Transcripts For CSPAN2 Lawmakers Press Veterans Affairs Secretary On Addressing Agency Problems 20170506

Good morning, were placed to welcome back a good friend, dr. David shulkin. She last time you appeared before our committee you were in the virginia undersecretary for health and now kicked upstairs after a nance confirmation vote and that says a lot in this political environment. So congratulations. You have a great background in the philadelphia area, just learned you were in marstown and you certainly bring lat of experience to the job and although im sure these days that the challenges are very dawning for you daunting for you. This hearing is unusual. Rather than the typical Budget Hearing we have at this time of year, were limited to a discussion of the skinny budget, the skinny budget materials the onb sent to the hill in march. They twopage entry for the va doesnt give us much to go on in terms of Program Priorities but the skinny budget gives us the administration is proposing a 4. 4 billion 6 funding increase for the agency and addition theres 2. 9 billion proposed in new mandatory funding for the virginia. You must be probably the only domestic federal agency not facing a substantial cut and so i suspect ill need a kevlar vest when talking to my fellow preparations subempty appropriations subcommittee. So when we say you full budget well be asking tough questions. The merits you propose increases when we no others bill we struggling. Despite not having a complete budget im sure the members will fine plenty of va topics to ask you about this morning. How you envision va striking balance, making Electronic Health records work for veterans as shay see more daughters how to choice. Your efforts to tackle appointment scheduling problems and approaching disability claim backlogs and appeals. Your plans to decrease veteran suicide and homelessness, your campaign to limit opioid abuse among veterans, plans to access care for rural and female veterans veterans and thats just the start. So well include your full statement in the hearing record and be pleased to hear your oral statement. But ill ask our Ranking Member if she has any opening comments to make and. So miss wasserman shiltz is recognized. Thank you, mr. Chairman, and welcoming are mr. Secretary. Its been a pleasure to talk to you and have you in any office. We appreciate you being here in your new capacity, and its an awkward situation we find ourselves in. Youre operating on a bigger stage than previously and with greating responsibility that comes with the duties of being the secretary of the va. Mr. Chairman, since fiscal yearing two the va has seen a tremendous 70 increase in accounts, the va medicare anses now 64. 4 billion and discretionary accounts increased to 74. 3 billion. Fy2018 is no different. This skippy budgets requested 78. 9 billion or 6 increase from the 2017 inactive level. The 20sel budget requests legislative authority and 3. 5 million in mandatory authority to continue the veterans Choice Program. And what is a question that arises is that this would support a program that was initially mend as a stop gap treasure fund. Mr. Secretary, while im thrilled to have you here today its up fortunate we wont be able to discuss the specific budget request and its challenging to tour on juror. Given the 70 increase over the past ten years its critical that the committee has the opportunity to app an analyze the unders and determine what the va has less than adequate okay and wait times. To it is crucial that we understand how these issues are being addressed. And once we more fully understand the issues at what point do we ask if this continued growth is unsustainable. Mr. Secretary i ask these questions with genuine concern for the future of the va. Obviously our driving concern must be to provide the best care to our veterans. We dont control costs and ennoor hat the resources the committee provides are used in an appropriate and efficient fashion. We actually hurt our ability to help veterans and deliver on our mission prove providing top quality care. Comes to mind we are providing Additional Resources were not seeing what would normally come as the commence membersat responsible from people receiving new services because of the challenges that the va is having in providing the services efficiently. Top quality care is our top priority and we need to mike sure we help you deliver on that mission. With that in mind, mr. Chairman, its imteartive we discuss a number of key issues including the Choice Program and the state of the vas Electronic Health records. How does theave envision choice . As after creating the Community Care account, 9. 4 billion in advanced fy18 appropriations why does the budget request include 3. 5 billion for the Choice Program . Additionally where is the va in implementing and improving the electron Health Records system and executing congress man dead for full interprincipal with dod systems. As we discussed a solution to this issue is long overdue. And finally, i hope you can address the significant number of vacancies the department and then the positions are expected to be filled. 11 senate confirmable positions are vehicle cant, including the undersecretary for benefit its, for health, and the undersoutheast for Memorial Affairs the general counsel, the assistant secretary for information and technology, the assistant secretary or policy and planning, the assistant secretary for management, and the chairman of the board of veterans appeals and by the way, the veterans appeals process is an absolute mess, and so for it to have no chair for as long as that has occurred is really unacceptable. And i believe that you ernestly want to reform improve the va it reflect of the confidence and its our duty to ensure you have adequate resources to do so. We have a lot to discuss today. Thank you for the opportunity to share my concerns. Id like to recognition the chair of the full committee. Thank you, chairman, and Ranking Member. First of al i want to give you a shotout for passing your bill last year, september. Thank you for that effort. You were the pace setter. I wish we could have followed your pace but i cant think of a more Important Department than the department of Veterans Affairs. Those who have served our country right now in dangerous places deserve when they get hem to get the best care possible and i know you from your time in new jersey and wonderful things you did there and for good reason you were unanimously confirmed by the senate. Not a lot of unanimity over there but im glad they focused their attention and support for you. Two areas areas of interest intt to me and i dont want to take time away from your remarks, questioning to be the appeals and benefits backlog. Its a nightmare. Ive even shared with you some of the three our four, year waiting periods for people, obviously evidence has to be checked and verified but in result its nightmarish president suspect and the confirmation of your undersecretaries might be helpful. The last area of interest is Electronic Medical records. Three years ago the then chairman rogers hosted chuck hagel, secretary of defense, and rick shen sick can i, we received a commitment from former we would have a luigs. Know that the department of defense and given the resources theyve been given, is getting up to speed but i do view your systems as sort of the weak link. So i just personally feel this is something which is enormously important in a day and age when we have so much information passing back and forth, obviously, encrypted and protected, that to not have that available to our Healthcare Providers is pretty inexcusable, but good luck and god speed and thank you, mr. Chairman. Thank you very much, and i would like to thank chairman dent and Ranking Member Wasserman Schultz for holding this important hearing and i welcome secretary shulkin today. We as members of congress and you as a secretary of Veterans Affairs, have a duty to provide the best care available to our veterans, who have sacrificed and faithfully served our nation. The va faces serious challenges in meeting their health