    [Senate Hearing 114-595]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-595

         KEEPING THE PROMISE FOR ARIZONA VETERANS: THE VA CHOICE CARD,
            MANAGEMENT ACCOUNTABILITY, AND PHOENIX VA MEDICAL CENTER

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               DECEMBER 14, 2015

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

                                 ________

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     23-617 PDF               WASHINGTON : 2017
    ____________________________________________________________________
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                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman
    Jerry Moran, Kansas                  Richard Blumenthal, Connecticut,
    John Boozman, Arkansas                   Ranking Member
    Dean Heller, Nevada                  Patty Murray, Washington
    Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
    Mike Rounds, South Dakota            Sherrod Brown, Ohio
    Thom Tillis, North Carolina          Jon Tester, Montana
    Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                         Joe Manchin III, West Virginia
                           Tom Bowman, Staff Director
                     John Kruse, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                               December 14, 2015
                                    SENATORS

                                                                       Page
    Sullivan, Hon. Dan, Acting Chairman, U.S. Senator from Alaska....     1
    McCain, Hon. John, U.S. Senator from Arizona.....................     3
    Flake, Hon. Jeff, U.S. Senator from Arizona......................     5

                                   WITNESSES

    Byers, Charles ``Chuck,'' Vietnam Veteran........................     6
        Prepared statement...........................................     8
    Mitchell, Katherine L., M.D., former employee of the Phoenix VA
      Health Care System.............................................     9
        Prepared statement...........................................    12
    Morris, Nicole, U.S. Navy Veteran................................    39
        Prepared statement...........................................    39
    Shulkin, David J., M.D., Under Secretary for Health, U.S.
      Department of Veterans Affairs; accompanied by Thomas Lynch,
      M.D., Assistant Deputy Under Secretary for Health Clinical
      Operations; and Kathleen Fogarty, Interim Director, VISN 18:
      Southwest Health Care Network..................................    42
        Prepared statement...........................................    44
        Letter clarifying testimony..................................    88
    McIntyre, David J., Jr., President and Chief Executive Officer,
      TriWest Healthcare Alliance....................................    49
        Prepared statement...........................................    52

         KEEPING THE PROMISE FOR ARIZONA VETERANS: THE VA CHOICE CARD,
            MANAGEMENT ACCOUNTABILITY, AND PHOENIX VA MEDICAL CENTER

                                  ----------

                           MONDAY, DECEMBER 14, 2015

                                            U.S. Senate
                                 Committee on Veterans' Affairs
                                                            Gilbert, AZ
        The Committee met, pursuant to notice, at 11:08 a.m., at
    Gilbert Town Hall, 50 East Civic Center Drive, Gilbert,
    Arizona, Hon. Dan Sullivan presiding.
        Present: Senators Sullivan [presiding], McCain, and Flake.

                OPENING STATEMENT OF HON. DAN SULLIVAN,
                        U.S. SENATOR FROM ALASKA

        The Chairman. The Senate Veterans' Affairs Committee
    oversight hearing will now come to order. I would like the
    first panel of witnesses to take their seats.
        Good morning, everybody. My name is Dan Sullivan. I am a
    U.S. Senator from Alaska, a Member of the Senate Veterans'
    Affairs Committee, and a veteran myself with 22 years of Active
    Duty and Reserve service as a Marine Corps infantry officer.
        Today's hearing is a continuation of oversight hearings we
    have been conducting on how the VA has been implementing a
    series of laws passed in 2014. I am very pleased to be joined
    by my distinguished Senate colleagues, Senator John McCain and
    Senator Jeff Flake.
        Alaska and Arizona are big States, proud States. While our
    winter temperatures might differ some, we have many things in
    common, in particular a large population of veterans.
        As many of you know, Arizona has over 535,000 veterans
    making up over 8 percent of this State's population. I am sure
    my colleagues from Arizona would agree that it is our strong
    population of proud veterans that truly makes the States of
    Arizona and Alaska resource-rich.
        This morning, we are here to continue the important work of
    ensuring that each and every veteran in Arizona, in Alaska, and
    throughout the country, gets the care they have earned and the
    care they deserve.
        Less than 2 years ago here in Arizona at the Phoenix VA,
    our country learned that our veterans here and across the
    Nation were not getting the care that they deserved, the care
    that they need, and the care that they have earned. From hidden
    waitlists and poor reporting, the VA was simply not doing its
    job, and veterans were falling through the cracks.
        Rightfully, the country was outraged; our veterans were
    outraged. Then, their elected officials in Congress acted.
        A few months after these issues came to light, Congress
    came together and passed the Veterans Access, Choice and
    Accountability Act of 2014, better known as the Choice Act.
    This bill was passed by a very bipartisan majority in the House
    and Senate. Within a week of its passage, the Choice Act was
    signed into law.
        One of the many reasons I am honored to be on this dais
    with Senators McCain and Flake today is that they were two of
    the leaders in the U.S. Senate to make this happen. Senator
    McCain, in particular, has been advocating for the Choice card
    and choice issues for years.
        However, since this bipartisan effort to pass the Choice
    Act, the implementation of the law has been rocky at best. Our
    veterans are still not seeing the quality of care or access to
    it that they deserve. They are still waiting too long for
    appointments.
        Twice Congress has had to correct issues with
    implementation since the passage of the Choice Act, once when
    improperly calculated distance requirements by the VA had to be
    changed in law; and, again, when the VA ran out of money to
    implement the Choice Act.
        Thus far, we have seen that while Choice is working in some
    areas, it is failing in other places like my State of Alaska,
    and is having serious implementation problems here in Arizona.
        I understand that the implementation of such a large
    program like the Veterans Choice Act is difficult. However, the
    fact that something is difficult cannot and should not be used
    for justification for delay or failure. Regardless of how
    challenging the task may be, our veterans always deserve the
    maximum effort and the best results from the VA and Congress.
        When the call went out for our veterans to serve, they put
    their country first and answered the call. We are here in
    Arizona today because, as a Nation, it is our turn to answer
    the call and put them first.
        Today's oversight hearing marks the sixth one that the
    Senate Veterans' Affairs Committee has held on the Veterans
    Choice program, the sixth one just this year: three in DC and
    field hearings in Alaska, Georgia, and now Arizona.
        The Committee felt it was particularly important to have
    such a hearing here, given that many of the problems were
    originally recognized here, and, as I mentioned, the leadership
    of Senators McCain and Flake in playing such an important role
    in devising the comprehensive solution to some of our VA
    problems throughout the country.
        I would also like to mention, under the strong leadership
    of the Veterans' Affair Committee, Chairman Johnny Isakson of
    Georgia has sought to remind the senior leadership of the VA
    who they really serve--not Congress, not the President, but our
    veterans.
        We have an outstanding group of witnesses today. As you
    see, with regard to the first panel, we have a former VA
    employee and a whistleblower who took a lot of courageous
    actions. It will be very interesting to hear from her. That is
    Dr. Mitchell. We have two Arizona veterans, Mr. Byers and then
    Ms. Morris, who is stuck and a little bit of traffic but she
    should be joining us soon.
        I would like to welcome all the veterans who are here today
    in the audience. It is important to recognize that although we
    will not be taking testimony from everybody, we will have the
    opportunity to hear from all of you. If you would like to
    submit written testimony, you can do so at this address. It is
    public_testimony@ Sullivan.Senate.gov. We can provide that
    again. I know that some of the veterans here wanted to make
    comments. You can submit written testimony that will be part of
    this official Senate hearing record. We will certainly be
    reading that.
        Without further delay, I now would like to recognize the
    chairman of the Senate Armed Services Committee, a veteran, a
    war hero, my good friend, Senator John McCain, for his opening
    remarks.

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

        Senator McCain. Thank you. I appreciate Senator Sullivan
    from the great State of Alaska being here to chair this field
    hearing of the Senate Veterans' Affairs Committee today.
    Senator Sullivan is a proud Marine, and he has worked
    diligently and tirelessly over the past year to improve our
    Nation's security and fight for those who have served in
    uniform. Veterans of this country are fortunate to have Senator
    Sullivan advocating on their behalf.
        I want to thank the Chairman of the Veterans' Affairs
    Committee, Senator Johnny Isakson from Georgia, who was unable
    to be here with us today. He is doing a great job as Committee
    chairman. He is examining many things, including how veterans
    are using and in some cases how the VA is not helping the use
    of the VA Choice card.
        I am grateful to the city of Gilbert for hosting us in this
    facility. Being here is very helpful to our having a full
    discussion. I would like to take a minute to recognize and
    thank the city of Gilbert for their support of veterans through
    their various programs such as Operation Welcome Home and
    support of homeless veterans through the Homeless Veterans East
    Valley Partnership. I would also like to congratulate the city
    of Gilbert, which was recognized this year as being in the top
    five best cities in the United States for veterans.
        I will never forget the town hall forum I hosted in Phoenix
    where I heard directly from the families of four veterans who
    passed away in recent months. They came and stood before a
    crowded room to tell their stories. With tears in their eyes,
    they described how their loved ones suffered because they were
    not provided the care they needed and deserved. They recalled
    countless unanswered phone calls and ignored messages, wait
    times and delays, mountains of bureaucratic red tape, while
    their loved ones, those who selflessly served their country,
    experienced painful, debilitating, and ultimately fatal
    conditions.
        No one should be treated this way in a country as great as
    ours. But, to ignore the pleas for help and care from those who
    have sacrificed on behalf of the United States is
    unconscionable. We should all--all of us--be ashamed.
        The scandal at Phoenix led to revelations of similar
    problems at other VA medical centers around the country where
    bureaucrats were gaming the system to get better bonuses by
    denying care to our veterans. This strategy created a crisis of
    confidence toward the VA, the Federal agency that was
    established to care for them.
        I am happy to note that Congress responded quickly in a
    bipartisan manner to this crisis in a matter of weeks. The
    House and Senate passed the Veterans Access, Choice and
    Accountability Act. This bill provided an unprecedented $15
    billion in immediate emergency appropriations that was added on
    the Veteran Health Administration's regular annual budget of
    about $60 billion to hire more doctors and nurses and to issue
    the VA Choice card for those veterans who could not get into a
    VA for their health care.
        The bill also gave the VA direct hiring authority so that
    all of the cumbersome rules and regulations for bringing on
    board new Federal employees could be waived to fill vacancies.
        We will be discussing more about the budget and resources
    provided to the VA on the next panel.
        Congress also provided the Secretary of the VA with nearly
    unprecedented ability to terminate senior executives who fail
    to care for our veterans. No other Cabinet official has this
    powerful tool to ensure performance and results from its
    department's top officials.
        I continue to be disappointed that Secretary McDonald has
    not used this authority to its fullest extent. As I have said,
    it is past time for accountability and leadership at the VA.
        I want to thank our witnesses today on the first panel. Dr.
    Mitchell is a former employee of the VA Medical Center and a
    whistleblower. She will have very interesting comments to make.
        Mr. Charles ``Chuck'' Byers is a Vietnam veteran himself
    and an advocate for all veterans here in Phoenix. His ability
    to receive care through the Choice program is a success story.
        Finally, Ms. Nicole Morris, who is still not here.
        I am sure everyone in this room agrees we owe a solemn debt
    to those in uniform who fought on our behalf in faraway places.
        I just want to make a brief comment on the makeup of our
    second panel, which will consist of VA witnesses, as there has
    been a last-minute change.
        Last Friday, my staff was informed that the VA determined
    that a senior manager at the Phoenix VA, who was originally due
    to testify today, retaliated against a VA whistleblower. In
    light of this recent information, he will not be testifying
    this morning while we determine what has occurred with his
    case.
        Needless to say, all of us take issue with whistleblower
    retaliation at the VA very, very seriously. We have been
    discussing the matter with Secretary McDonald, especially in
    light of concerns about systemic problems in this regard that
    the Office of Special Counsel raised directly with the
    President a few months ago.
        After today's hearing, Senator Flake and I are sending a
    letter to Secretary McDonald to find out exactly what occurred
    in this retaliation case we were just made aware of and how it
    was handled.
        With that in mind, we have a number of issues that more
    broadly impact Arizona veterans to cover, and many of those
    veterans are here today to tell us about their experiences.
    Today, we will be focusing on the Choice card implementation
    and continuing problems with excessive wait times that our
    veterans face.
        For the 9 million American veterans who are enrolled in the
    VA today and for the families who lost loved ones awaiting care
    that never came and are still grieving their losses, it is time
    to live up to the VA's mission today, ``To care for him who
    shall have borne the battle and for his widow and his orphan.''
        I thank you again, Senator Sullivan, for being here. I am
    very pleased to note, we did not have this hearing in Alaska. I
    thank you. [Laughter.]
        The Chairman. Thank you, Senator McCain.
        As I mentioned, it is truly an honor to be on a panel with
    both Senator McCain and Senator Flake, who, in my discussions
    with him over the course of the last year, I know is fully
    committed to taking care of our veterans. Again, the two
    Senators from Arizona played such leadership roles in
    addressing the issues that it is an honor to be here with both
    of them.
        Senator Flake, your opening statement?

