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


ACCESS AND ACCOUNTABILITY: EXAMINING OBSTACLES TO HIGH	QUALITY PATIENT 
                           CARE IN LOUISIANA

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

                             FIELD HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         MONDAY, JUNE 20, 2016

               FIELD HEARING HELD IN PINEVILLE, LOUISIANA

                               __________

                           Serial No. 114-74

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
 
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       
       

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
25-208                      WASHINGTON : 2017                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected].                      
                     
                     
                     
                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority 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

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

                              ----------                              

                         Monday, June 20, 2016

                                                                   Page

Access And Accountability: Examining Obstacles To High-Quality 
  Patient Care In Louisiana......................................     1

                           OPENING STATEMENTS

Honorable Dan Benishek, Chairman.................................     1
Honorable Ralph Abraham, Member..................................     3
Honorable John Calvin Fleming, House of Representative, 
  Louisiana's 4th District.......................................     3

                               WITNESSES

Charles Hunter, Veteran..........................................     4
Gordon Ryder, Father of Gerrit Paul Ryder, deceased..............     6
    Prepared Statement...........................................    33
Carroll Knott, Member and Former State Commander, Veterans of 
  Foreign Wars of the United States..............................    10
    Prepared Statement...........................................    35
Asbel Montes, Vice President, Reimbursement and Government 
  Affairs, Acadian Ambulance Service.............................    12
    Prepared Statement...........................................    36
Homer Rodgers, Under Secretary, Department of Veterans Affairs, 
  State of Louisiana.............................................    20
Janet L. Henderson, M.D., Chief Medical Officer, South Central VA 
  Health Care Network (VISN 16), Veterans Health Administration, 
  U.S. Department of Veterans Affairs............................    21
    Prepared Statement...........................................    37

        Accompanied by:

    Shannon Novotny, MPA, FACHE, Acting Deputy Network Director, 
        South Central VA Health Care Network (VISN 16), Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

    Peter C. Dancy, Jr., Medical Center Director, Alexandria VA 
        Health Care System, South Central VA Health Care Network 
        (VISN 16), Veterans Health Administration, U.S. 
        Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

Congressman Charles Boustany, Jr., M.D...........................    39
American Medical Response........................................    40
Veteran ACTION Coalition of Southwest Louisiana (VACSWLA)........    45

 
ACCESS AND ACCOUNTABILITY: EXAMINING OBSTACLES TO HIGH-QUALITY PATIENT 
                           CARE IN LOUISIANA

                              ----------                              


                         Monday, June 20, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 3:00 p.m., in 
Pineville City Council Chambers at Pineville City Hall, 910 
Main Street, Pineville, Louisiana, Hon. Dan Benishek [Chairman 
of the Subcommittee] presiding.
    Present: Representatives Benishek and Abraham.
    Also Present: Representative Fleming.

          OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN

    Mr. Benishek. Hello? Can you hear me now? The Subcommittee 
will come to order.
    Before I begin, I would like to take care of one minor 
procedural detail, and that is, I ask unanimous consent for 
Congressman John Fleming to sit at the dais and participate in 
today's proceedings. So, without objection, so ordered.
    With that out of the way, thank you all for joining us 
today. I am Dr. Dan Benishek, and I am the Chairman of the 
Subcommittee on Health for the Committee of Veterans' Affairs 
of the United States House of Representatives.
    And I also represent the Michigan's First District. That is 
the northern half of Michigan. It is half the State of 
Michigan. It is a very rural district, very much like this 
district in Louisiana. You have got a bigger challenge in your 
district than I have in mine, but the problem of rural veterans 
living far away from a major medical center is very near and 
dear to my heart. So I understand what is going on.
    I also worked at the VA for 20 years as a consultant. I am 
a general surgeon, and I took care of veterans there for a long 
time. I am not a veteran myself. My daughter is a 5-year 
veteran of the Teddy Roosevelt, served two war cruises.
    I am here today, joined by your congressman, Dr. Ralph 
Abraham. Of course, you know Dr. Abraham. He is sort of a jack 
of all trades. He is a veteran, a doctor, a veterinarian, a 
pilot, and lucky for us, a Member of the Subcommittee on 
Health, where his experience and input is vital to the work 
that we do to improve the care that veterans receive here in 
Pineville and across the country.
    Dr. Abraham, thank you so much for inviting me to Louisiana 
today--
    Mr. Abraham. You are welcome.
    Mr. Benishek [continued].--and for all the work that you 
do.
    I want to thank Dr. John Fleming for joining us this 
afternoon. Dr. Fleming is also a veteran and a doctor, and I am 
grateful for his service and his attendance here this 
afternoon.
    Before I go any further, I would ask that all veterans in 
our audience today please stand, if you are able, or raise your 
hand and be recognized.
    [Audience response.]
    [Applause.]
    Mr. Benishek. Thank you so much for your service.
    Ensuring that you and your veteran family, friends, 
neighbors, and colleagues, both near and far, have timely 
access to high-quality health care through the Department of 
Veterans Affairs is the sole mission of the Subcommittee on 
Health. And while we have certainly made progress on that 
mission, we have a long way to go.
    During today's hearing, we will discuss the care that is 
provided to Louisiana's veterans through the Alexandria VA 
Health Care System. Prior to running for Congress, as I said, I 
was a physician there, and I know firsthand the challenges that 
involved working for the VA, the Nation's second-largest 
Government bureaucracy.
    I am sure the vast majority of the employees at the 
Alexandria VA Medical Center come to work every day and do 
their very best for their patients, and for that, I thank them. 
However, the testimony that will be provided by the veterans, 
family members, and other advocates this afternoon clearly 
illustrate a facility in need of improvement.
    Perhaps nowhere is that more clear than in the devastating 
testimony of Mr. Gordon Ryder. Mr. Ryder's testimony details 
the final year in his son Gerrit's life, and show instance 
after instance where VA fell tragically short of its mission. 
His statement concludes by noting that, ``We have seen all too 
often, at best, the VA moves at a snail's pace. The rest of the 
world is watching DVDs, and they are stuck on cassette tapes.''
    Mr. Ryder, please accept, on behalf of all of us, our 
heartfelt condolences on the loss of your son.
    Mr. Ryder. Thank you.
    Mr. Benishek. Thank you for being here today to share his 
story, for helping us improve the system that so badly failed 
him.
    This afternoon, we will also discuss the 2013 case of an 
Alexandria VA Health Care System employee who was involved in a 
physical altercation with a veteran patient who later died. 
Though the VA's internal investigation found no wrongdoing, 
that employee was arrested for manslaughter in December of 2013 
and spent the next 2 years on administrative leave.
    That means that for 2 years, this employee continued to 
collect a taxpayer-funded paycheck without once reporting to 
work or providing any benefit to our veterans. That would never 
happen in the private sector, and it shouldn't happen in the VA 
either.
    The Committee continues to fight for increased 
accountability within the VA system, and stories like this one 
underscore just how important that fight is. The Committee has 
also worked to streamline and improve VA's community care 
program so that veterans have access to care when and where 
they need it most, whether that is in a VA medical facility or 
a community hospital.
    It is important to remember that the effects of VA's 
inefficiencies and lack of accountability are felt beyond the 
walls of a medical facility. Non-VA health care providers who 
try to serve veteran patients often wait exorbitant amounts of 
time before they are reimbursed by the VA, if they are 
reimbursed at all. That is not an appropriate or respectful way 
for Government to do business, and it often results in 
decreased access to care for veteran patients who need it.
    I look forward to our discussion this afternoon, and taking 
your thoughts and ideas back to Washington when we leave.
    Thank you all for being here this afternoon, and with that, 
I will recognize Representative Abraham for a brief statement.

          OPENING STATEMENT OF HONORABLE RALPH ABRAHAM

    Mr. Abraham. Thank you, Dr. Benishek.
    Just a quick note to everyone in the audience, thanks for 
being here. I know you took time and treasure in some cases to 
be here at this particular time. So much appreciated, and I 
assure you something good will come out of this hearing for 
sure.
    Dr. Benishek has come down from Michigan, Dr. Fleming. Both 
of these gentlemen are my friends. They have been my mentors, 
and their presence here just raises this to a whole higher 
level, in my opinion. So good people on my left and right. Good 
people in the audience.
    So, Dr. Fleming, Dr. Benishek, thank you so much. I yield 
back.
    Mr. Benishek. Thank you.
    Dr. Fleming, you are recognized.

       OPENING STATEMENT OF HONORABLE JOHN CALVIN FLEMING

    Mr. Fleming. Thank you, Mr. Chairman, for recognizing me, 
and it is great to see you all this afternoon.
    We have all lived through the many, many reports throughout 
the last 3 or so years of veterans who have been denied access 
to care, a long list that turns out were not lists at all 
because many veterans weren't even on a list, only to find out 
that some of them pass away, leave us without even the first 
opportunity to get treatment. So we are saddened by that.
    We have sent money to bolster the VA, the VA hospital 
system to try to improve care. And to be honest with you, we 
have not seen much in the way of results. We passed a bill of 
accountability from the House. It has not been taken up or 
passed from the Senate, and the President doesn't seem to be 
interested in signing it into law.
    So having said all of these things, we will continue 
working daily to make the VA accountable, to be sure that 
people who are not doing their job should be fired, people who 
are breaking the law should be prosecuted, and we will continue 
that endeavor.
    And I very much thank my friends and colleagues here today 
for holding this very valuable field hearing, and I look 
forward to our discussion.
    Thank you, and I yield back, Mr. Chairman.
    Mr. Benishek. Thank you, Mr. Fleming.
    We will begin today's hearing with our first panel of 
witnesses, who are already seated at the table. I am going to 
yield to Congressman Abraham to introduce our witnesses, but 
first, I want to thank them all for their presence and 
participation here this afternoon and for the work that they do 
for our veterans.
    I would also like to gently remind all of today's witnesses 
to be mindful of the 5-minute time limit for your testimony and 
the question-and-answer period that will follow. The light 
here--this is something we live with in Congress--is that is 
green for a while, then it turns yellow. And then when it turns 
red, that means the time has expired.
    So we try not to be too strict, but in order to give 
everybody an opportunity and chance to speak, time goes by 
really fast. So we are going to try to be good with it. But 
thank you in advance for that consideration.
    And now, Dr. Abraham, can you introduce our panel for us?
    Mr. Abraham. Yes, thank you, Mr. Chairman.
    Starting from my left, moving to my right, Mr. Charles 
Hunter, joined by his wife, Glenda. Is that right? Okay.
    Mr. Gordon Ryder, joined by his wife, Brenda, father of 
Gerrit Paul Ryder, deceased, as you have heard.
    Carroll Knott, who is a member and former State commander, 
Veterans of Foreign Wars of the United States. Thank you, sir, 
for being here.
    Asbel Montes, vice president, reimbursement and government 
affairs for Acadian Ambulance Service. Good to see you again.
    Mr. Chairman, I yield back.
    Mr. Benishek. Thank you, Dr. Abraham.
    Mr. Hunter, we will begin with you. You are recognized for 
5 minutes.

                  STATEMENT OF CHARLES HUNTER

    Mr. Hunter. Yes, sir. May I have permission to let my wife 
speak for me? Because I would get up there and get to 
stuttering.
    Mr. Benishek. Say what?
    Mr. Hunter. I will get to stuttering, and I can't put it 
out.
    Mr. Benishek. Oh, yes. Do you want to do the testimony, 
Mrs. Hunter? That is fine.
    Mrs. Hunter. We wrote it all down, sir.
    Mr. Benishek. All right.
    Mrs. Hunter. Okay. I am going to real quickly.
    Mr. Benishek. No, no problem.
    Mrs. Hunter. In 2014, Charles went to the ER in Alexandria 
because of a callus on the great toe of his left foot. He was 
seen by the ER podiatrist. The doctor decided to do surgery on 
the toe. After the procedure, we returned the next week and for 
7 consecutive weeks.
    Each time, the doctor did surgery on the toe. Finally, the 
doctor decided the toe was not going to heal, and Charles 
subsequently developed gangrene. The doctor told us he was 
going to have to amputate. He said the toe, maybe the foot, and 
possibly the whole leg. I immediately asked for a second 
opinion because I felt this was pretty drastic.
    We were sent to Shreveport. The vascular surgeon was 
concerned because no test for circulation was done on Charles 
in Alexandria before any surgery. The next day, the surgeon 
tried to put in stents in Charles' abdomen without success 
because of poor circulation.
    He was shipped off to Houston, where two stents were put 
in, and his left leg was amputated because of the gangrene, 
above the knee. We were then turned over to Dr. Ferreras in 
Alexandria for wound care, where we received excellent care. 
Dr. Ferreras was very caring, a professional, and concerned for 
Charles. He was treated for several months by Dr. Ferreras and 
improved. Thank God for Dr. Ferreras.
    In 2015, Charles hit his toe on the other foot on a piece 
of furniture. We went to Dr. Ferreras. The toe became infected. 
The doctor treated the toe and immediately sent us to a 
vascular surgeon in Alexandria for additional stents in his 
right leg to try and save the toe.
    Unfortunately, this did not help, and once again, we had a 
gangrene issue set in. Dr. Ferreras was very concerned about 
the gangrene and said the toe had to be amputated immediately. 
However, it took us 3 weeks and many, many calls begging for 
admittance to the hospital. Finally, we contacted Congressman 
Abraham's office, and an angel there by the name of Donna 
intervened and helped us and got us approval.
    We were then told to go to our local emergency room at 
Opelousas General Hospital. They wouldn't even return our 
calls. It was just terrible. We saw Dr. Hargrove in the 
emergency room, and he immediately admitted Charles. Dr. 
Thibodeaux was called in to perform the surgery. He had to take 
Charles' entire foot, and then we spent 7 months in Opelousas' 
LTAC unit.
    Charles had a total of 7 surgeries and 70 hyperbaric 
treatments, which resulted in eardrum rupture. Unfortunately, 
the doctor had to amputate this leg above the knee.
    It is truly unthinkable that a 100 percent service-
connected disabled vet would receive such poor treatment. If 
Charles would have been admitted when Dr. Ferreras had 
requested immediate surgery, then he may not have lost his 
second leg. Dr. Thibodeaux put in two more stents. Charles 
could very well have lost his life, as well as both of his legs 
because of the gangrene and waiting 3 weeks, which is 
unthinkable.
    Charles had two emergency room visits to Memorial Hospital 
in Mississippi in the middle of the night because we thought he 
was having a heart attack. The cardiac surgeon admitted him 
through the emergency room, and the next day, two more stents 
were put in behind his heart. Unfortunately, we are now getting 
bills from the private doctors that the VA refuses to pay, and 
now we are in collection agencies, which is ridiculous for 
especially the 100 percent service-connected vet.
    Something needs to be done to help our veterans. We are 
still waiting for a consult to a retina specialist because of 
Charles' severe diabetes due to Agent Orange from Vietnam.
    Charles Hunter gave 16 years of service to his country and 
returned home as a disabled vet. I firmly believe he deserves 
and has earned the medical care he needs. We would appreciate 
your help with getting these bills paid and give us a guarantee 
that Charles will continue to receive the proper medical care 
he needs.
    In the past, Charles did receive good care from the VA, but 
the above incidents listed are unbelievable and unacceptable as 
far as we are concerned.
    Thank you for your assistance, and may God continue to 
bless America.

    [The prepared statement of Charles Hunter appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. and Mrs. Hunter. Thank you for 
your service.
    [Applause.]
    Mr. Benishek. And thank you for the courage to be here 
talking about it.
    Mrs. Hunter. Thank you.
    Mr. Benishek. Mr. Ryder--
    Mr. Ryder. Yes, sir.
    Mr. Benishek [continued].--you are now recognized for 5 
minutes.