needs. After working four years to reduce the claims backlog, it is once again increasing. And the Choice Program will soon run out of money and is in need of reform. And the va and department of defense and not significantly closer to the interoperability of Electronic Health record than years ago. We owe it to all current and former, future veterans, to tackle these challenges now, and this subcommittee is committed to achieving that goal. I must say, after reading your resume, i am so optimistic, ass was referenced before, chairman rogers and i had four hearings. We also met in closed door sessions, but we havent been able to resolve this. Now, have my own personal preference about who is to blame as we were talking about it before. But that is irrelevant now. And looking at your resume, i am so enthusiastic and i know youre going to get this done. In my own district ive worked to secure federal funding to improve rehab facilities, and ensure that veterans can receive a high quality of care. But for too many, the va is enable to provide the types of services they require. From women struggling to find care in the Health System that has traditionally served men, to veterans who were turned away from va facilities when they are most in need, the virginia has a responsibility to serve all veterans who seek the care and treatment they have earned. In light of these challenges congress awaits the details of the president s fy18 budget request. The budget lack deed tail, providing seven bullet points of vague proposals. Why you may not be able to speak to details of the Budget Proposal now i hope youll return after its released so we can fully discuss it. Mr. Secretary, i again thank you for being here today. Thank you for your commitment to improving the lives of veterans and thank you for assuming the responsibility. I look forward to hearing about all your success sooner rather than later, so we wont in a bipartisan way, continue to talk about backlogs, and the lack of records so we have confidence in you and i thank you for appearing here today. Thank you, at this timed like to recognize secretary shulkin for five minutes. Chairman, Ranking Member lowe, and Ranking Member Wasserman Schultz shut and all here today i was ceremony pressed with our Opening Statements and so many topic outside have thought about and that you care about and i know are serious issues and we trying to do things differently the va that it have a terrific Opening Statement but im willing to, mr. Chairman, actually forego it and get right into the questions unless you prefer me to go through the Opening Statement. Because i think we have so many issues and i want to use your time most valuable. Ive submitted it for the record, and id be glad to read through my oral statement but live it up to you. Youd like to hear it . Okay, good i told you its terrific. Your bridge version,. Ill try to do it quickly but thank you. Okay. So thanks to town be here today to talk about the president s 2018 budget. I also want to to for your support of the 2017 budget that really gave us for the first time our full budget from the start of the fiscal year. It really speck speaks well of the u. S. Congress and the American People that despite all these differences, and you have mentioned this several times, we can come together on this topic to support our nations veterans. I have submitted the full statement for the record. The president s 2018 budget reflects his strong personal commitment to to the nation residents veterans, provides the necessary resources to continue to ongoing moored concernized moored concernization of the system. The requests. A 6 parts increase in funding for the va. It provided 4. 6 bill more for medical care, a 7. 1 increase, and the 3. 5 billion more in mandatory Budget Authority that was mentioned to continue the veterans Choice Program. More veterans are opting for choice than ever before. Five times more in fiscal year 2016 than fiscal year 2015. And choice authorizations are still rising. We have issued 35 more authorizations in the First Quarter of fiscal year 2017 than in the same quarter of 2016. All told, including both va facilities and the community we project a 6. 6 increase in ambulatory care. I urge you to support our request in order to meet increasing demand for va services to modernize the va systems and invest in choice. I came to the virginia during a time of crisis when it was clear that veterans were not getting the timely access to high quality healthcare they deserved. I know virginias made significant progress in improving care and servicers to veterans but i also know that much more must be done if va is to continue keeping president lincolns promise. Last book i had an opportunity to meat two courageous jung americans, michael and sarah of rhode island. All michael ever wanted to do was to be a soldier, and he became a soldier serving in the armys 82nd airborne division. Then he loss a leg and part of his arm in an explosion in afghanistan. He suffered other wound as well. They told me when he sought care from the va in 2014, they did not receive the care. We cannot allow ourselves to ever again fail our american heroes like this couple. Meeting michael and sarah underscored the need for modern ization, i want to provide care, modernize systems, focus resources mow efficiently to improve the timeliness of services and Suicide Prevention among veterans. We simply cannot tolerate employees who act counter to our values or put veterans at risk. January of this year, weve authorized an estimated 6. 1 million Community Care appointments, 1. 8 million more than last year of 42 increase. We now have Sameday Services for primary care and Mental Health at all of our medical Centers Across the country. Veterans cannot access wait ten days for an easy online tool where they can see those wait times. No other Healthcare System in the country has this type of transparency. Ba is any new trends with public , private partnerships. Last month, we announced a Publicprivate Partnership of ambulatory Care Development center with a donation of roughly 30 million in omaha nebraska, thanks to mr. Thornberrys help. Veterans now have or will have a facility being built with far fewer taxpayer dollars and in the past. Finally, the va is saving lives. Our top priority is Suicide Prevention. Twenty veterans die a day by suicide. A few months ago a crisis line had a rollover rate to a backup center of more than 30 . Today that rate is less than 1 . In support of our efforts for suicides we watched new Predictive Modeling tools that allow va to provide proactive care and support for veterans for the highest risk of suicide. Recently, i announced the va will providing emergency medical Mental Health care to former. We know these veterans are at greater risk for suicide and were now caring for them as well as we can. These are just a few of the efforts that were improving the lives of veterans. We want to keep moving forward we need your help. We need congress to realign our capital infrastructure, to dispose of property we dont need and support facilities where veterans can get better serve. We need congress to fund art modernization, to keep our legacy systems for failing and Electronic Health records to be essential to any highperforming integrated Health System. We are also laying options for adopting a commercial offtheshelf alternative to our legacy systems. I scheduled the decision for this in july. If it make sense, will need some Additional Support from you as well to go the offtheshelf route. We need congress to authorize for appeals process that many of you mentioned. Working closely with veteran Service Organizations and other stakeholders, va has drafted legislation to modernize the system. We submitted a proposal to the hundred and 14th congress and we resubmitted it in this current congress. We need congress to act on this. Most of all, we need congress to ensure the continued success of choice for veterans. Extending the Trace Program past its august and eight was an absolute necessity and thank you for that. But extending the program was the next step to the