
it's usually generally GS4, 5, 6. In previous work that we've 
done, we heard from facilities that it's a very high turnover 
position, I think it's the number one or two clinical position 
within VHA that turns over each year. And so there's not really 
a good career path for those individuals.
    And what we've heard is when someone demonstrates a high 
level of capability, they're often scooped up and moved 
someplace else. I think at one point a couple of years ago, 
they had instituted in some places a GS6, so there was a career 
path. My understanding is that that doesn't exist any longer.
    It's a lot of pressure and responsibility on these 
individuals, so, it is important that they have the support, 
and the training and the oversight.
    Because, as I said in my opening remarks, if someone 
continues to make the same errors, where is the oversight for 
that, and what happens when that continues to happen? Because 
that is what we've seen. So it raises the question about 
oversight. And, you know, quite frankly, whether some of these 
people are really able to do the jobs that they're put in.
    Ms. Brown. Thank you. Mr. Secretary, last thing. I have 
gone to the medical schools in the Orlando area with the 
Secretary, but I didn't know that there was some problems with 
it. I know we need additional slots. I am hoping that you all 
will get back with us, and if there is something that we, on 
our side, need to do, I know we want to do it because we need 
those additional physicians. And, of course, if they train and 
have those residents, they will probably stay in the area.
    Dr. Shulkin. Yes. Yes. We would--we'd welcome further 
discussion on that.
    Ms. Brown. And in closing, I am hoping that the veterans 
that is listening to what we are doing today understand that we 
are seeing over 2 million additional veterans in 2015 than 
2014, over 226 appointments per day.
    So if veterans need to come to the system, don't be dumbed 
down by what you hear in here, go and get assistance. Go to 
your Member's office. Go to the VA.
    And with that, you know, we all need to soldier up and make 
sure that the veterans are being taken care of. Thank you, and 
I yield back the balance of my time.
    Mr. Benishek. Thanks to the entire panel for being here. 
You are now excused.
    Today we have had a chance to hear about the many ongoing 
problems related to Veterans Access. Oh, I guess we are going 
to have the Chairman give a closing statement or something.
    The Chairman. [Presiding.] No. No closing statement. I just 
confirmed with the Caribbean health care system that the 
individual that we were discussing is still on the payroll.
    Dr. Shulkin. Thank you for correcting that.
    The Chairman. So, again, the question is, why in the world 
would somebody who has been convicted of armed robbery still be 
working at the Department of Veterans Affairs?
    Dr. Shulkin. Okay. Well, hard for me--hard for me to answer 
that right now. So I think we know owe you an answer.
    The Chairman. Please. Thank you.
    Mr. Benishek. Thank you, Mr. Chairman.
    We have had a chance to hear about many of the ongoing 
problems related to veterans access to health care that 
continue to occur today over two years since the wait time 
scandal.
    As we have discussed, the VA has not taken the aggressive 
steps needed to improve access to care for veterans. Until the 
VA stops using the excuse of poor training to explain away 
systemic wait time manipulation, begins holding itself 
accountable, nothing will change. Dr. Shulkin, it seems to me 
that the I CARE, and MyVA Access Declaration are just words. 
These ideas speak to an intent, but to this Committee and to 
veterans, results are what counts. Slogans and rhetoric 
designed to deflect blame are not good substitute for action-
oriented results.
    Until VA addresses the issues we have discussed today, 
beginning with accountability, our veterans will have to hope 
the VA gets itself squared away. But as we know, hope is not a 
plan.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks, and to 
include extraneous material. And without objection, so ordered.
    I would also would like to once again thank all of the 
witnesses and the audience members for joining us today. And 
with that, the hearing is adjourned.

    [Whereupon, at 12:35 p.m., the Committee was adjourned.]




                            A P P E N D I X

                              ----------                              

               Prepared Statement of Chairman Jeff Miller
    I would like to welcome everyone to today's hearing titled, ``A 
Continued Assessment of Delays in Veterans' Access to Health Care.'' 
This hearing marks two years since this Committee exposed the wait 
times scandal that gripped the department in 2014. I am proud of the 
work we have done in those two years, particularly digging into the 
actions of corrupt bureaucrats who put self-interest ahead of the 
veterans they are charged with assisting.
    The purpose of this hearing is to examine the efforts VA has taken 
to improve access to care for veterans and to identify where serious 
issues persist. Based on this Committee's investigation, GAO undertook 
an audit of new patient primary care wait times at six facilities 
across VHA. GAO's review found that veterans at those facilities waited 
between 22 to 71 days, which is significantly more than the five-day 
average Secretary McDonald declared earlier this month. This 
discrepancy can be easily explained.
    First, VA only tracks and monitors a portion of a veteran's actual 
wait time when tracking access data. Instead of considering a veteran's 
wait time to be from the date when the veteran first contacts VA to 
request an appointment to when the appointment takes place, VA 
considers a veteran's wait time to be from the date when the veteran 
wants the appointment to occur to the date when the appointment 
actually occurs.
    This is problematic because it does not take into account: the time 
it takes a VA scheduler to contact the veteran to schedule the 
appointment; the fact that it is a regular practice for schedulers to 
``negotiate'' a desired date with a veteran; or the fact that outright 
manipulation of desired dates to zero-out wait times is one of the most 
prevalent types of data manipulation occurring in VHA. In effect, VA 
continues to ignore the main forms of data manipulation, while it 
continues to come to congress saying it no longer occurs. To this 
point, you will not find what you do not seek.
    The obvious result of VA reporting only a portion of veterans' 
actual wait times is artificially low results. I still do not 
understand a culture that persists in presenting inaccurate data. A 
true picture of wait times, or more importantly the veteran experience, 
can help us ensure an adequate allocation of resources. But, when this 
Committee only hears requests for more manpower, more space, and more 
flexibility, it is hard to reconcile the additional resources with a 
reported ``wait time'' of only five days. This discrepancy between 
reality and VA's claims was captured by GAO in its report where VA data 
shows that wait times were at best understated by 2+ times and at worst 
11 times the full wait times experience of veterans reviewed in the 
audit.
    Another tactic VA uses to make its wait times appear lower is to 
combine the shorter wait times for the large pool of established 
patients with the longer wait times of the smaller pool of new 
patients. This dilutes the wait times data making new patients' waits 
appear shorter since they have been comingled with data from the other 
cohort.
    For years, VA has blamed incorrect appointment scheduling and long 
wait times on training issues, largely because it was warned about 
those issues as far back as 2005, when the OIG published a report 
highlighting improper scheduling practices and poor training. Many OIG 
and GAO reports since then have found the same scheduling problems. 
Yet, in the 11 years since, VA continues to blame wait time 
manipulation on the same cause, a cause over which VA has complete 
control.
    Secretary McDonald has repeatedly asked that we allow him to run VA 
like a business. But, I can assure you that if an executive running a 
company used the same excuse to explain away problems 11 years in a 
row, with no change to show for it, that individual would be out of a 
job. But, not at VA. Despite years of reports confirming systemic 
issues, the department has successfully fired just four people for wait 
time manipulation while letting the bulk of those behind its nationwide 
delays-in-care scandal off with no discipline or weak slaps on the 
wrist.
    Another issue regarding accountability is how VA continues to 
ignore retaliation against whistleblowers who report wrongdoing. The 
Committee asked VA for all adverse actions where an employee was 
disciplined for ``retaliation against a whistleblower''. VA provided 
the Committee a list showing that as of March 15, 2016, only six 
individuals were disciplined for whistleblower retaliation.
    However, upon further review, one of the listed employees is Sharon 
Helman, who the committee has shown was not successfully disciplined 
for whistleblower retaliation and was in fact successfully disciplined 
for failing to report accepted gifts. Two of the other disciplined 
employees listed were ``Houskeeping Aid Supervisors'', who are clearly 
not high-level supervisors. That leaves three employees: two received 
reprimands and one received a less-than-fourteen-day suspension. To be 
clear, according to VA provided documentation, no employee has been 
removed for whistleblower retaliation. This is representative of the 
fact that, contrary to public statements by VA officials, whistleblower 
retaliation appears to most certainly be tolerated by the department.
    So now, two years after what was and is a systemic crisis in care 
being brought to light, it is time for VA to stop using misleading data 
to tout wait times successes that simply do not show the real wait time 
experience of veterans. I want to hear what concrete actions have been 
taken, what fundamental changes have been made, and what tangible, 
cultural shifts are occurring. Advertising artificially lowered numbers 
does nothing to stimulate the change needed to improve veterans' access 
to care.

                                 
          Prepared Statement of Corrine Brown, Ranking Member
    Thank you, Mr. Chairman, for calling this hearing today.
    Following the wait time scandal in Phoenix, Congress passed, and 
President Obama signed, the Veterans Access, Choice, and Accountability 
Act of 2014. In it, we mandated that there be an Independent Assessment 
of veterans' health care.
    The Assessment highlighted many of the things we hear from our 
veterans. We hear that VA provides excellent health care, especially 
health care related to the special needs of our veterans. We also hear 
that in certain areas, VA is at the forefront of health care in this 
country. We also hear from our veterans that VA care is often 
fragmented, and that it can be difficult to navigate and arrange non-VA 
care. We hear of long wait times and limited access.
    Following the assessment, in the Surface Transportation and 
Veterans Health Care Choice Improvement Act of 2015, we mandated a 
report by the VA regarding a plan for how VA could consolidate all 
purchased care programs into one New Veterans Choice Program. We 
received that report late last year and this committee is currently 
working with the VA on the best way to implement the legislative 
requests.
    The VA is on track to see 6,277,360 unique patients, and 9,247,803 
unique enrollees. In FY2015, VA completed 56.7 million appointments, 
nearly 2 million more than FY2014. That is roughly 226,000 appointments 
per day.
    The number of patients the VA sees would put any other health care 
system to shame.
    I am pleased the GAO studied newly enrolled veterans and their 
access to primary care. In my conversations with veterans, time and 
again they say that once you get into the VA system the care is the 
best in the world. It is this initial appointment that is so hard to 
get. I am troubled by the GAO findings that ``nearly half were unable 
to access primary care because VA medical center staff did not schedule 
appointments for these veterans'' in a quick timeframe.
    The GAO report goes onto say that ``veterans' access to primary 
care is hindered, in part, by data weaknesses and the lack of a 
comprehensive scheduling policy.'' Just last week in a Subcommittee 
hearing, Under Secretary Shulkin and Assistant Secretary Council 
testified that they were working together through the MyVA initiative 
to modernize VistA and work on a scheduling system that is focused 
purely on scheduling. I support the VA in working to fix the scheduling 
and be able to get data we can trust.
    We are at a tipping point right now as to what the VA will look 
like and the services it will provide for veterans in the coming 
decades. I look forward to hearing from our witnesses today on what 
this aspect of the VA will look like in the future.
    Thank you, Mr. Chairman, and I yield back the balance of my time.

                                 
               Prepared Statement of David Shulkin, M.D.
    Good morning, Mr. Chairman, Ranking Member Brown, and Members of 
the Committee. Thank you for the opportunity to discuss the efforts 
that VHA has taken to improve access to care for Veterans. I am 
accompanied today by Dr. Thomas Lynch, Assistant Deputy Under Secretary 
for Health for Clinical Operations and Dr. Poonam Alaigh, Senior 
Medical Advisor.
    The year 2014 was one of the most significant times in VA's 
history. To say that we had a crisis on our hands would be an 
understatement. After losing the trust of the Nation, and most 
importantly, Veterans, we had to look at every basic principle of 
operating a health care system. Without the appropriate data, we were 
unable to truly understand how much space, staff, and other resources 
were really needed.
    When I first entered this office approximately 9 months ago, I 
began to realize that the access issues had been slowly building up for 
many years and that correcting those issues had to be addressed 
systematically, rather than piecemeal. We needed to re-design and re-
launch our approach to access in order to provide the care for Veterans 
that they have earned and deserved.
    As a whole, VA is working to rebuild trust with Veterans and the 
American people, improve service delivery, and set the course for long-
term VA excellence and reform, while delivering better access to care. 
This initiative is called MyVA. All of us in the VA health care system 
are focused on the MyVA initiative.
    To ensure that VHA remains aligned with MyVA, I developed five 
priorities that are the focus of VHA. My first priority is to fix the 
access issues and continue to work on reducing the wait time for 
Veterans who need our services. In order to do this, we need to get the 
right leaders in place at VHA who understand that it is their job to 
take care of Veterans. We also need to change the way that we measure 
wait times and put in place a new system for how we see Veterans that 
focuses on the clinical urgency.

Immediate Steps - Addressing Urgent Care Needs

    VA's ability to improve access to care and improve the Veterans' 
experience is tied directly to how we meet the urgent health needs of 
our Veterans. We must identify who needs the help the most and commit 
to treating those Veterans who have clinically urgent needs as soon as 
possible. As long as there is even a single Veteran with an urgent care 
need that we are not meeting in a timely fashion, we will not be 
satisfied. That is why VHA hosted two National Access Stand Down events 
- one on November 14, 2015, and a second on February 27, 2016 - at all 
VA Medical Centers. The immediate goal of the first event was to 
connect with Veterans that have urgent health care needs; address their 
needs; and reduce the number of Veterans waiting greater than 30 days 
for urgent care. This initiative ensured coordinated efforts to 
increase access to health care by:

      Maximizing the opportunities for ``same day'' 
appointments as much as possible;
      Getting timely and convenient care, referrals and 
information from any VA medical center, not just the Veteran's 
preferred VA care facility; and
      Ensuring Veterans see their provider within 30 days of 
their preferred date or date of clinical need.

    The February 27, 2016 event resulted in VA reviewing the records of 
more than 80,000 Veterans to get those waiting for urgent care off wait 
lists. Approximately 93 percent of Veterans waiting for urgent care 
were contacted. Since not every type of clinic appointment has the same 
urgency, or the same medical risk to the patient in the event of delay, 
we focused on addressing the highest priority needs first. Both of 
these events proved to be a success, and the goal is to keep the 
momentum going. We also know that it will take much more to fix access 
issues and achieve the goal of providing Veterans same day access for 
primary care.

Declaration of Access

    The focused Access Stand Down events in November 2015, and February 
2016, have addressed Veterans with urgent needs and significantly 
reduced the number of Veterans waiting for care. Moving forward, we 
developed the ``MyVA Access Declaration,'' a set of foundational 
principles for every VHA employee to improve and ensure access to care. 
The MyVA Access Declaration is our pledge to improve access to care for 
Veterans by committing to a list of access improvements. This list of 
principles will be distributed to VHA staff and VHA leadership and 
staff will hold themselves responsible for meeting these commitments 
over the course of the next year.
    We aspire to provide access to care based on the following core 
principles:

      Provide timely care including same-day access in Primary 
Care, as needed;
      Respond to routine clinical inquiries within 2 business 
days;
      Offer follow-up appointments upon the Veteran leaving the 
clinic;
      Involve Veterans in the process of making or canceling 
appointments;
      Not cancel clinic appointments without appropriate 
Veteran notification and rescheduling;
      Integrate community providers as needed to enhance 
access;
      Offer Veterans extended clinic hours, and/or virtual care 
options, such as Tele-Health, when appropriate; and
      Transparently report to the public and manage access to 
care data for Veterans.