                   STATEMENT OF GORDON RYDER

    Mr. Ryder. Well, I will try to condense this and go along 
to tell our story. It started in May of 2015. Our son felt a 
lump in his abdomen, and he was a fitness nut. It was getting 
in the way of his training.
    So I told him, ``Why don't you try to get an appointment 
with the VA?'' And he says, ``Well, you know, it is kind of 
hard to get in. I do have a check-up coming July 1st.'' He 
says, ``I will wait until then. I am going to go to a 
chiropractor. I will put heat on it. I will put ice on it. I 
will see what I can do.''
    He still had problems through June, and I was after him for 
that appointment. But he said, ``It is right around the corner. 
I will go July 1st.''
    July 1st, he went to the Lafayette VA, and the doctor was 
sick. So they sent him home, and they said you can either come 
back around August 15th, or you can come tomorrow and wait. So 
that night, when I got home about 8:30, we found him doubled up 
on the floor in pain. We went immediately to the ER at 
Opelousas General, where a scan showed he had a mass in his 
abdomen.
    The ER doc there, it wasn't no young doctor. He was old, 
knew what he was looking at, says, ``This is lymphoma. I am 
pretty sure. I am sorry.''
    We have a close relative who is an internist in Opelousas. 
The next day, we went to see him, and he said we got to get a 
game plan going. So we started with that. I made some calls. 
His physician, who I can't say enough about, his primary care 
physician in Lafayette, Dr. St. Cyr, when you could get to him, 
was excellent.
    I pulled some strings. I knew another doctor in Lafayette 
who knew Dr. St. Cyr, who, even though he was convalescing, got 
himself driven to the VA clinic to talk to Dr. St. Cyr to see 
my son. He saw him the next day.
    Let us see, that would be about--he saw him. I wasn't with 
him. He lined up out of network--he said, ``I stuck my neck out 
a little bit.'' He lined up a PET scan at Our Lady of Lourdes.
    So for the follow-up on that, I went with him, and Dr. St. 
Cyr was very concerned. He said, ``Your son needs care.'' He 
said, ``I am not seeing him because Dr. Brent Prather came to 
see me. I am seeing him because he needs help. He looks good 
now,'' and he said, ``I assure you a month from now, he will be 
in greater pain.''
    So that was when he says, ``I must contact the Alexandria 
VA. We saw some things in the PET scan that we need to look 
at.'' And he called. Immediately, they lined up for the next 
day an appointment to see about an upper and a lower GI.
    I rode with him that next day. The lady up there was 
extremely nice, worked us up. And I thought it unusual, about 
midway, she stopped, and she says, ``You know, pardon me, but 
we don't usually see somebody in the shape you are in.'' She 
said, ``It is refreshing to have somebody that is taking care 
of themselves, in good shape,'' you know? ``You don't smoke. 
You don't drink. You work out. I am sorry you are going through 
this.''
    So we lined up the upper and the lower GI. They wanted to 
make sure nothing was in the bowel, in the esophagus, and we 
prepped for that. We showed up at Alexandria, and he started 
his tests.
    Pretty soon, the surgeon came in. I think he was Dr. 
Dorval, came in, and he said, ``Listen.'' He said, ``There is 
nothing in the intestines. There is nothing in the esophagus. 
It looks good.''
    He said, ``Come back in 2 weeks. We are going to do an 
ultrasound.'' He said it might be benign. I said, ``Well, Dr. 
St. Cyr talked about maybe having a biopsy?''
    ``Oh, no, no.'' He said, ``I am in charge now.'' He said, 
``Probably benign. Come back in 2 weeks, an ultrasound,'' and 
left. So my son came back. He was recovering.
    We started our hour trip back to Opelousas, and he was 
agitated. He says, ``I tried to talk to this guy, tell him my 
symptoms,'' you know? We got three doctors saying it is 
lymphoma, but it is benign. Come back in 2 weeks, when we 
didn't think we had the time. Time was of an essence here.
    So before we could get back, I think Dr. St. Cyr looked, 
saw what was going on. About a half hour into the drive, we got 
a call and said, ``Listen, you will get a call. We are going to 
try to do a needle biopsy at Our Lady of Lourdes soon.''
    The next day he got a call. The needle biopsy was scheduled 
for the Friday. He went and had that done. We went back to Dr. 
St. Cyr after that, and he said, okay, we will schedule you 
with oncology in Alexandria, in Pineville. That is Dr. John 
Clement, very fine. I can't say good enough about the care you 
get when you get to the pure medical side of the house, you 
know?
    When you get through the red tape, which there is a lot of 
it, but the medical side of the house, they are caring and 
engaged people in the health care. You have a few dim bulbs in 
there, but by and large, they are bright lights in the VA 
system.
    Dr. St. Cyr mapped out a plan, and he said, ``Well, you 
have a 75 percent cure rate and a 95 percent remission rate.'' 
And he says, ``We will start in --'' I think it is R-CHOP at 
that time. ``We will start a chemo.''
    Now he is getting weaker all the time. He is starting to 
get--to feel bad, in a lot of pain, and we lined it up finally, 
I think it was on the 17th maybe? No, I am sorry. This was in 
August.
    Mrs. Ryder. August the 3rd.
    Mr. Ryder. August the 3rd, we went up to Alexandria to 
start the chemo, and he was getting very weak by then. We got 
there, I think almost immediately they gave him two units of 
blood. Well, we left him. We went home. We stayed in contact by 
phone.
    On his own, he tried to get himself off of some of the pain 
meds. He didn't know the pain meds caused such severe 
constipation. He started having a lot of bleeding because of 
this. Therefore, he was losing blood, plus the cancer. So on 
his own, he kind of weaned off of that, and he said he had 
several very bad nights there. But it was like he said, ``I am 
put on hold. They will come do a test. I don't see anybody for 
a day. They will come around and check on me.''
    But they gave him the blood. They installed a port. They 
did a scan and said, okay, we are going to start chemo 
tomorrow. We need some approval from, I think it was Little 
Rock. Well, the approval was late in coming because apparently 
somebody's car broke down, didn't go to work.
    But it finally came, and by the week's end, we started the 
chemo. He had a very bad week the next week. We went in for a 
check-up. They gave him three units of blood because he was 
down. That kind of picked him up.
    This went on for approximately four cycles. It appeared the 
chemo was working. When he went in for the fifth cycle, his 
blood was not good enough. So Dr. Clement said come back in a 
week. We came back in the week. He said still not good enough. 
Come back Monday. We are going to give you more blood. We are 
going to do a scan, and we will try to get to the bottom of 
this. Maybe a bone marrow biopsy.
    Well, he got the blood, four units this time. I went back. 
He called me. He says, ``They are not going to do the biopsy. 
They did a scan. I have more tumors. What I have is, some have 
shrunk. Some is growing.''
    From that point, he said I have to refer you either to MD 
Anderson or to Michael DeBakey in Houston, whoever we can get 
to first. And fortunately, within 2 days, Houston VA called and 
said can you be here the Monday after Christmas?
    We were there. We got excellent care there. There, one 
thing that stood out in my mind was as they processed him, and 
I won't rehash all of this. It is all written down, and I am 
sure you have all read it.
    This is a chemo-resistant lymphoma. He said, ``We will try 
to work with it. We have a lot of things we can do,'' and I 
remember the doctor pointing to the skyline. ``If we can't, MD 
Anderson is over there. I will send him there.''
    We started the different work-ups and the doctor says, ``I 
want to do a test. It is a genetic test.'' He says, ``It is 
only done in San Francisco.'' He says, ``It is kind of 
expensive, but I think they will approve it.''
    Well, that is the last I heard of it. I don't know what 
happened with that. We started a salvage chemo, where he went 
through one cycle of that. And upon returning, 28 days later, 
things still went downhill. He said I will immediately try to 
get you into MD Anderson, and there is where things kind of 
went awry. Trying to get this approval was like pulling teeth.
    We brought him home. There were numerous physical problems. 
We were at the ER several times. We would have to get fluid 
removed from his abdomen. I would call. I got to know a lady at 
MD Anderson very well. I said, ``Do you have any information on 
Gerrit Ryder?'' ``No, we need such and such approval, a Form 
7.'' I don't remember what it was.
    So I called back the next day. I called Dr. Abraham's 
office, which I think I called several times for help with some 
of this approval. And they called back and said this approval 
is forthcoming. Never got it.
    Through a contact, I think it was in Pineville, I got the 
number of TRICARE. That is an outfit in North Carolina that 
approves a lot of these out of network services. I called and, 
``No, it is going through the process. We will get this 
paperwork to you, 5 to 7 days.'' I said, ``Can you fax it? I 
have medical power of attorney.''
    ``Well, no, we can't do that. We can send it to you.'' So I 
got a little ugly on the phone, I think. But the next day, I 
received a call from a supervisor over there. Apparently, the 
calls are monitored, and she said, ``I assure you we will get 
this out today.'' A span of about a week, maybe longer, I don't 
know, things just kind of melted together on this rollercoaster 
ride we were on. We never got that approval that I know of, you 
know? I think it came in after we came back from MD Anderson.
    He went back into the ER. The doctors there said, look, it 
is not good. What about this approval? You have to get to MD 
Anderson. He said, ``I will try to approve you.'' Her cousin is 
the internist. He said, ``I will do a hospital-to-hospital 
transfer.'' They weren't taking transfers because they were 
full.
    We went back to the ER, and I said, ``Listen, I am going to 
wait until next Wednesday, and then I will get him over here.'' 
He says, ``You might not have until next Wednesday.'' So I 
said, ``Okay, we will leave tomorrow.'' And Gerrit says, ``Dad, 
give me a day to rest.'' He says, ``I am beat down.''
    So we rested on Sunday. Monday morning, I guess it was the 
scariest thing I ever did. I loaded him up in the car, and we 
drove 4 hours to the MD Anderson ER. Now I had given them all 
the information. They knew who we were.
    So I said here we are. Within 45 minutes, we were admitted. 
When you get to the pure medical side of the house anywhere, 
you know, it is great. You know, you guys all took an oath, you 
know? Do no harm. Treat. Care.
    We got there. If I would have waited, I would have never 
got there. They treated him for 8 days. By then, I am sure it 
was too late. Maybe if we would have had this genetic test, we 
would have found out earlier on. They said something about it 
was Burkitt's syndrome, double-hit. Never heard that, you know?
    When I got back, Dr. Brent Prather, he was the doctor who 
got out of his sickbed to go over and talk to St. Cyr. I called 
him to tell him Gerrit had passed away, and I mentioned 
Burkitt's, double-hit. He said, ``Oh, did he have 
mononucleosis?'' I said, ``Yes, he did in the Navy.''
    He said, ``People with mononucleosis are more prone to 
Burkitt's or some of the severe lymphomas.'' Well, that was the 
first time I heard that, and that came from a pediatrician who 
does allergy.
    But it is harder than it should be. As I stated, you know, 
you have got a DVD, you give to them, and they are shoving it 
in a cassette player. There is one side speaking English. One 
side speaking German. There is no continuity.
    It can be better. I don't know what else to say. It was 
like pulling teeth.
    Medical records. I had to put on my backpack, leave MD 
Anderson, walk a mile and a half over to Michael DeBakey to get 
his slides. The oncologist at MD Anderson asked me, he said, 
``I need to see the slides that they have before I can start 
this emergency chemo. Maybe we can give him some time.''
    So I called Dr. Clement, tried. I called, and he would 
answer his phone over here. He would pick up usually on the 
first time. He said, ``I will see what I can do.''
    So, finally, about 3:00 one afternoon, I put on my 
backpack, and I walked to the pathology department at Michael 
DeBakey. And I walked up to this nice lady, and I says, ``I am 
trying to get my son's medical records. Can you help me?''
    She looked at the paper in her hand. She said, ``Gerrit 
Ryder?'' I said yes. She said, ``I have been trying to find 
him. I got them here. I will get them for you. If you go back, 
I will overnight them.''
    I said, ``Well, if you don't mind, he is dying of cancer 
over there. I will just hand carry it,'' you know? So after 
about an hour, they packaged it up. I got them no problem. I 
walked it back.
    It is harder than it should be. When we left Michael 
DeBakey on the 28th of January, we signed everything to get 
transferred, to get medical records transferred, and this was 
the 10th of February, you know, and the records were still 
languishing somewhere.

    [The prepared statement of Gordon Ryder appears in the 
Appendix]

    Mr. Benishek. Well, I think we get the idea, Mr. Ryder.
    Mr. Ryder. Okay.
    Mr. Benishek. I really appreciate your testimony.
    Mr. Ryder. I have taken a lot longer than I should, you 
know?
    Mr. Benishek. And I really appreciate you both being here 
today.
    Mr. Ryder. And I am not going to beat up on you guys. I did 
write in my statement that if you would fold the VA system in 
the health care that you three guys got, it would be solved, 
you know?
    Mr. Benishek. Thank you. Thank you very much. Truly 
appreciate you being here.
    Mr. Ryder. Thank you, Mr. Chairman.
    Mr. Benishek. Mr. Knott, you are recognized.

                   STATEMENT OF CARROLL KNOTT

    Mr. Knott. Ladies and gentlemen, good afternoon.
    What I am going to be talking about is stuff that happened 
just 3 or 4 weeks ago. We have a very serious problem in our 
psychology department. We brought a young man over here who is 
psychotic. He is on crack, he is on methamphetamines, and he is 
an alcoholic.
    They kept him 5 to 6 days, and they wanted to kick him out, 
send him elsewhere. I got with Harvey Norris, who is a crisis 
intervention person, and he helped me extend that stay. So we 
kept him in for about 10 days, but they still want him to go to 
this SUDS program, which, what that is, is you go to your deal 
at the VA, but then you sleep at the Salvation Army.
    Ladies and gentlemen, there is more drugs at the Salvation 
Army than there is candy in a candy store. It is terrible.
    I have a problem. When a veteran calls and he is in 
distress and he asks to speak to somebody, a counselor or 
whatever, and the clerk tells him that it will be 30 days 
before they can get to him, this man goes kind of berserk, I 
guess you could say. He makes the statement, ``Well, I guess I 
will have to go to the park and start shooting people before 
you all will see me.''
    Well, needless to say, pardon my French, all hell broke 
loose. I was just about to my office when Harvey Norris called 
me again and said, ``Carroll, please, please help us.''
    Well, I got my guys all together. We got things going. We 
got him to come meet us. And I am going to tell you something. 
When that boy got out of that pickup truck, he rolled out for 
about 2 minutes, about 6'8'', 300 pounds of muscle.
    And he was in a combat position. He was ready to fight. He 
thought we were going to arrest him. I said, ``No, we are not 
here to arrest you. We are here to help you.'' And we were able 
to calm him down and get the problem under control. But when a 
clerk can cause that to happen to a veteran, we have got a 
serious problem.
    I know of a past State commander who went to the Lafayette 
VA and went to the Alexandria VA, and felt that he was treated 
like a stepchild. So a friend of his says, ``Hey, why won't you 
go to Lubbock, Texas? They treat us real well over there.''
    He did. He drives 250 miles one way to go to Lubbock, and 
they don't pay for his mileage. But the care and everything is 
so good, he will drive that 500 miles back and forth. I think 
we got a problem with that.
    I have got a veteran who had a foot problem. They put a 
screw in his foot. A year later, he lost his leg, right here in 
Alexandria.
    Now I am going to go over--I am running out of time just 
about. I am going to go to the union. My understanding is that 
the union has a very large part to do with who is hired in 
Alexandria. Ladies and gentlemen, we have got some people here 
that don't--they are lazy. There is no other way to put it. 
They are lazy.
    I hope that the clinic in Lafayette works like we want to. 
They put it in an area where there is heavy, heavy traffic, 
which I think could create a problem. One of the things we 
would like to know about our Lafayette clinic and our Lake 
Charles clinic is how much permanent staff are we going to have 
in Lafayette? How much are we going to have in Lake Charles? 
And is it going to be people that are going to be running from 
Alexandria to Lafayette or Alexandria to Lake Charles? That 
will be a problem, serious.
    Coming back to the union, more than 94 percent of the VA 
employees are union. I have been told that the union pretty 
much dictates who is hired and who is fired. It is true or not, 
I don't know. But I got it from pretty reliable source.
    Well, another problem that we have. It seems to me like 
here in Alexandria in the past 7 years, we have swapped 
directors, I mean like playing marbles. In the last 2 years, we 
have had four people. We had a director. He was transferred. 
Then we had three that were interim. They were transferred.
    I think Mr. Dancy is going to do a good job for us. I am 
hoping that they give him enough time to do a job. Because if 
you give him 6 months and then you move him away, you haven't 
accomplished anything.
    My next serious part is the telephone. I get a lot of 
questions, ``Why can't I call Lafayette VA?'' They have an 800 
number. They have a 337 number. The phone rings, and this lady 
comes on, you know, ``Your call is very important to us. Please 
hold on.'' And a few minutes later, a little old man comes up 
and he says it in French, same thing.
    It takes 45 minutes, and then the man hangs up. And then 
the veteran is upset. So I don't know what the phone problems 
are. But let me tell you, they are serious. They are very, very 
serious.
    And you know, I don't have any problems with the VA. I 
really don't. They have taken very good care of me. And I want 
to thank you, Dr. Abraham, for everything that you do for 
veterans. I cannot complain about the VA, but boy, I get a lot 
of, lot of, lot of complaints.
    So what causes that, I don't know. I see I am over my time.

    [The prepared statement of Carroll Knott appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Knott. Appreciate your 
testimony today.
    Mr. Montes, you are recognized for 5 minutes.