modernization of the Community Care the veterans deserve. We charted a course for modernization and are already moving forward but we need your help to keep up with the Choice Programs growth, maintain momentum and make our Community Care plan a reality. In closing, let me again express my thanks to the Appropriations Committee and to this subcommittee for the support that youve shown veterans in recent years. Without that support, we could not expand the choice to Record Number of veterans who are also curing so many veterans of hepatitis c. Youve made that possible and 77000 veterans are now free of hepatitis c as a result. Thank you for the opportunity to be here today. I look forward to all the questions that you may have. At this time i recognize the chair, if he has any questions. Very briefly. You talk with the legacy system, the acronym is vista. Now youre looking at the offtheshelf system. Isnt the issue is it system, different it systems at every hospital was mark where are you in the overall very briefly, where are you in terms of maybe some good news in the mix. Well, we only have a hundred 30 systems. The vista system is something that frankly, va should be proud of. They invented it, leader in Electronic Health records but frankly, thats all history. We have to look at keeping up and to modernize the system. I said two things, mr. Chairman, in the past. I said number one is va has to get out of the business of becoming a software developer. This is not our core competency and i dont see why it serves veterans. I think were doing this in a way that we cant keep up with. Ive said that will get out of that business. Were either going to find a commercial company that will take over and support vista or were going to an offtheshelf product. Thats what were evaluating now. We have an rfi out for essentially the commercialization of vista that we will no longer be doing internally. The second thing i said is that it was referenced in a few of your comments, youve asked the department of defense and va to Work Together probably for ten or 15 years and weve always found ways not to do that secretary matus and i have talked about this, we believe that we need to find ways to Work Together. When i come out in july, ill talk about a process that led to a decision to get us out of the Software Development business and find a way to work even closer with the department of defense that we have. Working rapidly for that decision and im committed to that date. Thank you. I recognize mrs. Lowy. Thank you so much. Thank you so much, mr. Chairman. There are so many questions but i must continue this discussion having been part of this issue of record for the last five, six , seven years. I gather we have spent 1. 4 billion on this. I dont even know what i want to call it, projects, sir. What im confused about, its my understanding that the Defense Department has already rolled out the system. It seems to me that it makes a lot of sense saying were not going to be in this business anymore and we want an offtheshelf system, however, an otter to force there and sure interoperability, whats wrong with the Defense Program and why wouldnt you, at least at the outset, explore that . If you choose another system and they have their system, whats it going to be another billion dollars that we could use for Suicide Prevention, for treatment, all kinds of important things. I have to tell you, as Ranking Member, we go to a lot of Committee Hearings but this affects my heart. When i talked to veterans in the district and i know the challenges they are facing and i know that you have all the confidence, background to do it but why wouldnt you start or are you looking at the system the Defense Department has rolled out . First of all, i hear. Frustration. Thats probably a good word. Weve had hearings with the anger was personable. Listen, congress has been very clear on this for years and years. Thats why i believe that you and the American People and the veterans deserve a clear direction on this. Im committed to doing that. I can tell you were exploring all options. I assert you understand this is a highly complex issue and ive lived through personal Electronic Medical records conversions and hospitals i lead these are not easy projects in single hospitals let alone the va system. Were taking this very seriously. I can assure you were explain exploring all those options. We also as we get more veterans out into the community, privatesector hospitals, we have to be very concerned about interoperability with those partners as well. If there was an easy solution here, i am sure, it would have been made already. Were going to make a decision and were going to move forward and were going to need your help in being able to implement that. I just want to say thank you, mr. Chairman. I want to thank you for assuming the responsibilities that are veterans certainly are looking for and deserve and i wish you the best of luck. I look forward to your coming back sooner rather than later. I dont want to have a another hearing on interoperability. Right. I want to remind you, 1. 4 billion have already been spent on trying to get the Defense Department and the va reported needed. Thank you so much again. We look forward to hearing from you as soon as possible. Thank you. Thank you, mrs. Lowy. Secretary, we understand that your floating ideas for system to consolidate the various non va care programs including choice. While we realize your proposals are by no means locked down, it sounds like youre contemplating a plan that would allow veterans to seek urgent care outside the va system. About whether the veteran should be seen in the community or by the va. That decision would be based on the results of a local Health Market in national identifying the capacity of the various services at a local va. Is the basic premise of this proposal to Keep Services within the va subject to availability, following an opening the doors to more broadly non va care . Let me try to describe it, mr. Chairman. A little differently than that. First of all, i think youre correct. What weve identified coming out of the 2014 wait time crisis in phoenix was that the va, i dont believe, had the appropriate Management Systems in place. The way i believe that you run a clinic system is that you picture clinical urgency first. If someone is waiting for a routine examination thats normal. Someone should be waiting if they have a tumor in their chest or if they have blood coming out of their parts of their body that it shouldnt be coming out of that needs urgent care right away. We are going to prioritize and make sure that veterans are waiting. Secondly, were trying to build an integrated system of care. That means if you look at that from the veteran perspective which is really the only perspective we should be looking at, you want to take with the va does best for veterans that you cant find as wellin the private sector and you want to take with the private sector does best that the va doesnt do as well and you want to make it a integrated experience for the veteran. Thats what were trying to do. Currently, one third of our care happens outside the va walls, two thirds insight. Were working now to get the proper mix in each of the communities because it will look different in new york city than it does in arkansas. Well try to figure out inequity what is the proper mix of inside va and working with the community. Thats what were hard at work and doing. I think that this will benefit the veteran the most. Just to follow up on it. What cost would you include to keep it at a manageable level . Im very sensitive to cost. My belief is that one of the reasons while we got into the problems that we did in va is because we were not properly funding the actual demand. Thats why i think its important that we you work with us to get what the president repressor for the 2018 budget. I think we need to. Im not looking for non sustainable increases year after year the way that we have in the past. I think as conger ms. Wasserman schultz said thats an unsustainable solution. The problem we have in the va is not primarily