    The MyVA Access' goal for 2016 is when a Veteran calls or visits 
primary care at a VHA Medical Center, their clinical needs will be 
addressed that day. It is important for Veterans to be in control of 
their health care. We are changing our old systems that have been in 
place for decades at VA to a system that works for Veterans and is 
focused on contemporary practices in access. This initiative and the 
Declaration represent VA's pledge to improve access to care for all 
Veterans seeking VA health services. MyVA Access will ensure 
coordination of initiatives and their rapid deployment to meet the 
access needs of Veterans at VA medical centers.
    Moving toward long-term transformation, VHA has already implemented 
a number of actions to address access, quality and patient satisfaction 
within the larger transformation of MyVA. Within the 12 Breakthrough 
Priorities laid out by Secretary McDonald, 2 focus squarely on health 
care outcomes, specifically improving access to care and improving 
community care. Since the introduction of the MyVA initiative, VA has 
made significant progress in improving access to health care:

      Nationally, VA completed more than 57.36 million 
appointments from March 1, 2015, through February 29, 2016. This 
represents an increase of 1.6 million more appointments than were 
completed during the same time period in 2014 through 2015.
      VHA and Choice contractors created over 3 million 
authorizations for Veterans to receive care in the private sector from 
February 1, 2015, through January 31, 2016. This represents a 12 
percent increase in authorizations when compared to the same period in 
2014 through 2015.
      From fiscal year (FY) 2014 to FY2015, Community Care 
appointments increased approximately 20 percent from 17.7 million in 
FY2014 to 21.3 million in FY2015.
      VA completed 96.46 percent of appointments in February 
2016, within 30 days of clinically indicated or Veteran's preferred 
date.
      VA continues to expand and improve the VCL, which has 
answered nearly 2 million calls since its launch in 2007. Nearly 
490,000 calls, or a quarter of these 2 million calls, were answered 
during the last fiscal year. VCL responders dispatched emergency 
responders to callers in crisis over 11,000 times last year - over 
53,000 times since 2007.
      VHA has increased net onboard staff by over 17,000 
employees since the beginning of FY15 through February 29, 2016. This 
includes over 6,000 nurses (RN, LPN & NA), 1,550 physicians, 112 
psychiatrists, and 450 psychologists.
      Women Veterans Call Center (WVCC), created to contact 
women Veterans to inform them about eligible services. As of February 
2016, WVCC received 30,399 incoming calls and made 522,038 outbound 
calls, successfully reaching 278,238 women Veterans.
      In FY2015, VA activated 2.2 million square feet of space 
for clinical, mental health, long-term care, and associated support 
facilities to care for Veterans.
      VA increased its total clinical work (direct patient 
care) by 10 percent over the last 2 years as measured by private sector 
standards (relative value units). This increase translates to roughly 
20 million additional provider hours of care for our Veterans.
      VHA offers an extensive community provider network of 
over 257,000 providers through the Patient-Centered Community Care/
Choice Programs and more are joining each month.
      VA Telehealth services are critical to expanding access 
to VA care in more than 45 clinical areas.
      In FY2015, 12 percent of all Veterans enrolled for VA 
care received Telehealth based care. This includes 2.14 million 
telehealth visits, touching 677,000 Veterans.

Veteran Experience - Veteran Satisfaction

    The ability to describe wait times does not exist anywhere outside 
of the VA, so there is no standard on how to report wait times. We have 
gone to such lengths to make sure that we document every aspect of wait 
time data that we have developed a system that is too complex and has 
proven too confusing to Veterans, our employees, and Congress. Although 
the data may be accurate, they do not reflect the actual Veteran 
experience. Therefore, we have decided to use a singular measure - 
asking Veterans, our customers - whether they were satisfied with being 
able to get care when they need it. VHA currently utilizes sign-in 
kiosks at VA facilities all across the country to assess patient 
satisfaction, of those Veterans who obtained appointments, with their 
ability to get their appointment when they wanted it. Eighty-nine 
percent of Veterans were completely satisfied or satisfied with their 
ability to get care when they wanted it.
    As the Under Secretary, I want to ensure that we can say there are 
no Veterans who need care now who are not receiving it. We are not 
fully there yet, but that is the direction to which we are moving.

Legislative Priorities

    VA is grateful for your continuing support of Veterans and 
appreciates your efforts to pass legislation enabling VA to provide 
Veterans with the high-quality care they have earned and deserve. As 
the Department focuses on ways to help provide access to health care 
across the country, we have identified a number of necessary 
legislative items that require action by Congress in order to best 
serve Veterans.
    Flexible budget authority would allow VA to avoid artificial 
restrictions that impede our delivery of care and benefits to Veterans. 
Currently, there are over 70 line items in VA's budget that dedicate 
funds to a specific purpose without adequate flexibility to provide the 
best service to Veterans. These include limitations within the same 
general areas, such as health care funds that cannot be spent on health 
care needs and funding that can be used for only one type of Care in 
the Community program, but not others. These restrictions limit the 
ability of VA to deliver Veterans with care and benefits based on 
demand, rather than specific funding lines.
    VA also requests your support for legislation that would allow VA 
to contract with providers on an individual basis in the community 
outside of Federal Acquisition Regulations, and includes explicit 
protections for procurement integrity, provider qualifications, price 
reasonableness and employment protections. Such legislation will ensure 
that VA is able to provide local care to Veterans in a timely and 
responsible manner. VA would support language that addresses concerns 
related to employment nondiscrimination and equal employment 
protections. We would have strong concerns with any legislative 
language, such as that currently being considered by this committee, 
that rolls back employment protections. VA further requests your 
support for our efforts to recruit and retain the very best clinical 
professionals. These include, for example, flexibility for the Federal 
work period requirement, which is not consistent with private sector 
medicine, and special pay authority to help VA recruit and retain the 
best talent possible to lead our hospitals and health care networks.

Conclusion

    VA is committed to providing timely access to Veterans as 
determined by their clinical needs. VA Medical Centers will be making 
sweeping changes over the next several months to realize the goal of 
same-day access for our Veteran population. We realize the significant 
work that remains ahead. The good news is that moving forward, along 
with Congress, we have an opportunity to reshape the future and make 
long-lasting valuable changes. We also look forward to the Commission 
on Care recommendations to inform or planning and execution. We 
appreciate Congress' support and look forward to responding to any 
questions you may have.

                                 
                Prepared Statement of Larry Reinkemeyer
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to discuss the Office of Inspector General's (OIG) recent 
work concerning veterans' access to health care. The OIG has issued 
many reports that have addressed various impediments to patient access 
to health care. Most recently, our audit work has centered on VA's 
purchased care programs and the challenges VA has faced in 
administering them. I am accompanied by Mr. Gary Abe, Deputy Assistant 
Inspector General for Audits and Evaluations.

BACKGROUND

    For more than a decade, the OIG has conducted oversight of the 
Veterans Health Administration's (VHA) performance in providing 
veterans timely access to care. Our reports have brought attention to 
problems relating to wait times, scheduling practices, consult 
management, data integrity, clinician staffing shortages, and the lack 
of physician and nurse staffing standards. We have repeatedly reported 
that VHA managers need to improve efforts for collecting, trending, and 
analyzing clinical data.
    Two years ago, VHA's inability to provide veterans timely access to 
care became the subject of national focus following allegations at the 
Phoenix VA Health Care System (PVAHCS) in Phoenix, Arizona, that 
included gross mismanagement of VA resources, misconduct by VA senior 
hospital leadership, systemic patient safety issues, and patient 
deaths. On May 28, 2014, we published a preliminary report 
substantiating serious conditions at the PVAHCS. \1\ We provided VA 
leadership with recommendations for immediate implementation to ensure 
all veterans receive appropriate care. Our August 26, 2014, final 
report reflected the full results of our review, including case reviews 
of 45 patients who experienced unacceptable and troubling lapses in 
follow-up, coordination, quality, and continuity of care. \2\ We made 
24 recommendations to correct conditions identified at PVAHCS. To date, 
VHA has implemented 20 of the 24 recommendations. \3\ Recommendations 
addressing potential disciplinary actions, consult reviews, use of the 
electronic waiting list, and efforts to improve procedures used by 
schedulers to make appointments will remain open until VHA completes 
the actions necessary to implement the recommendations.
---------------------------------------------------------------------------
    \1\ Interim Report - Review of Patient Wait Times, Scheduling 
Practices, and Alleged Patient Deaths at the Phoenix Health Care System 
(May 28, 2014).
    \2\ Review of Alleged Patient Deaths, Patient Wait Times, and 
Scheduling Practices at the Phoenix VA Health Care System (August 26, 
2014).
    \3\ Recommendations 9, 13, 19, and 21 remain open as of April 14, 
2016.
---------------------------------------------------------------------------
    As we have previously indicated, the surfacing of allegations 
related to wait times and delays in care at PVAHCS was a watershed 
event for VA and the OIG. Since April 2014, the national attention 
sparked by reporting on PVAHCS led to an increased public awareness of 
the OIG and resulted in a dramatic increase in the number of contacts 
to the OIG Hotline and the number of inquiries and requests sent to us 
by Members of Congress. A number of these Hotline contacts continue to 
allege inappropriate practices by VHA staff that undermine the 
integrity and reliability of wait time metrics as well as allege that 
VHA's initiatives to provide veterans community care are not working.
    Since the publication of our August 2014 report on PVAHCS, we have 
initiated a series of audits and reviews evaluating the extent to which 
veterans are able to receive timely care. Although we have completed 
audits and reviews and published comprehensive reports, a number of 
more recent reviews are still in progress. One example is an audit we 
are conducting at the request of Congresswoman Kyrsten Sinema to review 
the PVAHCS Human Resources Department to determine how effectively they 
manage their Medical Support Assistant workforce to facilitate veteran 
access to outpatient care. The results of our completed work are 
consistent-VA continues to face challenges in providing timely access 
to care and the management of consult appointments at various points of 
service.

HEALTH CARE ENROLLMENT

    Veterans are experiencing delays even at the initial application 
and enrollment for health care. Most veterans must apply and be 
determined eligible in order to be enrolled for VA health care. 
Eligibility for enrollment is determined by evaluating evidence of 
qualifying military service and financial income status, if necessary. 
The Health Eligibility Center (HEC), a component of VHA's Chief 
Business Office (CBO), is VA's central authority for eligibility and 
enrollment processing activities as well as the business owner for the 
Enrollment System (ES), the authoritative system for veterans' health 
enrollment and eligibility information. Although ES serves as VHA's 
official electronic system of record for veteran health care enrollment 
information, it also contains the names of all VA patients as well as 
applicants whose military service was not confirmed.
    In our September 2015 report, Review of Alleged Mismanagement at 
the Health Eligibility Center, we substantiated the existence of about 
867,000 pending records residing with the HEC that had not reached a 
final determination as of September 30, 2014. Pending records included 
entries for over 307,000 individuals reported as deceased by the Social 
Security Administration. However, due to limitations in the HEC's ES 
data, we could not reliably determine how many of the pending records 
existed because of applications for health care. We also determined 
that employees incorrectly marked unprocessed applications as completed 
and possibly deleted 10,000 or more transactions from the HEC's 
Workload Reporting and Productivity (WRAP) tool over the past 5 years. 
WRAP was vulnerable because the HEC did not ensure that adequate 
business processes and security controls were in place, manage WRAP 
user permissions, and maintain audit trails to identify reviews and 
approvals of any deleted transactions. The HEC identified over 11,000 
unprocessed health care applications and about 28,000 other 
transactions in January 2013. This backlog developed because the HEC 
did not adequately monitor and manage its workload and lacked controls 
to ensure entry of WRAP workload into ES. The Under Secretary for 
Health (USH) and the Assistant Secretary for the Office of Information 
and Technology concurred with our findings and recommendations. VA 
implemented Recommendations 2, 7, 9, and 13, and we will continue to 
follow up until the remaining nine recommendations are implemented.

MENTAL HEALTH CARE

    VHA's efforts to increase access to mental health care for veterans 
face many challenges. These include overcoming stigmas that veterans 
may associate with seeking care for mental health and fears that 
associated medical records documenting their care may have an 
adversarial impact on their lives and employment. Additionally, VHA 
struggles to attain and retain a sufficient mental health workforce 
capacity, establish a competency-based practice, and have adequate 
systems to support improving care nationwide. In the face of these 
challenges, we continue to focus our efforts on ensuring veterans 
receive timely access to mental health care. The OIG's Office of 
Healthcare Inspections has issued a number of reports detailing their 
reviews of alleged delays in mental health care. \4\
---------------------------------------------------------------------------
    \4\ See Healthcare Inspection - Mental Health-Related Deficiencies 
and Inadequate Leadership Responsiveness Central Alabama VA Health Care 
System, Montgomery, Alabama (July 29, 2015) and Healthcare Inspection - 
Mismanagement of Mental Health Consults and Other Access to Care 
Concerns, VA Maine Healthcare System, Augusta, Maine (June 17, 2015).
---------------------------------------------------------------------------
    In August 2015, the OIG Office of Audits and Evaluations issued a 
national review of veterans' access to psychiatrists. \5\ We found VHA 
had not been fully effective in its use of hiring opportunities or its 
use of existing personnel to improve veterans' access to psychiatrists. 
From fiscal year (FY) 2012 through FY2014, VHA increased outpatient 
psychiatrist full-time equivalents (FTEs) by almost 15 percent. 
However, during that time the number of veteran outpatient encounters 
with psychiatrists increased by about 10 percent, and the number of 
individual veterans who received outpatient care from a psychiatrist 
increased about 9 percent. This means that while VHA significantly 
increased the number of psychiatrists providing outpatient clinical 
care since FY2012, it did not show a corresponding increase in veterans 
receiving care from psychiatrists. In fact, some individual facilities 
did not increase encounters from FY2012 through FY2014 even with their 
additional psychiatrist FTEs. This occurred because VHA did not have an 
effective method for establishing psychiatrist staffing needs. 
Throughout recent hiring initiatives, VHA did not stress a specific 
need for psychiatrists; instead, facilities determined their own 
staffing needs. VHA did not ensure facilities used consistent and 
effective clinic management practices.
---------------------------------------------------------------------------
    \5\ Audit of VHA's Efforts To Improve Veterans' Access to 
Outpatient Psychiatrists (August 25, 2015)
---------------------------------------------------------------------------
    This resulted in 94 of 140 health care facilities that needed 
additional psychiatrist FTEs to meet demand as of December 2014. We 
found VHA facilities could have better used about 25 percent of 
psychiatrist FTE clinical time to see veterans in FY2014, which equated 
to nearly $113.5 million in psychiatrists' pay. Over the next 5 years, 
this would equate to over $567 million if clinic management is not 
strengthened now. The USH agreed to ensure facilities incorporate the 
Office of Mental Health Operations staffing model to determine the 
appropriate number of psychiatrists needed and attain appropriate 
staffing levels or identify alternative options. The USH also agreed to 
develop clinic management business rules, reassess the appropriateness 
of VHA's productivity target for psychiatrists, and develop a mechanism 
to monitor the variance in which psychiatrists code encounters. Since 
publication, VA implemented Recommendation 4, which was to develop a 
mechanism to monitor the variance in which psychiatrists' code 
encounters and determine appropriate coding guidance and training to 
ensure consistency.

CONSULT MANAGEMENT

    In our August 31, 2015 report, Review of Alleged Mishandling of 
Ophthalmology Consults at the Oklahoma City, OK, VA Medical Center, we 
substantiated that ophthalmology and teleretinal imaging staff, and 
referring providers, acted inappropriately on discontinued consults. We 
found:

      Ophthalmology staff discontinued about 31 percent more 
consults than the national average in FY2014, and about 42 percent more 
in FY2015 (reported as of March 10, 2015).
      Teleretinal imaging staff also discontinued about 9 
percent and 10 percent more consults, respectively, than the national 
average during these same periods.
      Ophthalmology staff discontinued consults without 
adequate justification and often because they could not provide eye 
exams to the patients within 30 days.
      Ophthalmology staff and referring providers did not take 
the necessary steps to refer the patients to non-VA care staff to 
obtain their medical care outside of the VA.
      Referring providers did not ensure that discontinued 
teleretinal imaging consults received the appropriate ophthalmology 
clinic follow-up.

    As a result of our inquiries, VA Medical Center (VAMC) leadership 
reviewed ophthalmology consults discontinued from January 1, 2014, 
through March 3, 2015, and identified issues with 439 of 1,937 
consults. However, ophthalmology leadership did not provide sufficient 
oversight for processing consults and the VAMC did not have well 
defined guidance to ensure staff took appropriate actions when 
processing consults. We recommended the Oklahoma City VAMC Interim 
Director take appropriate action on patients affected by ophthalmology 
and teleretinal imaging consults, as well as formalize guidance and 
train staff on processing consults. Actions by the VAMC to implement 
Recommendation 2, which was to initiate a review of discontinued 
teleretinal imaging consults and take action to provide eye care when 
necessary, remain in progress at this time.