                   STATEMENT OF ASBEL MONTES

    Mr. Montes. I will keep to my 5 minutes, I promise.
    Mr. Chairman, Dr. Abraham, Dr. Fleming, I am the vice 
president of reimbursement and governmental affairs for Acadian 
Ambulance Service. Our chairman and CEO, Richard Zuschlag, 
founded the ambulance service in 1971 with eight Vietnam 
veterans. Today, we now have over 4,400 employee-owners and 400 
of them being military veterans.
    Since the last hearing on June 3rd of 2015, where we 
provided information on this issue, our company, along with 
American Medical Response, the largest ambulance provider in 
the Nation, and the American Ambulance Association have worked 
diligently with our congressional delegation, including 
Congressmen Abraham, Boustany, and Coffman and other health 
care stakeholders, the Veterans Integrated Network Services, as 
well as the national leadership at the VA, to assist, 
recommend, and frankly, demand that the VA expedite the 
updating of their internal processes to promptly pay for 
emergency treatment that our Nation's finest receive by non-VA 
health care partners.
    Due to these continued efforts, we have seen significant 
progress made within VISN 16 and attribute these gains to the 
hearing conducted last year. However, there is still 
significant work to be done, and my colleagues within the 
ambulance industry nationwide are still experiencing 
extraordinary delays in processing and payment of other VISNs.
    For a real-life look at the progress made by the VA and the 
issues still prevalent, I would like to include two specific 
examples. In the first quarter of 2014, it was taking the VA in 
Alexandria approximately 138 days to pay for an emergency 
ambulance transport. Thanks to the efforts of Congressman 
Abraham and this Subcommittee, we are now receiving payments 
for approved care within 40 days through electronic submission.
    However, on the flip side, the Flowood, Mississippi office, 
and the Houston office in VISN 16 are still struggling to 
improve prompt payment efficiencies. For example, Flowood still 
requires that we send all claims and medical record via paper.
    In addition, claims are being underpaid now due to a new 
unregulated process that requires us to add the zip-plus-four 
to every claim. No other Federal or State payer or other VISN 
office requires this that we are aware of. It should also be 
noted that no one was ever notified of this requirement prior 
to the complaints being made as a result of the underpayments.
    In November of this past year, we had to engage the 
assistance of Congressman McCaul's office to address severe 
payment and processing--claim processing delays in VISN 17. 
This work is still ongoing, and our efforts are being 
coordinated with the Chief Business Office in Denver, Colorado, 
under the direction of Mr. Steven Gillespie. Our current aging 
receivables over 180 days are in excess of $600,000 still 
awaiting payment and denial.
    There are many more examples just like this one that can be 
given by providers and veterans alike across the Nation. This 
problem is especially acute for the majority of ambulance 
services, providers that serve as the local 911 responders in 
their communities who are prohibited from refusing emergency 
treatment for any patient, regardless of payer source or 
ability to pay.
    This failure to pay providers in a timely and accurate 
manner puts providers in the difficult position of having to 
shut their doors and eliminate access to care or to bill the 
veteran for emergency treatment, placing an unfair financial 
burden on the veteran due to the lack of response, invalid 
denial, or payment by the VA. Ultimately, it is the veteran who 
suffers for the lack of coordination, inefficiency of the 
internal systems at the VA.
    While the Chief Business Office has been very responsive to 
our company over the past 9 months, there is still an 
inefficiency in system design regarding prompt payment and 
processing of provider claims. As of 3 weeks ago, one facility 
in VISN 17 requested that we submit everything via paper until 
they could resolve our issues on why claims were not processing 
through their electronic system. This only continues to 
exacerbate the administrative and financial burden for 
providers who serve our Nation's finest.
    The Federal Government has a responsibility to ensure that 
our veterans receive the best health care we can provide. It 
also has a responsibility to ensure that they are not required 
to bear an unjustified financial burden as a result of the VA's 
failure to pay for non-VA providers in a timely and accurate 
manner.
    As stated in my previous testimony last year and 
subsequently introduced via legislation by Congressman Boustany 
in H.R. 4689, it is our recommendation that Congress remove all 
claims processing for non-VA providers from the Department of 
the VA, and place it with a single fiscal intermediary. 
Congressman Coffman has also introduced H.R. 5149 that will 
provide clarification on how the VA will reimburse emergency 
ambulance providers for the care provided to our veterans who 
meet the prudent layperson's definition of an emergency, to 
ensure our veterans are not financially burdened solely as a 
result of the VA's subjective and adverse treatment of these 
claims.
    This step would ensure consistency, efficiency, and 
expertise in personnel, as well as sufficient dedicated 
resources to process claims timely. Several other Government 
programs, including Medicare and TRICARE, utilize this 
strategy.
    Thank you for giving me the opportunity to provide 
information and to serve those who have sacrificed so much for 
our Nation. Look forward to answering the questions.
    Thank you, Mr. Chairman.

    [The prepared statement of Asbel Montes appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Montes. I appreciate your 
testimony.
    I appreciate all your testimony today.
    I am going to yield myself 5 minutes for questions. Then we 
are going to alternate with the other Members to see if we have 
any questions for you.
    I am going to start with you, Mr. Ryder.
    Mr. Ryder. Yes, sir.
    Mr. Benishek. It sounds like you had a really frustrating 
time with the VA. I want to ask you this specific question. Did 
you have an opportunity to work with a patient advocate at the 
VA, someone to help guide you through this?
    Mr. Ryder. I don't remember any here in Pineville. Once we 
got to Houston, yes. They carried me around. They helped him 
sign up for different programs, disability. Since he was 8 
years in the Navy, we didn't know he was due a pension while he 
was disabled, and that was in the process. But unfortunately, 
he didn't last that long.
    Mr. Benishek. Did the staff at the Alexandria VA Health 
Care System ever explain to your son or you the authorities 
that the VA can refer patients outside of the community, 
including Choice?
    Mr. Ryder. He knew a little bit about that, the Choice 
card, yes. Yes. Well--
    Mr. Benishek. You are not familiar with it?
    Mr. Ryder. I am a little bit familiar with it. I have just 
gotten my cards not that long ago. I mean, I haven't used them 
yet. But you know, we were dancing with the partner that 
brought us there.
    We started, like I said, in Lafayette, and the roadblocks 
that we would face, we see them disappear, and I got to think 
it was the hand of Dr. St. Cyr in the background. You know, he 
would do an end run. He did the PET scan. He had the needle 
biopsy done. He would go out--he would look and see what was 
input, I think, and then he would go around--
    Mr. Benishek. What can you say about how can we improve the 
customer service at Alexandria?
    Mr. Ryder. Contact. You know, it is a mixed bag. You have 
so many good people there. We ran into several of the oncology 
nurses, Dr. Clement. Most of them, by and large, were engaged 
in their patients' treatment. But some of them I get the 
impression that they were marking time.
    Voice. You got that right.
    Mr. Benishek. Let me ask Mr. Knott a question now.
    Mr. Knott. Yes, sir.
    Mr. Benishek. Mr. Knott, I deal with this phone issue 
myself in my district. My big complaint in Washington is the 
fact that in my district for a long time, if you have got the 
VA, you have got to push 1 for the clinic, push 2 for the 
pharmacy, press 3 for OR. But if you have a mental health 
emergency, please hang up and dial 866-778-5791.
    That is not very good phone etiquette. You know, to me, 
that mental health crisis should be the number-one thing. And 
it took more than 6 months of me complaining in Washington 
before a national audience before they actually changed that. 
And it sounds to me that you are having that problem here as 
well.
    So how long has that been going on? Does that happen every 
day?
    Mr. Knott. Well, I work with a lot of veterans. I am with 
the sheriff's office, and he has me kind of take care of the 
guys because, I mean, there is a lot of things out there that 
these people have no idea--
    Mr. Benishek. When you call, is it a long time?
    Mr. Knott. I am sorry, sir?
    Mr. Benishek. When you call the VA, does it take a long 
time to get through?
    Mr. Knott. Oh, yes, sir. Oh, yes. As a matter of fact, I 
did it just the other day, just to test before I said anything 
over here. Forty-five minutes, I hung up. I mean, it is like it 
goes in circles.
    And the lady keeps coming on, and then the little man comes 
on, and it just--I mean, it is just in circles. So you hang up. 
Now the 706 number, if you happen to have it, a lot of times 
you would get right on through.
    Dr. Kinchen was my doctor. His nurse will answer pretty 
much on the money. And I will be honest with you, I don't know 
how he does everything he does. He has called me at 10:30 at 
night, he is still working. So, basically, he is overworked.
    Mr. Benishek. All right. Thank you.
    Mr. Hunter, it doesn't sound like they did a vascular--I am 
a doctor. So, and I used to do vascular surgery, too. So it 
seems to me that usually if you have got a problem with your 
toe, that they usually do a vascular evaluation before they 
start operating on the toe, in my experience, unless there is 
pus right then and there. You have got to drain the pus right 
then and there.
    But it seemed like it took you a long time to get 
treatment.
    Mr. Hunter. Very long time.
    Mr. Benishek. Can you explain to me, did they give you any 
reason for that?
    Mr. Hunter. No. They just kept saying, well, we are going 
to get you fitted. Dr. Ferreras is the one that started this.
    Mr. Benishek. Fitted?
    Mrs. Hunter. Admitted.
    Mr. Benishek. Admitted.
    Mrs. Hunter. Dr. Ferreras was the one that actually--
    Mr. Benishek. He is in the VA, Dr. Ferreras?
    Mrs. Hunter [continued]. Yes, sir. He is here in 
Alexandria. He is excellent. He is in wound care, and he is the 
one that actually started getting the stents and--
    Mr. Benishek. But it took several weeks before you ended up 
seeing him, and then things started to move?
    Mrs. Hunter. Yes. Yes.
    Mr. Benishek. So I take it, you are diabetic then?
    Mrs. Hunter. Yes. But also I forgot to mention that the 
doctor, the orthopedic doctor in Mississippi has refused to 
give Charles a prosthetic leg because of his age.
    Mr. Hunter. He said I wouldn't walk again.
    Mrs. Hunter. He said he won't walk. So there is no point in 
giving it to him. Because he is 75, there is no point in giving 
him a prosthetic leg.
    Mr. Benishek. Yes, well, I am not going to try to figure 
that out. I am not an orthopod.
    Thank you. I am over time.
    Let us go with Dr. Fleming. We will give him the first run. 
Dr. Fleming, you are recognized.
    Mr. Fleming. Well, again--okay, thank you, Mr. Chairman.
    Panel, this is a general question to everyone here. The 
second panel today, the VA is going to claim that as early as 
this month, 90 percent of the veterans who used sign-in kiosks 
upon entering the Alexandria VA Health Care System were either 
completely satisfied or satisfied with their ability to receive 
care when they wanted it.
    So that is a 90 percent satisfaction rate. What would you 
say about their claim? Your experience, not just your own 
personal experience, but others around you?
    Mr. Ryder. I would say it is skewed.
    Mrs. Ryder. Quite skewed.
    Mr. Ryder. Skewed, that 90 percent is a skew. He would go 
in and sign in on the kiosk. I mean, we got to a point where he 
would just go on to oncology or go to blood, check blood, and 
then just go and sit and wait, an oncology would come, get him. 
But--
    Mr. Fleming. Okay. Mr. Knott?
    Mr. Knott. Yes, I am an amputee. And when I hear this man 
having all these problems that he is having, it is totally 
absurd. I am 71 years old. I have been wearing a prosthetic 
since I was 22. This man lost his leg. It doesn't make sense 
not to give him a prosthetic.
    It doesn't make sense for Mississippi to say we are not 
going to give you a leg because you are too old. Never heard of 
that before.
    Mr. Fleming. Okay.
    Mr. Knott. But to answer your question, I guess a lot of 
times, it is the way we present ourselves. You know, a lot of 
times we want everything to go perfect. It is not going to go 
perfect.
    It doesn't go perfect in civilian life. When you go to the 
doctor, you have got to wait. So--
    Mr. Fleming. Yes. Well, I have got some more questions. So 
let me go ahead and move on, and I will come back to you with 
this one, Mr. Knott. How often would you say that the veterans 
attempt to call the Alexandria VA, the health care system 
number, and they are left waiting for a long period of time, 
and what impact does that have on one's experience?
    I have already heard of you talking about 45 minutes. Is 
that rare or commonplace?
    Mr. Ryder. Average. Average. That is about average.
    Mr. Fleming. That is a typical number?
    Mr. Ryder. Thirty to 45 minutes.
    Mr. Knott. And I will tell you, most of the time, they have 
to take and go to the clinic and say, ``I have been trying to 
get hold of you all.'' Or you go through the operator, and you 
get the same thing.
    Mr. Fleming. Now if Enterprise Rent-A-Car had a 45-minute 
wait for their customers, how long would Enterprise Rent-A-Car 
be in business?
    Mr. Knott. Not very long.
    Mr. Fleming. Okay. All right. Again, Mr. Knott, would you 
please elaborate on the concerns expressed in your testimony 
about the mental health department at the VA, the Alexandria 
VA, and tell us what you think needs to be done to improve the 
provision of mental health care to veterans in need, 
particularly those who are at-risk homeless?
    Mr. Knott. I guess it is a situation where I just brought 
this young man over there about 3 weeks ago, and as I said, 
they were going to cut him loose in 4 days, 5 days--4 days 
unless he went to the SUDS program. He didn't want to go to 
that program because of the fact that he used everything that 
was going on over there.
    I hate to say it, but I am going to say it anyway. I just 
can't see the social workers not spending any time at all with 
the veterans. Or I can't see a social worker telling a veteran 
you need to leave your wife and go on your own, and that was 
done. That is absurd, you know?
    How do you deal with that?
    Mr. Fleming. Okay. I have got a little bit less than a 
minute left. Any other comments or reactions to questions or 
comments that I have made?
    Mr. Montes. The only statement that I would make to your 
first comment would be I would suspect the integrity of the 
data. And for example, that would be related to, if you have an 
issue with satisfaction scores where they are quoting it is at 
90 percent, I would immediately, the first thing that rang to 
my mind was suspecting it from a payment standpoint.
    Because everything was, actually, they found cases of 
claims that not just within Alexandria, but within the VISN 16 
system that weren't actually recorded into their system. So 
when they started to come back with this, payments were being 
made promptly.
    So I would suspect that from an integrity of the data 
standpoint, is that maybe not everything is inputted at that 
point, and so maybe it is skewed.
    Mr. Hunter. One more thing about the Alexandria, the 
emergency room there. I went in there to the emergency room and 
stayed a whole day waiting to see a doctor.
    Mr. Fleming. Well, I see my time is up. I would just say in 
closing that waiting 45 minutes for a response for a health 
care facility even one time is a disgrace.
    And I yield back, Mr. Chairman.
    Mr. Benishek. Thank you, my friend.
    Dr. Abraham?
    Mr. Abraham. Thank you, Mr. Chairman.
    You just have to shake your head hearing these stories. For 
your loss, we are all truly sorry, Mr. Ryder.
    I am having staff tell me that they stopped by the VA on 
the way up here, and there is a sign--and I will address this 
with Mr. Dancy on our second panel--that says the average wait 
time for a phone call in April was 90 seconds.
    [Laughter.]
    Mr. Ryder. Ninety seconds. Yes, before you get put on 
automatic--
    Mr. Abraham. So I see there is somewhat of a disparity, to 
say the least--
    Voice. That is a blatant lie.
    Mr. Abraham [continued].--in what we are told by one, by 
the VA and what we actually hear from you, our witness. So we 
appreciate the information.
    On Acadia, let us start with you, Asbel. Thanks for Acadia 
being such a provider for our veterans. Can you explain to us--
I think you and I know, we have had discussions on this 
before--how our veterans are impacted negatively when the VA 
just doesn't pay them, when they are deadbeats?
    Mr. Montes. So this issue came about, about 4 years ago 
back in 2011. At the time, we didn't really have a process when 
we were transporting patients that called 911 and they were 
going to non-VA related care. So a veteran would call us. They 
are having a heart attack, or they are having severe abdominal 
pain. We are taking them to one of the local hospitals, whether 
it is Christus here or it is Lafayette General.
    And we were--we didn't know they were a veteran at the 
time. We would either bill, then they would tell us, ``Hey, I 
have got the VA.'' We would bill the VA. There would be no 
payment for 90 days, and so the bill would roll to the veteran. 
They would go to collections, unfortunately.
    And at one time, we found out that if--the collection 
agency said, you know what, if you hand hold this through the 
process, you can eventually get paid in about a year to 18 
months. They may ask for all this information. So we 
immediately brought it back in, in house.
    So at that time, it was taking anywhere from 18 months to 2 
years, and there is a whole disconnected piece where the 
emergency room would have to provide emergency records for them 
to pay for the emergency room. And we eventually started to 
work that process through.
    The issue is, is not one department is responsible for it. 
Now since, the Chief Business Office has kind of taken over 
that. But for our veterans here, prior to us putting that 
process in place, they were going to collections. They were 
getting calls from the collection agencies. It was going on 
their credit files.
    We as a company--now not all ambulance services can do that 
because 80 percent of the ambulance providers in the Nation are 
very small ambulance services. Our company has made the 
decision that until we can get a response from the VA whether 
they are going to pay for it or not, we are no longer going to 
bill the veteran for that.
    So it stays, when I said that it stays within our aging at 
Acadia Ambulance Service, that we have over $600,000 over 180 
days across the VISNs. That is just not here locally to 
Alexandria, and that is the reason why. But most ambulance 
services, actually, the veterans are just getting billed for 
it.
    Mr. Abraham. Thank you.
    Mr. Hunter, I think it was you that alluded to the fact 
that we have here in Alexandria a very high turnover rate of 
personnel, and I will ask this to everybody on the panel. 
Certainly our first three, start with Mr. Knott. How is that 
impacting our veterans when you don't have that continuity to 
go back and see the face that you--Mr. Knott, you are nodding. 
I will take you.
    Mr. Knott. Yes, it--I don't think I understood the 
question.
    Mr. Abraham. Well, this VA here has had several directors 
in a very short period of time.
    Mr. Knott. Right.
    Mr. Abraham. Some have been temporary. Some have been into 
a permanent position. The question is, is that, in your 
opinion, affecting veterans' care?
    Mr. Knott. I personally think it is. Because we don't get a 
chance to get to know a director before he has been shipped 
out. I mean, this has been going on for 7 years, Dr. Abraham, 7 
years that we have been swapping people out and--
    Mr. Abraham. Mr. Hunter, do you have a comment? Mrs. 
Hunter?
    Mrs. Hunter. I feel the same way. You know, you start to 
get a rapport with someone, and you know, a month later or 2 
months later, they are gone. You start all over again, and you 
are just not getting the proper care that you need.
    Mr. Abraham. Well, the thing that, you know, every one of 
us on this panel will tell you, that the problems that we are 
hearing today, unfortunately, are across the Nation. Every 
veteran seems to have a story, and it is not a good one.
    It is like you said, Mr. Ryder, you know, once you get on 
the medical side--
    Mr. Ryder. It is fine.
    Mr. Abraham [continued].--things get good in most cases. It 
is just getting from that point A to that point B is sometimes 
like a Grand Canyon.
    So, anyway, thank you so much for your testimony. I see my 
time is up. Mr. Chairman, I yield back.
    Mr. Benishek. Thank you, Dr. Abraham.
    I want to thank--Mr. Knott, you want to add something? Just 
a moment, though. We have got to move along.
    Mr. Knott. Yes. I have one important thing. Can I submit--
on the psychology part of it, I would like to submit a deal 
written by the young man's wife, and I would like to have that 
put in the record.
    Mr. Benishek. Without objection, so ordered.
    Mr. Benishek. All right. Thank you. Thank you all for being 
with us here this afternoon, and thank you for your compelling 
testimony. We appreciate your courage for being here.
    You are excused from the panel. So you can take your seats. 
We are going to have our second panel of witnesses for the 
witness table. So you can make your moves.
    [Pause.]
    Mr. Benishek. All right. We are having a second panel. We 
have got to keep moving here. We have got another panel of 
witnesses. I would like to get to their questions. So please, 
please come to order.
    Voice. Mr. Chairman, before you all get started, I would 
just like to ask you a question. Does the Veterans Affairs 
still distribute all their bonuses yearly to the employees?
    Mr. Benishek. Well, I am not exactly sure what is 
happening, but they are supposed to have put a hold on all 
bonuses.
    Voice. Well, I would just like to say that as a veteran--
    Mr. Benishek. We will ask that--
    Voice [continued].--who hasn't received any bonuses for 
going to war--
    Mr. Benishek. All right. All right. That is good. Thank you 
very much for your comment, sir.
    Voice. Thank you.
    Mr. Benishek. I would like to yield to Congressman Abraham 
to introduce the second panel of witnesses.
    Dr. Abraham, you are recognized.
    Mr. Abraham. Yes, sir. Thank you, Mr. Chairman.
    We have got Mr. Homer Rodgers, Under Secretary, Department 
of Veterans Affairs, State of Louisiana; Janet Henderson, M.D., 
Chief Medical Officer, South Central VA Health Care Network, 
VISN 16, Veterans Health Administration. And she is accompanied 
by Shannon Novotny, Acting Deputy Network Director of South 
Central VA Health Care Center, VISN 16, and Mr. Peter Dancy, 
Medical Center Director, Alexandria VA Health Care Center, 
South Central VA Health Care Network, VISN 16.
    I yield back, Mr. Chairman.
    Mr. Benishek. Thank you, Doctor.
    Mr. Rodgers, you are recognized for 5 minutes. Please begin 
your testimony.