                     STATEMENT OF HON. JEFF FLAKE,
                       U.S. SENATOR FROM ARIZONA

        Senator Flake. Thank you, Chairman Sullivan. Thank you for
    chairing this hearing, and thank you for coming all this way
    and bringing Alaska winter weather with you anyway.
        I just want to say, from the beginning, with problems long
    before that, Senator McCain has been advocating for veterans.
    Throughout this issue, with the Phoenix VA as the epicenter of
    this latest problem that we had, Senator McCain from the
    beginning was pushing hard to make sure that veterans received
    Choice and that there is accountability. This field hearing is
    part of that.
        I am glad to have had the Choice Act passed. Yet, as
    Senator McCain and Senator Sullivan both said, there are issues
    with its implementation. We want to make sure that it goes
    forward.
        Also, in light of the October VA Inspector General report,
    noting problems still in the urology department in particular
    at the Phoenix VA, talking about substandard care there and
    delays that may have contributed to the deaths of veterans, we
    remain concerned and want to make sure that those issues are
    fixed. It is beyond unacceptable if we are still having those
    kinds of issues.
        Obviously, we want to make sure that, as I mentioned, the
    Choice Act continues to be implemented, and that the problems
    we had early on are dealt with.
        Thank you, Senator Sullivan, for coming here and thank you,
    Senator McCain, for pushing this issue all the time.
        I can tell you, being in the Senate, Senator McCain is
    always pushing veterans' issues and making sure that the
    veterans here and across the country get the care that they
    deserve. So, thank you for being here.
        The Chairman. Thank you.
        Now we will begin with our first panel. I would ask the
    witnesses to please try to keep their opening statements to 5
    minutes. Our goal is to have each panel for about an hour.
        Mr. Byers, the floor is yours.

                 STATEMENT OF CHARLES ``CHUCK'' BYERS,
                            VIETNAM VETERAN

        Mr. Byers. Thank you, Senator Sullivan, Senator McCain, and
    Senator Flake. Thank you for inviting me today to speak about
    the VA Choice card, management accountability, and the Phoenix
    VA Medical Center, and, as we say, keeping the promise to
    Arizona veterans.
        In August 2013, I moved to Arizona from New Jersey. I was
    enrolled in the Philadelphia VA health care system. I knew I
    had to transfer my eligibility to the Phoenix VA hospital care
    system. In September of that year, I applied to the Southeast
    Clinic in Mesa Arizona.
        I was told it would be at least 1.5 years before I could
    get a primary care doctor. I was even told that it might be
    sooner if I go down to the Tucson VA. I could not wait because
    I was receiving medication from my VA in Philadelphia. But, if
    the doctors do not see you, they will not renew your
    prescriptions.
        I went downtown to the Phoenix VA Hospital, which is about
    50 miles away from my home and was told the same thing. Then I
    spoke to an advocate. I was able to get an appointment in about
    9 months. They told me the reason for such a long wait time was
    due to a decrease in staffing and staff leaving for better
    paying opportunities outside the VA system.
        I was not satisfied so I called the Office of Inspector
    General in Washington, DC, and filed a complaint. In about 2
    weeks, I received a call from a VISN that oversees the Phoenix
    VA system and was given an appointment for a primary care
    physician at the Mesa Southeast Clinic.
        I know how to advocate, but there are a lot of veterans out
    here who do not. Some of them will just give up.
        Now I am officially enrolled in the Phoenix VA health care
    system, and I am out there seeing my primary care physician and
    receiving my medication.
        Before I left the Philadelphia VA, I was being seen for a
    urological condition and should have a follow-up. I requested
    an appointment for urology to my primary care physician. I
    waited over a year for my request for a urology appointment and
    was finally contacted by TriWest to see an outside urologist.
        I received excellent care with multiple visits with the
    outside group. At this time, the Phoenix VA offered very little
    urological services, and there were a lot of veterans who were
    referred out to this group for their care.
        After a follow-up visit, I was told the urology practice
    has dropped their contract with TriWest because of delayed
    payments for services provided. I understand that that issue
    has since been resolved.
        The Phoenix VA hospital has taken back my urology
    appointments now and also in the future. I feel the Phoenix VA
    health care system is improving and correcting some of the
    previous shortfalls. But, I am concerned that the level of care
    for veterans like myself will continue and not repeat some of
    the problems that we have had in the past. There are a lot of
    dedicated employees at the Phoenix VA system, and they are
    starting to see more and more veterans working in the health
    care system.
        I think it is important to continue the Veterans Choice
    card. However, I feel that there are still barriers that
    prevent the veterans from using it. For instance, the language
    states, ``40 miles to the closest VA facility that has a
    primary care physician.'' There are multiple CBOCs here in
    Arizona within those 40 miles. However, they cannot provide all
    the services that are needed for veterans and still have to
    travel great distances for care to the local VA hospitals.
    Sometimes this can be over 200 miles here in Arizona.
        I understand no system is perfect and a lot of these
    programs are new. But, I think it is important that we veterans
    keep the Choice card for an added insurance policy for our
    earned and deserved health care from our government.
        Us Vietnam veterans, we say, never will one generation
    leave behind another generation. Thank you.
        [The prepared statement of Mr. Byers follows:]
            Prepared Statement of Charles G. Byers, Vietnam Veteran

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you, Mr. Byers.
        Dr. Mitchell?

     STATEMENT OF KATHERINE MITCHELL, M.D., FORMER EMPLOYEE OF THE
                     PHOENIX VA HEALTH CARE SYSTEM

        Dr. Mitchell. I am deeply grateful for the opportunity to
    testify today. I am a former VA nurse and current VA physician
    with over 16 years' experience working within the Phoenix VA. A
    little over 1 year ago, I transferred from the Phoenix VA to
    the VA network office in Gilbert, AZ. However, I have
    maintained my Phoenix VA contacts.
        In April 2014, following in the steps of Dr. Sam Foote, I
    became a public whistleblower to report dangerous ER nursing
    triage, ER staffing shortages, whistleblower retaliation, and
    facility scheduling violations, among other issues.
        In my opinion, not much has changed with these issues since
    that time, except the scheduling rules are now being followed
    and there are certainly more staff in the ER.
        Throughout the last 20 months, Phoenix VA employees have
    privately contacted me to describe instances of poor patient
    care, delays in care, violations of policy, and retaliation for
    reporting problems. I was also made aware of significant
    problems for patients scheduling appointments through the
    Choice program.
        Although I continue to advocate for improvements within the
    Phoenix VA ER, in my current position, I have been told that I
    am not allowed to address issues that are still there. The
    continued presence of dangerous triage conditions in the
    Phoenix VA ER, as well as problems in the mental health clinic
    triage, were substantiated in a VA Office of Medical Inspector
    (OMI) report that was released internally to the national VA in
    March of this year and publicly released in September by the
    Office of Special Counsel.
        This official VA report called the Phoenix ER nursing
    triage ``a significant risk to public health and safety.''
        Although there were serious flaws in the OMI investigation,
    it still found many problems, including grossly inadequate
    nursing triage, nurses who failed to perform EKGs when ordered
    and failed to act upon orders for serious patient complaints
    such as chest pain. The triage in the walk-in mental health
    clinic was substandard and nursing triage protocols were called
    inadequate.
        After this OMI report's internal release to the VA in
    March, the Phoenix VA ER nurses were trained in a triage tool
    called Emergency Severity Index, or ESI. Unfortunately, while
    ESI is a valuable adjunct to triage care, ESI training does not
    teach triage symptom recognition nor imply a mastery of triage
    skill. In fact, the ESI fits on this small slip of paper and
    consists of only six questions.
        Watching the news, in my opinion, the Phoenix VA has misled
    the public into believing that ESI training resolved the safety
    deficits in triage. Problems, however, are still reported to me
    by Phoenix VA ER staff.
        Despite my formal recommendation, there has been no in-
    depth, standardized nursing triage training that would give the
    nurses the broad knowledge base needed to effectively evaluate
    patient symptoms. There are still no minimum qualifications to
    be a triage nurse.
        Nurses who jeopardize patient safety by not following
    patient care orders are still working in the ER.
        I have been told that there have been additional episodes
    of unstable patients escaping from the Phoenix VA ER since
    February 2015.
        Ill patients still wait too long, greater than 6 hours to
    be seen. The ER continues to be flooded.
        An email series just last week stated that all rooms were
    full and there were 30 people waiting in the waiting room. This
    email series also reported other conditions that were described
    in the email as ``a recipe for disaster.''
        I also remain extremely concerned about delays for consult
    care and appointments. I have encountered recent cases in the
    spring and summer where the failure to receive a timely VA
    appointment or consult may have contributed to a veteran death
    or, at a minimum, taken away quality-of-life before the veteran
    died.
        I am prepared to discuss some of these incidents today with
    the Committee, if it so chooses.
        Since the VA scandal erupted, there has been no significant
    change in the dysfunctional institutional culture there.
    Several of the offending senior administrators have voluntarily
    left the Phoenix VA without ever facing any consequences for
    their retaliatory behavior. Other unscrupulous Phoenix VA
    administrators and supervisors remain in positions of power.
        In fact, one administrator remains in a key leadership
    position although he has caused problems in several areas.
    According to a 2014 VA Office of Accountability and Review
    investigation, this same administrator retaliated against a
    whistleblower.
        Because your committee monitors the entire VA, I want to
    make you aware that the issues of which I speak are not only at
    Phoenix but potentially across the Nation. The national VA has
    never established standardized nurse triage training nor
    developed standardize nursing triage protocols, even though
    such training and protocols are readily available in the
    private sector at low cost or free.
        Whistleblower retaliation is rampant throughout the VA.
    Retaliation against physician whistleblowers has driven
    physicians out of the Phoenix VA specifically and elsewhere,
    which is discouraging others from applying.
        Because of time limits for this opening statement, I cannot
    go into detail regarding multiple other issues, including the
    dangerous design of the new ER that is obsolete even before it
    is built, gross difficulties with telephone access within the
    Phoenix VA, lack of digital faxes needed to avoid delays in
    record receiving, and the inappropriate switching of consults
    type without the ordering provider's approval.
        I must say that I am grateful to the many dedicated Phoenix
    VA staff both in and outside the Phoenix ER who have brought
    forward the issues of which I have spoken today. The Phoenix VA
    has the potential to be a stellar VA facility, because of the
    staff, but desperately needs your help to achieve this goal.
    Thank you.
        [The prepared statement of Dr. Mitchell follows:]
      Prepared Statement of Dr. Katherine L. Mitchell, Former Employee of
                         Phoenix VA Health Care System