PURCHASED CARE

    VA's purchased care programs include the Veterans Choice Program 
(VCP), Patient Centered Community Care (PC3), Fee Basis Care, and other 
non-VA care programs. VA's purchased care programs are critical to VA 
in carrying out its mission of providing medical care, including 
outpatient services, inpatient care, mental health, dental services, 
and nursing home care to veterans. Our audits, reviews, and health care 
inspections have reported the challenges VA faces in administering 
these programs, such as authorizing, scheduling care, ensuring 
contractors provide medical information to VA in support of the 
services provided, ensuring VA inputs the medical information from 
contractors into the veteran's VA medical record, and timely and 
accurate payment for care purchased outside the VA health care system.

Patient-Centered Community Care Network

    The PC3 program is a VHA nationwide program that provides eligible 
veterans access to care through contracts for certain medical services. 
VA medical facilities use the PC3 program after they have exhausted 
other options for purchased care and when local VA medical facilities 
cannot readily provide the needed care to eligible veterans due to lack 
of available specialists, long wait times, geographic inaccessibility, 
or other factors.
    In our July 2015 report, Review of Alleged Delays in Care Caused by 
Patient-Centered Community Care (PC3) Issues, we examined VHA's use of 
PC3 contracted care to determine if it was causing patient care delays. 
We found that pervasive dissatisfaction with both PC3 contracts has 
caused all nine of the VA medical facilities we reviewed to stop using 
the PC3 program as intended. We projected Health Net and TriWest 
returned, or should have returned, almost 43,500 of 106,000 
authorizations (41 percent) because of limited network providers and 
blind scheduling. We determined that delays in care occurred because of 
the limited availability of PC3 providers to deliver care.
    VHA also lacked controls to ensure VA medical facilities submit 
timely authorizations, and Health Net and TriWest schedule appointments 
and return authorizations in a timely manner. VHA needed to improve PC3 
contractor compliance with timely notification of missed appointments, 
providing required medical documentation, and monitoring returned and 
completed authorizations. The then Interim Under Secretary for Health 
agreed with our recommendations to ensure PC3 contractors submit timely 
authorizations, evaluate the PC3 contractors' network, revise contract 
terms to eliminate blind scheduling, and implement controls to make 
sure PC3 contractors comply with contract requirements. VA has 
implemented Recommendations 4, which was to revise contract terms to 
eliminate the option of scheduling appointments before communicating 
with the veteran.
    In our September 2015 report, Review of Patient-Centered Community 
Care (PC3) Provider Network Adequacy, we reported that inadequate PC3 
provider networks contributed significantly to VA medical facilities' 
limited use of PC3. VHA spent 0.14 percent, or $3.8 million of its $2.8 
billion FY2014 non-VA care budget on PC3. During the first 6 months of 
FY2015, VHA's PC3 purchases increased but still constituted less than 5 
percent of its non-VA care expenditures. VHA staff attributed the 
limited use of PC3 to inadequate provider networks that lacked 
sufficient numbers and mixes of health care providers in the geographic 
locations where veterans needed them. VA medical facility staff 
considered the PC3 networks inadequate because:

      The PC3 network lacked needed specialty care providers, 
such as urologists and cardiologists.
      Returned PC3 authorizations had to be re-authorized 
through non-VA care and increased veterans' wait times for care.
      Non-VA care provided veterans more timely care than PC3.

    For these staff, inadequate PC3 provider networks were a major 
disincentive to using PC3 because it increased veterans' waiting times, 
staffs' administrative workload, and delayed the delivery of care. 
Further, VHA had not ensured the development of adequate PC3 provider 
networks because it lacked an effective governance structure to oversee 
the CBO's planning and implementation of PC3, the CBO lacked an 
effective implementation strategy for the roll-out of PC3, and neither 
VHA nor Health Net and TriWest maintained adequate data to measure and 
monitor network adequacy. The Under Secretary for Health agreed with 
our recommendations to strengthen controls over the monitoring of PC3 
network adequacy and ensure adequate implementation and monitoring 
plans are developed for future complex health care initiatives. VA has 
implemented Recommendation 3, which was to develop action plans to 
improve provider networks that are unable to provide health care 
services at the specific geographic locations identified.

Veterans Choice Program

    As a result of Public Law 113-146, the Veterans Access, Choice, and 
Accountability Act of 2014 (VACAA) VA created the Veterans Choice 
Program (VCP) in November 2014. Following enactment of VACAA, VA turned 
to Health Net and TriWest, the administrators of the PC3 program, who 
had provider networks in place Nation-wide. The VCP allows staff to 
identify veterans to include on the Veterans Choice List, a list that 
includes veterans with appointments beyond 30 days from the clinically 
indicated or preferred appointment dates and veterans who live more 
than 40 miles from a VA facility. Under this program, VA facilities 
began providing non-VA care to eligible veterans enrolled in VA health 
care as of August 1, 2014, and to recently discharged combat veterans 
who are within 5 years of their post-combat separation date. With a key 
VCP eligibility criterion being a veteran's inability to receive care 
within 30 days, VHA's schedulers and supervisors must ensure they 
follow VHA scheduling guidance when calculating wait times.
    In our February 2016 report, Review of Alleged Untimely Care at the 
Community Based Outpatient Clinic, Colorado Springs, CO, we 
substantiated the allegation that eligible Colorado Springs veterans 
did not receive timely care in six reviewed services. These services 
were Audiology, Mental Health, Neurology, Optometry, Orthopedic, and 
Primary Care. We found that for 229 of the 288 veterans with 
appointments over 30 days, Non-VA Care Coordination staff did not add 
173 veterans to the Veterans Choice List in a timely manner and they 
did not add 56 veterans to the list at all. In addition, scheduling 
staff did not take timely action on 94 consults and primary care 
appointment requests. We reviewed 150 referrals for specialty care 
consults and 300 primary care appointments. Of the 450 consults and 
appointments, 288 veterans encountered wait times in excess of 30 days. 
For 59 of the 288 veterans, scheduling staff used incorrect dates that 
made it appear the appointment wait time was less than 30 days.
    As a result, VA staff did not fully use VCP funds to afford 
Colorado Springs veterans the opportunity to receive timely care. The 
Eastern Colorado Health Care System Acting Director agreed with our 
recommendations. Based on actions already implemented, we closed the 
recommendation to ensure that scheduling staff use the clinically 
indicated or preferred appointment dates when scheduling primary care 
patient appointments.
    In another February 2016 report, Review of Alleged Patient 
Scheduling Issues at VA Medical Center, Tampa, Florida, we 
substantiated that when veterans received appointments in the community 
through the VCP, the facility did not cancel their existing VA 
appointments. For example, we found that for 12 veterans, staff did not 
cancel the veterans' corresponding VA appointments because Non-VA Care 
Coordination staff did not receive prompt notification from the 
contractor when a veteran scheduled a VCP appointment and no longer 
needed the VA appointment. We also substantiated that the facility did 
not add all eligible veterans to the Veterans Choice List when their 
scheduled appointment was greater than 30 days from their preferred 
date, and that staff inappropriately removed veterans from the Veterans 
Choice List.
    This occurred because Tampa VAMC schedulers thought they were 
appropriately removing the veteran from the Electronic Wait List, when 
they were actually removing the veteran from the Veterans Choice List. 
The Director agreed with our recommendations to ensure the facility 
receives prompt notification of scheduled VCP appointments, determine 
if the contractor complies with the notification requirements, ensure 
appropriate staffs receive scheduling audit results and verify 
correction of errors, and ensure staff receive training regarding 
management of the Veterans Choice List. Based on actions already 
implemented, we closed four of the five recommendations, and will 
follow up to ensure the facility receives prompt notification of 
scheduled VCP appointments.

NEW OIG OVERSIGHT INITIATIVE

    The OIG's Office of Audits and Evaluations recently initiated a 
pilot project to audit one Veterans Integrated Service Network (VISN) 
and its facilities to evaluate three key components of access-data 
reliability of wait time metrics, implementation of VCP, and consult 
management. Our objective for this pilot is to provide comprehensive 
and timely oversight at all facilities within a VISN in order to 
provide facility directors a report detailing their current data and 
scheduling practices. We hope that by focusing OIG resources on this 
issue we can audit each VISN and its facilities every 3 years, as we 
currently do with the Veterans Benefits Administration's regional 
offices. We feel this work is important and will help provide a 
veteran-centric view of what actions VISN management is taking to 
ensure situations like Phoenix do not occur in the future.

CONCLUSION

    OIG work has shown that VA faces challenges in providing adequate 
access to health care. Risks to the timeliness, cost-effectiveness, 
quality, and safety of veterans' health care raised serious concerns 
about VA's management and oversight of its health care system and 
resulted in U.S. Government Accountability Office concluding VA health 
care was a high-risk area in 2015. A recent announcement by VA to once 
again change their plans on acquiring a new scheduling package aptly 
characterizes their inability to provide consistent and meaningful 
tools and guidance to the VA workforce tasked with ensuring veterans 
receive timely access to care. A major challenge is in administering 
its purchased care programs, in part because VHA schedulers and their 
supervisors do not follow established VHA scheduling guidance. We have 
a number of active projects involving VHA procedures that ultimately 
affect veterans' access through the VCP. We will continue to work with 
VA to provide the independent oversight and objective recommendations 
to help move these programs and initiatives forward on these issues.
    Mr. Chairman, this concludes my statement. We would be happy to 
answer any questions you or members of the Committee may have.

                                 
                  Prepared Statement of Debra A Draper
    Chairman Miller, Ranking Member Brown, and Members of the 
Committee:
    I am pleased to be here today as you discuss issues concerning 
veterans' access to health care. My remarks today are based on our 
report that was released yesterday, VA Health Care: Actions Needed to 
Improve Newly Enrolled Veterans' Access to Primary Care. This report is 
the latest in our ongoing body of work examining veterans' access to 
timely health care. \1\
---------------------------------------------------------------------------
    \1\  See VA Health Care: Actions Needed to Improve Newly Enrolled 
Veterans' Access to Primary Care, GAO 16 328 (Washington, D.C.: Mar. 
18, 2016). See also GAO, VA Mental Health: Clearer Guidance on Access 
Policies and Wait-Time Data Needed, GAO 16 24 (Washington, D.C.: Oct. 
28, 2015); VA Health Care: Management and Oversight of Consult Process 
Need Improvement to Help Ensure Veterans Receive Timely Outpatient 
Specialty Care, GAO 14 808 (Washington, D.C.: Sept. 30, 2014); VA 
Health Care: Reliability of Reported Outpatient Medical Appointment 
Wait Times and Scheduling Oversight Need Improvement, GAO 13 130 
(Washington, D.C.: Dec. 21, 2012); VA Mental Health: Number of Veterans 
Receiving Care, Barriers Faced, and Efforts to Increase Access, GAO 12 
12 (Washington, D.C.: Oct. 14, 2011); and VA Faces Challenges in 
Providing Substance Use Disorder Services and Is Taking Steps to 
Improve These Services for Veterans, GAO 10 294R (Washington, D.C.: 
Mar. 10, 2010).
---------------------------------------------------------------------------
    The Department of Veterans Affairs' (VA) Veterans Health 
Administration (VHA) operates one of the Nation's largest health care 
systems; it provided care to about 6.6 million veterans in fiscal year 
2014, including an aging veteran population and a growing number of 
younger veterans returning from military operations in Afghanistan and 
Iraq. VHA spent about $58 billion for their care in that year. Over the 
past decade, VHA has faced a growing demand for outpatient primary care 
services. From fiscal years 2005 through 2014, the number of annual 
outpatient primary care medical appointments VHA provided through its 
medical facilities increased by 17 percent, from approximately 10.2 
million to 11.9 million. Each year over that period, an average of 
380,000 veterans were newly enrolled in VHA's health care system. In 
fiscal year 2014, VHA provided about 730,000 primary care appointments 
for new patients-appointments for those patients who had not been seen 
in a primary care clinic in the past 24 months, including those who 
were newly enrolled.
    Primary care services are often the entry point to the VHA health 
care system for veterans, and access to these services is critical to 
ensuring that veterans obtain needed medical care, including specialty 
care. When veterans need specialty care-such as cardiology or 
gastroenterology-they are typically referred to specialists by their 
primary care providers, and each veteran's primary care team manages 
and coordinates the needed care. \2\ Veterans may obtain primary care 
services at VHA's medical facilities, which include 167 medical centers 
and more than 800 community-based outpatient clinics. Responsibility 
for ensuring timely access to primary care rests with 20 regional 
Veterans Integrated Service Networks (VISN), which oversee the medical 
centers, and with VHA's central office, which oversees the entire VA 
health care system.
---------------------------------------------------------------------------
    \2\  VHA provides primary care services through patient aligned 
care teams consisting of a primary care provider and support staff, 
including a nurse care manager, clinical associate such as a licensed 
practical nurse, and administrative clerk.
---------------------------------------------------------------------------
    In recent years, we and others have expressed concerns about VHA's 
ability to effectively provide and oversee timely access to health care 
for veterans, which, in some cases, reportedly has resulted in harm to 
veterans. Our prior work on VHA's oversight of primary and specialty 
care found VHA did not have adequate data and oversight mechanisms in 
place to ensure veterans receive timely care. For example, since 2012, 
we have issued several reports recommending that VA improve appointment 
scheduling, ensure the reliability of wait-time and other performance 
data, and improve oversight to ensure VA medical centers provide 
veterans with timely access to outpatient primary and specialty care, 
as well as mental health care. \3\ Based on these serious concerns 
about VA's management and oversight of its health care system, we have 
concluded that VA health care is a high-risk area and, in 2015, added 
it to our High Risk List. \4\ To help improve timely access to health 
care, Congress passed the Veterans Access, Choice, and Accountability 
Act of 2014 (Choice Act), which provided veterans facing long waits or 
lengthy travel distances the opportunity to obtain care from providers 
(non-VA) in the community. \5\
---------------------------------------------------------------------------
    \3\  See GAO 16 328, GAO 16 24, GAO 14 808, GAO 13 130, and GAO 10 
294R.
    \4\  GAO, High Risk Series: An Update, GAO 15 290, (Washington, 
D.C.: February 2015). GAO maintains a high-risk program to focus 
attention on government operations that it identifies as high risk due 
to their greater vulnerabilities to fraud, waste, abuse, and 
mismanagement or the need for transformation to address economy, 
efficiency, or effectiveness challenges.
    \5\  Pub. L. No. 113-146, 128 Stat. 1754 (2014). Under this 
authority, VHA created the Veterans Choice Program, which was 
introduced in November 2014. Under the program, for example, certain 
veterans are able to receive care in the community, including primary 
care, if the next available medical appointment with a VA provider is 
more than 30 days from the date a veteran wants to see a provider or if 
the veteran lives more than 40 miles driving distance from the nearest 
VA facility.
---------------------------------------------------------------------------
    In the context of these serious and longstanding concerns, my 
testimony today highlights selected findings from our most recent 
report on veterans' access to primary care. My remarks will therefore 
focus on the extent to which

    1.newly enrolled veterans access primary care in a timely manner; 
and
    2.VHA provides oversight of veterans' access to primary care.