financial. There primarily system issues that we havent kept up with and have it modernized. I am looking for an investment this year to help us modernize our systems, the it system will be one example where we need to come back but im not going to be seeking increases of this type in future years to come. We do need to put cost of mitigated strategies in place. One of the areas were focusing on that ive artie announced his fraud waste and abuse. I think there are huge opportunities to identify waste and abuse in the Current System. They are not the proper safeguards in place and we are going to be taking aggressive action to that. Their other cross mitigation strategies that we are seeking as part of choice. One of them would be for the va to be able value based purchasing. The private sector has now moved toward this where their Accountable Care organizations focus on quality and cost and where you can purchase care based on the best value which is cost over quality. We dont have those tools in the va. In fact, were restricted from using. We have to pay a flat medicare reschedule. Im taking the same tools of the private sector has to control costs and improve quality. Can i followup. Postmark would that mean for a workforce and facility instructor needs . In this budget marks back yes we are seeking the budget that we can hire the proper Healthcare Professionals. We have 45000 clinical openings in the Veterans Health administration and 4000 openings outside of the administration. 49300 employees that we are seeking. Frankly, the crisis that we went through and the lack of good press, so the impact on the morale of the workforce has really hurt us in recruiting. Of course, we had a hiring freeze in place up until april 12 so we had fallen behind and in particular, my Priority Areas like Mental Health, i need 15 new Mental Health professionals to join the va. We prioritizing that right now, in this budget and it would allow us to get up that staff. Thank you. Ill recognize Ranking Member ms. Wasserman schultz. Thank you. First and foremost, i wanted to suggest that as a number of members have mentioned it because the secretary is limited to only speaking about the skinny budget, it would be incredibly helpful and important once we have the president s budget released for us to ask him to come back and hold hearings on the actual full budget request. I would ask but the chair to consider doing that. So we can do a little more detail. Thank you. I want to focus on the Trace Program for a moment. You have asked for an additional three and a half Million Dollars and we talked about that yesterday a little bit but recently we extended as you mentioned the Trace Program past the august Expiration Date and there was 950 million left in the trace account. In part, odyssey, rather than letting that funding and considering that theres a need, that made a lot of sense. We did envision the Trace Program to be a temporary program initially. My understanding and correct me if im wrong, it was supposed to be a bridge for the va to transition to the Community Care program until we can get the Community Care program in a place where its able to provide the kind of Timely Services that we needed to. If thats not the case, can you explain the differences between the two . Youve also proposed choice 2. 0 so we have a choice, truths 2. 0 and Community Care and im not sure how it would ultimately help us realize our goals of efficiency if we have three different programs in the private sector to help make sure we can meet the needs of our veterans. Right. I couldnt agree with you more. Im looking for one program. Three programs doesnt work. We know having two programs that that didnt work very well. We confused veterans. We had two programs, Community Care and choice and they had different rules, they put veterans at risk with their credit because some paid for stoller and others didnt and you had to call different numbers to use them. We are proposing a Single Program for Community Care. As far as the intent of congress for three years, look, congress stepped up in a big way after the crisis went basically, the country and congress agreed that the Current Situation with veterans waiting for care was unacceptable. Va did exactly what Congress Asked us to do which is to put in place additional options for veterans to take care of the community. Now were seen those authorizations and appointments occurring at the community. When i started va, a little less than two years ago, we had a 20 of our care in the community. Today its about 32 . You can see were expanding those options. I dont think theres any turning back from this. Whether it was intended to be authorized for three years or not, i know that the legislation said but i think what were seeing is veterans need that care, theyre coming to va to seek that care and we need to continue to support that. Thats my opinion. The three and a half billion that was built into the program is very much a needed resource for our veterans. I understand. Given that your goal is one program, are you analyzing which program ultimately would be phased out we have a tendency to instead of phasing out programs because they have people with vested interest in them, simply they go along then to go along rather than rocking the vote. For adding three half billion to the Trace Program and it had 950 million left, there have been challenges with the Trace Program and confusion and there are still challenges with Community Care program, in what direction is the va thinking of going and what is the timeline for ultimately phasing out one program and only having one . With almost certainly, there will not be free programs. The current Choice Program will run out of money by the end of this calendar year. That program is going to go anyway. And should be through the december of this year. We are hoping to do is work with you so that we can introduce a Community Care funding program, the chairman referred to it as choice 2. 0 which is a program that make sense for veterans. Its a Single Program that operates under one set of rules for how veterans get care in the community. That new legislation, which we believe needs to be introduced by late summer or early fall, in order to make the timeline would end up with a Single Program. You eventually phasing out Community Care with the advent of choice 2. 0 thank you. I yelled back. Recognize the gentleman from florida. Thank you, mr. Chairman. Ill continue on the same line, briefly or maybe just make a statement, our chairman of the full committee as well as ms. Lowy, ms. Wasserman schultz, pretty much everybody appear agrees that weve given you a lot of money. Ive been on this committee with the general who i served under in fort hood with mr. Mcdonnell, military man, businessman, youre a doctor, by the way we have a lot of common even though im from formula, grew up in philadelphia, to for connection. Im rooting for you. You talk about working with general mattis and getting this continuing care. We all talked about when we are down in our districts that if you put the uniform on and serve this country then will take care of you as you mentioned lincoln often reference washington and the country can measure itself by how it treats its veteran. One of the things that we say from the time that you enlist or get commission to the time that you die, you will not be left out in the cold. Well take care of you. One of the things that people ask about is where does it fall through the cracks we often talk about how were giving you the money that you need that the difference between dod and the va is way too big and whether the electronic records or the fact that you have to basically start all over when you leave the military and pcs and the veterans programs, whatever it is, my first question to you is general mattis has a better idea than you do, will you agree to go to his program just to get this moved i ask you this for this reason. You could be the best va secretary of all time if you solve this one problem. Every time you sit up here and talk to people at this table that we always keep asking the same