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you, Dr. Mitchell.
        I believe we are still waiting on Ms. Morris. If she
    arrives, you can please let her know that she can join the
    witness panel. We will submit her written testimony, which I
    have read, for the record for this hearing.
        Now, what we would like to do is begin with some
    questioning of the witnesses to have a discussion of these
    issues. Out of respect for my colleagues from Arizona, I will
    defer my questions until after they begin. We will begin with
    Senator John McCain.
        Senator McCain. Thank you, Dr. Mitchell. Would you pull
    that a little bit closer so that we can hear you a little
    better? Thank you.
        Dr. Mitchell, you have watched the evolution of events,
    legislation, the Choice card, and all of that since the
    beginning of the terrible scandal here at the Phoenix VA, as we
    all know. What would you say has been the degree of progress or
    lack of progress since that happened?
        Dr. Mitchell. The VA has made progress. It was so far down
    in the hole as far as being behind in its ability to care for
    patients that any improvements are greatly welcomed. However,
    there are still too many patients waiting to be seen.
        It is very difficult to get appointments through the Choice
    program, now patients are no longer delayed waiting on the
    Phoenix VA waitlist, now they are delayed waiting on a Choice
    waitlist either through problems or difficulty reaching them.
        There certainly has been more staffing across the board--
    physicians and other ancillary service personnel--so that is an
    improvement. However, there is still incredible difficulty
    getting things scheduled in the VA. Consults that are needed
    are delayed because they do not have adequate providers.
        Senator McCain. I do not often talk about my own
    involvement, but I negotiated with Senator Sanders for the VA
    reform legislation that was passed overwhelmingly by both
    houses of Congress. I wanted a Choice card for everybody, no
    matter what. In the negotiations, I had to agree to the 40-mile
    distance or time on waiting list.
        Do you believe that we should go back over the criteria
    with the Choice card and make it available for every veteran,
    no matter where they are geographically located or any amount
    of wait time?
        Dr. Mitchell. I think the Choice card is a great idea,
    especially for specialists for which the Phoenix VA and other
    VA's are short-staffed, and for which there are considerable
    delays in care.
        The VA infrastructure is incredibly good. Although I am
    talking about the cracks in the VA care, the actual VA
    nationwide has millions of high-quality episodes in patient
    care every single year. The veterans who are able to get into
    the system, in general, are very happy with the care, and they
    get better care than they would in the community.
        I do think that the Choice program needs to be restructured
    because veterans are still waiting, and whatever structure
    changes can be made to decrease the wait are important.
        The other thing is that you need to look at the
    reimbursement for Choice providers. Part of the problem is not
    the fact that Choice cannot make appointments. It is that
    Choice cannot make appointments because they do not have
    providers signing up. The Choice reimbursement is much lower
    than the payments for non-VA care under other programs, and
    lower than Medicare. That should not be the case.
        Senator McCain. Mr. Byers, do you have a view on the Choice
    card?
        Mr. Byers. Yes, I actually concur, that we keep the Choice
    card and again remove some of those barriers that veterans are
    having difficulty with, and some of the language. The language
    is still not very clear to a lot of the veterans that we see.
        When it works, it works well. I can say that because I used
    the Choice card with TriWest, and they were able to get me a
    provider that provided the services for me. Yet, I still feel
    that we should have the Choice card. It is an insurance policy
    for us veterans. I think it is important that we keep it.
        Senator McCain. Well, I thank you both for being here.
        Dr. Mitchell, we will continue to rely on you.
        I guess just one final question to Dr. Mitchell. Maybe this
    is not a fair question, but I feel compelled to ask it. Would
    you go to the Phoenix VA emergency room for care?
        Dr. Mitchell. Absolutely not. There is a reason for that.
    There are physicians in that ER that are the best in the State
    of Arizona. There are nurses that fill that ER who are the most
    professional I have ever worked with. The problem is that you
    have to get past nursing triage, and you have to get past the
    flood of patients.
        Right now, the Phoenix VA health care system does not have
    a good way of dealing with urgent care patients, patients who
    do not need emergency care but certainly have issues that
    cannot wait until the next business day or the third business
    day or whenever the clinics can schedule them. As a result, you
    have a whole pool of people bearing down on this very small
    emergency room which dilutes getting care to people who are
    really sick, as opposed to getting care to people who can just
    wait.
        There is no standardized triage training. Without that, it
    is the luck of the draw if you have a triage nurse who knows
    what they are doing.
        Frankly, in my particular case, the nurses who retaliated
    against me by impeding my care for ill patients, most of them
    still work in the ER, and I do not trust their professionalism
    not to impede my care.
        Senator McCain. Thank you.
        Mr. Chairman, I think I would like to just add a comment
    for the record.
        We are deeply concerned, or we would not be having these
    hearings, we would not be passing legislation to try to fix it.
        On Veterans Day, after the parade, I went down to Phoenix
    VA and people who are in the hospital there are well-treated.
    We do have many dedicated people who are working there. There
    has been some improvement.
        Having said that, I think we should give credit to a lot of
    the outstanding men and women who are serving there. I think
    fundamental changes still have to be made in order to allow
    these dedicated men and women who are working at the VA to
    exercise their full capabilities. Right now, I do not think
    that is exactly the case.
        If there is one issue I would like for us to continue,
    which you and I and Senator Flake have had numerous
    conversations with Chairman Isakson, is to make the Choice card
    completely available.
        I thank the witnesses.
        The Chairman. Thank you, Senator McCain.
        Senator Flake?
        Senator Flake. Thank you.
        Mr. Byers, just to get an idea of how things have improved
    or have not improved, if you were to arrive today just like you
    did a few years ago from New Jersey, not knowing what you know
    now about how to navigate through the system, how long do you
    think your wait time would be for the same issues and needs
    that you had? What would be the change today from what it was
    before?
        Mr. Byers. I can answer that because I deal with a lot of
    veterans who come to me for eligibility and they need to get
    into the VA health care system.
        They go through eligibility and at least within 30 days
    they are assigned a primary care doctor. That is what the
    appointment says, and that is where they go.
        Senator Flake. That would have taken how long when you got
    here?
        Mr. Byers. I got here in August and I saw a doctor in
    November, but I was told it would be almost a year before I
    could even see a primary care doctor.
        For the veterans today, at least in my CBOC, here in
    Gilbert, the eligibility works very well. If you are in the
    system, they can get you a primary care doctor within 30 days.
        Now the problem is that you have a primary care doctor, but
    if you need any kind of specialty care or anything else that
    you have to have, that is where the bog-down occurs. I have
    some people who have to wait 6 months for an appointment.
        Senator Flake. Thank you.
        I should have mentioned in my opening statement, like
    Senator McCain, I appreciate what the city of Gilbert does, the
    programs that they have and the effort that they make to make
    sure that veterans here are treated well and receive the care
    that they can.
        Dr. Mitchell, you mentioned that the culture has not
    changed at the VA. What will it take to have a change in
    culture? Is that a decades' long process? How can we expedite
    that to make sure it changes faster?
        Dr. Mitchell. In my opinion, the Central Office has the
    ability to stop whistleblower retaliation today. They just have
    not sent out the memo that specifically states the penalty for
    whistleblower retaliation.
        For example, there is a significant amount of retaliation
    against physicians. There are sham professional standards
    boards, basically peer reviews where they say the physician is
    incompetent when they are not. These boards are held without
    notifying the physician of the accusations, without giving them
    access to the patient records, without having an impartial
    board given.
        Then, the ``not impartial'' board makes a finding, says the
    physician is incompetent, and either fires them or fires them
    and reports them to their professional standards board. There
    are very clear policies about how professional standards boards
    are supposed to be done.
        In the community, they are done only when there are there
    serious concerns that a physician is incompetent. I know of
    seven physicians in the VA system, either current or former,
    who have either undergone these sham peer reviews or are
    currently undergoing them. VA administrators have not followed
    the rules in each particular case.
        All Central Office has to do, all the Under Secretary has
    to do, is send out a memo that says, at this point, all
    professional standards board reviews are to be on hold until
    you get the memo that is coming in 10 days. In that memo, we
    are going to specify that the rules need to be followed.
    Whatever findings your boards have, they have to be verified by
    an independent third party.
        I think that is important because there are physicians who
    do not practice quality of care that need to be covered. Right
    now, it is a tool for retaliation. It is not considered a
    prohibited personnel practice, so the Office of Special Counsel
    will not get involved.
        Because Phoenix administrators and administrators elsewhere
    have retaliated against physicians--this is becoming well known
    in the community--physicians are not applying for the jobs we
    desperately need them for. The Central Office needs to come
    through. It needs to declare that it stops today, and then give
    teeth to it so that every chief of staff, every service chief
    who is involved in a sham peer review is held accountable
    immediately instead of just letting the physician fight on
    their own, which can take years and can be financially and
    professionally devastating to the physician.
        Senator Flake. Thank you, Senator Sullivan.
        The Chairman. Thank you, Senator Flake.
        Mr. Byers, I wanted to follow up on a couple questions.
        Can you explain a little bit about the handoff when you
    went from New Jersey to Arizona. I am sure that is obviously
    common for a lot of veterans to be moving. How did that work?
        Mr. Byers. From New Jersey, you mean?
        The Chairman. Leaving New Jersey. I know this is a
    beautiful State, so a lot of veterans are coming here, just
    like my great State of Alaska.
        So, how does that work in terms of the handoff, in terms of
    the ability to just track veterans from one VA center to
    another? Are there lessons that you learned that we could focus
    on that could help improve that handoff?
        Mr. Byers. I think it should be seamless. OK, you are in a
    VA----
        The Chairman. Was yours seamless?
        Mr. Byers. No. It was not. It was seamless for me to
    contact and work with the Philadelphia VA while I was here
    because I used My HealtheVet. My HealtheVet is a tool that we
    veterans can use to contact our primary care physicians, we can
    instant message them and be able to talk.
        But, when they do not see you, or they cannot, they cannot
    prescribe medication. So, the medication was the main issue for
    me for that. That is why it was important for me to get a
    primary care physician.
        I had the eligibility. I am priority one. I should not have
    any problems whatsoever going into the VA health care system.
    But the wait time, because they did not have a primary care
    doctor, that was the problem. That was not seamless at all.
        Then when you get into the VA system, they do not seem to
    be talking to one another.
        I understand that we have this great computer system, this
    CAPRI system, where everybody should be able to look at the
    medical records and see. It took quite a while for that to get
    transferred here to the Phoenix system. I am sure that that
    process, hopefully, has been improved.
        The VA should be portable. It should be portable. If I have
    to go somewhere, I am in the VA health care system, I should be
    able to use it anywhere.
        The Chairman. Another element about your testimony focuses
    on the delays--obviously, that is something that the Choice Act
    was focused on addressing is these lengthy delays.
        In your written testimony, you noted that you waited over a
    year for your urology appointment. Did it actually take a year
    or did something intervene?
        Mr. Byers. I requested a urological appointment because I
    had to follow up. This is what the Phoenix VA said when I came
    to Phoenix, to please follow up.
        So, I went to my primary care doctor. As we talked, I said
    I would like to have a referral for urology. I do not know at
    that time if urology was taking referrals. My understanding is
    that the urology department at the Phoenix VA were very, very
    thin. I understand there was probably one urologist at that
    time, and he was retiring. He was not taking any new patients.
        I stayed in the process until finally I complained. How I
    had to complain? I had to change my primary care doctor. I
    changed my primary care doctor. I got a new doctor. Probably in
    all that time with all of what was happening here with the
    Phoenix VA, that is when the referral went out, and I got my
    TriWest appointment.
        The Chairman. So, initially, they told you 1 year. You
    complained, and it took how long to get that appointment?
        Mr. Byers. It took me over a year to get my urological
    appointment.
        The Chairman. I hope the panelists on our next panel are
    listening to all of these incidences, because I think that a
    lot of the explanations have to come from the officials,
    whether at TriWest or the VA, on why 1.5 years after the Choice
    Act, we still have veterans who are waiting a year--a year--for
    an appointment. It is unbelievable.
        Mr. Byers. Senator Sullivan, this was before the Choice
    Act.
        The Chairman. Let me turn to Dr. Mitchell. I want to follow
    up on Senator Flake's comments about changing the culture.
        Senator McCain mentioned, and I think we all agree, that
    the VA has many, many great employees who are very dedicated at
    the hospitals throughout the country. But, your written
    testimony actually ends by saying you do not think the culture
    has moved in terms of addressing it almost at all.
        If you had a magic wand to address not only the facilities
    that you are familiar with here in Arizona, but the VA more
    broadly, how would you focus on starting to address the culture
    that you are still saying has not really moved a bit in terms
    of being able to address some of the huge systemic problems we
    have in the VA?
        Dr. Mitchell. I would make sure that everyone sees the
    consequences for whistleblower retaliation. Frankly, any leader
    who has been confirmed to have done whistleblower retaliation
    through an OSC investigation or an Office of Accountability
    investigation needs to be removed.
        Right now, Senior Executive Service are held to a different
    standard of behavior than the rest of the frontline employees.
    The frontline employees are grossly aware of that. Things that
    senior administrators do and get away with are things that
    frontline employees would be fired for immediately on the spot.
    That needs to change.
        It is not that there is a lack of people who are really
    good and dedicated to the VA, you are right. It is a problem
    that there are a few in positions of leadership who are making
    bad decisions for the entire VA.
        I am appalled at the lack of accountability for leadership.
    Frankly, I am really disappointed in the Central Office, that
    they have not come down and truly held--Senior Executive
    Service, they should be held to a higher standard of behavior
    than the rest of us.
        I would also like to state, although the Senior Executive
    Service, I certainly have known several that were less than
    stellar, there is one, Lisa Freeman out of Palo Alto, who
    rotated to the VISN office where I worked; she embodies some of
    the best characteristics of the Senior Executive Service I have
    ever met. The Central VA Office needs to take recognition of
    leaders like her and have them train the newest leaders coming
    up.
        The Chairman. Let me ask you two follow up questions that
    relate to culture. You mentioned it. Senator McCain mentioned
    that the Choice Act does provide the Secretary of the VA with
    significant authority to remove officials who have
    underperformed or performed in a way that should require their
    termination. Do you think that the VA is actually doing that or
    utilizing that authority? Is that a way in which to help change
    the culture, to hold more officials accountable?
        Dr. Mitchell. I do not think the VA is investigating the
    issues of retaliation seriously enough. In my particular
    instance, there was an Office of Accountability review
    investigation. I was interviewed last.
        The team refused to interview any of my physician
    witnesses, which could describe clearly multiple episodes of
    retaliation. The administrator who was involved was found
    guilty of retaliation in one instance when actually he was
    guilty of retaliation in multiple instances that not only
    showed a lack of leadership skills but showed a lack of basic
    medical ethics.
        Someone who refuses to investigate when six physicians tell
    him nurses are impeding care for ill veterans in the ER does
    not need to be in a leadership position, as he lacks basic
    medical ethics.
        The Chairman. What about the issue of funding? Since the
    implementation, since the passage of the Choice Act, the VA has
    actually received an additional $15 billion to implement this
    new law on top of significant increases in the VA's budget over
    the last several years. Do you believe it is a lack of funding
    for the VA? Or is it another issue?
        Some say it is a lack of funding. Others have actually said
    that might even be the problem, in terms of thinking the budget
    has been dramatically increased.
        How do you believe that the funding issue, either too
    little or too much, relates to changing the culture?
        Dr. Mitchell. I think that the funding issue is part of the
    problem with the VA, but certainly not the entire problem.
        The Chairman. Meaning that they are underfunded?
        Dr. Mitchell. That they are underfunded. The VA provides
    tremendous high-quality care. Every time we provide high-
    quality care to the veteran, it attracts another veteran.
        Frankly, even in the ER, when they were able to get
    additional staffing to be able to care for veterans, once they
    had more staffing, more veterans came. It is the same across
    the Nation. There has been a 10 percent increase in
    appointments.
        I do not think the public realizes how big the medical
    needs are for the veteran population.
        What I do think needs to be done also is that some of the
    funding needs to be better managed. I, like other people, have
    listened to the media reports, where I find that funding is
    being spent on public relations that it should not be or other
    issues. To give any more detailed answer, I am not qualified,
    because this issue is too complex.
        I do think there needs to be an expert panel looking at it,
    and a panel not of VA employees, but of outside people, such as
    Secretary McDonald gathering a panel to look at issues. I think
    that those would be invaluable to seeing where the improvements
    need to be made.
        The Chairman. Thank you.
        Ms. Morris, welcome. We are glad you are here. We would
    welcome the opportunity to hear your testimony. Please keep it
    to 5 minutes, then we will also have a few questions for you.
    So, welcome.