                   STATEMENT OF HOMER RODGERS

    Mr. Rodgers. Thank you, Congressman Benishek. I don't think 
this will take--I don't believe that it will take 5 minutes 
because most of the first panel had discussed our advocacy for 
the veterans that we had spoke to before.
    I do want to say that about the Choice cards seem to be the 
major issue that we hear with the Louisiana Department of 
Veterans Affairs--its use, its approval, and the time, amount 
of time that it takes for those things to be approved and used 
by the veterans. We do want to say that we are pleased to hear 
that the Lafayette clinic, CBOC, is about to open and that the 
Lake Charles CBOC is finally going to be breaking ground soon 
for our veterans in the southwest part of the State.
    And that is pretty much my testimony.

    [The prepared statement of Homer Rodgers appears in the 
Appendix]

    Mr. Benishek. All right. Thank you, Mr. Rodgers.
    Mr. Rodgers. Thank you, sir.
    Mr. Benishek. Appreciate your testimony.
    Dr. Henderson, the floor is yours for 5 minute.

             STATEMENT OF JANET L. HENDERSON, M.D.

    Dr. Henderson. Good afternoon, Mr. Chairman, Congressman 
Abraham, and Congressman Fleming.
    Thank you for the opportunity to discuss the efforts that 
VA has taken to improve access, patient care, accountability, 
and prompt payment of community providers. VA remains--
    Mr. Fleming. Mr. Chairman? Mr. Chairman? I think some in 
the room cannot hear. If you would ask the witness to bring the 
microphone closer?
    Mr. Benishek. Is it on? Is it on, Dr. Henderson?
    Dr. Henderson. Yes.
    Mr. Benishek. Can all of you hear in the room testimony?
    Mr. Fleming. Yes, they are having trouble out there, Mr. 
Chairman.
    Mr. Benishek. All right. Just try to speak so the 
microphone picks you up there, Dr. Henderson.
    Mr. Fleming. Make sure it is close enough and you are 
speaking into the microphone.
    Mr. Benishek. We want everyone to hear your testimony.
    Dr. Henderson. Excuse me. All right.
    Mr. Benishek. Thank you.
    Dr. Henderson. VA remains committed to ensuring America's 
veterans have access to the health care they have earned 
through their service. Veterans are demanding more services 
from VA than ever before. There has been a 1.83 percent 
increase in appointments over the past 12 months in Alexandria.
    Even as VA becomes more productive, the demand for benefits 
and services from veterans of all eras continues to increase. 
VA's top priority is to improve access to care for every 
veteran who needs it. Actions like the focused access stand-
down events in November of 2015 and February of 2016 have 
addressed the needs of veterans who require urgent medical care 
and have significantly reduced the number of veterans waiting 
for care.
    Veterans should be in control of their health care. This 
means 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 and access. That is why Under 
Secretary Shulkin developed the MyVA access declaration, which 
is a set of foundational principles for every VA employee to 
improve and ensure access to care.
    The goal for 2016 is when a veteran calls or visits primary 
care at a VA medical center, their clinical needs will be 
addressed that day. Alexandria is proud to say that we now 
provide veterans with this same-day access. Alexandria uses a 
sign-in kiosk to assess veterans' satisfaction with their 
ability to get their appointment when they wanted it.
    As of June 10th, 92.4 percent of veterans being seen at the 
facility using the kiosk were completely satisfied or satisfied 
with their ability to get care when they wanted it. We want to 
ensure there are no veterans who need care now who are not 
receiving it. We are not there fully yet, but we are moving in 
the right direction.
    Two of Secretary McDonald's breakthrough priorities focus 
squarely on health care outcomes, improving access to care and 
improving care in the community. Alexandria has already 
implemented a number of actions to address access, quality, and 
patient satisfaction within the larger transformation of MyVA.
    For example, the most recent data available, April 2016, 
shows that Alexandria completed over 93 percent of appointments 
within 30 days. Alexandria now offers an extensive community 
provider network of over 1,000 providers through the Patient-
Centered Community Care Choice programs, and more are joining 
each month.
    Alexandria VA is expanding community-based outpatient 
clinics in Lafayette and Lake Charles, which will provide 
primary care to over 9,000 veterans. Alexandria also provides 
telehealth to nearly 4,000 veterans. Telehealth services have 
been expanded to CBOCs for primary care, mental health, and 
specialty care services, which are critical to expanding access 
to VA care.
    In April 2016, 50 veterans attended a town hall in 
Natchitoches, held by the Alexandria director to hear veteran 
concerns. Town hall meetings like this will continue, with the 
next being June 29th in Lake Charles, and a follow-up meeting 
in Natchitoches in July.
    In addition to town halls, Alexandria has initiated 
employee recognition programs based on I CARE values. In 
partnership with the Office of Patient-Centered Care, the 
medical center has begun MIL-X training for employees, which 
provides awareness, insight, and understanding of military 
culture to help facilitate a healing relationship with the 
veterans we serve.
    During fiscal year 2015, it was discovered that there was a 
significant backlog of paper-billed ambulance claims at the 
Alexandria VA. System redesign principles were employed to 
streamline the process for payments of ambulance claims and to 
have all ambulance claims submitted electronically.
    This new process began in March 2016. Alexandria and staff 
from the Consolidated Fee Unit began breaching calls and status 
updates on ambulance claims. As of June 9th, there were 34 
ambulance claims on hand, totaling just over $57,000, and none 
of those claims were aged greater than 14 days. Not only was 
the backlog resolved, the process was streamlined and is 
sustainable.
    In conclusion, VA is committed to improving access, patient 
care, accountability, and prompt payment to better serve our 
veterans. We realize the significant work that remains ahead. 
The good news is that moving forward, along with Congress and 
our VSOs, we have an opportunity to reshape the future and make 
long-lasting, valuable changes.
    We appreciate your support, and look forward to responding 
to any questions you may have.

    [The prepared statement of Janet L. Henderson, M.D. appears 
in the Appendix]