    For our report, we reviewed relevant regulations, guidance, and 
other key documents, as well as interviewed staff with responsibility 
for ensuring timely access to primary care, including officials from 
VA, VHA, six VA medical centers, and the six corresponding VISNs that 
oversee the medical centers in our review. \6\ We selected the medical 
centers based on variation in average wait times for primary care 
appointments, facility complexity, and geographic location. From these 
medical centers, we selected a sample of 60 newly enrolled veterans (10 
randomly selected from each of the six medical centers), all of whom 
had requested VA contact them to schedule medical appointments, but had 
not been seen by primary care providers. We also selected a sample of 
120 newly enrolled veterans (20 randomly selected from each of the six 
medical centers), all of whom had requested that VA contact them to 
schedule medical appointments and were seen by primary care providers. 
We examined the medical records for each of these 180 veterans to 
determine the history of actions taken to schedule appointments, such 
as dates the appointments were scheduled and dates veterans were seen 
by primary care providers, if applicable. We also evaluated VHA's 
mechanisms for overseeing veterans' access to primary care against the 
Federal internal control standards related to control activities, 
information, and monitoring. \7\ Additional information on our scope 
and methodology is available in our report. The work this testimony is 
based on was performed in accordance with generally accepted government 
auditing standards.
---------------------------------------------------------------------------
    \6\  These medical centers were: VA Central Western Massachusetts 
Healthcare System (Leeds, Massachusetts); Tennessee Valley Healthcare 
System (Nashville, Tennessee); Fayetteville VA Medical Center 
(Fayetteville, North Carolina); Ralph H. Johnson VA Medical Center 
(Charleston, South Carolina); VA Eastern Kansas Health Care System 
(Leavenworth, Kansas); and VA San Diego Healthcare System (San Diego, 
California).
    \7\  See GAO, Standards for Internal Control in the Federal 
Government GAO/AIMD 00 21.3.1. (Washington, D.C.: November 1999). 
Internal control is a process effected by an entity's oversight body, 
management, and other personnel that provides reasonable assurance that 
the objectives of an entity will be achieved.

Problems Newly Enrolled Veterans Faced in Accessing Primary Care and 
---------------------------------------------------------------------------
    Obtaining Timely Access to Care

    Our review of medical records for a sample of newly enrolled 
veterans at six VA medical centers found several problems in medical 
centers' processing of veterans' requests that VA contact them to 
schedule appointments, and thus not all newly enrolled veterans were 
able to access primary care. For the 60 newly enrolled veterans in our 
review who requested care but had not been seen by primary care 
providers, we found that 29 did not receive appointments due to the 
following problems in the appointment scheduling process:

      Veterans did not appear on VHA's New Enrollee Appointment 
Request (NEAR) list. We found that although 17 newly enrolled veterans 
in our review requested that VA contact them to schedule appointments, 
medical center officials said that schedulers did not contact the 
veterans because they had not appeared on the NEAR list. \8\ According 
to VHA policy, as outlined in its July 2014 interim scheduling 
guidance, VA medical center staff should contact newly enrolled 
veterans to schedule appointments within 7 days from the date they were 
placed on the NEAR list. \9\ Medical center officials were not aware 
that this problem was occurring, and could not definitively tell us why 
these veterans never appeared on the NEAR list.
---------------------------------------------------------------------------
    \8\  Veterans who request on their applications for health benefits 
that VA contact them to schedule appointments are to be placed on the 
NEAR list. The NEAR list is intended to help VA medical centers track 
newly enrolled veterans needing appointments.
    \9\  Department of Veterans Affairs, ``Rescission of VHA Outpatient 
Scheduling Policy and Procedures and Interim Guidance,'' (Washington, 
D.C.: July 7, 2014). This interim guidance rescinded and replaced VHA 
Directive 2010-027 Outpatient Scheduling Processes and Procedures (June 
9, 2010).

      VA medical center staff did not follow VHA scheduling 
policy. We found that VA medical centers did not follow VHA policies 
for contacting newly enrolled veterans for 12 veterans in our review. 
VHA policy states that medical centers should document three attempts 
to contact each newly enrolled veteran by phone, and if unsuccessful, 
send the veteran a letter. However, for 5 of 12 newly enrolled 
veterans, our review of their medical records revealed no attempts to 
contact them, and medical center officials could not tell us whether 
the veterans had ever been contacted to schedule appointments. Medical 
center staff attempted to contact the other 7 veterans at least once 
each, but failed to reach out to them with the frequency required by 
---------------------------------------------------------------------------
VHA policy.

    For the remaining 31 of 60 newly enrolled veterans included in our 
review who did not have a primary care appointment:

      24 were unable to be contacted to schedule appointments 
or upon contact, declined care, according to VA medical center 
officials. These officials said that in some cases they were unable to 
contact veterans due to incorrect or incomplete contact information in 
veterans' enrollment applications; in other cases, they said veterans 
were seeking a VA identification card, for example, and did not want to 
be seen by a provider at the time they were contacted.
      7 had appointments scheduled but had not been seen by 
primary care providers at the time of our review. Four of those 
veterans had initial appointments that needed to be rescheduled, which 
had not yet been done at the time of our review. Appointments for the 
remaining 3 veterans were scheduled after VHA provided us with a list 
of veterans who had requested care.

    For the 120 newly enrolled veterans across the six VA medical 
centers in our review who requested care and were seen by primary care 
providers, we found the average number of days between newly enrolled 
veterans' initial requests that VA contact them to schedule 
appointments and the dates the veterans were seen by primary care 
providers ranged from 22 days to 71 days. Slightly more than half of 
the 120 veterans in our sample were seen by providers in less than 30 
days; however, veterans' experiences varied widely, even within the 
same medical center, and 12 of the 120 veterans in our review waited 
more than 90 days to be seen by a provider.
    We found that two factors generally impacted newly enrolled 
veterans' experiences regarding the number of days it took to be seen 
by primary care providers:

    1. Appointments were not always available when veterans wanted to 
be seen, which contributed to delays in receiving care. For example, 
one veteran was contacted within 7 days of being placed on the NEAR 
list, but no appointment was available until 73 days after the 
veteran's preferred appointment date, and a total of 94 days elapsed 
before the veteran was seen by a provider. In another example, a 
veteran wanted to be seen as soon as possible, but no appointment was 
available for 63 days. Officials at each of the six medical centers in 
our review told us that they have difficulty keeping up with the demand 
for primary care appointments for new patients because of shortages in 
the number of providers, or lack of space due to rapid growth in the 
demand for these services.
    2. Weaknesses in VA medical center scheduling practices may have 
impacted the amount of time it took for veterans to see primary care 
providers and contributed to unnecessary delays. Staff at the medical 
centers in our review did not always contact veterans to schedule 
appointments in accordance with VHA policy, which states that attempts 
to contact newly enrolled veterans to schedule appointments must be 
made within 7 days of their addition to the NEAR list. Among the 120 
veterans included in our review that were seen by primary care 
providers, 37 (31 percent) were not contacted within 7 days to schedule 
an appointment; compliance varied across medical centers.

    As a result of these findings, we recommended that VHA review its 
processes for identifying and documenting newly enrolled veterans 
requesting appointments and revise as appropriate, to ensure that all 
veterans requesting appointments are contacted in a timely manner to 
schedule them. VHA concurred with this recommendation, and indicated 
that by December 31, 2016, it plans to review and revise the process 
from enrollment to scheduling to ensure that newly enrolled veterans 
requesting appointments are contacted in a timely manner. VHA also 
indicated that it will implement internal controls to ensure its 
medical centers are appropriately implementing the process.

VHA's Oversight of Veterans' Access to Primary Care Is Hindered in Part 
    by Data Weaknesses

    VHA's oversight of veterans' access to primary care is hindered, in 
part, by data weaknesses and the lack of a comprehensive scheduling 
policy, both of which are inconsistent with Federal internal control 
standards. \10\ These standards call for agencies to have reliable data 
and effective policies to achieve their objectives, and for information 
to be recorded and communicated to the entity's management and others 
who need it to carry out their responsibilities.
---------------------------------------------------------------------------
    \10\  See GAO/AIMD 00 21.3.1.
---------------------------------------------------------------------------
    A key component of VHA's oversight of veterans' access to primary 
care, particularly for newly enrolled veterans, relies on monitoring 
appointment wait times. However, VHA monitors only a portion of the 
overall time it takes newly enrolled veterans to access primary care. 
\11\ For newly enrolled veterans, VHA calculates primary care 
appointment wait times starting from veterans' preferred dates, rather 
than the dates veterans initially requested that VA contact them to 
schedule appointments. (A preferred date is the date that is 
established when a scheduler contacts the veteran to determine when he 
or she wants to be seen.) Therefore, these data do not capture the time 
veterans wait prior to being contacted by schedulers, making it 
difficult for officials to identify and remedy scheduling problems that 
may arise prior to making contact with veterans. (See fig. 1.)
---------------------------------------------------------------------------
    \11\  We recently reported that VA similarly focuses on only a 
portion of the overall time veterans wait to see mental health 
providers. See GAO 16 24.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Our review of medical records for 120 newly enrolled veterans found 
that, on average, the total amount of time it took to be seen by 
primary care providers was much longer when measured from the dates 
veterans initially requested VA contact them to schedule appointments 
than it was when using appointment wait times calculated using 
veterans' preferred dates as the starting point. For example, we found 
one veteran applied for VHA health care benefits in December 2014, 
which included a request to be contacted for an initial appointment. 
The VA medical center contacted the veteran to schedule a primary care 
appointment 43 days later. When making the appointment, the medical 
center recorded the veteran's preferred date as March 1, 2015, and the 
veteran saw a provider on March 3, 2015. Although the medical center's 
data showed the veteran waited 2 days to see a provider, the total 
amount of time that elapsed from the veteran's request until the 
veteran was seen was actually 76 days.
    Further, ongoing scheduling errors, such as incorrectly revising 
preferred dates when rescheduling appointments, understated the amount 
of time veterans waited to see providers. \12\ For example, during our 
review of appointment scheduling for 120 newly enrolled veterans, we 
found that schedulers in three of the six VA medical centers included 
in our review had made errors in recording veterans' preferred dates 
when making appointments. For example, in some cases primary care 
clinics cancelled appointments, and when those appointments were re-
scheduled, schedulers did not always maintain the original preferred 
dates in the system, but updated them to reflect new preferred dates 
recorded when the appointments were rescheduled. We found 15 
appointments for which schedulers had incorrectly revised the preferred 
dates. In these cases, we recalculated the appointment wait time based 
on what should have been the correct preferred dates, according to VHA 
policy, and found the wait-time data contained in the scheduling system 
were understated. Officials attributed these errors to confusion by 
schedulers resulting from the lack of an updated standardized 
scheduling directive, which VHA rescinded and replaced with an interim 
directive in July 2014. \13\ As in our previous work, we continue to 
find scheduling errors that affect the reliability of wait-time data 
used for oversight, which make it difficult to effectively oversee 
newly enrolled veterans' access to primary care.
---------------------------------------------------------------------------
    \12\  VHA policy states that when a clinic cancels a veteran's 
appointment, the preferred date recorded in the initial appointment 
should be maintained in the system and not revised when the appointment 
is rescheduled.
    \13\  Department of Veterans Affairs, Rescission of VHA Outpatient 
Scheduling Policy and Procedures and Interim Guidance, (Washington, 
D.C.: July 7, 2014). This interim guidance rescinded and replaced VHA 
Directive 2010-027, Outpatient Scheduling Processes and Procedures 
(June 9, 2010). Subsequent to this interim directive VHA issued 
numerous individual memos to clarify and update its scheduling 
policies.
---------------------------------------------------------------------------
    As a result of these findings, we recommended that VHA monitor the 
full amount of time newly enrolled veterans wait to receive primary 
care, and issue an updated scheduling directive. VHA concurred with 
both of these recommendations, and indicated that by December 31, 2016, 
it plans to begin monitoring the full amount of time newly enrolled 
veterans wait to be seen by primary care providers. It also indicated 
that it plans to submit a revised scheduling directive for VHA-wide 
internal review by May 1, 2016.
    This most recent work on veterans' access to primary care expands 
further the litany of VA health care deficiencies and weaknesses that 
we have identified over the years, particularly since 2010. As of April 
1, 2016, there were about 90 GAO recommendations regarding veterans' 
health care awaiting action by VHA. These include more than a dozen 
recommendations to address weaknesses in the provision and oversight of 
veterans' access to timely primary and specialty care, including mental 
health care. Until VHA can make meaningful progress in addressing these 
and other recommendations, which underscore a system in need of major 
transformation, the quality and safety of health care for our Nation's 
veterans is at risk.
    Chairman Miller, Ranking Member Brown, and Members of the 
Committee, this concludes my prepared statement. I would be pleased to 
answer any questions that you may have at this time.

GAO Contact and Staff Acknowledgments

    If you or your staff members have any questions concerning this 
testimony, please contact Debra A. Draper at (202) 512-7114 or 
[email protected]. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
statement. Other individuals who made key contributions are Janina 
Austin, Assistant Director; Jennie F. Apter; Emily Binek; David 
Lichtenfeld; Vikki L. Porter; Brienne Tierney; and Emily Wilson.

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512-4400, U.S. Government Accountability Office, 441 G Street NW, Room 
7125, Washington, DC 20548

Public Affairs

    Chuck Young, Managing Director, [email protected], (202) 512-4800
    U.S. Government Accountability Office, 441 G Street NW, Room 7149, 
Washington, DC 20548