             STATEMENT OF NICOLE MORRIS, U.S. NAVY VETERAN

        Ms. Morris. Thank you. My name is Nicole Morris. I am a
    Navy veteran. I served overseas in Kuwait in 2004. When I came
    home, I was told I was eligible for VA benefits.
        My first experience was a positive experience. There was a
    procedure that I needed done, which they did not do at the VA.
    They were able to get me to a civilian doctor and have the
    surgery paid for. So, it was a very positive experience.
        However, a few years later, I was experience excruciating
    stomach pains. I did not have any other medical coverage. I
    went to the ER at the facility downtown at the VA, and I waited
    for 2 days in the ER to be seen.
        The first day, I waited until about 1 in the morning. I was
    told I was not going to be seen anytime soon. Then I went home
    and came back. It was probably around 11 o'clock at night when
    I was finally seen.
        When I was seen, it was very brief. They saw me in the back
    room for about 5 minutes, gave me some pain medicine, and told
    me to go on my way. There was not really an exam of what was
    going on with me physically. There was no follow-up. I was just
    given pain medication and told to go home.
        There were other veterans in the ER at the time waiting
    that had more serious problems. I talked to some of the
    veterans who had strokes, seizures, who were waiting in the ER
    for a very long time.
        I was told there was a priority list. It was not first
    come, first serve, but there was a priority list and I was down
    at the bottom of that priority list.
        After that experience, I did not want to go back to the VA.
    I am a single mom. I am a student. I do not have any other
    health coverage. It was very disheartening for me.
        I often have to pay out-of-pocket. If I have to go to the
    doctors, I have to pay hundreds of dollars out-of-pocket to go
    somewhere, to the urgent care, if I am sick.
        I have tried scheduling appointments. I no longer have a
    primary care physician. I never saw my primary care physician.
    It takes a month, 2 months to get in, if I want to.
        It is just very disheartening. It is very stressful to try
    to get an appointment. I am on the phone a long time waiting to
    get an appointment.
        I have been talking to fellow veterans, and they share the
    same stories.
        I appreciate having the VA coverage. I really do. I am
    thankful for it. But, I think that there are big improvements
    that could be done so I can be seen, I do not have to pay out-
    of-pocket, and that my fellow veterans can be seen as well.
        [The prepared statement of Ms. Morris follows:]
               Prepared Statement of Nicole Morris, Navy Veteran
        Good morning. My name is Nicole Morris. I am a Navy veteran who
    deployed to Kuwait in 2004 for Operation Iraqi Freedom. Immediately
    after leaving active duty, I was told I was eligible for VA health
    care. I needed to see a doctor and the VA actually referred me out to
    the private sector and paid the bill. It was a pretty positive
    experience. However, several years later and I was still eligible for
    VA health care and was experiencing severe stomach pains. I went to the
    VA emergency room at Phoenix at 8:30 a.m. and waited for someone to see
    me. Hours and hours went by without me being able to see a doctor. I
    ended up leaving that night because it was clear I wouldn't be seen by
    anyone. I came back the next day and ended up waiting again until 10
    p.m. I was finally seen however it was extremely brief and I was not
    given the proper medical checkup to determine the issue. I was issued
    pain meds and released without knowing what my medical issue was.
        There were other times I tried unsuccessfully to get appointments
    through the VA. It was always a hassle. Most of the appointments would
    be offered one to two months in the future. I'm not sure why I am
    supposed to stay sick for two months while waiting for a doctor to be
    available. Other times I would call and be put on hold for 30 to 45
    minutes or more.
        Another massive inconvenience was the policy that female veterans
    who needed specific health care specialists could only be seen on
    Wednesdays. I'm not sure who made that policy but it doesn't make sense
    to be the VA and only see female veterans one day a week. I work and go
    to school and also take care of my child and the VA's scheduling just
    does not meet my needs.
        I also have a close friend from my unit who has more serious
    complications from our deployment than me. She also cannot get seen by
    the VA for her conditions and it is extremely frustrating and
    disappointing to hear how she struggles and how the VA is failing to
    take care of her.
        I am sure the VA does provide for some military servicemembers'
    medical needs. But for me it just doesn't fit. It would be ideal for
    veterans like me to just have regular insurance that others have such
    as military retirees who are allowed to use TRICARE. That way I could
    call the doctor I choose when I am sick to schedule my appointment and
    not have to work through the VA. It would also help if my son/daughter
    and I could be covered on the same insurance policy.
        Thank you for allowing me to share my experiences with the VA
    today. I hope that this will lead to reforms of the current system and
    improved care for those of us that served.

        The Chairman. Thank you very much for that testimony, and
    thank you for your service. I will ask Senator McCain or
    Senator Flake if they have any questions for Ms. Morris.
        Senator Flake. During that emergency room visit, I cannot
    imagine being there 2 days with just an intervening short time
    at home. What was said during that time? Did they come out and
    check on you?
        Ms. Morris. Not at all, no. I often checked in with them.
        Senator Flake. There were others in the same condition or
    similar condition?
        Ms. Morris. Worse. There was a gentleman who had a stroke,
    a mild stroke, who I was sitting next to. He was there with his
    wife.
        Senator Flake. Did it seem to be just too few personnel
    there? What seemed to be the issue, that you could tell?
        Ms. Morris. I do not know. I do not know.
        Senator Flake. Dr. Mitchell, is that typical of some of
    what you have talked about?
        Dr. Mitchell. Yes. What happens is that there is a priority
    list, so the sickest patients are supposed to be seen first.
    However, that depends on if the triage nurse is skilled enough
    to actually elicit the appropriate symptoms. If not, then you
    are not put in the correct order and priority, and you wait
    longer than you should.
        There have been instances, which I have reported through
    the VISN office, the network office, even this year where
    strokes were being delayed in being evaluated, which there is
    this specific stroke protocol and that should never happen.
    There were strokes that the nurse did not recognize as a
    stroke. There were strokes where a physician did not recognize
    it is a stroke, and the veteran was sent home only to return 3
    days later with an inability to walk, a loss of vision, and
    having to be sent out to another facility that handles strokes.
        The other problem is that the ER is physically very small.
    Originally, it was 11 beds, eight rooms. Now they have
    expanded, so there are 22 rooms, but there are still only
    approximately eight beds that have cardiac monitoring
    abilities. So, if the facility is backed up as far as
    admissions, then those patients have to be held in the ER, and
    then everything else gets backed up.
        The facility does not allow us to close the ER, or at least
    it did not during the time I was there for 10 years. That means
    that although you can go on diversion and no ambulances show
    up, it does not stop very ill patients from coming to the ER.
    If they come to your ER and you do not have the capacity to
    care for the ill patient, our facility, at least at the time I
    was there, did not allow you to send them to another ER where
    they could get care quicker.
        That is an issue that needs to be addressed because there
    are ill patients.
        When you hear from panel two, you are going to hear a lot
    of really good statistics, and the statistics are good in some
    areas. But, there are certain things they are not going to want
    to mention. One of them is the greater than 6-hour waits in the
    ER. Those are calculated on a daily basis. Another thing that
    they are not going to want to mention are the extreme delays
    for non-VA care consults, which are outside the VA, that are
    greater than 90 days, and also the consult delays that are
    inside the VA that are greater than 90 days. Those numbers are
    huge. They are huge across the Nation. The VA is trying to
    figure out how to close them all and get people the appropriate
    care.
        You are also not going to hear about statistics like the
    all-employee survey where the Phoenix VA was in the dumps, as
    far as confidence in leadership and psychological safety, which
    all play into fear of retaliation.
        There are some serious problems in the ER that need to be
    addressed. There needs to be a way of managing these urgent
    care patients so that they get seen as well as the sickest
    patients.
        Right now, you are ethically obligated to see the most sick
    patients. You rely on your triage nurse to be able to identify
    the sickest patients. If they make a mistake, then sick
    patients wait too long while their conditions deteriorate.
        That has been an ongoing problem since I was there in 2003.
    It just got worse when our intake numbers increased.
        Senator Flake. Thank you.
        The Chairman. Ms. Morris, I had a question relating to your
    testimony where you talked about the limited hours available to
    receive gender-specific health care as a huge inconvenience for
    veterans. Can you talk a little bit more about that, your
    experience, and what you would recommend try to fix that?
        Ms. Morris. Sure. For years, the Well Women's Clinic has
    only been open on a Wednesday. Once again, it was very hard to
    get into that, if I needed something right away. I would have
    to wait a month, 2 months.
        Just recently, they actually changed it so the primary care
    physician can do the Well Women checkups, if they are
    designated to. However, they have to be accepting new patients
    in their network, they have to be your primary care physician,
    so not every woman probably has a primary care physician who
    can provide that service. Otherwise, you would have to wait on
    a Wednesday to receive that service. The waiting list is long.
        I think the recent change is a step in the right direction
    to enable the primary care physician to give those services.
    Maybe if we could open it up so it is not just on Wednesdays at
    the VA downtown, that would be a good suggestion as well, as I
    cannot get in to see my primary care physician, because right
    now they are only there on Wednesdays.
        The Chairman. Great. I want to thank the panelists very
    much. I want to thank you all for your service to our country,
    and, Dr. Mitchell, to the VA.
        We will take a brief recess to move from panel number 1. I
    want to invite the witnesses for the second panel to please
    come to the witness table. Thank you again. [Recess.]
        The Chairman. I want to welcome the second panel. The
    second panel will consist of Dr. David Shulkin, who is the
    Under Secretary for Health at the Department of Veterans
    Affairs. He is accompanied by Dr. Thomas Lynch, the Assistant
    Deputy Under Secretary for Clinical Health, and Ms. Kathleen
    Fogarty, Acting Director, Veterans Integrated Service Network
    (VISN) 18: Southwest Health Care Network.
        We also have Dr. David McIntyre, Jr., who is the President
    and CEO of TriWest Healthcare.
        Dr. Shulkin?

       STATEMENT OF DAVID J. SHULKIN, M.D., UNDER SECRETARY FOR
      HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
    THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH
     CLINICAL OPERATIONS; AND KATHLEEN FOGARTY, INTERIM DIRECTOR,
                 VISN 18: SOUTHWEST HEALTH CARE NETWORK