question and i know theres a lot of bureaucracy i know theres a lot of pride in whatever the problem is but we just hope that if it means you saying to mattis, youre right, we have a better program, will go with it. Will you do it . Thank you for your comments. I appreciate your perspective on this issue and how important it is. Im only here for one reason and thats to solve the problems that have plagued the a. I wish it was only one problem, by the way. I agree with you. This is certainly an important problem for us. Anybody, whether secretary mattis or anyone else was a better idea than i have, i will take it. The answer to your question is yes. We want to resolve this issue in the best way and if it means taking someone elses idea, we will do that. It would be so good to be able to go home and stand up on the sump and tell these guys, i come from a district with a lot of retirees in florida, a lot of military retirees and tell these guys if you put on the uniform in this country, we will take care of you basically if you need the help for the Mental Health after you serve, its one of the advantages of joining is that you know youll be taking care of when you get out. That would be a huge help to all of us up here who are trying to convince people that fighting for this country has benefits well beyond the pride of service one quick thing since im running out of time and this is more specific to my district, im having my constituent services represented down in florida are telling me they were getting a lot of people that are moving to florida as they always do from other parts of the country and theyre going in to get care and rva and because of hat they are toldn in coverage,t starting new Treatment Plants or return to the state from which they came from where theyre getting care from for whatever problems they were having and this is absurd from the standpoint we have five or six specific cases where people that live in florida cant get the care that they were getting in there other states so then rather than starting over florida going back to their state where they came from and using that va because theyre in that system. This again gets to that system where there shouldnt be any lapse in coverage but there is. Can you talk about that . Have you heard about this at all i have not heard about your specific situations. I hope your directors are watching this right now. What you described is unacceptable. We have one va system, veterans should be able to get care at any va that they go into and that is our commitment. I am not at all doubting that it doesnt work all the time, i certainly hear many examples where it does work and people are able to get care, traveling, lose their medications, able to get to aba, get the care they need, that is a system that it expectation of how we manage the system. I will be clarified that to our field. Thanks, doctor. Good luck. Thank you. If i could just interject on that point for a moment. You just described the current joint legacy viewer and what it can do to ensure va records for the benefit of the members. Yeah, im sorry that congressman lowy left for this. I didnt say this to her but we did certify interoperability with the department of defense in april of 2016. That is to the joint legacy and thats where a lot of her 1. 4 billion went to but i dont think it was that much. What this does is it allows any va permission and dot clinician to access records from the other systems so it is a read only system, its a being ten used tens of thousands of times a month by our clinicians in both systems. It does work and its a lot better than before when we didnt have that ability. Its better care. But it is not the complete interoperability that i think that all of us would hope for. Its a read only system at this point. Thank you for that clarification. Mr. Bishop. Thank you, very much. Let me join my colleagues and congratulating you and thanking you for your commitment to get this problem, these problems, fix. Let me go to an area of approving service that is thirdparty uncollected billing. The. [inaudible] we identified the amount of thirdparty Health Billings that are owed to the va and annual amount additionally requires that the va can put a plan to capture uncollected thirdparty billings that was directed to initiate a Power Program and figure out how best to capture the uncollected billings. The difference between billings and collections in fy 15 was 4. 7 billion and fy 16 it was 5. 164 billion. This is alarming because it means that billions of uncollected are not available to the vh by the services veterans. What is the status of the Pilot Program and who in the department is responsible for fiscal management of thirdparty billings and collections . If you could answer that quickly. The private sector can do selections better and that is part of the pilot work we are doing. We are using another federal agency that seems promising. I can give you a more detailed answer because i dont want to take up time about the pilot project. Thank you. Secretary, your predecessor started an initiative known as the my va. The vision was to strengthen to va. Can you tell us how your plan differs from mr. Mcdonald and whether or not you plan to build upon the my va . And can you provide an update on the veteran integrative Service Networks . That is the first part of the question. You mention an alignment strategy and the last time nay made a major decision for the needs was the Capital Asset realignment for the cares project. Do you envision that the departme department would embark on the assets . Is the program similar to the mill tartitary alignment . There is a lot there congressman. I will try do this quickly. The my va program under secretary mcdonald i think no doubt had has the correct intent which is to design a veteran experience and focus on that. That is one of the benefits of the being under secretary mcdonald is i know what was working. I dont want to stop the progress that was going made but yobl we are making progress fast enough. So i am looking to continue the parts of the program that work, but i am seeking broader, bolder transformation of this department and that is where i set my five priorities. In terms of vision alignment, we had 21 and are done to 18. Whether 18 is the right number or not we are always continuing to look at that. But we are going to change the role and function of the dividand which is another lay of complexity to a much more profound functioning in managing their local markets and moving toward the valuebased purchase concept and make sure veterans get the best care in the community and va care. We are working on that transformation as we build the Choice Program. The realignment. I wasnt here when the care program was implemented. I know we have closed a thousand facilities so that there has been progress made in the past. I dont believe i have heard anybody with excitement bringing back the care model. I think we learned a lot of lessons. Whether the brack is a model we should look at. We are beginning to have conversations with members of congress. We have 431 vacant buildings and 735 under utilized buildings and we want to stop supporting maintenance of buildings we dont need and reinvest that in the buildings we know have capital needs. We are going to be looking forward to working with you on that. Thank you very much, mr. Secretary. Thank you. Mr. Secretary, welcome. Thanks for the breakfast yesterday and the opportunity to engage you in conversation before this hearing. It has been my experience down through the years that organizations, particularly Large Organizations that find themselves in a bit of trouble, sometimes and many times, stem from the fact that they get away from their core competency and they expand into areas where they are not terribly knowledgeable, capable, and certainly not efficient. And they sometimes serve as kind of a weight, an albatros, if you will, around the neck of the organization and it it causes other things to be compromised. I suspect the va probably fits into this category. My specific question is you spent time talking about