    Mr. Benishek. Thank you, Doctor.
    I don't know, Dr. Henderson. This is the kind of answers 
that I get really frustrated with. I don't know who wrote that, 
but it sounds as if somebody from Washington wrote that because 
it is the same kind of testimony we get from the VA every 
single time we have a hearing, okay?
    So it gets pretty frustrating for me to hear you say all 
that stuff just after we had these veterans here talk about 
real problems, okay? It would be nicer for me for you to have a 
personal statement, and I know you probably can't do that 
because somebody told you to read that. But it is just very 
frustrating to me here.
    I yield myself 5 minutes to ask a few questions myself. I 
want to focus on some of the things that were brought up here 
at this meeting because this answer that you gave, somebody 
wrote that for you as a standard statement that the VA says at 
every single hearing that we ever hear. So it is just a little 
frustrating for me to hear you have to go through that, even 
though somebody told you to do it.
    So, Mr. Dancy, I want to talk to you about the phone thing.
    Mr. Dancy. Yes, sir.
    Mr. Benishek. All right? So do I have to call the VA right 
now and see how long it takes, okay?
    Mr. Dancy. Yes.
    Mr. Benishek. Because I tend to believe these guys, and 
this 90-second number that somebody said I don't buy. So what 
are you going to do to fix that?
    Mr. Dancy. Well, first, Chairman, I would like to thank you 
for the opportunity to speak before the Committee. And as an 
Army veteran, I feel I am--
    Mr. Benishek. That is great, Mr. Dancy. But unfortunately, 
I have only got 5 minutes.
    Mr. Dancy. Yes, sir.
    Mr. Benishek. So I wanted--what are you going to do to fix 
the phone problem?
    Mr. Dancy. With regard to the phone system specifically, I 
know it was reported that there was 90 seconds. Obviously, that 
is not the case. I have heard veterans that are waiting 30, 45 
minutes. Bottom line, sir, unacceptable. And that is an area 
that I am going to look into.
    Mr. Benishek. So when can we have that answer, Mr. Dancy? 
Is it by the end of the week or next week, are you going to 
have the solution to this problem so that when I call one of 
these people that just testified, Mr. Knott, for example, he 
can call and expect 90 seconds?
    Mr. Dancy. Sir, I can't guarantee that we will have it by 
the end of the week, but I think we will have a solution--
    Mr. Benishek. Have a plan for me by next week maybe, how is 
that? Not to have it done, but then maybe by the end of the 
month, the end of next month we can have it done.
    I want to come over here to you, Mr. Novotny, because I 
want to ask you another question. I will leave the phone thing 
with Mr. Dancy. But, and I mentioned this to you earlier before 
the hearing that one of my pet peeves is the problem of the 
directors of a medical center not having enough time in that 
medical center to actually make a difference or know where the 
bathroom is or, you know, be able to solve the problem, and 
then they are whisked off to another assignment.
    Now what is the story here in your VISN about the tenure of 
the director of a medical center? What is the typical tenure of 
a director of a medical center?
    Mr. Novotny. Those tenures are really evolved from medical 
center to medical center. What is significant to note about the 
leadership vacancies, you know, first and foremost, we do 
realize that leadership matters. Leadership does make a huge 
difference.
    When a director vacates one of these facilities, in a 
perfect world, and that is if the system works, everything 
works correctly, it is a 6- to 9-month process in order to 
identify, go through the selection process, the vetting process 
to bring another director on. And that is excluding if they 
have been a sitting director before.
    An individual who has never been a director before has to 
go through the SES certification process--
    Mr. Benishek. Why does it take 6 to 9 months to hire that 
person?
    Mr. Novotny. Okay. That is because there is a specific 
period of announcement. There is a specific period of reviewing 
of the applications, and then there is a vetting process that 
occurs in central office.
    Mr. Benishek. Okay. So once somebody gets in there, then 
how long do they typically stay at a VA? We have heard 
testimony that there has been like some interim directors. Is 
it really hard to find individuals to be a director?
    Mr. Novotny. In Alexandria's case, it has been a challenge. 
I mean, you know, history indicates that it has been a 
challenge. Over the past 5 years--
    Mr. Benishek. Why is that?
    Mr. Novotny. There are several reasons. Alexandria, like 
many hospitals across the country, is a highly rural location. 
And although I grew up in the South, I love the South, it is 
not considered a destination location to some individuals.
    Alexandria also is what is called a Level 3 hospital. And 
so sometimes directors will go to Level 3 hospitals to prepare 
for assignments of greater responsibility.
    Mr. Benishek. So someone can't advance if they stay here?
    Mr. Novotny. I am not following.
    Mr. Benishek. Well, you know, that is what my frustration 
is about--one of the things about the VA is they plan for the 
director to only be there for 2 years because he can't get a 
raise or an advancement within the VA unless he moves somewhere 
else. So the whole system is rigged so that Mr. Dancy here, 
although he may want to stay here, if he wants to go anywhere 
with his career, he has got to move somewhere else.
    So you know that in 2 years, 6 to 9 months are going to be 
taken to hire a new guy. But that doesn't allow for continuity 
within the hospital, right? I mean, I was able to change that 
in my district. We were able to get a director who was actually 
from the area. He has been there like 5 or 6 years now.
    And you know, he has actually made some improvements. It is 
hard to make an improvement in the local hospital and then, you 
know, he leaves and then somebody else comes, ``Well, I got a 
different idea for improvement.'' So nothing ever makes any 
progress.
    Do you understand what I am saying? And I think that the 
upper levels of the VA need to have a better recognition of 
this problem.
    And somebody mentioned that is the way the military does 
it. Well, I am not sure that is the best thing for the military 
base either. It may be good for the commander, who gets a broad 
experience, but it is not good for the base.
    Well, I am out of time, and I know I talked too much and 
didn't ask enough questions. But I have to yield now to Dr. 
Abraham.
    Mr. Abraham. Thank you, Mr. Chairman.
    And everybody in this room, especially the panel members, 
you can feel the palpable frustration level up here, and 
certainly in the back of the room because, like Dr. Benishek 
says, Dr. Henderson, your speech, I mean, your opening 
statement, you could have--we have heard that exact statement 
20 or 30 times on these hearings.
    The MyVA, it is a wonderful concept. When Secretary 
McDonald, he brought us a pin that said MyVA, and Under 
Secretary Sloan Gibson. They wear their pins, but we are 
finding that is all it is. It is just a pin. There is no 
substance to it.
    I want to ask you, Dr. Henderson, you said--and please 
correct me if I misstate your statement here--but do you now at 
the VA center have same-day access?
    Dr. Henderson. Yes, sir. In Alexandria, there is same-day 
access. Now same-day access means that if you present to a 
clinic, you have a medical issue. The issue will be addressed. 
It doesn't necessarily mean you will see a physician that day.
    Mr. Abraham. Ah, see, there is a difference, but--
    Dr. Henderson. But if you need to--
    Mr. Abraham [continued].--let me interrupt you.
    Dr. Henderson. Okay.
    Mr. Abraham. You are a physician, and you got three here.
    Dr. Henderson. Yes. Yes, sir.
    Mr. Abraham. And we know if a patient comes to a medical 
facility, and if that patient feels that they have a condition 
that they need to see a doctor that day, that is why they show 
up that day. So let us peel the onion, so to speak.
    So let us say somebody comes with a diabetic foot ulcer, 
and who are they assessed by? Let us get into the logistics. 
Walk me through it.
    Dr. Henderson. Okay. And I would say that this would apply 
across VA, no matter which facility that you presented to. If 
you present to your primary care provider with a diabetic 
ulcer--
    Mr. Abraham. But you have got to get to him, and you are 
telling me they may not see that provider that day.
    Dr. Henderson. Well, I said they may not see their primary 
care provider, but if the primary care provider was unable to 
see them, the VA has emergency departments. Alexandria has an 
urgent care department.
    Mr. Abraham. Do you all track those patients that come in? 
For same-day access, do you all have tracking--Mr. Dancy, I 
will ask you--that tells the outcome of that particular 
patient, if they actually saw a physician, a nurse 
practitioner, or a health care provider? Or if they were given 
an appointment? Are those tracked on a daily basis?
    Mr. Dancy. I can't say for sure that those are tracked. I 
don't know, Congressman.
    Mr. Abraham. Okay. I think that is important--
    Mr. Dancy. Yes, sir.
    Mr. Abraham [continued].--for metrics to know where if you 
need to go--if we are doing any good. So if you could maybe 
look at that, I would appreciate that.
    Mr. Dancy. Yes, sir.
    Mr. Abraham. And Mr. Dancy, I will come back to you. You 
and I met before. We have had this discussion. Where does the 
VA rank, or do you know, as far as in national turnover rates 
of directors and of personnel, per se?
    Mr. Dancy. I don't know about directors, but I can speak, 
Congressman, to--in terms of personnel, and I will talk about 
providers specifically. Two locations that I will speak to 
specifically are our Natchitoches clinic CBOC, and also our 
Lafayette clinic, for example.
    In Natchitoches, it is a one provider, one PAC team 
facility. We recently lost a provider, a primary care provider, 
probably a couple of months ago, unexpected loss. And I don't 
recall--
    Mr. Abraham. Did they die?
    Mr. Dancy. No, no. He left.
    Mr. Abraham. Okay.
    Mr. Dancy. He left.
    Mr. Abraham. Well, I mean, why would you--they just picked 
up stakes and left that day?
    Mr. Dancy. Well, he gave his--the individual gave a notice 
that he was going to be leaving unexpectedly. From that 
standpoint, we basically had a gap in terms of a provider.
    Mr. Abraham. And how about here--I see my time is running 
out. How about at the VA? Let us not talk about Natchitoches or 
Lafayette. What about right here in Pineville?
    Mr. Dancy. In terms of--
    Mr. Abraham. Turnover. How does it rank?
    Mr. Dancy. I don't know where we rank, but typically, we 
have normally about a 10 percent vacancy rate, 10 to 15 percent 
vacancy rate.
    Mr. Abraham. And how does that compare with the Nation?
    Mr. Dancy. Sir, I don't know, but I can--
    Mr. Abraham. If you would, I would appreciate that.
    Mr. Dancy. Yes, sir.
    Mr. Abraham. I yield back, Mr. Chairman.
    Mr. Benishek. Thank you, Doctor.
    Dr. Fleming, you are recognized for 5 minutes.
    Mr. Fleming. Okay. Thank you, Mr. Chairman.
    I would like to ask the panel, given the disasters that we 
have learned about since Phoenix, egregious circumstances, 
veterans dying waiting for care on a waiting list that actually 
didn't exist. In all that time, how many people at the Veterans 
Administration hospital system have actually been fired?
    Mr. Dancy. I can speak locally. Over the last--since I have 
been as a director, and this has been January, there have been 
two people under my watch.
    Mr. Fleming. Related to these types of circumstances?
    Mr. Dancy. No, sir. These are related to just disciplinary 
action, but not related to wait times.
    Mr. Fleming. Well, no. I am talking about--I am talking 
about the inadequate response, not caring for veterans.
    Mr. Dancy. Oh, my apologies. That has not been the case.
    Mr. Fleming. So we don't know of anybody in this--I guess 
it has been 3 years since Phoenix. Am I correct about that? So 
with all of the veterans who have died--or perhaps 2 years has 
been suggested that we have had a number of cases, egregious 
cases where people simply never got care, and they ended up 
dying or losing limbs. And we heard this terrible situation 
with the Ryders' son.
    So my question again is, how many staff have been fired 
related to these types of delay in care in the whole system?
    [No response.]
    Mr. Fleming. I assume by your--
    Mr. Dancy. I don't know, sir.
    Mr. Fleming. I must assume by your silence that is zero. Am 
I correct? Do you have a statement?
    Mr. Novotny. I have data on separation and removal for VISN 
16. I am prepared to speak to numbers for the system as a 
whole.
    Mr. Fleming. Okay. Well, the reason why I bring that up, I 
believe it was Mr. Knott who brought up the fact that he is 
told by folks who are in the know, and I would like to hear 
your response that, look, if the union says you get hired, you 
get hired. If the union says you get fired or you don't get 
fired, you don't get fired.
    So what is the role of the union for employees for the VA 
system, and what control do they have over disciplinary 
actions?
    Mr. Dancy. I would be happy to address that, sir. From the 
hiring perspective, a supervisor has--can hire based on a list 
of qualified applicants.
    Mr. Fleming. Well, I am actually interested in firing. I 
don't care about the hiring, okay?
    Mr. Dancy. Okay. Sure, sure.
    Mr. Fleming. So it is the firing.
    Mr. Dancy. From the union's perspective, in terms of 
firing, if an employee is a bargaining union employee, then 
that union can represent that employee in those proceedings. So 
the union is a representative.
    Mr. Fleming. So if--if a VA employee mistreats a veteran, 
then the power of the union itself comes down on their side to 
protect the employee against being held accountable for the 
actions they took or didn't take that led to the death or 
severe illness of the patient?
    Mr. Dancy. I can't speak, sir, in terms of what the union's 
position would be regarding representing--
    Mr. Fleming. But they are an advocate for the employee, not 
for the patient? I think that is fair in saying that.
    Mr. Dancy. Yes, sir.
    Mr. Fleming. Now, look, I have been in hospital systems for 
40 years, including the U.S. Navy, private hospitals, even a 
little bit in VA hospitals back, way back to the day. I have 
never heard of a system that advocates for the employee over 
the patient.
    Now I think that is a huge problem here. We passed a bill 
out of the House that would have created some accountability, 
and it was never taken up in the Senate, and the President said 
he wouldn't sign it. So isn't the problem, in fact, it doesn't 
matter how much money you throw at, it doesn't matter who you 
put in charge, if you don't hold people accountable for their 
actions or lack of actions, you are never going to get good 
results.
    So we are talking--you are saying the calls are 90 percent, 
I mean, I am sure on paper your statistics are excellent. But 
we hear testimony from good people, veterans. They are not here 
to lie. They just want to get good care.
    And in fact, when it is good, they say so. They say when we 
actually get in the system, we get good care. So they have 
absolutely no investment in saying otherwise.
    So the point being here that there is just simply a lack of 
accountability, and the union works on behalf of the employee 
against the interest of the patient. And ladies and gentlemen, 
we are never going to fix this problem until we fix that.
    Mr. Chairman, I yield back.
    Mr. Benishek. Thank you.
    I am going to ask a few more questions. I am not going to 
use my whole 5 minutes, but I've time to take a few more 
questions, if you don't mind.
    Dr. Henderson, this is compelling testimony from Mr. Ryder 
about his son, all right? And so I am wondering, what would 
somebody in Mr. Ryder's position, a family member or a veteran 
who is grievously ill and in need of immediately treatment to 
save or extend his life, but is waiting for community care 
authorization, what should that person do if it seems to be 
taking a long time?
    Dr. Henderson. Well, I can say in our facilities that we 
have nurse navigators within the community care departments, 
and their role is to help the patient navigate through that 
system. I heard when you asked Mr. Ryder if at any time he had 
had contact with a patient advocate at Alexandria, and he said 
that he had not.
    Mr. Benishek. I mean, aren't you sort of appalled by what 
happened in that case?
    Dr. Henderson. It is a heartbreaking story. There is no 
question about that.
    Mr. Benishek. That shouldn't happen to anybody, right, 
Doctor?
    Dr. Henderson. It should not happen. No, you are correct.
    Mr. Benishek. So, we don't want to see that happen again, 
do we?
    Dr. Henderson. It would be my desire that it would never 
happen again.
    Mr. Benishek. So, how does that person, when they are 
frustrated at the system there, they come in and rather than 
threatening to go off on a deep end, which is another story we 
heard about a different patient, what do they do? Who do they 
call? You understand the frustration of the people that 
testified here today?
    What do we do? Do you have any input on any of that?
    Dr. Henderson. Well--
    Mr. Benishek. I mean, you are the Chief Medical Officer for 
the VISN, right?
    Dr. Henderson. That is true.
    Mr. Benishek. One of my complaints, to tell you the truth, 
Doctor, is the fact that the doctors have very little say in 
how the VA works. When I worked there, it would seem to be the 
nurses and the bureaucrats that were running the show, and what 
I wanted didn't really matter because I was just a doctor.
    You know what I mean? So when I wanted to have two nurses 
in my clinic so I could move patients through quickly, well, 
that is not your job, Doctor, to decide how many nurses belong 
in the clinic, even though I could see twice as many patients 
in the same period of time because I am sitting around 
twiddling my thumbs between patients because there is not 
enough people to move the patients in and out.
    So do you feel as--you probably can't tell me. But do you 
feel as if that you don't have enough input in the way things 
are done in this kind of a situation?
    Dr. Henderson. I think that throughout health care, not 
just VA health care, but I mean, I think that we need to 
improve our process. I have been here since May 1st. I am aware 
of--
    Mr. Benishek. Do you have any input in that process, 
Doctor?
    Dr. Henderson. I have a seat at the table. I do. I am still 
getting familiar with the various facilities that we have 
within our VISN.
    Mr. Benishek. How long have you been with the VA, Dr. 
Henderson?
    Dr. Henderson. I have been with the VA total since--almost 
10 years this August I will have been with the VA. I have been 
in VISN 16 since May 1st.
    Mr. Benishek. So you are new to the--you are all relatively 
new to your positions, right? Mr. Dancy has just been since 
January, as I understand it.
    Mr. Dancy. Yes, sir.
    Mr. Benishek. And you have only been on for how long?
    Dr. Henderson. I have been in VISN 16 since May 1st.
    Mr. Benishek. So, and then, Mr. Novotny, are you relatively 
new to your position, too?
    Mr. Novotny. No.
    Mr. Benishek. Oh, you have been around a long time?
    Mr. Novotny. No, I am--no, I have been around a long time.
    Mr. Benishek. So what do you think of my statement to Dr. 
Henderson there that, I mean, I feel as if doctors don't have 
enough input in the way things are run.
    Mr. Novotny. So I am married to a physician, and if I 
didn't support physicians in all things, I would be in a lot of 
trouble. But that aside, I believe fully that our providers are 
an integral part of our team, both at the floor and at the 
midlevel, and at the executive levels, as evidenced by Dr. 
Henderson being here in this room. That is part of the reason 
why she is here.
    All of our providers are integral members of the medical 
board. All medical centers have chiefs of staff who are senior 
leaders on the executive team, and play an essential role in 
the day-to-day operations of these hospitals.
    Mr. Benishek. All right. Well, you are convincing me, I 
guess. But let me ask you this other question that Dr. 
Henderson didn't answer. What does Mr. Ryder do or somebody 
like Mr. Ryder do when they are faced with a situation where he 
thinks his son is dying, which he was, and they can't get a 
referral? So what do they do?
    Dr. Henderson. If I can speak to my previous experience at 
the VA was that before, when we were dealing only with non-VA 
health care, we identified similar situations with what we 
called high-risk consults like oncology consults, GI consults--
    Mr. Benishek. I know you are talking a lot, Dr. Henderson, 
but you are not answering the question. What do they do? Answer 
that question. What does that person do?
    Dr. Henderson. It sounds like what they did, they had a 
champion at the local VA, and sometimes it takes a person. It 
takes a person to--
    Mr. Benishek. Mr. Ryder didn't have a champion.
    Dr. Henderson. Well, I believe he said whenever he would 
get in touch with Dr. St. Cyr, things would get done.
    Mr. Benishek. Yes, okay. I give you that.
    Dr. Henderson. And unfortunately, sometimes that is what it 
takes. But we have a system that needs to have some 
improvements. I am going to say that. That when we have high-
risk consults like this, as we did at my facility, we 
established nurse navigators to help the patient and their 
family--
    Mr. Benishek. All right.
    Dr. Henderson [continued].--get what we considered those 
critical consults accomplished, and I hope that we can get 
something in place here.
    Mr. Benishek. Well, I want you to dedicate your time to 
making sure that that happens so we don't hear another story 
like Mr. Ryder.
    I am over my time. Dr. Abraham?
    Mr. Abraham. Thank you, Mr. Chairman. Just a couple, and I 
will just continue on this line.
    Everybody in this room has been involved in the military. 
They understand SOP procedures, and you would think a patient 
like Mr. Ryder--and there are, unfortunately, many patients 
like Mr. Ryder that have life-threatening conditions every 
day--would get an approval just like that. Because we know what 
happens when they don't. They die.
    Do you guys have a manual, or is there a timeframe that we 
are supposed to get an approval? I mean, again, I go back to 
private practice, and I understand we are dealing with 
bureaucracy with the VA, and I understand it is a big 
bureaucracy.
    But the most important thing is we are dealing with lives. 
It is not like dealing with some other entity. These are human 
beings that die when we don't do our jobs. So I guess the 
question is, there has got to be something in place that if one 
doc picks up the phone and another doc, it needs to be those 
two docs.
    Like Dr. Benishek says, I have talked to many doctors in 
the VA system. And Mr. Novotny, I know you said they are chiefs 
of staffs and they are places of leadership, but they do not 
have the autonomy that they need in this VA system to make 
decisions that private doctors make every day in practice, and 
that is a problem because people die when you have that delay.
    So what are we going to do about that? Do we need to do 
something as Congress? Do you guys--I mean, where is the 
disconnect? Because this is unacceptable.
    Dr. Henderson. And I will agree that it is unacceptable. I 
think that with--the VA is sort of transitioning when we look 
at care in the community. And I just need to say this because 
it is a process. It is a bureaucracy that has been created.
    With the traditional non-VA care, it was a little bit 
easier to get out and get patients appointed. With the Choice 
Act that we are dealing with, there is another layer in that we 
are dealing with another health entity--
    Mr. Abraham. Doc, let me interrupt.
    Dr. Henderson. I would say that, if I may just finish this 
one thing, in terms of, we in VISN 16, since I have been here, 
because I can only speak to since I have been here. But I can 
tell you that we are actively looking at stat consults that are 
going out to Choice that should be appointed within 48 hours to 
be seen.
    We are pulling those back in actively. At our facilities, 
we are looking at those on a daily basis to actively pull them 
back in, and if Choice cannot get that, then we are going 
through our care in the community to try to get these patients 
seen.
    I can tell you that we all are concerned about these delays 
in care, and these certainly are tragic stories that we have 
heard today. And they are not stories. They are veterans' 
lives.
    And I say that we have a way to go. I would say that there 
is an awareness now. We are trying to develop the systems to 
support being able to tightly follow these consults so that we 
have the clinical staff, as our nurse navigators, in place to 
help the veteran to break down these barriers to care.
    It is not there yet. But I can tell you that at VISN 16, 
since I have been here, we know it is a problem. We are 
actively working towards trying to solve the issues that are 
coming up. I mean, we actively report up delays of care.
    Mr. Abraham. And I understand, Doctor, and I will apologize 
for interrupting because I am sure I am running out of time, 
too. And I understand.
    But this isn't something that has just come to surface. 
This has been going on for years, and the VA just doesn't get 
it. And I will use the analogy that I have used in other 
Committee hearings, is that when we allow the VA to try to heal 
themselves, it is like sending the Hindenburg to rescue the 
Titanic. It just never works.
    So, again, I hope we can continue this dialogue, and we can 
get to that simple phone call to phone call so that veteran can 
get immediate care when he or she needs it.
    Thank you, Mr. Chairman. I yield back.
    Mr. Benishek. Thank you, Dr. Abraham.
    Well, I think I have had enough questions for you all. 
Thank you for being here.
    And I want to thank all the witnesses for being here today 
and the audience members for joining us as well. It has been a 
pleasure for me to be here in Louisiana with you all.
    I want to also say that I think all the members of the 
audience have heard the compelling testimony from both the 
first panel and the second panel, and you know, these folks 
here today on the second panel, they sound like pretty 
reasonable folks, don't they? And yet they are part of a 
bureaucracy that doesn't seem to change, and so we still have 
this first panel, people that aren't being heard.
    So we want to encourage all you good-hearted people that 
work within this bureaucracy to you be part of the change. If 
you don't make it happen, it is not going to happen. And I know 
how difficult that is. So I encourage you, the three there that 
are here before us today, to make yourselves felt within your 
organization, and make the changes that we need to have in this 
organization. You have to do that.
    Thank you.
    With that, I will ask unanimous consent that all Members 
have 5 legislative days to revise and extend their remarks and 
include extraneous material.
    So, without objection, that is ordered.
    Mr. Benishek. This hearing is hereby adjourned. Thank you.

    [Whereupon, at 4:40 p.m., the Subcommittee was adjourned.]