                                 
                       Statements For The Record

                          THE AMERICAN LEGION
    The American Legion has been actively tracking the amount of time 
it takes for veterans to access the health care they have earned for 
over a decade. In 2002, The American Legion launched the ``I Am Not a 
Number'' campaign to identify and document the delays veterans were 
facing in obtaining medical care from the Department of Veterans 
Affairs (VA). This project grew into to the ``System Worth Saving'' 
(SWS) Task Force of The American Legion. The SWS team has been 
crisscrossing the country annually with boots on the ground to evaluate 
the Veterans Health Administration (VHA) in the field ever since. The 
American Legion has not been shy about raising concerns, such as in the 
testimony of Mr. Roscoe Butler in March of 2013, fully a year before 
the Phoenix wait time scandal would break, where Mr. Butler raised 
concerns about inaccurate self-reporting from the VA as well as the 
large number of empty medical staff positions that needed to be filled 
if VA was to have any hope of maintaining manageable wait times for 
care. \1\
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    \1\  Witness testimony of Roscoe Butler, The American Legion - HVAC 
Subcommittee on Oversight and Investigation, "Waiting for Care: 
Examining Patient Wait Times at VA" - March 14, 2013
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    When the scandal broke in Phoenix, The American Legion not only led 
the chorus demanding accountability, but also continued to put 
resources toward solving the problems and helping veterans receive 
care, by establishing Veterans Crisis Command Centers (VCCCs) and 
conducting town hall meetings to facilitate communication between 
veterans and the VA and help veterans access with the care they needed. 
Today, we know from validated reports that there was systemic 
falsification of wait times at VA medical facilities. \2\
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    \2\  "VA Bosses in 7 States Falsified Vets' Wait Times for Care" - 
USA Today, Donovan Slack April 7, 2016
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    The American Legion and the American people were rightfully 
concerned. The obvious concerns and the conclusions that can be drawn 
from this may not be easily solved by some of the pat solutions being 
thrown around. Some of these concerns are shared by the larger health 
care industry of America as a whole and while these problems may not be 
easily solvable - transparency must be a staple of VA, and the ability 
to report accurately will be critical toward finding solutions for 
veterans.
    Chairman Miller, Ranking Member Brown, and Members of the 
Committee:
    On behalf of National Commander Dale Barnett and the over two 
million members of The American Legion, we welcome this opportunity to 
comment on improving the access to the health care system of the 
Department of Veterans Affairs (VA).
    While veterans wait for care in the VA system, many find that the 
private sector is just as rife with delays and wait times that rival or 
exceed those at VA. Newspaper reports note ``emerging evidence that 
lengthy waits to get a doctor's appointment have become the norm in 
many parts of American medicine, particularly for general doctors but 
also for specialists'' \3\. A report from the National Academy of 
Sciences noted ``tremendous variability in wait times for health care 
appointments exists throughout the United States, ranging from same day 
service to several months.'' \4\ In addition, veterans have mentioned 
problems accessing care in the private sector, including a veteran in a 
major East Coast city who reported a minimum of 90-100 days to get a 
simple dermatology consult, no better, and in many cases far worse than 
veterans would be receiving utilizing local VA health care centers.
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    \3\  New York Times The Health Care Waiting Game - Elisabeth 
Rosenthal, July 5, 2014
    \4\  Science Daily Wait times for health care services differ 
greatly throughout US - July 29, 2015
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    The American health care system as a whole has problems with wait 
times, and sometimes it is important to reflect on VA's position not 
solely as an island, but as a barometer that can help forecast what to 
expect. The American Legion believes that this is an area the Committee 
could more fully explore by focusing on how to underpin the existing 
system so that we not only shore up VA, but set the example of how the 
national health care industry should operate. This wouldn't be the 
first time innovation at VA would lead the Nation, and The American 
Legion believes that this Committee has provided excellent oversight 
and analysis with a comprehensive slate of hearings examining the VHA. 
In addition, The American Legion believes that a hearing or series of 
hearings examining VHA in relation to the larger health care picture of 
America would prove beneficial. Wait times, opioid pain killer 
prescription, elder care, mental health care, these are all problems 
that VA must tackle, but they are also problems the American health 
care landscape as a whole is grappling with, and the comparison and 
contrasts are illuminating.
    While emergency measures such as the Veterans Access, Choice and 
Accountability Act of 2014 \5\ (VACAA) provided the opportunity for 
some relief while utilizing private sector resources as a pressure 
release valve, the private sector has many of its own struggles with 
wait times and cannot be seen as a sole solution to the problems of 
waiting veterans. VACAA and subsequent efforts to consolidate care in 
the community under a single streamlined system should make the process 
easier when veterans need help accessing care, and reforming this 
portion of the system is important. However, this only addresses part 
of the access problem.
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    \5\  P.L. 113-146
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    The American Legion recognizes the importance of communication and 
coordination between all components of the health care community - VA 
facilities, private sector resources, public-private partnerships such 
as agreements with teaching hospitals and universities, Veterans 
Service Organizations (VSOs) and others who provide resources to help 
veterans, Congressional as well as local governments, and most 
importantly the veterans themselves. When all of these stakeholders 
communicate it is easier to determine what resources are available to 
serve the needs of the veteran. That cooperation can only occur when 
the communication is open and free from fear of reprisal.
    The real and striking problem identified by watchdogs like The 
American Legion well before the Phoenix scandal broke which was 
confirmed by the scandal itself, was the culture in VA that led to 
systemic false reporting of critical information. Without accurate 
information about the delays veterans were facing, there is no way to 
correctly identify where help is needed. When self-reporting continued 
to signify that all was well, those connected to the veterans who were 
struggling had to find alternative ways of gaining access to more 
accurate information.
    The American Legion made independent, third party oversight visits 
to facilities through the System Worth Saving Task Force and tried to 
highlight the problems we saw through testimony before Congress as 
noted above. Representative Beto O'Rourke from this very committee, 
frustrated with incongruities of data reported by VA with what the 
veterans in his district reported regarding mental health care wait 
times, commissioned private surveys to develop a more accurate picture.
    When criticism comes forward to address problems, it must be met 
productively. Where change is necessitated, it must occur to meet the 
needs of veterans. As a result of the Phoenix wait time scandal 
veterans now have new management at VA; from Secretary Bob McDonald, to 
Undersecretary for Health Dr. David Shulkin, as well as most of VA's 
senior leadership team. These new leaders have stressed the importance 
of retraining employees and management at every level to fix these 
problems.
    According to the Independent Assessment \6\ VA is inconsistent from 
region to region. In some regions, VA does an excellent job of managing 
the health care needs of veterans. Veterans receive treatment within 
the VA where possible, and overwhelmingly veterans report favorably on 
the treatment they receive within VA even when they are frustrated with 
the administrative aspects such as appointments. \7\ In some locations 
when they cannot deliver the care veterans need, they can smoothly make 
appointments to get the veterans care in the community. This indicates 
the system has the capacity to deliver the care veterans want and 
deserve, utilizing the best VA resources and private sector resources 
in places where this is necessary, but while the capacity is there the 
consistency of this execution is falling short.
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    \6\  http://www.va.gov/opa/choiceact/documents/assessments/
integrated--report.pdf
    \7\ Vet Voice Foundation polling data, November 2015
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    The foundation to build that consistency requires better reporting, 
better communication between all parties, and better teamwork between 
all partners. Regional problems can't be fixed unless awareness of 
those problems filters up to those who can commit the resources 
necessary to fix the problems and it will take new and innovative 
solutions to succeed. Representative Ryan Costello has proposed the VET 
Act \8\ which builds on the example set by American Legion VCCCs and 
sets up a pilot program using Veteran Engagement Teams to help connect 
veterans with resources. Representative O'Rourke's Ask Veterans Act \9\ 
proposes surveying veterans directly to get outside the closed loop of 
VA management reporting on its own progress, and Representative Corrine 
Brown has introduced legislation that would make VA establish a 
quadrennial plan for committing funds and coordinating care 
effectively. These and other ideas will be necessary to help restore 
trust in the system; even as VA's new management works to do the same.
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    \8\  H. R. 3936
    \9\  H. R. 1319
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    The American Legion is committed to ensuring that veterans have the 
best health care system available to meet their unique needs and we are 
encouraged by some of the progress VA is making \10\. VA's MyVA 
initiative combined with the successful implementation of VISTA 
evolution, My Healthy Vet, working weekends to knock down the 
appointment and consult wait times, and expanding telehealth are just a 
few examples where VA is showing promise and improvement. The Wait Time 
scandal illuminated problems within that health care system. In the 
time of immediate crisis, the most obvious answer to that problem 
seemed to be that the resources to meet need weren't there and 
therefore veterans must be turfed off to community providers, but we 
all see now that it is just not that simple. The solution will require 
patience and diligence to be sure, but above all honesty and the 
humility to admit that you need help. Management and employees cannot 
be afraid of poor reviews causing them to hide their inability to admit 
they aren't meeting needs. VA cannot be so afraid of criticism that 
they fall back on knee jerk habits to deny and deflect accusations 
rather than owning their shortcomings and providing a plan for how they 
aim to make up for them.
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    \10\  http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2775
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    Overwhelmingly - VA still delivers a ``System Worth Saving''. This 
is the Nation's largest, most extensive, most comprehensive integrated 
health care system and is a system that has led the way on integrated 
health records, on treatment for heart disease, on new and innovative 
treatments for mental health issues, and especially Posttraumatic 
Stress Disorder. But this is also a system that needs to be viewed 
through a lens that not only observes VA's own internal struggles but 
also the struggles of the Nation's health care landscape as a whole.
    The American Legion thanks this Committee for their diligence in 
pursuing improvements to the VA health care system and for their 
attentiveness to the struggles of veterans who seek to access care. 
This Committee was instrumental in calling attention to the initial 
Wait Time problem, and has been at the forefront of oversight through 
the past two years of reform efforts. As we continue to work toward the 
future of veterans' health care, we look forward to continuing the 
important partnership and dialogue with all partners at the table from 
veterans to VA to Congress, toward building the robust and dynamic 
health care system veterans have earned with their service and 
sacrifice.
    Questions concerning this testimony can be directed to The American 
Legion Legislative Division (202) 861-2700, or [email protected]

                                 
                         Questions and Answers

                                PASSBACK

QUESTIONS FOR THE RECORD FROM CHAIRMAN JEFF MILLER

    Question 1: What is the VHA-wide average wait time for Veterans 
seeking primary care at VA? Please provide the number for new patients 
and established patients. Does that average take into account the time 
from the first contact the Veteran makes with VA until the appointment 
actually occurs? In other words, does it include the time from the 
create date to the appointment date, not just from the preferred date 
to the appointment date.

    Department of Veterans Affairs (VA) Response: In April 2016, the 
average wait time for Primary Care was 4.66 days. This number includes 
both new and established patient appointments and a new method of 
computation. This new method uses either the date that an appointment 
is deemed clinically appropriate by a VA health care provider, the 
Clinically Indicated Date (CID), or, if no such clinical determination 
has been made, the date a Veteran prefers to be seen, the Preferred 
Date (PD), to calculate wait times. The current method reports the wait 
times for all patients combined, and does not include the create date. 
This is consistent with the wait time goals of the Veterans Health 
Administration (VHA) published in the Federal Register on October 17, 
2014. \1\
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    \1\  Available at: https://www.federalregister.gov/articles/2014/
11/05/2014-26274/publication-of-wait-times-for-the-department-for-the-
veterans-choice-program.
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    The previous method used to calculate wait times was based on the 
create date (the date an appointment is made) and the desired date for 
scheduling an appointment. The create date time stamp provided valuable 
information for new patients but not for established patients. So, the 
desired date time stamp required further definition based on the source 
of the appointment request. VA now uses CID for provider driven 
appointment requests and PD for patient driven appointment requests. 
The majority of appointments are made from provider driven requests, 
and providers must document CID. Use of CID makes the scheduling of 
appointments less susceptible to manipulation.

    Question 2: VA has used the excuse of training problems for more 
than a decade when addressing wait times errors or manipulation. One 
very simple way to address training deficiencies is to ensure your over 
25,000 schedulers are trained properly, both the trainer and the 
trainee certify that training is in compliance with VHA policy, and 
then hold them accountable for actions outside of training. Will VA 
implement this simple step of requiring a written attestation of 
competency in order to hold people accountable for the continuing 
abuses in the scheduling system?

    VA Response: In response to the events of 2014, VHA simplified the 
scheduling procedures and published a Deputy Under Secretary for Health 
for Operations and Management memorandum on June 9, 2015, which revised 
procedures to require providers to write a return-to-clinic order and 
schedulers to enter the date contained in that order as the CID. This 
new process keeps future appointment decision-making with the provider 
and patient, rather than the scheduler. Associated training was updated 
at that point and provided to employees who could schedule 
appointments. A written attestation is included as part of the 
training. Additionally, VHA uses the ``scheduling trigger tool'' 
database to identify and notify facility leadership of scheduling 
irregularities. Of note, a root cause of scheduling errors is the 
highly manual, 30-year old scheduling software. VHA will implement 
VistA Scheduling Enhancement (VSE) this summer. VSE updates the legacy 
command line scheduling application with a modern graphical user 
interface. This capability reduces the time it takes schedulers to 
enter new appointments, and makes it easier to see provider 
availability. VSE provides critical, near-term enhancements, including 
a graphical user interface, aggregated facility views, profile 
scheduling grids, single queues for appointment requests, and resource 
management reporting. VHA anticipates this new scheduling software will 
reduce the number of scheduling errors.

    Several initiatives are planned for VHA's ``Summer of Scheduling,'' 
including:

      National Rollout of VSE: The rollout of VSE will be 
achieved through a train the trainer or ``Super User'' approach, 
developing local experts to train others. The rollout will occur 
between May and July 2016, with ongoing sustainment training.
      Hire Right, Hire Fast: This project's goal is to ensure 
that every facility has the right number of Medical Support Assistants 
(MSA), with the right skills, and who can provide the right experience 
for Veterans.
      Own the Moment: VA knows that every moment between an 
employee and a Veteran matters. This project reinforces the importance 
of serving with a focus on principles and values, empowering VA 
employees to pursue what's right for the Veteran when procedures serve 
to limit services.
      Standardized MSA Onboarding/Training: New MSA Onboarding 
would include a two-week training program that draws its curriculum 
from scheduling rules for technical training, customer experience 
training, and medical center policies. The onboarding will provide a 
mentor for all new MSAs and use the VSE ``Super Users'' model. 
Deployment will follow the National Rollout of VSE.

    Question 3: Who at VA Central Office is responsible for training, 
and has anyone been held accountable for this, since it has been used 
as an excuse for wait time manipulation and errors for so long?

    VA Response: VHA's Access and Clinical Administration Program 
Office is responsible for developing scheduler training and policy. 
This office is creating, in collaboration with the VA Talent Management 
Service, a simulation-based learning platform that enhances decision-
making by allowing organizations to easily create assessment, 
education, and training programs to improve outcomes through ``real-
world'' engagement. Simulation-based training is interactive and allows 
a scheduler to choose various pathways in a decision tree. Once the 
training is developed and released, each facility will ensure their 
staff successfully completes the training prior to issuing the 
scheduling menu options.

    Question 4: GAO pointed out in its report that medical center 
directors are responsible for ensuring any staff who access the 
scheduling system have completed the appropriate training. Given the 
numerous instances of improper scheduling that continue to this day, 
how many directors have been disciplined specifically for the failure 
to ensure his/her staff is properly trained? Please provide a list of 
each director, the discipline received, and the specific charge that 
successfully led to the received discipline.

    VA Response: VA's goal continues to be strengthening its culture of 
accountability and putting a renewed focus on employee-led, Veteran-
centric change. Regarding disciplinary actions, no director has been 
disciplined ``specifically for the failure to ensure his/her staff is 
properly trained;'' however, as of July 8, 2016, VA has taken 
disciplinary action against 52 employees for wait time data 
manipulation. The breakdown of these actions includes: 17 Suspensions - 
Less than 14 days, 9 Reprimands, 8 Removals, 5 Admonishments, 4 
Suspensions - 14-29 days, 3 Demotions, 2 Employees retired in lieu of, 
1 Employee resigned in lieu of, 1 Suspension - over 60 days, 1 
Settlement Agreement, and 1 Probationary Termination.

    Question 5: Whistleblower disclosures that have been in the media 
\2\ show that Phoenix has had about 33,500 cancelled clinic 
appointments since October 2015, 10,000 of which had not been 
rescheduled at least as of February 2016. Please explain this.
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    \2\  Available at: http://www.azfamily.com/story/31371254/va-
insider-comes-forward-regarding-recent-controversy-in-vet-health care.

    VA Response: From October 1, 2015, through March 3, 2016, a total 
of 33,789 appointments were identified as being cancelled by clinics 
across all services in the Phoenix VA Health Care System (PVAHCS). This 
number includes individual appointments, group appointments, 
Compensation & Pension, and telephone clinics.
    VA identified 10,604 of the cancelled appointments as having ``No 
Action Taken.'' ``No Action Taken'' could indicate such things as a 
future appointment scheduled in a different stop code or appointments 
made in error (e.g., scheduled into the wrong clinic, with the wrong 
date, for the wrong patient, etc.). A random audit of 100 patient 
records demonstrated that 14 need to be contacted to attempt to 
reschedule. Based on the random audit, the facility will review further 
to determine if any of the Veterans require a follow-up. Additionally, 
PVAHCS is developing an action plan to review the 10,000 records, with 
a target completion date of mid-June 2016.

    Question 6: According to a recent OIG report on Colorado Springs, 
36 percent of the consults reviewed identified that Veterans waited 
from between 31 to 148 days for a specialty care consult and 78 percent 
waited for from between 32 to 229 days for a primary care appointment. 
How is VA addressing the specific problems identified by the OIG?

    VA Response: VA Eastern Colorado Health Care System (VAECHCS) has 
already implemented measures to improve access and to ensure the 
facility has trained staff to timely process consults. Scheduling staff 
at the PFC Floyd K. Lindstrom Outpatient Clinic at Colorado Springs 
received multiple formal training sessions on appropriate scheduling 
practices in the last several months, which included use of the 
earliest appropriate date when scheduling new patient appointments. A 
``stand-down'' on December 5, 2015, was also held, where all schedulers 
were brought in on a Saturday to review and train on all of the 
critical components of scheduling. Detailed refresher training for all 
scheduling staff was additionally conducted on March 8-10, 2016. All 
new schedulers are required to attend and complete formal classroom 
training, followed by a practicum and assessment of scheduling 
competencies, before transitioning permanently to their respective 
clinics. Moreover, scheduling audits continue, with 100 percent of 
required audits being completed for all scheduling staff in February, 
March, and April 2016. Based upon the results of the audit reviews, 
supervisors provide immediate feedback to schedulers, along with any 
necessary corrective action. In addition to these efforts, consult 
metrics are being closely monitored as part of the VHA Consult 
Improvement Initiative.