i. T. Which i am beginning to believe is not a core competency of the va. We have had many indications that the construction of property is not, aurora, colorado being the poster child, not a core competency. You talked about collections and that is not a core competency but i will throw it on the table and let you respond. Is it your intent as the secretary of va to protect the core competency of the va by outsour outsourcing some of the other things that served the bog down the system . I think your assessment of what is happening at the va is pretty accurate. I think we have learned the hard way and taking too long to make decisions in areas that frankly we dont deserve to be in that business. I think you have identified a few. My only modification if you wouldnt mind is i think i. T. Has to be a competency of any organization. We dont want to be in the software and product Development Business but managing i. T. Systems is important. I dont know that outsourcing is the right word. I believe if we are going to serve veterans we need to work with a core group or staff on the core functions. When we stray outside building buildings, doing Software Development, doing, you know, claims and billing, i do think we should be looking toward private Sector Solutions or at the minimum private Public Partnerships where where he can get the competency into the federal government. The last question i have is one of the problems facing the congress and many previous congre congre congresses is the fact the entitlement programs continue to chew up available revenue and put downward pressure on the discretionary piece of the budget and that is getting worse, not better. And i think part of that is because people are living longer, and this is good news, they are receiving benefits from those systems for a lot longer period of time than they were expected to at the time. Do we have a pretty good handle on the number of people that will be entering the va system so that we can right size the funding request to ensure that we meet those needs and not play from a position of weakness by being behind . I only have about 45 seconds left. Can you help me have confidence in knowing that we know what is going to be filling that pipeline, say over the next generation . We certainly have a handle on the demographics of the veteran population. As you know, we have 22 million veterans today and that is expected to decline. What we cant predict is obviously new conflicts that would happen because that can change the picture. What we cant predict is new science that would show there is additional mandatory coverage we would need to include as science shows there is a connection between military service and some of the disabilities and that work is always ongoing. So, i think we do have acturally models in both health care, cemetery and benefits in that we can share some of the parameters for needs. But they are not fully accurate because of the unknowns out there. But, i think for what you are asking we can share that with you. Thank you for your service and congratulations on your appointment. I yield back. I would like to recognize ms. Lee. Good to see you, secretary. I want to say congratulations and i am glad you are at the helm of the va and thank you for being here. A couple questions and i will try to ask them quickly. One is relating to the oakland va regional office. In january 64 they found there was significant delays in processing the claims and the management provided the oversight needed to ensure timely and accurate processing of informal claims. We had about 1248 informal claims. This was before the National Work queue. We are on the National Work queue and i would like to find out has this helped reduce the claims backlog significantly and is it helping to streamline benefiting processing specifically regarding the oakland va regional office. That is the first question. The second question has to do with what we discussed as it relates to minority veterans. I have looked at your Health Disparities report, which as a very thorough report, and of course, it cited the fact that minority veterans were diagnosed with ptsd at rates higher than white veterans. Also in the report you go into some of the recommendations to begin to address, not only ptsd in terms of this disparity, but all of the others and it says that we need more research and more information. And i am wondering, though, as it relates to this report and the recommendations as it is specifically relating to Health Disparities with minority veterans where are we . Are the recommendations being followed up . I cant help but wonder why more research would be needed. We have an office of Minority Health at hhs and so i am not sure if you are coordinated with health and human services. I think this as a very good report and i know many minority veterans struggling with issues around health care especially ptsd. And finally, i asked this at the hospital in terms of utilization and minority owned businesses. I would like to find out how we are doing as it relates to african, hispanic, Asian Pacific islander firms. I havent been able to drill down and get that report. The va is a specific entity that contracts quite a bit out and i would like to find out how minorityowned contractors are fairing and we need to understand what the data is showing so we can do better because i have a lot of complaints from minorityowned businesses they cant penetrate and get into the system for a fair shot. Thank you, congresswoman lee. These are all really important issues. On the claims backlog and what the impact of the National Work flow has been we do believe that has been helpful. We are seeing improvements in productivity. I would like to get back to from the impact of 1248 in oakland and see where we are today so we can track that progress together but i think that is important. On the Health Disparities report, i agree with you. I think the work our National Center is doing identified significant issues and this, of course, is an example where i think va is leading and addressing issues that are important for all of the American Public and in health care we know that disparities is a very significant issue particularly in many of our locations across the country. I think va is leading in this area but we have additional work to do still. We are treating this as a priority issue and looking at the recommendations you have talked about. The research that the report recommended, i think, is research on disparities and veterans. Va research has Significant Health Services Research components and the difference between the Health Services research and the va and then the hhs like the agency for research and quality is our research is specific to veterans. So we do believe there are questions that are important to ask in order to understand what the most effective implementations are. Let me comment. I know the research is important but i know when you look at africanamerican veterans with ptsd you have other factors wei weighing in and the office of health could let you know what those determinants are to help come up with treatment modalities right away. I agree. Research is only good if you act on it. There are some things we know already and i think this is where we are looking at this in terms of imelementing the recommendations that we know need to happen. It way the va can lead and help the rest of American Health care implement these. I would like to talk to you more about the working groups. And on the small businesses, the minority advantage, i dont know how that data can be centrally categorized let me look into that and get back to you. I would like to recognize the gentlemen from california for five minutes. Thank you, chairman and thank you mr. Secretary. I am sure you are aware in 2002 the va applied the agent orange act to apply to those that stepped food in vietnam. Veterans who served on ships or blue water veterans were not included unless could prove exposure to blue water or agent orange. However, exposure is nearly possible due to a lack of Record Keeping and inability to know the precise locations of the