[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
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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
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Available via the World Wide Web: http://www.fdsys.gov
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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
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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
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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
[email protected]. 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