        Dr. Shulkin. Good morning, Senator Sullivan, Senator
    McCain, Senator Flake. Thank you for the opportunity to discuss
    the improvement of access to and the timeliness of veterans'
    health care in the Phoenix VA health care system.
        As you mentioned, Senator Sullivan, I am accompanied by Dr.
    Thomas Lynch to my left, who is the Assistant Deputy Under
    Secretary for clinical operations at VA, and Ms. Kathleen
    Fogarty, who is acting director of the VISN here in the Phoenix
    region.
        I would like to thank Mr. Byers and Ms. Morris, for their
    service to the country and for their testimony today. I would
    also like to thank Dr. Mitchell for her testimony. We must
    depend on our employees to be vigilant about potential sources
    of harm to our patients and to voice their concerns, if patient
    safety is at risk, and they need to feel safe in doing so.
        In September 2014, the GAO issued its report on managing
    the oversight of the consult process. VA concurred with all six
    recommendations and is taking actions to address the concerns
    raised by the GAO.
        During this past year, VHA completed a national assessment
    of progress note completion and created the technical
    capability to assess and complete consults. Solutions were
    implemented by extensive national consult training within all
    the VISNs, weekly national consult calls, and the creation of a
    consult training module.
        In October of this year, VA's OIG Office of Health Care
    Inspections delivered its evaluation of access to care concerns
    in the urology service here in Phoenix. It was determined that
    Phoenix suffered a significant urology staffing shortage, and
    its leaders did not have a plan to provide urological services
    during that shortage of providers.
        To fill this need, VHA has hired six new urology employees
    since January 2013. As of December 7 of this year, the urology
    service had no patients waiting on its electronic waitlist. It
    had three consults waiting greater than 90 days. All three of
    those have now scheduled appointments. Now 99 percent of new
    patients are seen within 30 days.
        Appointment volume doubled from the previous year, while
    the average wait time from the preferred date was at 3 days, 8
    days lower than it was 1 year ago. Urgent care appointments in
    urology are available the same day.
        VHA's efforts to issue disciplinary actions in Phoenix and
    to resolve the administrative leave status of two employees
    have been delayed by our inability to interview witnesses who
    have not been cleared by the U.S. Attorney's Office, and only
    recently were we given additional evidence by the VA OIG that
    we had been requesting for the last several months.
        Until we have reviewed all of that relevant new evidence
    that we received, we have been unable to make a determination
    on what disciplinary action may be warranted related to the
    patient scheduling waitlist issues. These employees are going
    to remain on administrative leave.
        VA has reached expedited settlements with the Office of
    Special Counsel on the whistleblower retaliation allegations
    made by three employees at the facility. Since some of the
    subject officials in these retaliation cases are the same as
    those in the patient scheduling wait time case, we have not
    issued disciplinary actions related to these retaliation
    allegations.
        VHA is taking a number of actions in response to the events
    in Phoenix, such as: building partnerships with care in the
    community providers; reducing wait times; holding a national
    stand down for access this past November; and adding over 630
    full-time equivalent employees to the medical center.
        In November 2014, the former medical center director was
    terminated. On October 20, 2015, Ms. Deborah Amdur was
    appointed as the permanent director. Today is actually her
    first day.
        VHA is continually monitoring wait times and making
    adjustments as needed to ensure that veterans have access to
    the best care they rightly deserve.
        During fiscal year 2015, Phoenix VA increased completed
    primary care appointments by 7.72 percent, mental health
    appointments by 18.38 percent, and specialty care by 15.25
    percent. During this period, Phoenix completed over 680,000
    outpatient appointments. Overall, the Phoenix VA has completed
    95 percent of all patient care appointments in fiscal year 2015
    within 30 days of the date the veteran preferred and the
    average wait time for all patients in primary care has
    decreased to 6 days, as of December 7 of this year.
        The average wait time for all patients in specialty care is
    9.1 days, mental health 4.8 days, and urology 3 days.
        On November 14, 2015, VA medical centers across the
    country, including Phoenix, participated in the first national
    access stand down. Prior to this stand down, there were 1,650
    open priority one level consults at Phoenix open greater than
    90 days. After this stand down, there were just 91 priority
    consults that still needed to be addressed and were authorized
    for care in the community.
        I should say most of those we have been unable to contact.
    That is why there are 91 still left open.
        Although the intent of this effort was to reach those
    veterans with the most urgent care needs, we will not rest
    until we fix our system in order to better serve the health
    needs of all veterans.
        VHA is also improving access through extended hours into
    the evenings and weekends to leverage limited space and enhance
    convenience for veterans. Designated patient care teams perform
    extended hours on a rotational basis.
        In October 2015, VHA delivered the new Veterans Choice
    program to Congress, proposing improvements for health care
    delivery to veterans. The plan addresses enhanced partnerships
    between VA and community providers to deliver care in the
    community more seamlessly. With the new Veterans Choice plan,
    enrolled veterans will have greater choice and ease in use of
    access to health care services at VA facilities in the
    community.
        Through September 2015, contractors have added over 9,100
    Choice authorizations for approximately 7,200 veterans in
    Phoenix. Additionally, the Phoenix VA created nearly 43,000
    authorizations to veterans to receive care in the private
    sector between October 1, 2014, and September 30, 2015, a 45
    percent increase in authorizations when compared to the
    previous year.
        The VA is committed to providing the highest quality care
    to our veterans who have earned and deserve this care. Our work
    to effectively and timely treat veterans continues to be a top
    priority at the Phoenix VA health system and throughout VHA.
        We really appreciate Congress' support and look forward to
    answering any questions you may have.
        [The prepared statement of Dr. Shulkin follows:]
       Prepared Statement of David J. Shulkin, M.D., Under Secretary for
      Health, Veterans Health Administration, U.S. Department of Veterans
                                    Affairs
        Good morning, Senator Sullivan, Senator McCain, and Senator Flake.
    Thank you for the opportunity to discuss this important topic regarding
    the improvement of access to and timeliness of Veterans' health care at
    the Phoenix VA Health Care System (PVAHCS). I am accompanied by Dr.
    Thomas Lynch, Assistant Deputy Under Secretary for Health for Clinical
    Operations, Kathleen Fogarty, Acting Director, Veterans Integrated
    Service Network (VISN) 18, and Dr. Darren Deering, PVAHCS Chief of
    Staff.
                                     pvahcs
        The Veterans Health Administration's (VHA) mission is to honor
    America's Veterans by providing exceptional health care that improves
    their health and well-being. By extension, this is also PVAHCS' mission
    and providing timely access to that care is critical. Access enables
    VHA to provide personalized, proactive, patient-driven health care;
    achieve measurable improvements in health outcomes; and align resources
    to deliver sustained value to Veterans.
        VHA has taken a number of actions in response to events in Phoenix,
    such as building partnerships with Care in the Community providers,
    reducing wait times, holding a National Stand Down, and adding over 500
    employees. In November 2014, the former Medical Center Director was
    terminated by VA and on November 20, 2015, Ms. Deborah Amdur was
    appointed as the permanent Director of PVAHCS. As previously mentioned,
    Ms. Kathleen Fogarty serves as the Acting Director for VISN 18 while
    VHA continues to recruit for a new VISN Director.
        VHA is continually monitoring wait times and making adjustments, as
    needed, to ensure that Veterans have access to the best care they
    rightfully deserve. During Fiscal Year (FY) 2015, PVAHCS increased
    completed primary care appointments by 7.72 percent, mental health
    appointments by 18.38 percent, and specialty care by 15.25 percent.
    This means that during this period, PVAHCS completed over 680,600
    outpatient appointments. Through September 2015, the contractors have
    created over 9,100 Choice authorizations for approximately 7,200
    Veterans. Additionally, Phoenix created nearly 43,000 authorizations
    for Veterans to receive care in the private sector from October 1, 2014
    through September 30, 2015--a 45 percent increase in authorizations
    when compared to the same period in previous years. Overall, PVAHCS
    completed 95 percent of all patient appointments in FY 2015 within 30
    days of the date the Veteran preferred and the average wait time for
    all patients in primary care has decreased to 6 days (as of December 7,
    2015). This means that PVAHCS is serving more Veterans and providing
    this service when they need it.
        On November 14, 2015, VA medical centers (VAMC) across the country
    participated in the first ever National Access Stand Down. Prior to
    this Access Stand Down, there were 1,650 open priority level 1consults
    at PVAHCS (as of November 6, 2015). After the Access Stand Down, there
    were 91 priority level 1 consults that still needed to be addressed (as
    of November 16, 2015) and were authorized for care in the community.
    Although the intent of this effort was to reach those Veterans with the
    most urgent needs, we will not rest until we fix our system in order to
    better serve the health needs of those who need our help most.
        PVAHCS opened a new Community-Based Outpatient Clinic (CBOC) in
    northeast Phoenix in May 2015. Additional CBOC locations have been
    identified in southwest and central Phoenix, with both activations
    planned for August 1, 2016, and reassigned specialty care clinic space
    to the second floor of the Community Living Center. Vacated space in
    the Ambulatory Care Center has been reallocated to primary care for
    additional exam rooms and future growth. PVAHCS is also improving
    access through extended clinic hours into evenings and weekends to
    leverage limited space and enhance convenience for Veterans. Designated
    Patient-Aligned Care Teams (PACT) perform extended hours on a
    rotational basis on Saturdays at the main facility and Southeast Clinic
    for a full shift. A limited number of PACTs also provide extended hours
    on Thursdays.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Since January 2014, PVAHCS has seen a net gain of 630 full time
    employee equivalents (FTEE), or an increase of 25.5 percent. As of
    October 2015, PVAHCS increased primary care staffing of physicians,
    nurses, and clerks by 77 additional full-time employees from April 2014
    to present. PVAHCS has approximately 160 FTEE on board, who are funded
    through the Veterans Access, Choice, and Accountability Act (Choice
    Act). The graph above shows a history and foundation for sustained
    high-production hiring for the local Human Resource (HR) office. We are
    confident that PVAHCS leaders are monitoring operations closely and are
    in position to continue making H.R. improvements throughout the
    facility.
                         veterans choice program (vcp)
        Implementation of VCP, established by the Choice Act, has helped
    generate an 87-percent increase in the number of PVAHCS consults going
    out to the community for Veteran care from FY 2014 to FY 2015. PVAHCS
    is located in the same metro area as the TriWest Healthcare Alliance.
    PVAHCS has used this geographic access to develop strong working
    relationships with TriWest leadership and staff. As a result, PVAHCS
    has undertaken initiatives such as actively participating in the
    redesign of the TriWest Portal; enabling streamlined communication of
    records between the agency and vendor for all VAMCs served by TriWest;
    discussing potential new initiatives with TriWest to physically locate
    two to three TriWest staff members within PVAHCS to address Veteran/
    vendor issues more promptly; and holding periodic meetings and
    teleconferences between the leadership and staff of PVAHCS and TriWest
    to address issues raised directly from Veterans.
        In October, VHA delivered to Congress a plan for how VA could
    consolidate all purchased care programs into one New Veterans Choice
    Program (New VCP) to deliver care in the community more seamlessly.
    With the New VCP, enrolled Veterans will have greater choice and ease
    of use in access to health care services at VA facilities and in the
    community. The New VCP will clarify eligibility requirements for care
    in the community, build on existing infrastructure to develop a high-
    performing network of community providers, streamline clinical and
    administrative processes, and implement a continuum of care to improve
    coordination of services. Clear guidelines, infrastructure, and
    processes to meet VA's community care needs will improve Veterans'
    experience and access to health care. As VA continues to refine its
    health care delivery model and examine how the Veterans Choice Program
    interacts with other VA health programs, we look forward to providing
    more detail on how to convert the principles outlined in the New VCP
    Plan into an executable, fiscally-sustainable future state. In
    addition, we plan to receive and potentially incorporate
    recommendations from the Commission on Care and other stakeholders.
                  va office of inspector general (oig) report
        In August 2014, VA OIG published its final report, ``Review of
    Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices,
    the Phoenix VA Health Care System,'' which noted delays in care and
    quality of care concerns. Of the 24 recommendations, OIG agreed to
    close three by the time the report was published and VHA has completed
    action leading to OIG closure on another 15 as of November 25, 2015.
    Six are still in progress. We will continue to focus on rebuilding
    employee commitment and morale and moving forward to provide
    accelerated, timely access to the high-quality health care Veterans
    have earned--when and where they need it.
               u.s. government accountability office (gao) report
        In September 2014, GAO issued its report, ``Management and
    Oversight of Consult Process Need Improvement to Help Ensure Veterans
    Receive Timely Outpatient Specialty Care.'' GAO found that VHA's
    management of the consult process had not ensured that Veterans always
    receive outpatient specialty care in a timely manner. VA concurred with
    all six recommendations and is taking actions to address the concerns
    raised by GAO. During the past year, VHA completed a national
    assessment of progress note completion and created technical capability
    to assess for incomplete consults. VHA implemented an interim consult
    standard operating procedure that standardizes consult management
    processes and developed a comprehensive compliance audit tool and
    protocol for robust oversight.
        Additionally, VHA established business rules outlining appropriate
    use of cancellation and discontinuation and defined the circumstances
    requiring clinical determination and documentation of the reasons for
    discontinuation. VHA standardized the procedures for future care
    consults and authorized future care consults as the only approved
    method for managing consult requests for care intended to take place
    beyond 90 days from the date the consult was created. Facility level
    consult steering committees were established to identify and share best
    practices for managing consults. VHA also developed national guidance
    for management of patient no-shows and canceled appointments. Solutions
    were implemented by extensive national consult training with all VISNs,
    weekly national consult best practice/training calls, and creation of a
    consult training module.
        Although VHA has greatly increased access through more hires and
    expanded clinic hours, demand has also significantly increased,
    resulting in Veterans waiting longer for care longer than VA's wait
    time performance standards. As mentioned above, on November 14, 2015,
    VAMCs across the country participated in the first ever National Access
    Stand Down. A team of clinical leaders, administrators and volunteers
    was on site at every VAMC to reach out to all Veterans identified as
    having the most important and acute needs to make sure that VHA is
    meeting their health care needs immediately. VHA's efforts to fix
    access issues will continue until our system can improve the health
    needs of those that need our help most.
     va oig office of healthcare inspections (ohi) access to urology report
        On October 15, 2015, VA OIG's Office of Healthcare Inspections
    (OHI) delivered its evaluation of access to care concerns in the
    Urology Service at PVAHCS. OHI determined that PVAHCS suffered a
    significant urology staffing shortage, and its leaders did not have a
    plan to provide urological services during the shortage of providers in
    the Urology Service. To fill this need, VHA has hired six Urology
    employees since January 2013.
        OHI also determined that non-VA providers' clinical documents were
    not consistently available for PVAHCS providers to review in a timely
    manner. OHI concluded that referring providers may not have addressed
    potentially important recommendations and follow-up because they did
    not have access to these Care in the Community clinical records. Even
    in the event that further recommendations were not needed, or there
    were no critical findings, this disconnect between the referring
    provider and the specialist compromised the overall management of the
    patient.
        OHI also concluded that PVAHCS Urology Service and non-VA Care
    Coordination staff did not provide timely care or ensure that timely
    urological services were provided to patients needing the care. OHI
    identified 12 patients who experienced significant issues that may have
    affected their clinical outcomes. Two were quality of care issues and
    the other 10 were wait time issues. Such delays placed patients at
    unnecessary risk for adverse outcomes. Of these, VHA conducted further
    reviews and found eight requiring institutional disclosure, six of
    which are already complete.
        VHA concurred with all three of OHI's recommendations and provided
    acceptable improvement plans. To address OHI's recommendation that
    PVAHCS ensures that resources are in place to deliver timely urologic
    care to patients, the facility has hired additional staff to provide
    urologic care. Currently, PVAHCS has a Chief of Urology, two full-time
    urologists, and one part-time urologist, a nurse practitioner, and
    three physician's assistants. Recruitment continues for another staff
    urologist, which is the only unfilled position in Urology Service.
    According to data on PVAHCS as of December 7th, the Urology Service has
    no patients waiting on an Electronic Wait List (EWL); 3 consults aged
    greater than 90 days (all with scheduled appointments); and 99 percent
    of new patients are seen within 30 days. Appointment volume doubled
    from the previous year while the average wait time from preferred date
    was at 3days--8 days lower than it was 1 year ago. Urgent appointments
    are available within 1 day.
        To address OHI's recommendation that PVAHCS ensure that Care in the
    Community providers' clinical documentation is available in the
    electronic health records in a timely manner for PVAHCS providers to
    review, PVAHCS meets with TriWest leadership on a monthly basis to
    improve communication and assess the timely availability of records.
    PVAHCS developed a system by which patient records are downloaded from
    the TriWest portal on a daily basis. As the patient records are taken
    from the TriWest portal, they are placed in a facility folder where
    they are uploaded to Document Manager and linked to complete the Care
    in the Community consult in the Computerized Patient Record System
    (CPRS) in portable document format (pdf). The completion of the consult
    notifies the Ordering Provider automatically via CPRS Alert that the
    non-VA care consult results are available. All TriWest non-VA care
    providers are obligated by contract to provide medical records within
    14 days. TriWest is obligated by contract to load those records into
    the portal within 48 hours of receipt so VA staff can retrieve the
    information.
        To address OHI's final recommendation of ensuring that the cases
    identified in this report are reviewed and for patients who suffered
    adverse outcomes and poor quality of care, PVAHCS conducted in-depth
    quality of care reviews of the 12 identified cases and determined that
    8 protected peer reviews and 8 institutional disclosures were
    warranted. Additionally, external reviews are being conducted to
    validate these findings.
     human resources restoration and revitalization (hr3) site evaluation
                                     report
        As part of the H.R. 3 Report, VA conducted a needs assessment for
    the PVAHCS human resources (HR) team, and the resulting report focused
    on 65 actions needed for improvement. The most notable finding of the
    assessment was the poor state of the office culture which was having a
    negative impact upon H.R. operations, ultimately impacting their core
    mission of hiring those who could provide access to care. Action plans
    were developed and implemented locally which provided a framework for
    PVAHCS H.R. operations.
                                      myva
        At the enterprise level, the work that is underway to transform VHA
    operations also supports an effective response to past events in
    Phoenix. MyVA is our transformation from VA's past way of doing
    business to one that puts Veterans in control of how, when, and where
    they wish to be served. It is a catalyst to make VA a world-class
    service provider. It will modernize VA's culture, processes, and
    capabilities to put the needs, expectations, and interests of Veterans
    and their families first. The MyVA vision provides a seamless, unified
    Veteran experience across the entire organization throughout the
    country.
        One of the five pillars of MyVA is improving the Veteran's
    experience. At a bare minimum, every contact between Veterans and VA
    should be predictable, consistent, and easy. But we are aiming to make
    each touch point exceptional. This means that Veterans should be able
    to make appointments for timely treatment. Events such as the National
    Stand Down and practices such as extended care hours improve the
    accessibility of health care in Phoenix and the Veteran's experience.
        Another of the five pillars is to enhance strategic partnerships
    that will allow us to extend the reach of services available for
    Veterans and their families. We are making it easier for Federal,
    state, and local government, as well as private sector organizations,
    to partner with VA by standardizing our partnership processes. This
    improves health care for enrolled Phoenix Veterans by making it easier
    for a Veteran to access Care in the Community, when VA care is
    inconvenient or unavailable.
                                   conclusion
        VA is committed to providing the highest quality care our Veterans
    have earned and deserve. Our work to effectively and timely treat
    Veterans continues to be a top priority at PVAHCS and throughout VHA.
    We appreciate Congress' support and look forward to responding to any
    questions you may have.
                                     ______