agent orange in the air or water runoff. The va continues to decline claims for Brown Water Navy veterans despite showing higher rates of cancer and nonhodgkin lymphoma than those who fought on the country. I wrote the blue water Navy Veterans act which has over 270 bipartisan cosponsors including half of this distinguished subcommittee. I stand ready to work with colleagues to pass this bill the department of Veterans Affairs has the power to right this wrong itself without the help of congress. Have you been made aware of the issue and to your knowledge is the va working on a solution to this issue . Thank you for that question. Yes, i have been made aware of this issue. I would say 20 of my inbox is on this issue. I hear from a lot of people. What i have done is i have actually sat down and met with some of the leaders in this Blue Water Navy movement to understand what they believe the science shows and what they are recommending. Commander wells is one of them, john ross another that i met with in my office. They have followed up with Additional Information which i appreciate. The vas position on this has been the science isnt there. I am not convinced the full story. I have asked for additional recommendations so that as you said if the department of Veterans Affairs has the ability, and i agree with you, to change some of these and the evidence suggests that is the right thing to do for veterans i am going to recommend that. This is very active. I can tell you this week alone i have been reviewing additional studies. I will be certainly willing to engage in further conversation and i am aware of your legislation. I appreciate you acknowledge there is other science out there. There are studies out there with the way they treat and clean the water that says it concentrates the chemicals and makes it worse for those serving. Mr. Secretary, i understand the air force is conducting a clinical human trial at Tinker Air Force base to investigate transcranial magnetic therapy on veterans suffering from ptsd and tbi traumatic brain injury. After four weeks after active treatment, the treatment reduced an average pclm score from 66 to 37. The air force concluded the preliminary results suggested this is a promising treatment modality to help veterans suffering from ptsd. With this information, can you please share with the committee what the va is doing to capitalize on this promising new treatment to address ptsd in the veteran community . Well, i am very familiar with the technology and i am very concerned about finding new therapies that help our veterans with ptsd as well as other conditions related to the brain. We do use the va has extensive use already of transcranial magnetic stimulation. The issue is whether the merk Technology Adds additional value to what we are currently using. I have recently in the last ten days visited walter reed and talked to them about this. We are looked at the science. I would like to see the results of the studies. If there is evidence and science suggesting this is helpful effective and a Noninvasive Technology we absolutely want to be using it. I am not aware of studies showing it offers advantages over the transcranial stimulation being used. With new information coming from the air force, i would be very open to seeing that. Thank you. Thank you. I would like to recognize the gentlemen from west virginia, mr. Jenkins. Thank you for the opportunity to visit with you in advance of this meeting to talk about your leadership and direction. I applaud your effort. Let me start off with the award of compliment i learned about your push to provide transparency and quality data, information about wait times, our veterans satisfaction. You shared with us the website accesstocare. Va. Gov thank you for that plug. You didnt ask for it but i give it to you. I did look after you made mention and as i understand it this data has been out there, it has been available but nobody was willing to authorize that the switch get flipped to make this available and you did that. Yes. So thank you for doing that. I encourage people to take a look. Transparency is good. The other, i want to make mention of the most recent executive order relating to some of the whistleblower and accountability efforts. I cant tell you the number of times from whether it be a va employee or others about fruseration or concern, maybe briefly describe this executive order, and what kind of reassurance to those on the ground at the grassroots feel their concerns or voice will be heard about reforming the system and holding it accountable and Holding People accountable for the need for good performance . Well, i think i think that it is very important that people understand that we are taking these issues extremely seriously. Any organization that has been in trouble has to look towards its own leadership. We want to make sure the people serving in our leadership positions are consistent and fulfilling the values that we owe our veterans. So, when we become aware of issues of poor performance or people that strayed from those values we are taking action. I think you can see there has been a large number of those actions taken recently. Because of that we have established the executive ordorder an Accountability Office that will report directly to me. We are putting our Whistleblower Office in that Accountability Office to make sure our employees know if they raise issues to us, and they are legit issues, those employees will be protected. We do not tolerate retaliation. These two concepts of adhearing to our values and protecting employees who raise the issue are essential to our success. One area i would like you to have staff look into is we get a number of calls to our office relating to the payment processes of the va. You have decribed an effort to work collaboratively with Academic Health centers, local hospitals, that have real cuneck dau connectioconnections to. One of the problems i hear is with the restructuring of the payment section in the va. I have an Academic Center that values and appreciates their good working relationship but the va doesnt pay in a timely fashion. They have hundreds of thousands of dollars in accounts receivable from their standpoint over 120 days. I have a local hospital with over ten million in accounts receivable from the va over a 120 days past due. So, i am not sure what is going on in the accounts payment and claims processing but i think we have got real timeliness issues and i hope that will be taken seriously. You have to understand this is the world i came from. I do believe if you deliver a service you deserve to be paid and deserve to be paid timely. It is too hard operating those health Care Organizations to not get paid for the help you are doing. I believe we have to get better and i am not being defensive about this. We are not doing a good enough job in that area. The way i would suggest we proceed is when you find a Community Hospital that thinks we have 10 million, please let us know. When we dug into these we absolutely owe them money but it is usually not the ten million. There are duplicated claims and rejected claims and sometimes they are looking at charges instead of the fee schedule we pay them. We can work through that and put a team on that and get them the money they deserve and get it to them quickly. Thank you. Mr. Taylor. Thank you, mr. Chairman and thank you, secretary, for being here. We understand there is nothing little about the big challenges you face in your current position. Appreciate you for that. I come from an area that has hampton va Fastest Growing womens population and i am in the va system myself. This is something i am passionate about and looking forward to working with you to figure out the challenges and fix them. Quick question, if one of us submits a question for your office, what is your policy in terms of the response . How many days . Yeah, we categorize them into two types of responses. There are some that need urgent responses and i think we are shooting for that, i know i am going to get it wrong because we just shortened the time frame, 14 days is our short one . And