                           A P P E N D I X

                              ----------                              

                   Prepared Statement of Gordon Ryder

    Testimony from Gordon Ryder

    Gerrit Paul Ryder 11-9-1976 to 3-6-2016

    In May 2015, Gerrit felt a lump in his abdomen, had some traveling 
pains and had difficulty exercising. He went to a chiropractor a few 
times thinking he had a pulled muscle or pinched nerve.
    On Memorial Day 2015, he still managed to do the ``murph'' in just 
over an hour.
    In June 2015, still having pains, can't sleep on his back. I told 
him to make an appointment with the VA. He said it was too difficult to 
get an appointment and he would wait for his July 1st annual checkup.
    In July 1st, the VA doctor was sick and they told him to come back 
August 15th or he could sit and possibly get an appointment the next 
day. That night at about 8:30 p.m., we found him doubled up in pain on 
the floor of our house after a big meal. We went to the Opelousas 
General Hospital emergency room where a scan showed a mass in his 
abdomen. The ER doctor said it looked like lymphoma. The next day we 
went to Dr. Gary Blanchard, a relative, to make a game plan. I also 
called Dr. Brent Prather, Gerrit's doctor when he was a child. He knew 
Dr. Mark St. Cry, the VA doctor, and would talk to him about seeing 
Gerrit. Gerrit saw Dr. St. Cyr at the VA the next day, 7-3-15. He 
arranged for a PET scan at Our Lady of Lourdes.
    On July 7th, I went with Gerrit to his appointment with Dr. St. Cyr 
for the follow up of the can. He was very concerned and thought we had 
no time to waste. He contacted Alexandria VA to schedule an upper and 
lower GI test for Gerrit. We went to Alexandria for pre-op the next 
day, July 8th. They were going to schedule it for the following Monday. 
One of the nurses told us that wasn't enough time, then I showed her 
Gerrit's CT scan results. After reading it, her whole attitude changed. 
``Yes,'' she said, ``we must hurry and get these tests done.''
    On July 13th, I brought him to Alexandria VA for the tests. After 
the tests, the doctor, Dr. Dorval, came to talk to me, wanting us to 
come back in two weeks for an ultrasound. I asked about a biopsy Dr. 
St. Cyr was trying to schedule. He, in no uncertain terms, informed me 
he was in charge. The tumor was probably benign and to come back in two 
weeks for an ultrasound! On the ride home, Gerrit was very aggravated, 
told me that the doctor wouldn't let him finish explaining his symptoms 
and what was going on physically with him. Before we go home, 
approximately a one hour drive, the Lafayette VA called Gerrit. Dr. S.t 
Cyr saw the Alexandria VA results and would schedule a biopsy at Our 
Lady of Lourdes in Lafayette out of the VA network. We received a call 
from Lourdes scheduling a biopsy July 17th. After the biopsy, he 
received a call from the Alexandria VA to set up an appointment with 
the oncologist, Dr. John Clement. Dr. Clement told us that with the 
lymphoma, Gerrit had a seventy-five percent possibility of cure and a 
ninety-five percent possibility of remission. Chemo was to start August 
3rd.
    On August 3, 2015, we went to Alexandria, the VA, Gerrit was 
starting to feel very bad and was having to take a lot of pain 
medicine. They performed a number of tests, placed a port for chemo 
treatment on August 4th. We were told chemo would start on August 5th. 
The night of August 5th, Gerrit told me he had withdrawals from the 
pain meds, which he quit using because of the constipation it caused. 
This, in turn, caused very heavy rectal bleeding. Chemo did not start 
because approval from Little Rock, Arkansas, was needed and treatment 
could not start because we had not gotten the approval. We are not sure 
what the hold up in Little Rock was, but we were told it had something 
to do with somebody having car trouble. Along this time frame, he was 
given two units of blood. The first cycle of chemo started August 7th. 
We brought Gerrit home August 8th and he felt bad all week.
    We went back August 13th to check the bloodwork and when he checked 
in, he found out he was mistaken, that his appointment was for the 
14th. He was feeling so bad, the doctor worked him into the daily 
schedule. When his bloodwork was returned, they decided to keep him 
overnight and give him three units of blood, and he felt much better 
after receiving the blood.
    On August 22, 2015, Gerrit's hair began to fall out.
    On September 8th, second round of chemo. He didn't feel too bad, 
was still going to college at this time, but he does have a high pain 
threshold.
    On October 9th, third round of chemo, everything seemed to be going 
well.
    On November 13th, fourth cycle of chemo. The week before treatment 
has been getting very painful. He is in much discomfort now.
    On December 11th, he went for the fifth cycle, but his blood count 
was too low and he was told to return December 18th.
    On the 18th, his blood count was still too low. Now he was to come 
back December 21st to receive more blood, have another scan and 
possibly bone marrow biopsy.
    On December 21st, received four units of blood and had a scan.
    On December 22nd, Gerrit called me in the morning, telling me to 
come pick him up. The scan showed the tumor was growing. Dr. Clement 
wanted him to go to Houston, either M.D. Anderson or Houston VA, 
whoever could see him first because the chemo was not working.
    He received a call December 23rd from Houston VA, giving him an 
appointment on December 28th. We drove him to Houston VA December 28th, 
approximately a four hour drive from our home, had bloodwork at 11:00 
and saw the doctor at 1:30. The doctor was very concerned and told us 
the Houston VA would try to help him and said if they couldn't help 
him, they would refer him to M.D. Anderson. He was immediately admitted 
and assigned a team of doctors to treat him.
    From December 28th to January 5th, there were a lot of tests, 
biopsies, scans, ultrasounds, many tests. Because this cancer is so 
aggressive, we were told about a special test that is only done in San 
Francisco. The doctor said it was very expensive but he thought they 
would approve it. We never heard any more about this test. They decided 
to give him what was called ``salvage chemo.'' We could see the 
strength draining out of him. We returned home January 5th and were 
told to go back for the second cycle on January 28th.
    The week before January 28th, Gerrit was getting more and more 
uncomfortable, He doesn't complain much, but I know he is hurting.
    Drove to Houston the 27th of January. He had a very bad night that 
night. Upon examining him January 28th, they found more tumors. This 
chemo failed also. They would immediately try to refer him to M.D. 
Anderson. Drove home the 28th and at 8:30 that night, he collapsed in 
pain again, and we had to go to the Opelousas General emergency room. 
There, they drained four liters of fluid off of his swollen abdomen.
    Started called M.D. Anderson on February 1st, but they had no 
record of Gerrit at that point. I started a referral and gave them all 
the medical information I had. We were waiting for the VA approval of 
out-of-network medical care. Called Congressman Abraham's office for 
help with approval. His office told us the office in North Carolina was 
the approver and it was forthcoming. Called North Carolina and could 
not get any answers. Received a call the next day from the North 
Carolina office because the previous call was monitored. They assured 
me they would hurry with the approval.
    February 5th, back to OGH ER to drain abdomen because of discomfort 
and hard to breathe. Called M.D. Anderson, still nothing from the VA. I 
was told no appointment would be scheduled until they got the VA 
approval. While in Opelousas General Hospital, I told Dr. Gary 
Blanchard I would wait until the next Wednesday for the approval. He 
said Gerrit might not have until then. I let him rest the next day, and 
February 8th, we got in the care and drove four hours to the M.D. 
Anderson ER, where they promptly admitted him. The physicians there 
told us of an experimental treatment but at this time, his blood counts 
were too low to qualify and they would try some of the previous chemo 
to see if they could shrink the tumors to give him time for his blood 
to improve so he would qualify for the experimental treatment. M.D. 
Anderson installed a chest drain to receive the pressure in his 
abdomen. The doctor kept asking for the pathology reports and lab 
slides from the Houston VA. He needed to see the reports before he 
could start Gerrit's chemo. We had sent permission to Houston VA on 
January 28th to release all medical records. I called and could not get 
a good answer as to why the records have not been sent yet. Of course, 
VA approval for treatment had not been sent either. I talked to Dr. 
Clement at Alexandria VA several times. He was also trying to find 
where the records were and why they weren't sent. I walked from M.D. 
Anderson to the Houston VA, approximately a mile and half, went to the 
pathology department, tracked down the correct person to get the 
records from, sat with her until she got them together, and hand 
carried them back to M.D. Anderson. She told me she could send them 
over the next day. I told her if it was all the same, my son was dying 
of cancer at M.D. Anderson and I would just as soon take them myself. 
All this time, I am watching him get weaker and weaker.
    He had the chemo and we returned home February 16th from M.D. 
Anderson. His mother commented, when he returned home February 16th 
from M.D. Anderson, he looked worse than when he left.
    We went to Alexandria VA to have his blood checked on either 23rd 
or 25th of February. It's getting hard for him to walk now, and the 
fluid is seeping through the skin on his leg and feet. Still no 
appointment from M.D. Anderson. We keep checking.
    On February 27th, Dr. Gary Blanchard checked him at home and told 
us to bring him to the ER at Opelousas General because he was 
dehydrated.
    On March 1st, I left for a short trip. Gerrit got progressively 
worse.
    I was called home March 4th.
    Gerrit passed away in the hospital March 6, 2016, at 2:53 a.m.
    I wonder if we had been referred earlier to Houston VA or M.D. 
Anderson if it would have saved Gerrit. Through this whole process, I 
got the feeling that veterans are given crumbs, secondhand services, 
leftovers. At best, the VA moves at a snail's pace; the rest of the 
world is watching DVD's and they're stuck on cassettes. They like to 
say, ``We'll get back to you in five to seven business days,'' or 
``Call back Monday,'' but cancer and other diseases grow on the weekend 
and twenty-four hours a day during the week, too. We had a lot of 
people truly engaged in Gerrit's treatment. I could see the frustration 
in a lot of them because they weren't given what they were needed to 
provide for their patients. I wonder if Joe Biden had this much trouble 
when his son fought cancer. I am a veteran of the U.S. Air Force, 
Gerrit served eight years in the U.S. Navy, I have another son who was 
a U.S. Marine. Why can't we and the other veterans get health benefits 
equal to you people in the U.S. Congress? We served our country, but it 
is the opinion of a lot of people that all you do is receive from our 
country.

                                 
                  Prepared Statement of Carroll Knott
    **Veteran Derek Johnson; submitted by his wife**

    Social worker, Sharon Deluche, advised me Derek's team meeting 
would be at 3pm. I arrived at 2pm: they had seen Derek already. Gave 
Sharon copy of messages where Derek threatened to commit suicide. 
Sharon left them on her desk and went on vacation. Psychologist told 
both Derek and I that nothing was wrong mentally with Derek; he just 
had a drug problem.
    When I left I called the crisis hotline because I felt Derek's 
treatment team was not doing anything. I was advised the Derek could 
request to be sent to a different VA, which he told them several times 
he wanted to go to Biloxi and they ignored him. I was also told by his 
psychologist, Dr. Mollanor, to get a restraining order against Derek.
    Sharon Deluche insisted on Derek going to SUDS program in 
Alexandria and living at the Salvation Amy homeless shelter. This was 
the ONLY option she gave my husband because she did not believe him 
when he said he wanted help. Sharon refused to put a consult to Biloxi 
for Derek to do the impatient substance abuse program there.
    I called her boss, Harvey Norris, and he is the one who actually 
helped us. He sent the consultation to Biloxi for us. He also wrote a 
letter stating Derek was not ready to be discharged because of the 
suicide threats. Derek's social worker, Sharon, did not do any of this 
for us.
    Sharon never contacted me to let me know when any of his team 
meetings would be. She never called me to give me updates either. The 
nurses would not help me; they would just transfer me to Sharon who 
would not return my calls.
    Sharon advised me to leave Derek alone, to let him go and for 
myself to seek counseling. She then went told Derek that I did not want 
him home and that he was still in there because of the letter that 
Harvey wrote while trying to help us. This made my husband stop talking 
to me while he was in there.
    On Derek's day of discharge, he was discharged with a follow up to 
the SUPS program, which he told them several times he was not doing. 
Biloxi called the VA on 6/16 with the time and date for his screening 
appointment for their impatient program. Sharon NEVER passed this 
information onto us. I had to call Harvey Norris to find out when we 
would hear from Biloxi for his consultation. The psychiatrist put Derek 
on thorazine 2 days before he was released back to us which does not 
help an unstable combat veteran deal with civilian life that soon.

                                 
                   Prepared Statement of Asbel Montes
    Mr. Chairman and distinguished members of the Subcommittee:

    My name is Asbel Montes and I am the Vice President of 
Reimbursement and Government Affairs for Acadian Ambulance Service, the 
largest private, employee-owned ambulance service in the nation. The 
Chairman & CEO of our company, Richard Zuschlag, founded the ambulance 
service division in 1971 with eight Vietnam veterans. Today, we now 
have over 4,400 employee owners, with over 400 of those being military 
veterans.
    I am honored to sit before you today to represent not only the 
industry, but even more so, the veterans we serve.

Background

    Since the last hearing on June 3, 2015 where we provided requested 
information on this issue, our company, along with American Medical 
Response, the largest public ambulance provider in the nation, and the 
American Ambulance Association have worked diligently with our 
Congressional delegations, including Congressman Abraham, Congressman 
Boustany and Congressman Coffman, other healthcare stakeholders, the 
Veteran Integrated Network Services (VISNs), as well as the national 
leadership at the VA to assist, recommend and frankly demand that the 
VA expedite the updating of their internal processes to promptly pay 
for the emergency treatment that our nation's finest receive by non-VA 
healthcare partners.
    Due to these continued efforts, we have seen some significant 
progress made within VISN 16 and attribute these gains to the hearing 
conducted last year. However, there is still significant work to be 
done and my colleagues within the ambulance industry nationwide are 
still experiencing extraordinary delays in claims processing and 
payment in other VISNs.
    For a real life look at the progress made by the VA and the issues 
still prevalent, I would like to include two specific examples. In the 
first quarter of 2014, it was taking the VA in Alexandria approximately 
138 days to pay for an emergency ambulance transport. Thanks to the 
efforts of Congressman Abraham and this subcommittee, we are now 
receiving payments for approved care within 40 days through electronic 
submission. However, on the flip side, the Flowood, Mississippi office 
and the Houston office in VISN 16 are still struggling to improve 
prompt payment efficiencies. For example, Flowood still requires that 
we send all claims and medical records via paper. In addition, claims 
are being underpaid due to a new unregulated process that requires us 
to add the ZIP+4 to every claim. No other Federal or State payer or 
other VISN office requires this that we are aware of. It should also be 
noted that no one was ever notified of this requirement prior to 
complaints being made as a result of the underpayments.
    In November of this past year we had to engage the assistance of 
Congressman McCaul's office to address severe payment and claims 
processing delays in VISN 17. This work is still ongoing and our 
efforts are being coordinated with the Chief Business Office in Denver, 
Colorado under the direction of Mr. Steven Gillespie. Our current aged 
receivables outstanding over 180 days are in excess of $600,000 
awaiting payment or denial.
    There are many more examples just like this one that could be given 
by providers and veterans alike across the nation. This problem is 
especially acute for the majority of ambulance service providers that 
serve as the local 911 responders in their communities, who are 
prohibited from refusing emergency treatment for any patient, 
regardless of payer source or ability to pay. This failure to pay 
providers in a timely and accurate manner puts providers in the 
difficult position of either having to shut their doors and eliminating 
access to care due to lack of funds to operate or to bill veterans for 
emergency treatment, placing an unfair financial burden on the veteran 
due to the lack of response, invalid denial or payment by the VA.
    Ultimately, it is the veteran who suffers due to the lack of 
coordination and inefficiency of the internal systems at the Veterans 
Administration. While the Chief Business Office has been very 
responsive to our company over the past nine months, there is still an 
inefficiency in system design regarding prompt payment and processing 
of provider claims. As of three weeks ago, one facility in VISN 17 
requested that we submit everything via paper claim until they could 
resolve our issues on why our claims were not processing through the 
OB10 system. This only continues to exacerbate the administrative and 
financial burden for providers who serve our nation's finest.

Solution

    The federal government has a responsibility to ensure that our 
veterans receive the best healthcare we can provide. It also has a 
responsibility to ensure they are not required to bear an unjustified 
financial burden as a result of the VA's failure to pay non-VA 
providers in a timely and accurate manner. As stated in my previous 
testimony last year and subsequently introduced via legislation by 
Congressman Boustany and Congressman Abraham in H.R. 4689, it is our 
recommendation that Congress remove all claims processing for non-VA 
providers from the Department of Veterans' Affairs and place it with a 
single Fiscal Intermediary, providing guidelines and policies to 
address the issues stated here today. Congressman Coffman has also 
introduced H.R. 5149 that will provide clarification on how the VA will 
reimburse emergency ambulance providers for the care provided to our 
veterans who meet the prudent layperson's definition of an emergency to 
ensure our veterans are not financially burdened solely as a result of 
the VA's subjective and adverse treatment of these claims. This step 
would ensure consistency, efficiency and expertise in personnel as well 
as sufficient dedicated resources to process claims timely. Several 
other government programs, including Medicare and Tricare, utilize this 
strategy successfully.
    Thank you for giving me this opportunity to provide information and 
to serve those who have sacrificed so much for our nation. I look 
forward to answering the Committee's questions and serving as a 
resource as the Committee's work continues beyond this hearing.

                                 
                 Prepared Statement of Janet Henderson
    Good morning, Mr. Chairman, Ranking Member Brownley, and Members of 
the Committee. Thank you for the opportunity to discuss the efforts 
that the Department of Veterans Affairs (VA) VA has taken to improve 
access, patient care, and accountability. I am accompanied by Shannon 
Novotny, Veterans Integrated Service Network (VISN) 16 Acting Deputy 
Network Director and Peter C. Dancy, Jr., Alexandria VA Health Care 
System Medical Center Director and a 22-year Army Veteran.
    VA remains committed to ensuring that America's Veterans have 
access to the health care they have earned through their service. 
Veterans are demanding more services from VA than ever before. From 
March 1, 2015, through February 29, 2016, Alexandria VAHCS completed 
more than 244,000 appointments; this represents an increase of 4,407 
appointments (1.83 percent) over the same time last year.
    Even as VA becomes more productive, the demand for benefits and 
services from Veterans of all eras continues to increase. VA's top 
priority is to improve access to care for every Veteran who needs it.
    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 this initiative. The first priority of MyVA is to fix 
the access issues and continue working to reduce the wait times for 
Veterans who need our services.