    Question 7: In the same report, the OIG found that VA staff did not 
fully use Veterans Choice Program funds to afford CBOC Veterans the 
opportunity to receive timely care. Please explain, in detail, where 
and how that money was spent.

    VA Response: The omission of 100 patients from the Veterans Choice 
List (VCL) occurred in the infancy of the program. Early in 
implementation, a report to add patients to the VCL did not include all 
sites of care within VAECHCS. This issue was identified and resolved 
through training for the Community Care manager, as stated in the 
facility's initial published response to VA's Office of Inspector 
General. Veterans Choice Program (VCP) funding that would have been 
spent for the care of these Veterans remained in the VCP Fund for 
purposes of paying for other care under the program.
    VAECHCS fully supports an eligible Veteran's choice to receive care 
through VCP. VAECHCS is currently in the top five facilities in the 
Nation in volume of VCP referrals. Through March of fiscal year (FY) 
2016, VAECHCS has referred 27,716 episodes of care to our region's 
third party administrator, Health Net Federal Services, resulting in 
17,251 appointments in the community. To ensure we maintain this 
success, VAECHCS added VCL entry criteria to the performance plans of 
schedulers and issued the revised plans during mid-year review in March 
2016.

    Question 8: GAO noted, as this Committee has for years, that VA's 
reported wait times data only includes a portion of the time it takes a 
newly enrolled Veteran to access primary care, by using a Veteran's 
desired date as opposed to the time the Veteran first contacts VA. 
Given the fact that calculating wait times in this manner understates 
actual wait times, why does VA do it this way?

    VA Response: There is no clear standard to evaluate appointment 
wait times. While using the create date is easier to capture and 
appears to calculate wait times simply, it is not clinically relevant 
and doesn't reflect the Veterans' preference for when to be seen. In 
the private sector, most large health care organizations focus on 
patient satisfaction, and that's where we think VA needs to go.
    The create date time stamp may provide useful information for new 
patients but not for established patients. Our patient population is 
older and has more chronic conditions. As a result, a very large 
portion of appointments are ``return to clinic.'' For example, if a 
Veteran sees a doctor for diabetes and the doctor wants a follow-up 
appointment in 6 months, it doesn't make sense to report that as a 180 
day wait time. While the follow-up care would be delivered at the 
clinically appropriate time, it would inaccurately inflate a facility's 
wait time average. A Veteran could see extraordinarily long wait times 
at a facility due to this inflation and may be discouraged from seeking 
care there. The desired date time stamp must be further defined based 
on the source of the appointment request. However, reporting wait times 
based on create date in addition to our current, more appropriate, 
practice would risk creating even more confusion. VA now uses the CID 
for provider driven appointment requests and PD for patient driven 
requests.
    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) 
is a widely used survey throughout health care in America. A standard 
set of questions deals with timely access to routine care and care 
needed right away. Historically, VA has underperformed industry 
averages. Notably, however, Veteran responses in the first and second 
quarters of FY2016 were the most favorable since 2013. More than 83 
percent of respondents indicated they usually or always received access 
to routine care when they needed it, and 72 percent of respondents 
indicated they received access to care needed right away.

    Question 9: Officials from each of the facilities audited by GAO 
stated that they periodically audit scheduled appointments to help 
ensure schedulers are complying with scheduling practices. Is that a 
uniform policy across all VHA facilities? If not, please explain why.

    VA Response: Yes. Current VHA policy requires scheduling 
supervisors to audit schedulers on a yearly basis, at a minimum. An 
updated scheduling directive, currently in the concurrence process, 
will require quarterly audits. The audit format was standardized and is 
now a national auditing tool. Some sites are piloting the audit tool. 
Once the scheduling directive is released, all sites will be trained on 
the use of the audit tool for quarterly audits for all staff assigned 
the scheduling menu options.

    Question 10: In a December 2012 report, GAO recommended VA improve 
efficiency and oversight of its scheduling process, including use of 
the EWL and ensuring appropriate training. Now, over three years later, 
that recommendation remains open, and VA continues to blame wait time 
manipulation on improper training. When is VA planning on fixing its 
training procedures so it can stop improperly characterizing its 
attempts to pad numbers on those deficiencies?

    VA Response: In May 2014, VA began retraining every employee whose 
position includes the responsibility of scheduling appointments, to 
eliminate inconsistencies across VHA or within any VA facility. This 
training clearly directed that all scheduling of appointments must use 
the official VA scheduling software and Electronic Wait List (EWL) so 
that we can better track demand and need for additional resources. 
Additional training was added and is provided to front line staff on an 
on-going basis. To ensure compliance with required directives and 
policies, VA conducted another review of all schedulers in August 2015. 
Employees who had not received the required training had their 
scheduling authority removed and were blocked from scheduling until 
properly trained.
    In spring 2016, VA launched a 2-week, enhanced training program 
specifically for schedulers and other front line staff, which will 
focus on critical customer service skills. MSA onboarding, to include 
its mentorship program, will also support technical and policy 
training. Additionally, VA requires each Veterans Integrated Service 
Network (VISN) Director and Medical Center Director to conduct 
Scheduling Inspections on a regular basis at VA hospitals and clinics. 
Over 11,500 of these inspections have occurred, and this practice will 
continue. Finally, an interactive training program is being developed 
for scheduling staff, which will be released after the scheduling 
directive is approved.

    Question 11: A consistent weakness that has been highlighted with 
regard to scheduling practices is the lack of effective oversight. What 
is the role of VISNs and central office with regard to oversight?

    VA Response: In May 2014, VA began retraining every employee whose 
position includes the responsibility of scheduling appointments, to 
eliminate inconsistencies across VHA or within any VA facility. This 
training clearly directed that all scheduling of appointments must use 
the official VA scheduling software and EWL so that we can better track 
demand and need for additional resources. Additional scheduler training 
on updated scheduling procedures was conducted in the summer of 2015. 
To ensure compliance with these new procedures, VHA directors certified 
that all schedulers completed the appropriate training. Employees who 
were not properly trained had their scheduling authority removed and 
were blocked from scheduling until properly trained.
    Additionally, VA requires each VISN Director and Medical Center 
Director to conduct Scheduling Inspections on a regular basis at VA 
hospitals and clinics. Over 11,500 of these inspections have occurred, 
and this practice will continue. We have made a deliberate effort to 
educate our staff. In addition to training, we have multiple audit 
tools in place that actively scan VA's metadata to look for 
abnormalities in the scheduling process. Use of the ``scheduling 
trigger tool'' database to identify and notify facility leadership of 
scheduling irregularities is an additional protection against 
scheduling errors. Any such abnormalities are flagged and provided to 
facility leadership for appropriate follow-up. VA's tracker tools 
identify the error and log the appropriate action taken to remediate 
that error.
    VA's new scheduling software, VSE, will change the business 
processes that schedulers use to make, cancel, and reschedule 
appointments. These business processes are anticipated to make 
scheduling more reliable and reduce errors. Specifically, VSE will:

      Eliminate the ability to ``zero out'' appointments;
      Improve the accuracy of lists;
      Eliminate cancellation by clinic errors;
      Improve the accuracy of CID/PD for multiple book 
appointments; and
      Eliminate ``next available'' errors.

    Question 12: Why are audits and external reviews still finding 
errors in scheduling appointments in spite of training? What is VA 
doing to ensure these errors stop?

    VA Response: One reason is that schedulers are generally entry 
level employees who experience a 25 percent turnover each year. The 
Hire Right, Hire Fast initiative is intended to ensure MSAs with the 
right skills are in the right place to provide a premium experience to 
Veterans. Medical center directors will certify required administrative 
baselines to ensure successful implementation. Additionally, the 
current scheduling process is complex, requiring schedulers to manually 
apply many of the business rules and procedures that could be done by 
an electronic scheduling system. VA deployment of VSE will update VA's 
legacy ``roll and scroll'' scheduling application with a modern 
graphical user interface. This capability will reduce the time it takes 
for schedulers to enter new appointments and make it easier to see 
provider availability. VSE implementation creates a need to update 
schedulers on new software functions and procedures. VA will combine 
VSE training with a module focused on critical customer service skills.

    Question 13: With regard to the designation of Veteran's health 
care as one of GAO's high-risk programs, what does VA expect to 
accomplish in this regard through the end of the current 
administration?

    VA Response: VA's Under Secretary for Health, Dr. David Shulkin, 
has a vision for a system that provides same day access to primary care 
and mental health care. Same day access is defined as the ability of a 
facility to address a Veteran's clinical needs the day that a Veteran 
calls or visits a VHA medical center. Central to this vision is a 
commitment to enhanced access and a consistent set of expectations 
regarding what a Veteran deserves when s/he enters any VHA facility. 
This commitment is summarized in the MyVA Access Declaration and the 
Veteran experience statement.
    Our goal is to provide same day access for primary care and mental 
health care by December 2016. This means that when Veterans call or 
visit a VHA medical facility, VHA will connect them to their primary 
care provider, connect them to an alternate provider, such as a walk-in 
clinic or emergency room, or attend to their needs by telephone, 
through telemedicine or other available methods, on the same day as 
when the care they need is deemed medically necessary. In addition, 
Veterans reporting or identified as being in crisis, including 
suicidality, will receive an immediate crisis response. When Veterans 
call for a new mental health appointment, they will receive a suicide 
risk screening and immediate care, if needed. Veterans already engaged 
in mental health care identifying a need for urgent attention will 
speak with a provider that same day.
    We will accomplish this through a firm commitment to our 
foundational principles, known as the MyVA Access Declaration. These 
foundational principles support our collective commitment to our 
Veteran population and serve as a pledge to Veterans regarding their 
ability to access care in a timely manner. The MyVA Access Declaration 
is as follows:

    1.  Provide timely care, including same-day services in Primary 
Care, as needed;
    2.  Provide timely Mental Health care, including same day services, 
as needed;
    3.  Provide Veterans medically necessary care from another VA 
Medical Center while away from their primary facility;
    4.  Respond to routine clinical inquiries within 2 business days;
    5.  Offer appointments and other follow-up options upon leaving a 
clinic;
    6.  Actively engage Veterans for timely follow-up if a clinic is 
canceled due to unforeseen circumstances;
    7.  Integrate community providers, as appropriate, to enhance 
access;
    8.  Offer Veterans extended clinic hours and/or virtual care 
options, such as Telehealth, when appropriate; and
    9.  Transparently report access to care data to Veterans and to the 
public.

    Dr. Shulkin recognizes VHA medical facilities' efforts, the 
collective commitment to the above MyVA Access Declaration, and the 
need for additional support to achieve same day access to care. 
Accordingly, he charged a team of clinical and administrative field and 
central office leaders to identify, evaluate, and recommend high impact 
solutions for application across the health care system. Multiple high 
impact solutions were selected for rapid deployment.
    Local deployment of these solutions is supported by VHA's Veteran 
Engineering Resource Center (VERC). VERC's mission is to facilitate 
innovative solutions to health care delivery challenges identified by 
national, network, and facility leadership, as well as to propose 
important opportunities for change and improvement. In support of MyVA 
Access, the VERC provides a continuum of support, including face-to-
face training and support to the VHA medical facilities as they 
implement the solutions critical for improving access. Local deployment 
is also supported by other trained improvement professionals, such as 
Systems Redesign Coordinators, Transformation Coaches, and other 
internal subject matter experts.

    Specific planned accomplishments prior to December 2016 include:

      MyVA Access VERC partners are engaging VHA health systems 
and coordinating implementation planning through local leadership 
teams.
      In May 2016, VHA's Office of Operations and Management 
commenced training to 116 Group Practice Managers (GPM) from 92 VHA 
facilities across the country. GPMs provide oversight of all VA Medical 
Facility Ambulatory Care Services, including Primary Care, Mental 
Health, Specialty Care, and outpatient surgical clinics. This oversight 
includes resource utilization, patient scheduling, Veteran access, and 
clinic efficiency. GPMs facilitate critical discussions related to the 
clinical practice and identify potential alternatives and subsequent 
outcomes.
      The GPM training focused on the tools and resources 
needed for successful clinical operations management. Topic areas 
included open access in primary care, optimizing the health operations 
dashboard, and meeting the mental health needs of Veterans in a timely 
manner. The training will continue in August 2016.
      VSE will begin implementation in late 2016 and will 
facilitate Veteran-centric and consistent experience when scheduling 
follow-up appointments. The scheduler is able to quickly and easily see 
multiple clinic profiles in one calendar view, and the enhanced 
graphical user interface allows users to seamlessly navigate through 
the scheduling process. An improved reporting structure will also 
create a quick report to measure and track supply, demand, and 
utilization.
      Direct Scheduling for audiology and optometry will be in 
place nationally by December 2016. Through direct scheduling, audiology 
and optometry clinics will be able to immediately see Veterans upon 
request, without first requiring a consult from their primary care 
provider.
      The Telemental Health Hub Expansion initiative includes 
four regional hubs that have defined relationships with several 
facilities with particular challenges in their ability to provide 
timely mental health care. The first hub will begin providing services 
on zJune 6, 2016, and the other hubs will commence later this summer. 
All hubs will be operational by the end of the calendar year.

    Question 14: Has VA conducted any analyses of its capacity, 
including health care providers, specialty services, and other needs, 
by facility, and if so, what do these analyses show, and what are VA's 
plans for ensuring adequate capacity?

    VA Response: Yes. VA assesses the capacity and staffing of each VA 
medical facility. Establishing, filling, and projecting requirements 
for VA's health care system is a complex task. There is no ``one size 
fits all'' solution, making it particularly challenging for VA's large 
health care system. Many factors influence the ability of VA to meet 
the critical needs of a medical facility. Specifically, Primary Care 
panel capacity varies by facility, but, as of May 2016, the average is 
88 percent. This means that approximately 740,000 additional Veterans 
can be accommodated at present staffing levels. Currently, 33 sites are 
above 95 percent of capacity, with 8 of them over 100 percent. As 
demand increases, sites generally add Primary Care teams within local 
constraints on budget, space, and recruitment ability.
    VHA has taken a number of steps in recent years to improve clinical 
staffing management of medical professionals and support staff. This 
includes establishing team based, patient-centered care, development of 
productivity standards, and integration of workforce and succession 
planning.

    Question 15: The GAO report discusses the lack of a comprehensive 
national scheduling policy, which has contributed to at least some of 
the observed scheduling problems. In your response to GAO's 
recommendation to finalize and disseminate such a policy, you noted a 
completion date of May 1, 2016. If the scheduling policy was rescinded 
in 2014, why has it taken so long to revise it? Further, what steps are 
you taking to ensure you will meet the May 1 completion date?

    VA Response: The Outpatient Scheduling directive was ready for 
review in February 2016; however, the directive had to be rewritten to 
include content from the handbook. The directive was submitted for 
review on May 20, 2016. In the meantime, the 2010 scheduling directive 
has not been rescinded. Once the 2016 directive is released, it will 
replace the 2010 scheduling directive.
    In the last four years, VHA has undergone changes that affected the 
policies and procedures in the directive. With the implementation of 
VSE, Veteran Appointment Requests, the Direct Patient Scheduling 
Application, the Choice initiative, and changes to performance 
measures, the directive has been under a constant state of revision. A 
scheduling directive stand down was held in Washington, DC, inviting 
individuals on a concurrence list to attend and review the draft 
directive. Following the stand down, 74 questions/comments from the 
group were forwarded for action. These questions/comments have been 
addressed in the current draft of the directive and are now awaiting 
final review. Once approved, the directive will return to concurrence 
for final signature.

    Question 16: The GAO report also recommended improved efforts to 
ensure newly enrolled Veterans requesting an appointment are contacted 
in a timely manner, and the importance of monitoring the full amount of 
time newly enrolled Veterans wait to be seen. In your response to the 
GAO's recommendations, you noted a completion date of December 31, 
2016. What steps are you taking to ensure you will meet the completion 
date?