      Letter of Revised Data from Hon. David J. Shulkin, M.D., Secretary,
                      U.S. Department of Veterans Affairs

        The Chairman. Mr. McIntyre?

      STATEMENT OF DAVID MCINTYRE, PRESIDENT AND CHIEF EXECUTIVE
                  OFFICER, TRIWEST HEALTHCARE ALLIANCE

        Mr. McIntyre. Good morning, Senators Sullivan, McCain, and
    Flake. I appear before you today on behalf of TriWest
    Healthcare Alliance nonprofit owners led by Blue Cross Blue
    Shield of Arizona and our nearly 2,500 employees, most of whom
    are veterans or family members of veterans, to discuss the
    support that we are privileged to provide VA in 28 States and
    the Pacific, including the great States of Arizona and Alaska,
    as they execute their noble mission of caring for our Nation's
    warriors.
        Our core job is to establish a provider network and make
    sure that care is placed with it when it is unable to be
    provided by VA because of wait times or the care exceeds 40
    miles from their home.
        I am pleased to appear alongside the team from VA, led by
    new Under Secretary for Health David Shulkin, with whom I have
    been very impressed in the short time I have had the privilege
    of working in support of his leadership. I would like to thank
    him for coming to the furnace and stepping in to lead the way.
        Most importantly, I would like to say thanks to Chuck Byers
    and Nicole Morris and all the veterans in attendance today for
    their service. We are inspired and humbled by your presence.
    Know that we will not rest until the final refinements of
    Choice are in place and the program has achieved its potential.
        Mr. Chairman, I ask that my written testimony be accepted
    into the record.
        The Chairman. Without objection.
        Mr. McIntyre. General George Patton once said, ``A good
    plan violently executed now is better than a perfect plan
    executed next week.''
        I cannot speak to pre-April 2014, but all of us associated
    with the effort since to ensure that access exists for veterans
    when and where it is needed here in Arizona and elsewhere know
    firsthand the definition of a good plan violently executed. In
    fact, it was the result of a collaboration that we were able to
    collectively in Phoenix work off the waitlist of nearly 15,000
    veterans, as the country was learning about Phoenix and the
    fact that it was not the only place where supply did not match
    demand.
        Though the Department of Defense took nearly 3 years for
    the design and implementation of TRICARE, the situation post-
    April 2014 in VA called for a schedule for more aggressive, 2
    months for design and 1 month for execution.
        I would say that our fellow citizens who bore the costs of
    battle deserve such intensity. Senators, initial success was
    achieved with the design, production, and mailing of the Choice
    cards to veterans, with more than 9 million delivered. The
    phone systems were fully operational on day 1 and care began to
    be placed in the community.
        Most in industry said it would take 12 to 15 months just to
    do that, but we all got it done in 30 days, a good plan
    violently executed. But, that was a year ago.
        Since then, as you know, you and your colleagues in
    Congress have broadened the definition of an authorization so
    that cancer patients, pregnant moms, and post-surgical cases
    will no longer face a 60-day care authorization limit. You
    broadened the definition of 40 miles, and you removed the pre-
    August 2012 enrollment limit.
        For our part, we and VA have been collaborating fully,
    implementing a program to support the Phoenix VA medical center
    in its emergency room to ensure that when patients show up with
    mental health emergencies and cannot be handled directly by VA,
    then we are able to place them downtown. We placed 166 veterans
    in the last couple of months, providing them with needed
    protection.
        We have identified and are working to close gaps in
    operation. We have developed and refined tools to better
    support the needs of veterans, providers, and our staffs. We
    have identified unmet demand and further expanded the provider
    network to bring care even closer to home. We are identifying
    resolutions to claims challenges that are needed, just like we
    did in the early days of TRICARE, on our road to becoming the
    fastest and most accurate payer in the marketplace.
        While we are not done and we are not where we want to be, I
    think we are making progress. Today, there are more than 11,600
    providers in the network in Arizona, more than 156,000 across
    the 28 States that we are privileged to serve. Three hundred to
    500 are being added still daily.
        Second, the number of appointments sought has grown from
    2,000 in November 2014 to an expected 110,000 this month. For
    those of you who did your math quickly, that is an increase of
    4,900 percent in that period. In Arizona, we will be delivering
    on more than 4,000 appointments this month.
        Our staff has had to grow from March at 400 to now almost
    3,000 individuals.
        Third, we have handled 3.8 million veteran calls in that
    period, volume that has grown at 20 percent a month, with more
    than 690,000 in November alone.
        Our abandonment rate is a mere 3 percent. We are not where
    we want to be yet. We do not like it at 3 percent. We would
    like lower. We want to be at the same industry-leading
    performance that we were in TRICARE, as validated by five
    successive J.D. Power awards.
        Full success? Not yet. However, we believe that together we
    can get there faster than we did in TRICARE, and our Nation's
    veterans deserve no less.
        So, what is the work that remains, from our perspective?
        First, we are implementing major improvements in provider
    experience that was developed in collaboration with the
    providers from our network and our longtime partners at the
    Arizona State University (ASU) customer service institute.
        Second, we are approaching the second round of demand
    forecasting with VA to determine where a network is optimally
    placed.
        Third, we are soon going to train the behavioral health
    providers in our network on veteran experience in combat, just
    like we did in the early days of the war under TRICARE.
        Fourth, we will soon be implementing the expansion and care
    authorizations for cancer, pregnancy, and post-surgical
    patients.
        Fifth, we are going to be embedding staff at the VA
    facilities here in Phoenix and in Alaska to re-create the
    successful service center concept that we developed in TRICARE.
        Sixth, we will be relentlessly focused at the start of next
    year on gaining feedback from veterans and partnering with ASU
    to improve veteran experience.
        Senators Sullivan, McCain, and Flake, I believe the overall
    experience is getting better, but we have a lot of work to do
    before we achieve the vision that you and your colleagues had
    in the unprecedented action to both authorize and fund the
    Choice Act in one bill.
        It is with deep humility and profound respect for our
    fellow citizens who put it all on the line for our freedom that
    we continue to lean forward. The same is true for our owners
    who by the end of March 2016 will have invested nearly $60
    million of their own money in an effort to scale, stabilize,
    and ultimately refine our operation, so that we achieve our
    potential and honor the commitments we made when we stepped
    forward to be the high-performing partner to VA that we were to
    DOD in TRICARE.
        We take our responsibility very seriously for VA, for
    veterans. This Committee can rest assured that our entire focus
    is on ensuring that our work in support of VA and the veterans
    who rely on them for care is fitting of the sacrifices of our
    heroes and is worthy of their trust.
        It is for this reason that we will remain impatiently
    focused on the path of violently executing the plan until we
    achieve the success that we know is possible.
        Mr. Chairman, this concludes my testimony.
        [The prepared statement of Mr. McIntyre follows:]
       Prepared Statement of David J. McIntyre, Jr., President and CEO,
                          TriWest Healthcare Alliance