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. Alexandria VAHCS 
completed 112 combined Veteran appointments at the Alexandria campus 
and Lafayette Community-Based Outpatient Clinic (CBOC) during the 
November 2015 Stand Down. They also completed 134 combined Veteran 
appointments at the Alexandria campus, Fort Polk CBOC, and Lafayette 
CBOC during the February 2016 Stand Down.
    It is important for Veterans to be in control of their health care. 
This means 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. That is why the Under Secretary for 
Health developed the ``MyVA Access Declaration,'' which is a set of 
foundational principles for every VA employee to improve and ensure 
access to care. The MyVA Access' goal for 2016 is when a Veteran calls 
or visits primary care at a VA medical center, their clinical needs 
will be addressed that day. This initiative and the MyVA Access 
Declaration represent VA's pledge to improve access to care for all 
Veterans seeking VA health services.
    Two of Secretary McDonald's Breakthrough Priorities focus squarely 
on health care outcomes: improving access to care and improving 
community care. Moving toward long-term transformation, the Alexandria 
VAHCS has already implemented a number of actions to address access, 
quality, and patient satisfaction within the larger transformation of 
MyVA.

      Alexandria VAHCS completed 93.28 percent of appointments 
in April 2016 within 30 days of the clinically indicated or Veteran's 
preferred date.
      Alexandria VAHCS increased its total outpatient 
unduplicated encounters by 1.49 percent from fiscal year (FY) 2014 to 
FY 2015. This equals roughly 6,165 additional completed encounters for 
our Veterans.
      Alexandria VAHCS has a 97 percent utilization rate for 
Care in the Community referrals through the Veterans Choice Program 
(the Choice Program), authorized by the Veterans Access, Choice, and 
Accountability Act of 2014. There have been 4,361 consults to VA 
Community Care via the Choice Program this fiscal year.
      Alexandria VAHCS offers an extensive community provider 
network of over 1,000 providers through the Patient-Centered Community 
Care/Choice Program, and more are joining each month.
      Alexandria VAHCS is the health care provider of choice 
for 31,998 Veterans within our catchment area. Of these, 25,872 
Veterans receive Primary Care Services.
      Alexandria VAHCS is activating two new permanent CBOCs: 
Lafayette, Louisiana CBOC and Lake Charles, Louisiana CBOC.

      I The current Lafayette CBOC provides Primary Care to 7,351 
Veterans.
      I The current Lake Charles CBOC provides Primary Care to 1,809 
Veterans.

      Alexandria VAHCS provides Telehealth to 3,958 Veterans, 
or 12.37 percent of our Veteran population. Telehealth services have 
been expanded to CBOCs for Primary Care, Mental Health, and Specialty 
Services and these are critical to expanding access to VA care.

Patient Care

    The Alexandria VAHCS utilizes sign-in kiosks to assess patient 
satisfaction in terms of their ability to schedule an appointment when 
they want it. As of June 3, 2016, 90% of Veterans utilizing the sign-in 
kiosks at the facility were completely satisfied or satisfied with 
their ability to receive care when they wanted it. We want to ensure 
that we can say that there are no Veterans who need care now who are 
not receiving it. We are not fully there yet, but that is the direction 
in which we are moving.
    The Alexandria VAHCS Director has emphasized to Veterans that he 
wants the Alexandria VAHCS to be the provider of choice within the 
community. To that end, below are some of the initiatives that have 
been put in place to address patient care issues within the community:
    Between February 27, 2016, and June 5, 2016, Alexandria VAHCS 
decreased the amount of appointments at Level 1 clinics (defined as 
clinical services judged to have higher relative risk and more time 
sensitivity) from 354 appointments to 63 appointments over 90 days, 
resulting in an 82.2-percent decrease.
    VA has partnered with the Veterans Engineering Resource Center for 
the MyVA Access initiative, which will focus on improving access to 
care for our Veterans across the Nation. Alexandria VAHCS is scheduled 
to have their initial site visit with the Veterans Engineering Resource 
Center the week of June 13-17, 2016.
    Alexandria VA HCS has also hired a full-time group practice manager 
who will provide general oversight for all ambulatory care access at 
the Alexandria VAHCS.
    In April 2016, the Alexandria VAHCS Director held a Veteran town 
hall meeting in Natchitoches, Louisiana to hear Veteran concerns; 
Approximately 50 Veterans attended. Town hall meetings will continue, 
with the next scheduled for June 29, 2016, in Lake Charles, Louisiana. 
To ensure follow-up on actions on the concerns expressed by Veterans at 
the April 2016 Town Hall in Natchitoches, Louisiana, the Alexandria 
VAHCS Director will hold another Town Hall meeting in July 2016.
    In partnership with the Office of Patient Centered Care, the 
Alexandria VAHCS has begun engaging employees in Mil-X training, which 
is an ``experience'' that provides awareness, insight, and 
understanding of Military Culture to help facilitate a healing 
relationship with the Veterans we serve. The main objectives are to 
develop a better understanding of basic Military Culture, align 
Military Culture with VA's Mission and Core Values, and connect 
effectively with Veterans to improve the Veterans experience. Since May 
2, 2016, 63 employees have attended this interactive training. 
Trainings will continue until all staff has the opportunity to 
experience this model.

Accountability

    The Alexandria VAHCS Director also has emphasized that he would 
like the Alexandria VAHCS to be the health care employer of choice. He 
has held eight employee town hall meetings at the local facility and at 
CBOCs to hear employee concerns, address rumors, and to share the 
direction the HCS is headed with a focus on the I-CARE values of 
Integrity, Commitment, Advocacy, Respect, and Excellence.
    He has also initiated recognition of employees who have exhibited 
I-CARE values through weekly presentations at an executive morning 
meeting using I-CARE certificates. These certificates give supervisors 
an opportunity to recognize employees who have demonstrated I-CARE 
attributes through their work. To date, over 15 certificates have been 
awarded. Supervisors have taken the initiative to replicate this 
recognition at their own staff meetings.
    Each year during patient safety week, the Alexandria VAHCS Director 
issues a memorandum to all staff regarding the culture of safety and 
the importance that each individual makes to the organization by 
reporting unsafe conditions, adverse events, and near-miss incidents. 
We are deeply committed to promoting a culture of safety in this 
organization by emphasizing ``how'' an event occurred rather than 
``who'' may have made an error. Patient events are discussed in a 
supportive, non-punitive environment, using open communication to 
improve processes and prevent a recurrence of the event. We are 
dedicated to developing strong leaders devoted to fostering a 
foundation of respect, accountability, and responsibility at every 
level of the organization.

Conclusion

    VA is committed to improving access, patient care, and 
accountability to better serve our Veterans. We realize the significant 
work that remains ahead. The good news is that moving forward, along 
with Congress' assistance, we have an opportunity to reshape the future 
and make long-lasting valuable changes. Mr. Chairman, this concludes my 
testimony. We appreciate your support and look forward to responding to 
any questions you may have.

                                 
                       Statements For The Record

                      Congressman Charles Boustany
    Chairman Benishek and Subcommittee Members:

    Thank you for providing me the opportunity to submit written 
testimony today. I am especially grateful to the Subcommittee for 
traveling to my home State of Louisiana to conduct this critically 
important field hearing. As you consider legislation to reform the 
Veterans Choice Program and other Department of Veterans Affairs (VA) 
policies, I believe it is of vital importance to seek solutions to the 
problem of delayed payments for veterans' medical care.
    In June 2015, I submitted written testimony to the House Veterans' 
Affairs Subcommittee on Health regarding the seriousness of the backlog 
of non-VA emergency medical care claims within the VA. I detailed the 
case of one Louisiana veteran, Mr. Al Theriot, who waited over a year 
for the VA to contact him regarding his emergency care claim. I also 
provided information from two Louisiana hospitals with a cumulative 
backlog of over $5.5 million in unpaid claims from the VA. At the time 
of my previous testimony, the VA's own data demonstrated a nationwide 
backlog of more than $878 million. Today, almost one year later, the 
nationwide backlog is still a staggering $788 million.
    While it is disturbing in itself that these figures have only 
slightly improved, it must also be noted that since the time of my 
first inquiry for emergency claims data from the VA, the agency has 
internally changed its timely processing standard from within 30 days 
to within 45 days. Consequently, the most recent claims reports I have 
received from the VA reflect that change, making it impossible to 
accurately measure their progress in this area.
    In 2015, I recommended that, should the VA fail to improve its 
performance on claims processing, lawmakers should consider legislation 
to direct the VA to contract with a third-party entity to process 
claims. Therefore, due to the lack of improvement from the VA, I 
introduced H.R. 4689, the Timely Payment for Veterans Emergency Care 
Act, in March 2016. My legislation would direct the VA to transfer non-
VA emergency care claims processing authority from the VA to a third-
party contractor. Medicare and TRICARE currently employ third-party 
claims processors, and according to testimony of the Government 
Accountability Office (GAO) to this Subcommittee in February 2016, both 
programs have much higher success rates for timely processing than the 
VA.
    Additionally, my bill would mandate that the entity selected for 
the contract must be able to accept electronic medical records. Lost 
records have unfortunately become a frequent problem, and providers 
still report to me that they are doing everything in their power to 
ensure the necessary medical records are received by the VA, including 
sending medical records via certified mail. Despite this, the VA is 
still denying many claims by asserting that they never received the 
necessary medical records, even when providers can produce proof of 
receipt. Ensuring that providers have the ability to submit records 
electronically will greatly increase the VA's accountability to 
providers in this area.
    America's veterans should never have to worry that an ambulance 
ride or a trip to the emergency room will negatively affect their 
personal finances - they should instead be focused on their health and 
recovery. As your legislative discussions continue, I urge you to give 
the utmost consideration to H.R. 4689. I sincerely appreciate the work 
done by the Subcommittee to support our nation's veterans, and thank 
you again for allowing my testimony.

                                 
                       American Medical Response
    Submitted by
    Debora M. Gault, National Vice President of Federal Reimbursements 
& Regulatory Affairs

    Mr. Chairman and distinguished members of the Subcommittee:

    American Medical Response (AMR) is honored to have this opportunity 
to submit a written statement to the House Committee on Veterans 
Affairs' Subcommittee on Health for the hearing on June 20, 2016. AMR 
is the nation's largest single ambulance provider with operations in 
over 2100 communities in over 40 States. AMR proudly serves our 
nation's veterans on both an emergency basis, through 911 calls, and a 
non-emergency basis through contracts with the Department of Veterans 
Affairs (VA). Like so many other non-VA providers in the country, AMR 
has had consistent difficulty getting reimbursed by the VA for services 
we provide to veterans. Despite the fact that AMR has been working 
diligently with the VA for over 2 years now to try to get the backlog 
resolved, the current payment backlog at the VA for AMR claims totals 
approximately $15.8 million. Unfortunately, there has been very little 
progress after two years of biweekly conference calls with members of 
the VA CBO and VISNs. As stated in our initial testimony provided for 
the Committee's hearing in June, 2015, our work has been useful in 
obtaining the names of contacts that work directly on medical 
transportation claims, but very little improvement has occurred in 
terms of actually resolving the issues we have uncovered or in timely 
payments received.

Background

    AMR has been operating since 1992 and currently provides over 3.3 
million transports annually to patients in the communities we serve. 
Approximately 100,000 of these services are provided to veterans across 
the nation. AMR has over 19,000 employees nationally and many of them 
are veterans. We continue to be diligent in our recruiting efforts to 
attempt to reach and provide employment to as many veterans as possible 
and have established recruiting and training programs specifically 
directed to provide a career path within AMR for our military heroes 
who are returning to civilian life. Our objective is for every veteran 
who desires a career in the world of Emergency Medical Service to be 
able to attain their goal.
    Each of AMR's operations provides clinical ambulance services to 
our nation's veterans. As a result, AMR works directly with 20 of the 
VA's Veteran Integrated Service Networks (VISN) when submitting claims 
and the required documentation as we attempt to secure reimbursement 
for our services. Unfortunately, as we stated previously, this is not 
an easy task. While we do everything possible to ensure that veterans' 
covered services are paid directly by the VA with as little involvement 
by the veteran as possible, the VA's current lack of consistent 
processes, the lack of electronic capability for claims submission and 
the huge backlog of delinquent payments make this goal extremely 
difficult, if not impossible.
    AMR submitted written testimony to the House Committee for 
Veteran's Affairs for the hearing on June 3, 2015, entitled ``Assessing 
VA's Ability to Promptly Pay Non-VA Providers.'' Throughout our 
testimony, AMR discussed several issues that had been discovered 
through our work with the VA that were causing delinquent payments. As 
we discussed in our original testimony, AMR's work with the VA began in 
May, 2014 when Congressman Coffman facilitated weekly conference calls 
between AMR and representatives of the VA.
    Because another year has passed since the discussion of the issues 
in our testimony for the June 3, 2015 hearing, AMR would like to take 
this opportunity to update the Committee on the status of the major 
issues today.

The VA continues to be Delinquent in Payment for Both Emergency and 
    Non-Emergency Claims

    Although the conference calls between the VA Central Business 
Office (CBO), VISN staff and AMR have occurred on a biweekly basis, 
payments for both Emergency and Non-Emergency Claims continue to be 
processed very slowly and the total currently owed to AMR by the VA 
exceeds $15 Million. Of that total, $4.5 Million of all claims 
(contract and non-contracted fee basis claims) are over 90 days old.
    Despite the requirement of prior authorization that is included for 
contracted services with VA facilities, over $967,000 of contracted 
claims remain outstanding over 90 days from the date the service was 
provided to the veteran and authorized by a VA facility. These claims 
are subject to the prompt payment rule and should be paid within 30 
days. Unfortunately, even though AMR is fulfilling our commitment to 
the veteran and the VA facility, clearly, the VA is not fulfilling its 
contractual obligations to AMR. Nor is the VA processing claims within 
the 30 day prompt payment regulation that they are mandated to comply 
with through statute.
    Claims payments for emergency services to veterans have not 
improved either. Claims processing continues to be done primarily on a 
manual basis and processing of these claims is extremely slow once the 
VA receives the documentation required. In addition, the VA continues 
to follow what we believe to be a misrepresentation of their own 
processing requirements as it pertains to emergency ambulance services. 
We will discuss this and what we are doing to attempt to resolve this 
problem a bit later in our testimony. Due to the VA's mishandling of 
emergency claims, the backlog of VA emergency claims only at AMR 
currently totals over $11 million. Of this amount, over 27% of these 
claims have remained outstanding more than 90 days past the date the 
service was provided to the veteran.

Discussions with the VA have not Resulted in Solutions to Payment 
    Challenges

    Although consistent dialog has continued and issues are addressed 
during every discussion, the VA does not seem to be able to make 
substantial progress. The total amount due to AMR when we began working 
directly with the VA staff in May, 2014 was $10 million. Since our work 
began, the total due to AMR has been as high as $18 million and 
averages from $13 to $16 million on a regular basis. No other payer 
demands as much of AMR's claims processing time and resources, and no 
other payer's reimbursement methodologies are as cumbersome. 
Ironically, even with all the additional time and attention expended on 
VA claims at AMR, the VA remains the most delinquent of all our payers.
    The VA was tasked with reviewing the cost/benefit of outsourcing 
the claims administration portion of their service at the June 3, 2015 
hearing. However, we were recently informed that because the agency is 
implementing Electronic Claims Transmission (ECT) pilot programs to 
resolve the delinquent payment issues, they do not plan on putting such 
an analysis together. We will discuss the ECT pilot programs in and 
AMR's involvement with them in more detail later in this testimony.
    Utilizing third party contractors to process Medicare claims works 
very well for ambulance providers. At a minimum, AMR feels strongly 
that the VA should follow Congress' instruction and produce the 
requested cost/benefit analysis to study the pros and cons of utilizing 
third party contractors for their claims adjudication process so that a 
sound decision can be made. Additionally, AMR supports and urges the 
Committee to consider H.R. 4689, ``The Timely Payment for Veterans' 
Emergency Care Act'' sponsored by Congressman Boustany.

Several Problems Continue to Contribute to VA's Delinquency in Claims 
    Processing

    The following portion of our testimony includes an update on the 
various problems that were discovered through our work with the VA and 
discussed in our previous testimony for the June 3, 2015 Committee 
hearing.