    VA Response: Welcome to MyVA (W2MyVA) provides newly enrolled 
Veterans a warm welcome to VA, an overview of benefits for which they 
may qualify, and assistance with scheduling their first appointment by 
a warm transfer of the Veteran to the facility of their choice. After 
hours, the facility's phone number is provided to the Veteran to call 
at his/her convenience. Outbound calls are completed within 5 business 
days from the enrollment date.
    VA is developing a monitoring plan to gauge the ``Veteran Feel'' 
(how long it actually takes/overall time) from application to scheduled 
appointment. VHA will monitor timeframes on a consistent, frequent 
basis to detect deficiencies in the processes of providing newly 
enrolled Veterans with access to care. The National Elapsed Time report 
will be updated to calculate the time between application and 
appointment. Time frames will be monitored to improve visibility and 
accountability, allowing oversight of successful scheduling for newly 
enrolled Veteran appointments.
    Steps that are in place to meet the completion date include the 
following:

      Submit revised specifications to VSSC - target June 2016;
      Update W2MyVA Report and National Elapsed Time Report - 
target July 2016;
      Test the revised reports - target September 2016;
      Submit Communication Plan to VISN and facility level - 
target September 2016; and
      Complete revised W2MyVA Report and National Elapsed Time 
Report - target October 1, 2016.

    Question 17: Does VA know which facilities are in greatest need of 
using contracted, non-VA care, and does it know the specialties for 
which Veterans are most likely to use such care? If so, what plans are 
VA undertaking to ensure that these services are available on a 
contracted basis to Veterans and that Veterans receive timely access to 
this care?

    VA Response: There is very similar utilization of community care 
across VHA; however, the top 5 facilities utilizing community care 
include VAECHCS, the Kansas City VA Medical Center (VAMC), the Alaska 
VA Healthcare System, the Spark M. Matsunaga VAMC, and PVAHCS, which 
collectively encompass 11.4 percent of total utilization in FY2016 by 
all medical centers. There were two significant front runners for 
categories of care being requested: Ophthalmology and Optometry; 
closely followed by Primary Care and Physical Therapy.
    Based on data trends and forecasting, VA works with HealthNet and 
TriWest to identify and target specialties and providers of need. Both 
contractors have continuously worked with local VA medical facilities 
and VISNs to identify needed specialties and bring those providers into 
the network. As of May 2016, the Choice Provider Network has grown by 
85 percent. In April 2015, the network had 191,237 providers and 
facilities contracted. As of May 31, 2016, the network has 353,674 
providers and facilities contracted. In the event that either 
contractor is unable to provide the necessary service and returns the 
authorization to VA, VA may utilize Veterans Choice Provider Agreements 
in accordance with established protocol to purchase the care directly.

    Question 18: Does VA ever cancel Veteran applications for health 
care without receiving written authorization from the Veteran? If so, 
when is doing so proper?

    VA Response: In accordance with 38 Code of Federal Regulations 
Sec.  17.36(d)(5), a Veteran enrolled in the VA health care system will 
be disenrolled only if the Veteran submits a signed and dated document 
stating that the Veteran no longer wishes to be enrolled or VHA 
determines that the Veteran is no longer in a priority category 
eligible to be enrolled.

    Question 19: In Dr. Shulkin's written testimony, he stated that VA 
has ``gone to such lengths to make sure that we document every aspect 
of wait time data.'' How can VA say that it documents every aspect of 
wait time data when it only captures a small portion of the time a 
Veteran actually waits?

    VA Response: In the past, VA computed wait times for new patients 
based on the create date - the date on which an appointment was made. 
Under this method, a computer-generated time stamp was applied that did 
not reflect the Veteran's preference or what was deemed clinically 
necessary by a health care clinician. VA computed wait times for 
established patients using a desired date - the date the patient wanted 
to be seen or the date clinically indicated by a provider when the 
Veteran needs care.
    The create date time stamp may provide useful information for new 
patients but not for established patients. Our patient population is 
older and has more chronic conditions. As a result, a very large 
portion of appointments are ``return to clinic.'' For example, if a 
Veteran sees a doctor for diabetes and the doctor wants a follow-up 
appointment in 6 months, it doesn't make sense to report that as a 180 
day wait time. While the follow-up care would be delivered at the 
clinically appropriate time, it would inaccurately inflate a facility's 
wait time average. A Veteran could see extraordinarily long wait times 
at a facility due to this inflation and may be discouraged from seeking 
care there. The desired date time stamp must be further defined based 
on the source of the appointment request. However, reporting wait times 
based on create date in addition to our current, more appropriate, 
practice would risk creating even more confusion. VA now uses the CID 
for provider driven appointment requests and PD for patient driven 
requests.
    As VA refocused its efforts on Veterans' perceptions, VA sought 
best practices from several industry experts, Veterans, and Veteran 
service organizations to develop a wait time metric that balances 
Veterans' preferences and provides the best clinical care. VA 
determined that the preferred date would be used for all patients and 
reported in a consistent manner, as it most accurately reflects the 
Veteran's and physician's preference.
    As the health care industry and private sector have demonstrated, 
patient wait time data is but one of many indicators used to monitor 
access and measure customer satisfaction. VHA is now utilizing realtime 
Veteran responses to access - a system called VetLink, where Veterans 
check in at kiosks and are asked if they were satisfied with their 
ability to get an appointment on time. Our VetLink data shows that 
Veterans who were surveyed at the time of clinic check-in report that 
they are satisfied or very satisfied with their scheduled appointment 
nearly 90 percent of the time. In our new survey of Care in the 
Community, 85 percent of Veterans were satisfied with their experience 
of Care in the Community and 77 percent scored their VA Community Care 
Provider an 8 or higher on a scale of 10.

    Question 20: In his testimony, Dr. Shulkin stated VA is planning to 
measure access to care by simply asking Veterans whether they were 
satisfied with being able to get care when they need it. How will such 
a vague, subjective standard alone provide more accurate data than also 
objectively monitoring the full time a Veteran waits for care?

    VA Response: We recognize that Veterans are still waiting too long 
for care. However, in an effort to determine how we can better meet 
Veterans' needs, Veteran satisfaction is an essential and complementary 
component. Veterans have expressed that wait times are not the only 
worthwhile indication of their experience with VA, and that's why we 
must transform the way we do business. We have learned that figures 
measuring the wrong metric can cause unintended consequences and 
confusion, like the 14 day metric in 2014 that was central to employees 
working to a metric rather than the real needs of patients. Further, 
arbitrary wait time metrics, alone, are clinically irrelevant. For 
example, if a patient's condition requires an appointment within a 
week, a 14 day wait is a failure, albeit within the stated limit. VA 
will not do away with wait time metrics, but we must expand how we 
assess access, in the same way the private sector does.
    VA is working hard to increase access to care. We have hired more 
doctors and nurses; increased clinic space; extended clinic hours; and 
worked more closely with community providers to refer Veterans. 
Additionally, we focus first on patients with the most urgent health 
care needs. To improve customer service, VA is collaborating with 
private sector companies known for providing positive experiences to 
their customers to understand how we can ensure the highest quality 
care to the Veterans we serve. Hearing directly from Veterans that we 
are effectively serving them is the best gauge of success.
    VHA is the only health care system in the country that publicly 
reports wait times, but we have also come to realize the shortcomings 
in how this figure was captured in our scheduling systems. For 
instance, we cannot readily distinguish appointments for urgent needs 
(for which same or next-day access is critical) from appointments for 
routine check-ups or follow-up. Nor can we parallel our performance 
with private sector providers, because they do not routinely collect or 
publish comparable data. At best, our wait time metric is an 
``operational indicator'' that we will continue to use on a daily basis 
to address the match between patient demand and capacity to deliver 
care.
    We made the commitment in 2016 to use feedback from the Veterans we 
serve as our most important accountability measure for Access. We have 
adopted the Consumer Assessment of Healthcare Providers and Systems 
(CAHPS) patient survey, which is the industry standard used by every 
large integrated health care delivery system in the United States. The 
CAHPS survey includes several questions about Veteran's experience 
getting care for routine and urgent needs over the prior 6 month 
period. We know, from CAHPS, that Access is a problem for a significant 
proportion of our Veterans, although they do give us high marks for the 
quality and comprehensiveness of our care once they are seen. Asking 
the Veteran what their experience with Access has been will ensure our 
efforts will stay truly focused on their needs. This Veteran-centric 
approach to assess Veteran satisfaction is also in line with the MyVA 
Access Declaration Statement principles.

QUESTIONS FOR THE RECORD FROM CONGRESSWOMAN JACKIE WALORSKI

    Question 1: VA has stated that IT scheduling software was the 
reason for manipulated wait times, but as we discussed in the April 14 
joint Subcommittee hearing, this is a self-inflicted wound. Will VSE 
and VSR prevent employees from manipulating data, and will it have 
audit controls that cannot be shut-off so that any changes are 
documented?

    VA Response: VSE is VA's new scheduling software. Among other 
things, it will change the business processes that schedulers use to 
make, cancel, and reschedule appointments. These updated business 
processes are anticipated to make scheduling more reliable in VA, 
reduce scheduling errors, and eliminate scheduling manipulation. 
Specific process improvements will include:

      Eliminating the ability to ``zero out'' appointments:
    - In legacy VistA, the application allows schedulers to first enter 
a preferred date and then search for available appointment slots. Once 
available slots are found, the scheduler can go back and change the 
preferred date to match the open appointment slot. This is known as 
``zeroing out'' waiting times.
    - VSE does not allow zeroing out appointments. In VSE, the first 
step is to create an appointment request document by entering the date 
the patient wants or needs to be seen. Once entered, the date cannot be 
changed. The second step is to display the calendar and make the 
appointment. Even if multiple calendar queries are necessary to find an 
open appointment date in the calendar, the original preferred date 
remains ``greyed out'' and unable to be changed.
      Improving the accuracy of lists:
    - In legacy VistA, when an appointment is made from any of numerous 
lists, the scheduler must both make the appointment and intentionally 
remove the patient request from the list. If the scheduler fails to 
remove the patient from the list, duplicate appointments may be made.
    - VSE consolidates all of the current waiting lists (Appointment, 
Electronic Wait List, Consults, New Enrollee Appointment Request, and 
Recall) into a single request queue. Appointments may only be made by 
opening the request from the consolidated list. Appointment creation in 
VSE automatically closes out the request resulting in improved accuracy 
of the ``lists.''
      Eliminating cancellation by clinic errors:
    - In legacy VistA, when a user cancels a patient by clinic, they 
must write down the CID/PD on a piece of paper. Then the user makes a 
new appointment and transfers the CID/PD manually to the correct field 
in the new appointment. This is the standard way that the correct CID/
PD is preserved.
    - In VSE, when the user chooses cancel by clinic, the original CID/
PD is ``greyed out'' and preserved. The cancellation request then 
reverts to the request list. When a new appointment is made from that 
request, the original CID/PD is automatically entered into the new 
appointment.
      Improving the accuracy of CID/PD for multiple book 
appointments:
    - In legacy VistA, when making sequential appointments, for 
example, for group clinics, the CID/PD from the first appointment in 
the sequence was used as the reference point for each subsequent 
appointment. This inflated wait time measurements.
    - In VSE, when making sequential appointments, the CID/PD is 
entered once when making the first appointment in the sequence and the 
computer calculates the correct CID/PD for each subsequent appointment. 
If future appointments in the sequence are cancelled and rescheduled, 
the correct CID/PD is used for the rescheduled appointment.
      Eliminating ``next available'' errors:
    - In legacy VistA, the user must respond to the question ``is this 
a next available appointment?'' If the user answers ``yes,'' the CID/PD 
is set to ``today.'' If the user answers ``no,'' the CID/PD must be 
entered by the user. The easiest way to use legacy VistA is to respond 
``yes'' to this question, artificially inflating wait times.
    - In VSE, the workflow is totally redesigned. The user enters the 
CID/PD as a first step. Once entered, it cannot be changed. When 
entered correctly, the application displays the appropriate times on 
the calendar, making appointing more efficient.

    However, we recognize that a technical response, alone, will not 
serve to develop a premium Veteran-centric mindset in VA employees. To 
foster enthusiasm for Veteran service in VA's workforce, VA will 
implement structural processes to reinforce a high performing ethos 
with passionate leadership. In the fall of 2014, the Secretary of 
Veterans Affairs, Robert A. McDonald, announced the transformational 
initiative, MyVA, with an emphasis on executing and cascading 
principles embedded in the 2014-2020 Strategic Plan. Wait time goals 
were eliminated from network and facility directors' performance plans, 
and managers will be trained to use performance indicators, goals, and 
awards that are appropriate for the Veteran service environment. This 
will help VA leaders to use performance data in the appropriate way, to 
identify challenges and begin a conversation about root causes and 
potential remedies; not as input solely for punishment and reward.
    To address Secretary McDonald's MyVA Breakthrough Priority of 
improving employee experience, the Leaders Developing Leaders program 
was established. Leaders Developing Leaders will transform VA from a 
rules-based to a principles-based organization by developing authentic 
servant leaders. Leaders Developing Leaders will reach approximately 
7,300 VA leaders and front line staff and will result in more than 400 
projects to strengthen leadership skills and enhance the culture of VA.
    As leaders and their teams adopt this mindset and put it into 
practice, teams will experience greater levels of trust, engagement, 
and enhanced productivity. The MyVA ultimately effect culture change 
within the organization that is more closely aligned to, and more 
effectively supports, long-term organizational goals and innovation.

    Question 2: A VA Policy from the Northern Indiana Health Care 
System states that a Primary Care Provider ``has no obligation to 
follow a treatment plan or medication provided by the community 
provider if they disagree with the plan..'' How is that Veteran-
centric? Are VA physicians required to at least contact the Choice 
provider to discuss the recommended treatment and coordinate any 
changes prior to substituting their own treatment? If not, why not?

    VA Response: There is both a VHA policy and a local policy that 
outline processes for co-management of patient care. Outlined in the 
Plan to Consolidate Programs of Department of Veterans Affairs to 
Improve Access to Care report, care coordination for all Veterans in 
the future will fall along a continuum of intensity, from basic care 
coordination or patient navigation to care or disease management to 
case management. This continuum is influenced by a variety of factors: 
the complexity of clinical conditions, Veteran preference for 
engagement, the primary care provider, and the care setting. VA 
currently offers many diverse care coordination programs that can be 
difficult to understand and navigate, but we plan to consolidate these 
programs into an integrated, enterprise-wide model implemented locally. 
As care coordination matures at VA, it will be provided as a service to 
community providers who care for Veterans in need of more intensive 
coordination. The impact of this coordination continuum is to enable 
Veterans to receive the type of care management and coordination 
necessary to achieve positive health care outcomes.

    Question 3: At the Marion VAMC, a Veteran with Alzheimer's was seen 
by a non-VA specialist. That physician prescribed non-formulary 
medication that VA then would not authorize. VA required its formulary 
drugs to be tried first, with suitable time for evaluation for each of 
these drugs separately, before allowing a non-formulary request to even 
be considered. How is that Veteran-centric? Are VA physicians required 
to first contact the non-VA specialist to discuss the situation? If 
not, why not?

    VA Response: As with all other VA medical centers, the Marion VAMC 
has a policy which requires providers to first prescribe medications 
that are on our formulary. If a request is made to utilize a non-
formulary medication, either by a community provider or a VA provider, 
we first see if we have a suitable medication on our formulary that has 
the same indication and efficacy. If it is found that a formulary 
medication is either not tolerated or is insufficiently efficacious, 
then a provider may request a medication that is not on the VA 
formulary.
    VHA would happily provide more specific information regarding this 
Veteran if more details and a privacy release from the Veteran are 
provided. In addition, VHA could ensure ongoing coordination of 
services for this Veteran.