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you, Mr. McIntyre.
        I know we have a number of questions. I will begin with
    Senator McCain.
        Senator McCain. Thank you for your testimony.
        Dr. Shulkin, you have made a very favorable impression on
    those of us who have had dealings with you. I believe that you
    are working very hard, and I also appreciate your efforts to
    improve our communication and relations with Members of
    Congress, including the Veterans' Affairs Committee. I thank
    you and Dr. Lynch for coming out here to be at this hearing
    today.
        Mr. McIntyre gives a rather optimistic view.
        In front of you is a chart that shows that obviously
    veterans waiting over 30 days for appointments, it kind of
    contradicts what Mr. McIntyre said, because if TriWest was
    doing the great job that he claims, I would think that veterans
    waiting over 30 days for medical appointments would show a
    decline.
        Maybe you can respond to that, whether you disagree with
    that chart, or what your comments are about that.
        Dr. Shulkin. Thank you, Senator.
        First of all, I do want to thank you as well. I think that
    all three of you, your willingness to speak out on behalf of
    veterans and to work with us to improve the system is very much
    appreciated. As you know, Senator, I believe unless we do this
    together, we are not going to achieve the best results. I thank
    you again.
        The wait times that currently exist are not acceptable to
    VA. That is why we are working so hard to make this better.
        The way that we are working is really a dual approach. We
    are hiring additional staff in the Phoenix VA. We have hired
    over 600 new employees. We are adding space; we recently added
    some space and have additional plans to add significantly more
    space. We are improving our efficiencies, so we are working
    internally.
        Most importantly--again, thanks to Congress, because of
    your leadership with the Choice plan, we have really utilized
    care in the community. We are about 80 percent in terms of care
    in the community from where we were.
        Now we have a lot more to go, but I want to make one
    additional point.
        As we have been saying recently--really I think Dr.
    Mitchell made this point--as VA gets better and veterans regain
    their trust in the VA, we are going to see more veterans coming
    back to get care in the VA system. So, our overall wait times
    are probably not going to go down.
        What we are really focused on now is making sure that
    nobody who is waiting is being harmed. We are focusing on those
    veterans who need care with the highest priority, the most
    urgent care.
        We can really tell you that is what our stand down was
    about, making sure that people who need care are getting in to
    see VA or getting into care in the community. We are not
    satisfied with that, Senator. So, we are making sure that
    people are not waiting and being harmed.
        Senator McCain. It seems to me, then, from what you are
    saying, that wait times will not go down anytime soon. That is
    an urgent call to make the Choice card universal.
        Dr. Shulkin. Senator, I think that is accurate. We are not
    saying that wait times overall are going to go down
    significantly or at all. In fact, as we improve the system,
    they may actually go up.
        That does mean that we need to make sure that we are
    working better with providers in the community using the Choice
    program. We are focused on improving the Choice program. That
    is why we submitted a new plan to Congress that asks for your
    help in making sure that we can make this system work better
    for veterans.
        We need legislation for new provider agreements. We need
    the flexibility to have funding for care in the community be in
    a single pot rather than separate programs. We want to make
    this program that you gave us work even better than it is
    working now.
        Senator McCain. Well, I do not want to belabor the point,
    but I think the prospect of veterans waiting over 30 days, no
    matter what their medical need, is not acceptable. If they had
    a Choice card, they would not have to wait 30 days. They could
    go out the next day and get an appointment with the physician
    of their choice.
        Ms. Fogarty, do you have full confidence in your emergency
    room today?
        Ms. Fogarty. Senator, thank you. The emergency room has
    really experienced quite a lot of change over the past year and
    made several improvements. I would like to give you a sense of
    what those are.
        We have increased the ER and mental health staffing. We
    have increased the space, as Dr. Mitchell identified, and we
    currently have a construction project underway.
        We have added 24/7 social work coverage that was not there
    before. We have approved and recruited additional psychiatry to
    also have 24/7 coverage. We have added five mental health RNs
    to the ER. We have established a standard medical clearance
    protocol for patients that need to be admitted to our mental
    health.
        We really thank our partners with TRICARE and TriWest
    because they do allow us, when we are full, to have care in the
    community, they would be allowed to take our patients that we
    could not.
        We have had standardized training in documentation for
    patient safety, observers called sitters, who are sitting and
    watching any suicidal ideation patients that come in. We
    redesigned four of those exam rooms and a restroom to make them
    safer for suicide ideation patients, to help prevent a serious
    elopement.
        Senator McCain. You are aware of the Clay Hunt Suicide
    Prevention Act?
        Ms. Fogarty. Yes, Senator, very much.
        Senator McCain. Is that helpful?
        Ms. Fogarty. It is, and we thank you for that.
        It is one of those that we worry the most about, those
    coming with suicide ideation. We really have to be the most
    diligent on those who come.
        Senator McCain. Do you have some examples of intervention
    that have saved some lives? I do not ask for them, but you do?
        Ms. Fogarty. Oh, absolutely.
        Senator McCain. Are physicians leaving the Phoenix VA?
        Ms. Fogarty. Are physicians leaving?
        Senator McCain. Are physicians leaving the Phoenix VA?
        Ms. Fogarty. No, sir.
        Senator McCain. They are not.
        Ms. Fogarty. As you saw here, of what we have netted of 600
    FTE, we have hired over 160 on the Veterans Access, Choice and
    Accountability Act funding for us. I can give you some
    specifics on the physicians.
        Senator McCain. That is all right.
        Ms. Fogarty. We do have attrition, as you know, physicians
    who retire or do leave with family moves. We have had six.
        Senator McCain. You do not have physicians leaving the VA.
    Thank you.
        Mr. McIntyre, what has been your experience with the Choice
    card? Does it need to be made universal?
        Mr. McIntyre. I think it is starting to take hold in terms
    of its use. The fact that there are 110,000 appointments that
    are going to come our direction this month from 2,000 at the
    start of this indicates that we are on the right----
        Senator McCain. Mr. McIntyre, the fact that there were only
    2,000 at the start is because they did not know about it. So,
    please do not keep throwing that one up at me.
        I want to know whether you think the Choice card should be
    made universal or not.
        Mr. McIntyre. I think the people's ability to access care
    downtown when it is not available in the VA and when it is not
    close to their home is exactly the right thing to be doing.
        Senator McCain. What impediments to you see to better
    usage?
        Mr. McIntyre. I think that people understanding the
    program, first of all, from an education perspective, which we
    all can share in, is valuable. Second, I think changing the
    kinds of policies that have been changed will help smooth this
    out. Third, I think our operations need to continue to get
    stronger and more integrated in order to make this process work
    more effectively.
        Senator McCain. Thank you.
        Dr. Shulkin, one of the sources of great frustration to
    many of us, especially here in Phoenix, is the fact that it is
    undeniable that there were really people who did not do their
    job. Otherwise, we would never have had 50 veterans who were on
    a nonexistent waiting list.
        Yet, to our knowledge, maybe you can help us out, there is
    only one person--one person--that has been removed from office.
    People do not understand that when 50 people die on a
    nonexistent waiting list and there is only one person that is
    held responsible, and many others are on ``administrative
    leave'' with full pay, paid for by the taxpayers. Please help
    us out on that one.
        Dr. Shulkin. Senator, we hear that frustration loud and
    clear. There is no question about that. We did remove the
    director, as you said. We placed two other officials on
    administrative leave.
        Senator McCain. That means paid. That means being paid.
        Dr. Shulkin. Paid administrative leave.
        We would very, very much like to conclude our
    administrative and disciplinary actions against those two
    officials. The U.S. Attorney, as I said in my statement, has
    prohibited us from interviewing those individuals. The OIG just
    30 days ago gave us 10,000 additional pages of evidence on
    these individuals, and last week an additional 1,000 pages. As
    soon as we can go through that evidence, we are committed to
    making an action.
        On December 9, Deputy Secretary Gibson testified before the
    House committee and said we are no longer going to wait for the
    IG to act. VA will act independently as soon as we can.
        We are committed not to putting additional people on
    administrative leave, but we will detail them to work. If the
    taxpayers are paying these individuals, they need to be
    working.
        Those are changes in the way that we are going to be
    dealing with this in the future.
        Senator McCain. Well, I thank you, but I would remind you
    what you know, and that is the Senior Executive Service is a
    unique situation, as opposed to your average civil servant. The
    SES people are eligible for many benefits and rewards for
    excellent performance, but they are also liable or can be fired
    and removed from office with much less reason than an ordinary
    member of the civil service.
        Many of these individuals who were in charge are members of
    SES, and yet that option has not been exercised. Maybe you can
    respond to that.
        Dr. Shulkin. Yes. Since Secretary McDonald was sworn in,
    July 2014, there have been eight SES removed by the Secretary.
    That option is available to him.
        I think that we are all firm believers--the Secretary, the
    Deputy Secretary, and myself--in accountability. We have
    articulated that we believe we must do this principally based.
    There has to be evidence to match the actions or the punishment
    or the reward.
        We are making sure that the evidence does match this. We
    hear you loud and clear, and VA is committed to moving quicker.
    We will not wait for IG actions in the future because it is
    very important that people understand that if people are not
    following our values, they do not belong in the VA.
        Senator McCain. Thank you.
        I thank you, Senator Sullivan.
        I just want to repeat again, Dr. Shulkin, you have been, I
    believe, admirably involved with Members of Congress in
    communicating with us and being frank in your assessments. That
    is appreciated by Members of this Committee. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator McCain.
        I want to make a quick comment, just on what he mentioned
    to Ms. Fogarty. The Clay Hunt Suicide Prevention Act, which was
    the first bill that I cosponsored in the U.S. Senate, named
    after a young Marine sniper who suffered through despair and
    did not get the service that he needed from the VA and ended up
    taking his own life.
        The number 1 cosponsor of that bill in Congress, which
    passed unanimously, was Senator McCain. That is what he was
    referring to. Let us talk about an issue that really matters,
    veteran suicide, and the one member of the U.S. Senate who has
    led on that more than anyone is Senator McCain.
        I am glad to see that is having an impact, because there is
    nothing worse--nothing worse--whether it is a Vietnam vet or a
    vet from Iraq or Afghanistan, coming back experiencing
    depression and despair and having nowhere to go. That is
    probably our highest responsibility, to take care of those
    veterans.
        Senator Flake?
        Senator Flake. Thank you.
        Ms. Fogarty, if Ms. Morris were to go to the VA emergency
    room today like she did before and present the same symptoms,
    what would be her experience?
        Ms. Fogarty. First, I would like to acknowledge how
    disappointing to hear those statements of a veteran coming to
    our emergency room and having that wait. It just is not what
    our standard of care should ever be.
        Today, I believe that she would have a very different
    experience in what we have approved and made. I would also
    believe that there is that opportunity with the Choice card
    that she could seek care in a private facility and have that
    reimbursed as well.
        Senator Flake. If she were to go down to the ER, her wait
    time in the ER itself would be considerably shorter, and she
    would have a different experience than she had before?
        Ms. Fogarty. I would truly hope that is the experience,
    because that is what we are working on, always to have
    exceptional experiences, and have done great things in our
    emergency department to make that experience be----
        Dr. Shulkin. Senator Flake, let me just add, the average
    wait time in our Phoenix E.D., from the time that you register
    to when you see a physician or provider, the average is 35
    minutes. That is an average.
        You will still find times in an emergency department where
    there are critically ill patients and patients like Ms. Morris,
    that do not have a critical illness, will wait a lot longer
    than the patient wants to.
        This is a national issue with emergency department
    overcrowding. So, we would not want to say that this would be
    her experience, but there would be times when patients will
    wait.
        Senator Flake. All right. Thank you.
        Dr. Shulkin, I, like Senator McCain, believe we need to get
    to a point where the Choice card is used universally and not
    with restrictions on mileage or whether there is a clinic or
    whatever else. But, that gets to the nut of the whole issue
    here, how much Choice can the VA withstand?
        If a significant number of veterans choose that option, at
    what point does it impact the ability of the VA to have the
    funds and resources to operate at facilities and have the level
    of care that veterans should expect? Are we close to that
    tipping point? Is that why we have the restrictions that we do?
        Can you explain that conundrum that we are in?
        Dr. Shulkin. Sure. Senator, it is a very complex issue, as
    you said. First of all, as I previously said to Senator McCain,
    we are very grateful for Congress' leadership in providing us
    the Choice program. We think it was the right thing to do and
    we want to make this program work better for veterans. We know
    too many veterans have experienced the complexity of it, the
    confusion, the lack of knowledge about it, as has been
    mentioned. We are committed, as Mr. McIntyre said, to making
    this program work.
        We have submitted what we think is a very thoughtful plan
    to Congress that we delivered approximately a month and one-
    half ago that lays out how we want to take the original Choice
    legislation and make it work better. We need your help.
        We need provider agreements as soon as possible. We need
    the flexibility to make the spending easier for us to serve
    veterans and offer care in the community.
        We are very much in support--VA has been providing care in
    the community for years. Over $10 billion of our dollars were
    spent for care in the community.
        We think our plan is a very thoughtful balance of keeping
    the VA strong, because America needs a strong VA, and serving
    veterans by allowing them the ability to seek care in the
    community with the highest quality providers.
        Senator Flake. Mr. McIntyre, has the VA done enough to
    advertise the Choice plan among veterans and to ensure that
    they understand their rights and ability to access private
    care?
        Mr. McIntyre. I think the VA has done a remarkable job over
    the last couple of months of really stepping up the focus in
    that arena. Part of the thing we are all hampered by----
        Senator Flake. Your comment implies that it is only a
    recent phenomenon?
        Mr. McIntyre. No. At the very front end, we had 30 days to
    stand this up. It is hard to educate people internally and
    externally in an effective manner. There has been a real effort
    within the VA to figure out which populations need to be
    reached and how we do that collectively more effectively.
        What I will tell you, though, is part of the challenge we
    all face is that the policies have not yet stabilized for how
    this all works and where you access and what the limitations
    are.
        I would encourage that once that is done by, essentially,
    what is going to be the end of January, that there is dramatic
    new push by everybody, including the media and Members of
    Congress, ourselves, and the VA, to make sure that people
    really understand what it is that they have.
        It is rather remarkable. We have providers all over this
    State, so that if you live in a rural area, the number of
    primary care providers that are accessible to you is rather
    dramatic. You have new rights under the Choice program to
    actually go and seek care in the ZIP Code in which you reside,
    not to have to drive a long distance in order to get that care.
        Senator Flake. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Flake.
        I want to echo Senator McCain's comments about Dr. Shulkin.
    For the audience's knowledge, he came on board as the Under
    Secretary, the number 3 official at the VA, just in August. As
    I have said, he certainly did not cause these problems. He is
    someone from the private sector, an accomplished doctor who has
    run hospitals. He wants to do what is right to fix the
    problems, and he is aware that the Committee will not be
    standing by if we do not see the problems are being fixed.
        So, Dr. Shulkin, I did want to follow up on what Senator
    McCain talked about on accountability. I think it is really
    important for Members of Congress but, more importantly,
    members of our veteran community across the country to see that
    something is being done.
        You mentioned that we hear you loud and clear what you said
    to Senator McCain. I was disturbed by reading a recent article
    in The Washington Post on a House Veterans' Affairs Committee
    hearing just last week with Deputy Secretary Gibson not
    sounding like he is hearing us loud and clear at all.
        He said, when asked about accountability of members of the
    VA, he was pushing back, saying, ``You cannot fire your way to
    excellence. In my many years in the private sector, I have