    VA Continues to Require External Records from other Health Care 
Providers before Paying Emergency Claims

    The VA is holding emergency ambulance claims prior to processing or 
payment until medical records are received for the veteran's entire 
episode of care on the day of the ambulance transport. Even if the 
veteran meets the additional requirements established within the VA's 
payment regulations (e.g., whether the incident is service or non-
service related, whether the patient has been seen within a specified 
period of time prior to the current date of service), the VA does not 
truly utilize the prudent layperson standard to establish payment for 
emergency medical services. In addition to the ambulance service's 
documentation, the VA still claims that it also requires documentation 
from other medical providers that are involved with the patient's care 
on the date in question before the VA can pay any of the claims 
received. Putting these criteria in the ambulance service's context, 
the ambulance provider's claim cannot be reimbursed until all medical 
records from the hospital and other clinicians that see the veteran on 
the day of their ambulance transport are received and reviewed by the 
VA. This means that even though the ambulance service personnel are not 
even present and the ambulance service has absolutely nothing to do 
with the care that is rendered once the patient is transferred to the 
receiving facility, the ambulance provider's claim is delayed until all 
other claims are received and evaluated to determine whether the entire 
incident can satisfy the need for medical care on that date.
    This retrospective lookback using the facility medical records 
provides the physician at the VA much more definitive information about 
the outcome of the veteran's medical encounter than the ambulance 
provider is aware of during their entire time with the patient. Because 
the VA regulations state that the Prudent Layperson Standard is the 
standard by which the VA will reimburse emergency medical services, 
that is the standard that should be used. Unfortunately, that is not 
the case.
    In April of 2015, Congressman Coffman contacted VA Secretary 
McDonald about this issue on AMR's behalf. Acadian Ambulance Services 
also requested that Congressman Boustany submit a request for review of 
this issue to the VA. The Deputy Secretary of the VA responded and 
stated that the VA was applying their claims methodology for emergency 
ambulance services properly. We were informed that if we did not agree 
with their current practices, we would need to seek a legislative 
solution.
    Because of this response to our inquiry, Congressman Coffman 
recently introduced H.R. 5149 which would specifically require the VA 
to reimburse emergency ambulance services based solely upon the Prudent 
Layperson Standard. The bill was introduced by Congressman Coffman on 
April 29, 2016 with the bipartisan support of Congresswoman Titus, 
Congressman Abraham, Congressman Takano and Congressman Boustany as 
original cosponsors of the legislation. The American Ambulance 
Association is supportive of H.R. 5149, and we have included a copy of 
their statement as an addendum to our testimony document. We urge the 
Committee to include the language from H.R. 5149 in any VA reform 
legislation that may be developed this year so we can resolve this 
issue for veterans and ambulance providers once and for all. Enactment 
of the language in H.R. 5149 would help resolve the VA's current 
misinterpretation of the emergency ambulance service claims 
requirements and alleviate much of the emergency claims backlog (up to 
30% of emergency claims are currently held or denied because of this 
one issue). Veterans would no longer be held financially responsible 
for emergency ambulance claims that the VA should have paid and 
ambulance services would be reimbursed based upon the true application 
of the Prudent Layperson Standard, which is the standard that other 
large payers such as Medicare, Medicaid, Medicare Advantage and Blue 
Cross/Blue Shield apply to establish medical necessity for emergency 
ambulance services. Ambulance providers nationally would appreciate the 
Committee's consideration of H.R. 5149 when VA Reform legislation is 
discussed this year, and we applaud Congressman Coffman for his 
leadership on this issue.

Electronic Claims Transmission (ECT) is Still Not Available for 
    Submission of All Ambulance Claims

    The VA began conducting an ECT pilot program to provide electronic 
claims submission for all types of ambulance claims in 2015. The main 
goal of the ECT pilots were to ease the burden for the provider since 
no eligibility tool is available and VA program requirements for 
ambulance service eligibility are extremely complicated. The VA is 
currently claiming great success of Phase I of their ECT pilot which 
includes five sites (Atlanta, GA, Alexandria, LA, Minneapolis, MN, Las 
Vegas, NV and Boston, MA). Although the VA claims the ECT pilot has 
decreased the time taken to pay claims, this has not been the outcome 
of the program at AMR. AMR has participated in two of the five pilot 
programs and, thus far, we have not seen faster payment turnarounds as 
an outcome of the process.
    AMR has seen some benefits of the ECT programs that have been 
implemented. Some of these benefits are: reduction of paper, visibility 
of claims submission, tracking of claims acceptance at the VA, ability 
of reporting at the VA of claims received and faster processing status 
for denials which generate a paper response received as correspondence 
on determination. Unfortunately, the current internal shuffling of 
claims between the different departments within the VA to determine who 
is responsible for processing the claim and determining whether all of 
the eligibility criteria has been met continues to hamper the process 
from showing as much effectiveness and efficiency as possible.
    Because of the VA's own cumbersome process requirements, the 
current ECT pilot cannot be as streamlined and successful as it would 
be if the process regulations were clarified. Currently, the claim is 
transmitted by the provider and received electronically and the 
provider receives proof of receipt very quickly. However, because of 
the VA's own process requirements that must be followed and medical 
claims from other healthcare providers that must be retrieved and 
approved for coverage before the ambulance claim can be paid, the 
ambulance claim is still taking a significantly long time to actually 
process for payment. Until the specifications included in H.R. 5149 are 
passed into law, the ECT process that the VA believes will resolve 
ambulance provider payment problems will not be effective.
    We were recently told that the VA was so pleased with the outcome 
of Phase I of the ECT pilot program that they are moving forward with 
Phase II. Again, while this may improve the submission of the 
information of the veteran's episode of care to the VA, it will NOT 
solve the delinquent payment problems. Until the regulations are 
clarified and the Prudent Layperson Standard is applied correctly by 
the VA, the ECT pilot program only allows the claim to arrive at the VA 
more quickly--the processing time remains the same. The ECT pilot 
program that the VA has implemented is not, in the true sense of how 
other payers use ECT, fully capable of processing the claim for payment 
or denial. All it does is allow the VA to accept the information into 
its system through electronic means while the rest of the process 
requirements are still performed manually.

VISNs Claim Lack of Funding

    When AMR discusses delinquent claims problems with individual 
VISNs, we continue to be told that the VA must request additional 
funding because insufficient dollars were appropriated for ambulance 
services in their budget. This funding request must then go through the 
VA's internal approval process and causes a large part of the problem 
with delinquent payments on facility contracted claims. This continues 
to occur as early as the first quarter of the year. The CBO has 
sufficient funds to pay ambulance claims but the internal authorization 
process that must be followed to obtain the funding to pay ambulance 
providers at the VA facility level takes a substantial amount of time. 
This process is especially frustrating because the VA has already 
agreed that the claim should be paid.
    The root cause of this problem remains the same as was discussed in 
our initial testimony. Rather than work with the ambulance 
professionals during their budgeting process to ensure that the proper 
amounts are included in their budgets for clinical ambulance care and 
transport of veterans in each area, the VA budgets are based upon past 
volumes on a cash basis. If the VA would work together with the 
ambulance companies to discuss whether there will be volume 
fluctuations because of various demographic or other differences, much 
of this problem could be eliminated and resources could be saved for 
both the VA and the providers and ultimately decrease the number of 
delinquent claims. AMR and other ambulance providers have reached out 
in attempts to work with the VA on this issue but the VA has not 
reciprocated.

There are Not Enough Resources within the VISNs to Process Ambulance 
    Claims

    Another problem that continually is used as the number one reason 
claims cannot be processed is that there are not enough resources 
within the VISNs to process ambulance claims. The VISNs have continued 
to be very honest that this is true. We continue to be told by VA 
personnel that the reason there is such a backlog of our claims is that 
they simply do not have enough people working on them. The problem is 
exacerbated when one of the dedicated personnel at the VA is not 
working for a period of time, and there is no process to accommodate 
any backfill of that person's work. So, they leave a backlog when they 
go on vacation or medical/personal leave and come back to a backlog 
that is exponentially worse because no one has been processing any of 
these claims in the meantime. While the VA continues to tell us that 
they will find a solution to this problem, it is now a year later and 
after two years of being told this is the number one hurdle to their 
successfully adjudicating claims timely, no solution has been 
forthcoming.

When VA does not Pay Claims, Veterans are Affected

    As discussed previously, when the VA does not pay claims that they 
are responsible for paying, veterans continue to be held financially 
responsible. AMR is still committed to doing everything possible to 
hold claims until we receive notification directly from the VA that the 
claim is either not covered or is paid. Despite the fact that there are 
claims are over a year old that AMR continues to hold open, hoping we 
can work through whatever issue is prohibiting the VA from paying the 
veteran's claim, we feel strongly about not holding the veteran 
financially responsible if the VA should be covering their service.
    As we explained in previous discussions and testimony, larger 
ambulance providers are able to operate despite the VA's delinquent 
payments and can hold claims open for longer periods of time as they 
attempt to retrieve reimbursement from the VA. Smaller ambulance 
providers are a harder time than ever holding VA claims open without 
payment for long periods of time. Many small providers have simply 
stopped serving veterans in non-emergency and contracted scenarios. 
This has put even more of a burden on large ambulance providers. Since 
the VA has no emergency ambulance service capability, a non-VA supplier 
must always provide these services for our veterans. Because small 
ambulance providers can no longer afford to provide these services to 
veterans, much of their previous service areas must be covered by 
larger providers. This may result in increased response times as 
another company must travel longer distances to treat veterans which 
ultimately reduces the quality of care provided to our veterans and 
creates an even higher financial burden on the large providers as they 
absorb more and more VA services.
    In addition, as the VA payment cycle increases, it becomes more 
common for veterans to be held responsible for paying their ambulance 
bills. In a recent survey of several members of the American Ambulance 
Association, over 70% of respondents stated that they had no choice but 
to hold the veteran responsible for paying their ambulance claim after 
waiting for VA's payment for over 60 to 90 days. Some smaller providers 
could only wait for VA to pay their claims 45 days and then held the 
veteran responsible for payment. As a result, veterans have begun to 
question whether they should dial 911 for fear of being held 
responsible for paying ambulance claims - and perhaps their hospital 
bill as well - if the VA determines that the veteran's ultimate 
diagnosis could have been treated in another manner. Hindsight is 20/20 
but do we really want our veterans to feel that they should think twice 
about dialing 911 for help when they truly need it? Once again, H.R. 
5149 deals with this issue and would help ensure that the veteran would 
never have to be held responsible for paying an emergency ambulance 
claim that the VA should be responsible for paying because of a 
retrospective lookback using information that was not available when 
help was truly needed. Veterans should never be afraid to ask for help 
in an emergency because of the VA's inappropriate application of the 
Prudent Layperson Standard. The VA should treat emergency ambulance 
claims in the same manner as other payers have done for well over a 
decade and use solely the Prudent Layperson Standard to establish 
coverage of the service.

Conclusion

    We appreciate the Subcommittee's consideration of these issues. 
While we were all hopeful that the Veterans Access, Choice and 
Accountability Act, which was signed into law in 2014, would help 
resolve critical payment issues, unfortunately it has not. We were 
hopeful again after the June 3, 2015 hearing that ambulance services' 
claims payment problems would improve. Unfortunately, that has not been 
the case either. In fact, the situation has gotten much worse in almost 
all areas of the country. The VA is already subject to prompt payment 
laws-laws the agency is not following. Respectfully, we submit that 
Congress needs to take aggressive action to fix the VA's health care 
system and ensure that our nation's veterans receive the care they 
deserve. By supporting the provisions included in H.R. 5149 and H.R. 
4689, the Committee would make great strides toward preserving high 
quality clinical ambulance services for veterans without creating the 
current level of anxiety about becoming financial liable for medical 
claims that the VA should be paying and, at the same time, provide a 
path forward for much fairer treatment for our nation's ambulance 
service providers.
    AMR thanks the Chairman and the Committee for the privilege of 
submitting this testimony.

                                 
       Veteran ACTION Coalition of Southwest Louisiana (VACSWLA)
    The NASA photograph below of the USA at night clearly demonstrates 
the relative populations and relative economic activity of the 
Alexandria, Lake Charles and Lafayette, Louisiana areas. The Lafayette 
and New Iberia Metropolitan Statistical Area (MSA) is now the third 
largest in Louisiana behind only New Orleans and Baton Rouge. 
Lafayette, New Iberia and Lake Charles are growing very fast. 
Alexandria is not.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    1. For more than forty (40) years the VA Staff in Alexandria LA 
forced veterans in Lake Charles and Lafayette to drive the four-hour 
plus round trip to Alexandria to receive VA health care which those 
veterans have earned by their service to our country. The VA Alexandria 
Staff prevented construction of a VA clinic in Lake Charles prior to 
2016. Congress should demand that the VA deliver health care where 
veterans live. Congress funded two new VA Clinics in Lake Charles and 
Lafayette that are now under construction. This entire process 
transpired as The CBOC's in Lafayette and Lake Charles remained 
tremendously understaffed.
    2. There are 35,000 veterans in the thirteen (13) Parishes around 
Alexandria, LA The Alexandria area has 1,240 VA Staff members that 
means 28 veterans per VA Staff member. There are 69,500 veterans in the 
fifteen (15) Parishes around Lafayette and Lake Charles, LA that has 
eighty (80) VA Staff members or 868 veterans per VA Staff member. The 
Lafayette and Lake Charles populations are growing RAPIDLY.
    3. Veteran population distribution indicate 1,340 VA permanent 
staff should be as follows: Alexandria clinic 433 staff for 35,000 
veterans; Lake Charles clinic 312 staff for 24,000 veterans; the 
Lafayette clinic 590 staff for 45,500 veterans. The VA Staff in 
Alexandria will block that distribution unless Congress intervenes.
    4. Often veterans arriving in Alexandria were redirected to private 
specialty physicians in Alexandria - not on the VA Staff - to receive 
their VA health care. Private specialty physicians were and are 
available in Lake Charles and Lafayette. Physician ``turnover'' rate at 
the Alexandria VA facility is high reflecting the need for more 
physicians in specialties in Lafayette and Lake Charles , both working 
in the CBOC's and in the private sector.
    5. The Alexander, Lake Charles and Lafayette (28 Parish area) VA 
Medical Care Expenditures for ten years, FY 05 -14, was 
$2,082,676,342.00 More than TWO BILLION Dollars in VA funds have been 
managed by the VA Alexandria Staff in those ten years. Lake Charles and 
Lafayette had little to show for that gigantic amount of money. More 
than THIRTEEN MILLION dollars of construction funds were expended in 
Alexandria in FY 05-FY 14. NOT ONE PENNY of construction funds were 
expended in Lake Charles or Lafayette in those ten years. Fortunately 
that trend is changing.
    6. Veterans in the Alexandria area receive many more VA health care 
dollars ``per veteran'' than veterans in the Lake Charles and Lafayette 
areas. ``Unique Patients'' are veteran patients receiving health care 
from the VA. There is a much higher percentage of ``Unique Patients'' 
in Alexandria when compared to the total veteran population living in 
that surrounding area than in Lake Charles and Lafayette communities. 
Additionally, the Alexandria ``Unique Patients'' receive many more VA 
health care dollars than the ``Unique Patients'' from Lake Charles and 
Lafayette thus suggesting that Alexandria veterans use VA healthcare at 
a greater rate because of the lack of travel barriers.
    7. Because of Veteran Volunteer groups and our national 
congressional input, and new leadership in Washington Congress funded 
new VA clinics in Lafayette and Lake Charles to ensure VA health care 
is delivered where veterans live. The Lafayette Clinic is under 
construction with the Lake Charles construction to follow shortly. 
However, the permanent VA staffing and equipping will determine the 
success of those two clinics by determining what specialty and primary 
health care is delivered to veterans at those new clinics.
    The facts above merely skim the surface. Many more facts are 
available on the VA Expenditures web page below:
    http://www.va.gov/vetdata/Expenditures.asp
       Fairness to Veterans under the VA-Union Master Agreements
    Apparently, allegedly the five existing VA and union Master 
Agreements (contracts) are barriers to delivery of timely, quality 
health care to veterans. The Federal Tort Claims Act is the source of 
employee immunity from lawsuits for federal workers, not the union 
master agreement. The act substitutes the federal government for the 
employee except for certain law enforcement and investigative agencies. 
However, under the Master Agreements, Union members, after the first 
year of employment, can be terminated for cause only with great 
difficulty and after lengthy appeals. One VA staff member in 
Alexandria, Louisiana remained on the payroll after being charged with 
manslaughter in the beating death of an Alexandria, Louisiana VA health 
center patient.
    More than 94% of eligible VA employees are union members.
    Please see the bottom of page four listing the five unions with 
which the VA has Master Agreements (contracts). Page four also lists 
the union members within VA VISN 16 of the south central United States.
    VA Secretary McDonald has the opportunity, as the next contracts 
are being formulated, to fight for veterans, helping to make the future 
Master Agreements ``veteran friendly'', which has not been the case in 
the past. The current Master Agreements were in place before Secretary 
McDonnel arrived and appear to place the unions effectively in control 
of the Department of Veterans Affairs--and in control of delivery of 
health care to veterans.
    When the VA-Union Master Agreements are renegotiated to make them 
``Veteran Friendly'' there will certainly be points of impasse where 
the Union negotiators will not agree under any conditions. These points 
of impasse will be resolved by the all-powerful Federal Services 
Impasses Panel. (See Title 5 United States Code Chapter 71 Article 7119 
(two pages) ).
    All seven members of the Federal Services Impasses Panel are 
appointed by the US President.
    Any member of the Panel may be removed by the US President.
    It is recommended that future VA-Union Master Agreements be 
``Veteran Friendly'' by having veteran representation on the VA 
negotiating boards and on the Federal Services Impasses Panel.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 

                                 [all]