    Question 4: In another example, a disabled Veteran rated at 60% for 
back and nerve damage has been denied for care closer to home and 
instead VA is requiring the Veteran to drive 64 miles round trip three 
times a week for treatment at VA. How is this Veteran-centric care?

    VA Response: VHA would happily provide more specific information 
regarding this Veteran if more details and a privacy release from the 
Veteran are provided. VA authorizes care in the community in accordance 
with applicable law, including the Choice Act, and VA policy. With 
respect to VCP, Veterans may be eligible based on wait-times, 
residence, or because they face an unusual or excessive burden in 
travel. Eligibility determinations based on the unusual or excessive 
burden criterion are made at the local level based on the particular 
facts of the Veteran's circumstances.

    Question 5: In Evansville, Indiana, VA staff discussed a provider 
staffing shortage that required the Call Center to stop making and/or 
rescheduling appointments for primary care. The facility specifically 
indicated ``appointment slots are limited, and we are hoping this will 
decrease the amount of movement of the patients.'' This is alarming. 
Please tell me what VA Central Office is doing to correct these types 
of actions.

    VA Response: Capacity at the Evansville Health Care Center is 
adversely affected by five Patient Aligned Care Team (PACT) clinician 
vacancies. To assure patients are scheduled appropriately, appointments 
are triaged by clinical staff so that each Veteran's needs are properly 
addressed through the correct appointment type. Types of appointments 
include face-to-face appointments with a provider; phone appointments 
with a provider; appointments with ancillary services as indicated; 
appointments at other locations; or CHOICE.
    Calls to the Evansville Health Care Center (HCC) do not go through 
the Call Center. The facility uses the nationally approved call tree 
for Primary Care and calls go directly to the clinic. If the extension 
is busy, the call will route to the next available clinic in the 
Primary Care queue. In the event a Veteran would call the Marion VA 
Medical Center number and request to speak to an Evansville HCC clinic, 
the call would be transferred to the appropriate location with a warm 
hand-off or a message entered in the Computerized Patient Record System 
for the clinic to return the call to the Veteran.

    Question 6: The Evansville VA has assigned Veterans to ``vacant 
panels,'' which, according to a whistleblower, means there is a 
documented appointment but no doctor to see the Veteran. Why are these 
patients not sent to Choice?

    VA Response: Evansville HCC currently has five PACT clinician 
vacancies and two float position vacancies. Provider vacancies resulted 
from clinician retirement, transfer, or separation. No new Veterans 
have been assigned to panels without a provider to see the Veteran. For 
Veterans previously assigned to a vacant panel, several options for 
appointment are offered to each Veteran:

      The six staffed PACT teams utilize two slots a day for 
appointments for Veterans assigned to vacant panels.
      Vacant panels are clinically reviewed to determine how 
best to meet each Veteran's needs - through face-to-face or phone 
appointments with PACT or appointments with an ancillary service such 
as Behavioral Medicine, Social Work, Nutritionist, etc.
      If appointments are not available on the Veteran's 
preferred date, the Veteran is offered an appointment at other 
Community Based Outpatient Clinic locations.
      If no other location with earlier appointments is 
acceptable to the Veteran, the Veteran is offered the next available 
appointment at the Evansville HCC. If the wait time is greater than 30 
days, the Veteran is offered community care through VCP.

                                 
         Letter From Michael J. Missal to Chairman Jeff Miller
    The Honorable Jeff Miller Chairman
    Committee on Veterans' Affairs United States House
    of Representatives Washington, DC 20515

    Dear Chairman Miller:

    At the Committee's April 19, 2016, hearing on ``A Continued 
Assessment of Delays in Veterans' Access to Health Care,'' the Office 
of Inspector General (OIG) indicated that it would provide additional 
information in response to questions asked by Congressmen Hueslkamp, 
Coffman, and Abraham regarding the number of OIG referrals made to the 
U.S. Department of Justice in connection with our investigations into 
allegations of manipulation of appointment wait times throughout the 
Veterans Health Administration. Additionally, Congressman Abraham 
inquired about the scope of the OIG's work in response to allegations 
of secret wait lists at the Edward Hines, Jr., VA Hospital in Hines, 
Illinois, and the Overton Brooks VA Medical Center in Shreveport, 
Louisiana. Enclosed is our response to those questions.

    Thank you for the opportunity to provide this information for the 
hearing record.

    Sincerely,

    MICHAEL J. MISSAL

    Enclosure

    Copy to: The Honorable Corrine Brown, Ranking Minority Member
    The Honorable Tim Huelskamp
    The Honorable Mike Coffman
    The Honorable Ralph Abraham

                                 
                    Additional Questions and Answers
    Mr. Huelskamp: I understand we had 58 cases referred to the 
Department of Justice for possible criminal charges. What has the 
response been from the Justice Department for those 58 criminal cases 
and the disposition of those?

    Mr. Coffman: How many criminal referrals occurred of people who 
were involved in this [wait times] scandal?

    Mr. Abraham: Were there any criminal charges that were sent up to 
the DOJ for prosecution that you know of?

    OIG Response: The VA Office of Inspector General (OIG) opened 116 
investigations at 100 unique Veterans Health Administration (VHA) sites 
regarding allegations that wait times for outpatient appointments were 
manipulated to give the appearance of a shorter wait for care or that 
consult appointments were inappropriately cancelled with apparent false 
justifications. We opened more than one investigation at some 
individual VHA facilities when allegations appeared to be unrelated 
schemes.
    To date, the OIG made formal referrals to the Department of Justice 
for 57 of the 116 investigations. Federal prosecutors indicated that 51 
of the investigations do not warrant further consideration. Opinions 
regarding prosecutorial merit for four investigations are currently 
pending. One case was accepted for prosecution in Georgia, and the 
defendant, Cathedral Henderson, was indicted on July 8, 2015. \1\ The 
trial in this case is scheduled for May 23, 2016. A second case, which 
initially started as a wait times investigation but became a conflict 
of interest case, was accepted for prosecution, and the defendant, 
Sharon Helman, pled guilty on March 1, 2016, to making a false 
statement.
---------------------------------------------------------------------------
    \1\ http://www.justice.gov/usao-sdga/pr/va-employee-charged-
falsifying-medical-records-numerous- veterans.
---------------------------------------------------------------------------
    To date, we have referred supporting evidence or detailed memoranda 
regarding 81 sites to VA's Office of Accountability Review for any 
administrative action VA deems appropriate. In February 2016, we began 
releasing the findings of the completed investigations by state so that 
veterans and Congress could have a complete picture of the work 
completed in their state. To date, we have published 76 administrative 
summaries of investigation. As we continue to complete these 
investigations, we intend to post them to this webpage.

    Mr. Abraham: In a February 25, 2016, letter to the President from 
the Office of Special Counsel, [OSC] said that VA OIG investigations of 
whistleblower disclosures regarding wait times at Hines, Illinois, and 
Shreveport, Louisiana, which is in my state, were inadequate. OSC found 
that, ``the OIG investigations found evidence to support the 
allegations that the employees were using separate spreadsheets outside 
of the VA's electronic scheduling and patient record systems. However, 
the OIG largely limited its review to determine whether the separate 
spreadsheets were `secret.''' Please explain why the OIG limited these 
reviews?

    OIG Response: Thank you for the opportunity to explain this matter 
more fully. OSC has two specific functions under Title 5 U.S.C. Section 
1213 and 1214.

      Under Section 1213, OSC has the authority to accept 
complaints or disclosures of violations of law, rule, regulation, gross 
mismanagement, gross waste of funds, an abuse of authority, or a 
substantial and specific danger to public health and safety. OSC does 
not, however, have authority to investigate these allegations. If OSC 
determines that the matter should be investigated, OSC is required, 
within 15 days of receiving the allegations, to refer the matter to the 
head of the agency for investigation. For disclosures specific to VA, 
the Secretary of Veterans Affairs is the individual to whom the 
referral is sent under Title 5 U.S.C. Section 1213. Under the statute, 
the head of the agency is required to conduct an investigation and 
provide a written report that includes specific information defined in 
the statute within 60 days. The OIG does not receive Section 1213 
referrals from OSC and has no statutory responsibility to conduct an 
investigation or provide a written report to OSC. If the OIG has 
ongoing work relating to a Section 1213 referral, that work is provided 
to VA and may be the basis for VA's report to OSC.
      Under Section 1214, OSC has the authority to investigate 
allegations of prohibited personnel practices. When OSC conducts an 
investigation that requires the production of records maintained by the 
OIG, OSC sends a written request to the OIG's Information Release 
Office and the records are provided as allowed by statute. We are not 
aware of any request by OSC for documents that have not been timely 
provided to OSC pursuant to its Section 1214 authority.

    On June 5 and December 22, 2014, respectively, OSC, under its 
statutory authority granted under Title 5 U.S.C. Section 1213, referred 
allegations to the Secretary of Veterans Affairs for investigation 
concerning the Edward Hines, Jr., VA Hospital (Hines VA Hospital) in 
Hines, Illinois, and the Overton Brooks VA Medical Center (VAMC) in 
Shreveport, Louisiana. VA submitted its responses to OSC in July and 
August 2015, respectively. VA's responses to OSC relied on two prior 
OIG investigations conducted at each facility. In its February 25, 
2016, letter to the President, OSC opined that:

    ``The OIG investigations that the VA submitted in response to both 
referrals are incomplete. They do not respond to the issues that the 
whistleblowers raised. The OIG investigations found evidence to support 
the whistleblowers' allegations that employees were using separate 
spreadsheets outside of the VA's electronic scheduling and patient 
records systems. However, the OIG largely limited its review to 
determining whether these separate spreadsheets were ``secret.''

    However, neither of the OIG wait time investigations cited by OSC 
in its letter to the President was conducted in response to a Section 
1213 referral from OSC to the VA Secretary. In both cases, OSC made a 
Section 1213 referral to the VA Secretary months after the OIG 
investigations had begun.

Overton Brooks VAMC, Shreveport, Louisiana

    This OIG investigation was conducted in response to a complaint to 
the OIG Hotline on June 11, 2014, to which the complainant attached 
what was referred to as a ``secret wait list'' that was ``obtained from 
the Mental Health shared drive in Shreveport.'' The complainant alleged 
that a specific VA employee had ordered other employees that she 
supervised to ``not have clerks place persons on the electronic wait 
list and keep a separate list.'' The complainant stated that he ``got 
his hands on the list after a Nurse gave [him] her password to the 
list.'' The OIG interviewed the complainant on June 18, 2014, more than 
6 months prior to OSC's December 22, 2014, Section 1213 referral to VA. 
During that taped interview, the complainant stated that he did not 
have personal knowledge of the purpose of the list and told the 
investigators that other individuals had told him about the list. 
Further, the individuals the complainant identified as having knowledge 
of the ``secret list'' were interviewed but did not support the 
complainant's allegations. In this case, the OIG investigation did not 
substantiate the allegations the complainant raised in his OIG Hotline 
complaint. The allegations attributed to the complainant in the 
December 22, 2014, Section 1213 OSC referral to the Secretary were not 
raised by the complainant during the OIG investigation. In addition, 
neither the complainant nor OSC provided any documentation or other 
information to support the allegations in the Section 1213 referral.
    As discussed in the Administrative Summary of Investigation 
published on our website, the investigation was expanded proactively to 
look at wait time manipulation in non-mental health areas. Mental 
health was not included in the investigation because mental health 
issues were the subject of a separate health care inspection that was 
initiated in response to a September 19, 2014, request by the then 
Ranking Member of the Senate Veterans' Affairs Committee, Senator 
Richard Burr. During that inspection, additional issues relating to 
mental health were raised and made part of the inspection. The 
inspection report was published on the OIG website in January 2016, a 
month before OSC wrote a letter to the President.
    The OIG completed investigation was referred to VA's Office of 
Accountability Review (OAR) in August 2015. It is our understanding 
that VA then provided the required Section 1213 written report to OSC 
on or around August 26, 2015. Unfortunately, there were no 
communications between the OIG and OSC regarding the Section 1213 
referral to VA before or after VA sent the written report to OSC. In 
addition, we are not aware of any communications between OSC and VA 
regarding the written report between August 26, 2015, and OSC's 
February 25, 2016, letter to the President.

Edward Hines, Jr. VA Hospital, Hines, Illinois

    The OIG investigation at the Hines VA Hospital began in response to 
reports by various Chicago and national media outlets regarding 
``secret backlog lists.'' The media reports were generated by 
information provided to the media by a complainant. After seeing the 
media reports, the OIG immediately began an investigation. Beginning on 
May 14, 2014, OIG investigators made numerous attempts to interview the 
complainant. She agreed to be interviewed on May 27, 2014. In addition, 
on May 21, 2014, the OIG received a letter from Senator Mark Kirk 
requesting that the OIG investigate allegations that ``veterans at the 
Hines VA facility were provided informational briefings and general 
consultations in lieu of medical care in order to meet the VA's 
mandated fourteen-day window for appointments.'' In addition, Senator 
Kirk advised that his office had ``received additional reports that 
veterans seen within the fourteen-day window were sometimes not able to 
see a doctor, and instead met in group consultation/informational 
sessions without actually receiving medical care.'' Senator Kirk 
requested that the OIG investigate three specific issues, which are 
addressed in our Administrative Summary of Investigation. OSC did not 
submit a Section 1213 referral to the Acting VA Secretary until June 5, 
2014, after our investigation into the complainant's allegations and 
Senator Kirk's request for an investigation had begun.
    As noted in our Administrative Summary of Investigation relating to 
the Hines VA Hospital that is published on our web site, during the 
interview the complainant made a number of allegations but did not 
provide documentation or other information to support her allegations. 
The complainant did provide two emails that she claimed supported the 
allegations; however, investigative interviews with the authors of the 
emails did not support the complainant's claim. The complainant 
admitted to having no personal knowledge of any other scheduling 
manipulations or improprieties at the Hines VA Hospital or first-hand 
knowledge of patient deaths or drastic changes in patient conditions 
relating to wait times or scheduling manipulation at Hines. Although 
the complainant stated that they had been contacted by 20-25 people who 
claimed to have knowledge of these issues, the complainant refused to 
provide names or further information such as details of these contacts. 
Further, the complainant also claimed to have relevant documentation 
but refused to provide it without written assurance that they would not 
be held responsible for violating the Health Insurance Portability and 
Accountability Act, an assurance the OIG has no authority to make. In 
addition, the complainant specifically denied that they had any 
additional emails, documents, or evidence to provide. Despite the fact 
that the allegations lacked specificity and the complainant could or 
would not provide any supporting evidence, the OIG conducted an 
investigation of the allegation relating to the mental health service 
and an investigation into scheduling issues in other clinical areas.
    The June 5, 2014, Section 1213 referral to VA consisted of general 
allegations from the complainant but also lacked specificity, 
investigative leads, and supporting documentation. In addition, the 
discussion in the referral letter did not include the names of the 
employees who complained to the complainant or would have relevant 
information, the names of the supervisors who engaged in the conduct, a 
specific date or timeframe during which the conduct occurred, or a 
specific clinic. Although several services were listed, the list is 
followed by ``and other units.'' Such vague allegations coupled with 
the fact that the complainant did not provide more specific information 
to the investigators rendered it difficult, if not impossible, to fully 
investigate.
    OIG work at the Hines VA Hospital was not limited to wait time 
allegations. In April 2014, we issued a report concerning unnecessary 
cardiac interventions and poor management of cardiovascular care. We 
are currently doing follow-up work on this issue. In the original work, 
we engaged the services of consultants, including a non-VA thoracic 
surgeon to review patient records and to identify if any patients were 
harmed. In the follow-up work, we engaged a non-OIG consultant to 
assist in the evaluation of clinical cases.
    The Hines VA Hospital investigation was sent to VA's OAR on January 
26, 2015. It is our understanding that VA provided OSC with a written 
report compliant with Section 1213 in September 2015. It was not until 
we saw OSC's letter to the President that we learned OSC had concerns. 
There was no communication between OSC and OIG staff regarding this 
matter.

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