    never encountered an organization where leadership was measured
    by how many people you fire.''
        ``We will not administer punishment based on IG opinions,
    referrals to the Department of Justice, recycled and
    embellished media accounts, or external pressure. It is simply
    not right.'' He called some of these cases ``failures of
    judgment, but not ethical breaches.''
        Last week, the number 2 guy in the VA sounded like he was
    pushing back against Congress' very legitimate questions about
    who is being held accountable in the VA. So, I think one of the
    things that we would want you to do is take back to the Deputy
    Secretary and the Secretary of VA that I certainly do not think
    that those kinds of statements are appropriate. It does not
    sound like he is getting the message at all loud and clear.
        To go back to Senator McCain's question, how many VA
    officials in the last 2 years over all these scandals and wait
    times and our veterans not being treated the way they should be
    treated, how many VA officials have been terminated from their
    jobs?
        You come from the private sector. You have a very, very
    stellar record in the private sector. I know that the hospitals
    you worked at would be firing a lot of people had things like
    this that happened in Phoenix.
        What is the number?
        Dr. Shulkin. Senator, as you said, I have been in the
    system only a few months. I will tell you, I spend a fair
    amount of my time with Deputy Secretary Gibson and Secretary
    McDonald talking about these issues. I will tell you these are
    two of the finest leaders I have ever worked with in my career.
    They take this very seriously. I do not think that is an
    accurate representation of the Deputy.
        The Chairman. I was simply quoting him.
        Dr. Shulkin. Yes, absolutely.
        Where the Deputy stands on this, I know the Secretary as
    well, is that we are committed as leaders, and I stand right
    with them, that we are going to take a look at the evidence and
    we are going to make decisions about who deviates from values
    and policies, and we are going to hold our employees
    accountable.
        What we are not going to do, we are not going to have
    people tried in the press and tried through allegation. We are
    going to treat people fairly, because that is the way you run
    great organizations.
        The data that you asked for, eight SES have been removed
    since the Secretary was confirmed in July 2014, and 2,100
    employees have been terminated. We will continue to hold people
    up to these accountability standards and we are going to use
    the evidence.
        What the Deputy said in that hearing was that he welcomes
    anybody else, a Member of Congress, to come and look at that
    evidence and show him if we are not making good decisions. But,
    he is going to uphold his leadership responsibility, and I
    stand with him on that.
        The Chairman. Twenty-one hundred VA employees have been
    terminated for wrongdoing since these scandals?
        Dr. Shulkin. Since July 2014 when the Secretary was
    confirmed.
        The Chairman. Perhaps for the record you can provide us the
    details on those and the eight that you mentioned.
        Those have been fully terminated or, as Senator McCain
    mentioned, are on leave?
        Dr. Shulkin. No, those SES have left service. They have
    either been terminated, have resigned, or chosen to retire.
        The Chairman. So, I would like, for the record, the detail
    on all of those for the Committee's review.
        Dr. Shulkin. Yes, sir. I will be glad to do that.
        The Chairman. Thank you.
        Another quick question is something that you and I saw in
    Alaska that I continue to see, which I think is something that
    we need to continue to work on. I still see veterans who come
    up to me talking about appointments they have had--you and I
    saw this when we were up there--that have been approved by the
    VA and somehow the reimbursement is not happening quick enough
    and these veterans are now being sent to collection agencies. I
    am still seeing that.
        I would like to get your commitment to work with the
    Committee to put a halt to this. The idea that a veteran gets
    approved by the VA for an appointment, goes to it, the provider
    either through TriWest or the VA does not reimburse what has
    happened with regard to who is providing the service, and then
    a debt agency is collecting upon the veteran is outrageous.
        You saw it when we were up in Alaska. I am still seeing it.
    I would like to get your commitment to work, both of you, Mr.
    McIntyre, on this issue, which just obviously adds enormous
    stress for our veterans, when a collection agency is calling
    them, saying they have a $50,000 bill.
        Dr. Shulkin. Yes. First of all, I heard this with you,
    absolutely. It is outrageous. We do not want that to be
    happening. If the VA authorizes care, the veteran should not be
    held accountable for that. You have my commitment. That should
    not be happening.
        I would like to get the names and the specifics of anybody
    you are hearing about from any of your offices, and we will
    intervene to make sure that it does not happen.
        The Chairman. Thank you.
        Mr. McIntyre, you mentioned in your testimony that the
    relationship between the VA and TriWest has matured
    substantially. What more needs to be done to develop that
    relationship in a way that ultimately does what you are
    supposed to be doing, which is benefiting our veterans.
        Mr. McIntyre. Senator, I would like to thank you for that
    question. I would also like to state that I, too, am committed
    to make sure that if you have cases where veterans are getting
    billed inappropriately by providers, that we would like to
    understand what they are so we can work those issues out, and
    we will do that in support of Dr. Shulkin.
        With regard to the maturation of this program, we believe
    that the inner-threading relationship that is starting to
    develop at the ground level is really important. One of the
    things that we are going to be launching in Alaska, as you
    know, effective January 11, is the opportunity to have a joint
    service center at the ground level.
        I will tell you that it is one thing for us to have policy-
    based discussions and operational-gap discussions up at the
    top, but it is quite another thing when you get down to the
    deck plate where veterans are being served on a day-to-day
    basis.
        Your concept, which we are also going to be rolling out,
    Senators McCain and Flake, here in Phoenix of having an
    integrated service center that is located close in proximity to
    the veteran could not be more right on the money from the
    standpoint that you could walk a veteran down the hall after an
    appointment in the VA, educate them about Choice so that there
    is no lack of understanding, give them some materials, and find
    out what their preferences are in terms of appointments, how
    they would like to be contacted and the like. It is exactly
    what we ought to be doing.
        Dr. Shulkin, our organization, and our entire teams are
    working to make sure that it is going to get prototyped in both
    Alaska and Phoenix.
        The Chairman. Are you looking at, in terms of your call
    centers, which I know have been an enormous frustration for
    veterans across the country, because there is no localized
    component. So, a veteran from Arizona calls--I do not know
    where your call centers are located--but someone calls from
    Arizona or Alaska and they are having issues. Are you looking
    to start localizing and integrating those call centers
    throughout the country?
        Mr. McIntyre. Great question. Thank you for the question,
    by the way.
        When we started Choice, we had 30 days to go from a blank
    sheet of paper to full on operations on November 5. We had to
    hire 850 people, but we did not know the number until we were
    10 days out. So, we turned to a third-party vendor that
    supports other organizations in managing backup in their
    contact center operations.
        That was separate from how we were running our operation in
    PC3. We took all the calls, directed them to that organization.
    We have been weaning ourselves off of that when we came to the
    conclusion in the summer, when we were at 37,000 appointments a
    month, that we were going to face a meteoric rise in demand.
        Tomorrow we will announce in El Paso the tenth operations
    center. Eight of them are now up and fully operational. The one
    that serves Arizona is right here near Gilbert. It is in Tempe,
    and we have a number of employees here. The operation for
    Alaska is served out of Puyallup, which very effectively served
    Alaska for PC3.
        Then, what we are doing is we are inserting, on a test case
    to start with, these customer service staff at the local level,
    integrated with the VA staff, much like we did in TRICARE.
        If you can think about it, it is a hub-and-spoke operation.
    You have a hub that is subgeographic in its location, and you
    have these nodes facility-by-facility-by-facility.
        That is how we hit world-class service in TRICARE. Our
    intention is to roll out the same and be done with that by the
    beginning of March, which is the trajectory that we are on.
        The Chairman. Thank you.
        On the pilot program we talked about in Alaska, what is the
    date that it is going to be implemented?
        Mr. McIntyre. There are three phases. The first phase was
    to take all calls and route them into Puyallup for Alaska. That
    happened right after the Alaska field hearing in August that
    you chaired.
        The second phase is to place staff colocated in a service
    center within the Anchorage VA. We are also going to have other
    staff in Alaska on the ground in Fairbanks and probably in
    Southeast. That will go live January 11 and there, as we will
    do in every other location where we roll this out, we are
    taking seasoned staff that already know the market to go there
    first. Then, we will hire right behind that, so we can make
    sure we do not miss a beat.
        The third phase, as you know for Alaska and unique to
    Alaska, is that the scheduling configuration will change. We
    will have more engagement between the VA staff in Alaska and
    the veterans and the providers in that community. We are in the
    process together of finishing the design with that, so that
    will next be able to roll out.
        The Chairman. Let me ask a final question.
        Mr. Byers talked about the problem with providers being
    reimbursed and how there was an issue with the lack of
    reimbursement, and then all the veterans who had appointments
    with that provider doing urological services were going to be
    dropped.
        Have both of you been focused on making sure that those
    kind of things do not happen? That is a key element of the
    Choice Act. If the providers do not have any kind of clarity,
    it is going to be difficult for them to provide the services
    they need to our veterans.
        Dr. Shulkin. Senator, I will be glad to start, and then if
    Mr. McIntyre wants to add to this, that is fine.
        Actually, TriWest does a very good job of paying its
    providers. I think, if I am not correct, you are close to 100
    percent within 30 days. So, this is actually a problem for VA
    because TriWest pays the Choice bills. VA pays the care in the
    community bills.
        We have not been doing as good a job as we need to, in my
    opinion, in paying our providers. Coming from the provider side
    where I spent my life, when you give a service, when you see a
    patient, you deserve and expect to get paid. We are about 75
    percent payment within 30 days.
        We have antiquated roles and antiquated systems. We have
    asked for some help in this in simplifying the care in the
    community funds from Congress because we need this to get
    better.
        Our new plan says that we are going to take a look at VA's
    ability to pay and make a build-by decision, because, quite
    frankly, we either need to invest and improve a lot better in
    our payment or we need to get out of the payment business and
    give it to people who know how to do this. The status quo is
    not acceptable.
        Here in Phoenix, we, frankly, have too large of an accounts
    receivable for your big systems like Banner and Dignity and
    your other providers. We have our teams on site here in Arizona
    working out those payments right now because is it not
    acceptable to me that providers have to wait this long.
        Mr. McIntyre. If I might follow that, and thank you for the
    kind comments, we have our own challenges from time to time in
    this space.
        My dad was a doc. He served as an Army doc in Vietnam, and
    then went on to operate in private practice, including in the
    great State of Alaska as an ophthalmologist.
        What I will tell you is that it is really important, as we
    discovered in TRICARE, to make sure that the payment is timely
    and accurate, because we are asking people to stretch
    themselves and take this patient population, which they very
    much want to do, make it the least bureaucratic as we can, and
    make sure that the timing of the payment works right.
        What I will tell you is that we are gaining on where we
    want to be, but we are not there yet. We are spending a lot of
    time with providers trying to figure out where the gaps are so
    that we can make sure that we are able to give feedback to the
    VA on operations changes that we want to make and they might
    think about making. We are collaborating very closely on that.
        The Banner situation, we own a part of it, the VA owns a
    part of it. We are working together very closely to try to
    resolve those issues. I am confident that we will.
        Here is what I will tell you. We are at 95-plus percent for
    paying claims within 30 days. That is 1 year in. It took us
    longer to get there with TRICARE. What I am going to commit to
    all of you and to the veterans that we are privileged to lean
    forward for at the side of VA, and the providers in this
    community and elsewhere is we will get this right. We will get
    it right together. It is really important that it is right so
    that people do not feel like, ``The bill is not going to get
    paid over here, so I am going to send the veteran to
    collections in order to be able to pay my bills.''
        The second thing is, in urology in Phoenix, AZ, when the
    furnace lit off in April, we ultimately came to find that of
    the 14,700 on a waitlist, 3,300 of them were urology patients.
    At the time, there were 72 urologists in Maricopa County. The
    VA had us on speed dial. We rolled up our sleeves together. We
    figured out how to design a demand capacity mathematical
    process together, which we are using to grow our network
    together across the 28 States and the Pacific. Then, we figured
    out what it would take to place providers, how to do it on a
    severity basis, and make that happen.
        While Chuck was testifying, I had the information pulled
    with regard to his experience, because it was a while ago. I
    was having a hard time remembering it.
        We received his care requests from VA on June 10. We had
    him appointed on June 17. The practice that saw him took more
    than 50 percent of the 3,300 urology patients and processed
    them within 7 weeks. They should be sainted. Their patients
    agreed to step aside in their own calendars and serve people
    like Chuck. Chuck got seen initially on the 20th, 3 days after
    he was appointed.
        That is the way this should work. There are providers in
    this community and your great State and all over this country
    that said, ``I do not want to replace the VA, but I will be
    there if I am needed. Just hand me a few; and, like what we did
    with TRICARE, let me take care of them and then make sure that
    I get paid properly for the work I have done and on time.''
        That is our commitment. I know from the work I have done
    with these three, that is our collective commitment in terms of
    where we want to be. We want to get there as fast as we
    possibly can.
        The Chairman. Well, they should be sainted, but they are
    not going to continue to be committed to our veterans unless
    they are reimbursed. I think that is a key issue.
        Senator McCain?
        Dr. Shulkin. They have been and they are still in the
    network.
        Senator McCain. I want to refer you, Dr. Shulkin, back to
    that chart that shows the veterans waiting over 30 days.
        The Phoenix VA line is roughly double that of the national
    average. That, obviously, is very disturbing to anyone who
    represents the State of Arizona, that we should be almost
    double the percentage of people who are waiting over 30 days.
        We are not proud of the fact that this whole thing really
    was ignited by what happened at the Phoenix VA. I would hope
    that extraordinary efforts would be made at least to bring that
    orange line down to the blue line. That part is really
    something that is not acceptable to those of us who care about
    our veterans in Arizona.
        Dr. Shulkin. Senator, it is not acceptable to me, as well.
    As you know, the country is experiencing a shift from VAs that
    were in the rustbelt down to areas like Arizona that are very
    attractive to veterans particularly who are retiring. We saw a
    6 percent increase in unique veterans using the Phoenix VA last
    year, so we are growing. We have to plan for that. That is, in
    part, making this more difficult.
        We will not rest until we can add capacity. We have 738
    positions we are recruiting for today. We are adding new space.
    Our new director started today. We need stable leadership in
    order to make this work. I have extreme confidence in our new
    leader to be able to do this.
        I can assure you, extraordinary efforts are what we are
    going to make to get this fixed.
        Senator McCain. Thank you.
        I want to again thank the Senator from Alaska for being
    here, as one of the most important Members of Veterans' Affairs
    Committee, to conduct this hearing. I thank you, Senator
    Sullivan.
        The Chairman. Thank you, Senator McCain.
        I want to thank the witnesses from both panels. I want to
    thank my colleagues. It is an honor to be up here on the dais
    with Senator McCain and Senator Flake, two leaders in the
    entire U.S. Congress on these issues, as I mentioned earlier.
    Their names are on the legislation that we are talking about,
    and I think that is great not only for Arizona, but for the
    country.
        Finally, I want to thank our veterans who joined us today.
    I assure you, as Dr. Shulkin said, this Committee and the
    entire U.S. Senate will not rest either until we have addressed
    these issues in a way that is faithful to the service you
    provided our great Nation.
        I will mention one more time, if there are those of you in
    the audience who are interested in submitting written testimony
    to this hearing for the Veterans' Affairs Committee in the U.S.
    Senate, the email again is
    public_testimony@Sullivan.Senate.gov. You have 2 weeks to
    submit that written testimony, which would be Monday,
    December 28.
        This hearing is now adjourned.
        [Whereupon, at 11:08 a.m., the hearing was adjourned.]

     Clarification of Testimony of David J. Shulkin, M.D., Under Secretary
                for Health, U.S. Department of Veterans Affairs