then is it 30 days for our longer one . She said he said i got it right. Something really urgent, we will do it in 14 days, otherwise 30 days. I know that has not been the past experience from va to your offices. This is our new commitment to respond in a more reasonable and timely way. Thank you. I have a bunch of questions. Suicide is something that has been talked about and dear. I have a friend who committed suicide and we have these issues in our area. I understand the va according to the ig has decentralized if you will. Is there a uniform policy currently with people who are trained to intake folks who come up physically that either exhibit signs of suicide or say they are suicidal . Is there a uniform policy for the crisis hotline which i understand is being manned by call centers . Are you saying we are over 30 days . This is how i learn. My guess is you will get a response pretty soon. I am aware of the issue there is a concern about a lack of consistency of training between Suicide Prevention coordinators and veteran crisis line responders who respond from atlanta or upstate new york. They are different professionals. They are licensed and receive training. Our Suicide Prevention coordinators dont have to do that. They are doing different functions. Many coming out of different disciplines. So there are different trainings but among those two categories there should be consistency. Also, is there open to potential projects with qualified nonprofits . There are veterans not comfortable with going to the va but may feel more comfortable with the nonprofits out there that are manned by veterans. Is there openness to Pilot Programs for Public Private to help with that . 14 of the veterans who commit suicide dont get their care within the va system and 6 are. If we dont do the partnerships you are talking about there is no way we can address this. We are working with vso on this and Public Service announcements. There is a new group i reached out to call head strong, the ga galient organization. If you have new partnerships you would like us to explore we are absolutely open to this. Thank you, mr. Secretary. I will have follow ups on the next round but you mentioned how many buildings were vacant . 435. Thank you. I would like to recognize the gentlemen from ohio. Mr. Ryan. Thank you. Good to see you again. Let me say publically i think what you are doing in your patientcentered carrier with tracy goddet is some of the most exciting stuff going on not just in the va but government today. Figuring out quality solutions, integrating care and all the rest. Thank you for throwing your weight behind that. I think it is important and i think we will start seeing a lot of savings because of that and healing a lot of vets. In our conversations we have had, i appreciate the balance you are trying to strike between the va and the Choice Program. I know that is not always easy. One problem area we have become aware of in my office is despite the Choice Program being authorized and appropriated we have veterans traveling significant distances to get care. If a veteran has a clinic within 40 miles but doesnt offer the services they are being told they are denied for the Choice Program. There appears to be no policy that places a cap on the distance the veteran has to travel if they fall into this loophole. In my district, which includes veterans in warren, ohio travelling 34 hours round trip weekly, sometimes more than once a week, to receive treatment in cleveland and i was at my sons soccer practice and i had a couple vets grab me about this issue. The primary care physician or primary coordinator benefit has independent authority to assign a veteran to travel a distance with no limit established or they can refer them to a local doctor they can elect to refer them through choice but it requires a justification there is an ex excessive burden on the veteran. I cannot find a pamphlet or billboards that explains to the veter veterans what defines a burden to them. I cosponsored legislation to correct this issue. So my question is do you have the authorities you would need to fix the problem . What can we do quickly to provide more transparency and then roll our bets in the decision for their care . If we cant fix it immediately, is there a legislative issue we need to deal with . And i guess lastly and more comprehensi comprehensively while the choice 2. 0 with Community Care correct this problem . Lots of important questions you have in that. So, in designing a Health Care System, i would not necessarily have picked mileage and wait time as my criteria for how to design the system. I understand why congress did and frankly to put up a National Program so quickly i think it was a wellthought out effort congress had. Now we have had time to experience this i believe a Health Care System should have a clinical basis to the way it is designed. It is my intent in working with you to present an alternative to 40 miles and 30 days. In other edwards words to eliminate that and replace it with something that makes sense. Look at access and clinical quality as the alternative to geoography and wait time. Under the Current System we have, which is still having to follow the rules that were set by congress, 40 miles and 30 days, we do as you correctly said, have the ability to define excessive burden. What i found is we put out five bullet points about examples of excessive burden. The field had interpreted that as those were the only exceptions. We clarified that and what we are trying to do is get the veteran and their doctor or provider to have an interaction about what excessive burden is and now we have loosened up the requirements so that the field can make reasonable judgments about excessive burden. Some of the examples like the ones you are giving are really not acceptable. Thank you, mr. Chairman. Recognize the gentlemen from nebraska. Vice chairman of the subcommittee. Secretary, welcome. Are you enjoying the new job . Yes. I am grateful for your protection of an attitude of entrepreneurship and compassion. Thank you for that. In your Opening Statement, you referenced the new idea that emerged and has been empowered by legislation of a unique Public Private partnership that is going to happen in omaha. I want to unpack that a little more so everyone understand how transformative this could be. The congressional leadership said we have built housing for veterans, we built housing for troops, could we possibly participate through a charitable entity in updating and upgrading the hospital there which is in serious need of not only a face lift but modernization. So, working with my predecessor congressman brad ashford we got it to you and the committee committed 130 million and we will move forward. I think it is exactly the model of what you are talking about in terms of creating the 21st century architecture that is looking for Community Services when available to go not just into looking for Charitable Funds for donation purposes but an integrated Service Environment as you referenced earlier. This is going to be an add on and proximate to creighton med school and the university of nebraska med school who you already work with. So the synergy will be seamless or as we say the veteran will not know the distinction between the care they are getting. They are just getting the best resources because that is the objective. I wanted to spend time unpacking that further and hopefully given the very difficult, sad experiences we have had with watching urgent cost overruns at the denver hospital being the poster child, that this way of proceeding forward is undoubtedly going to tap into a large pool of good will that exists out there in the country among Charitable Organizations and leadership in various communities to want to assist you in modernizing in the private sector but under the va. I am excited about this and sorry to spend so much time on it. I want to mention 50 miles town the road in lincoln we have a traditional, beautiful campus for a va clinic. Similar type of dynamic is occurring where a Charitable Foundation with the city has agreed to build out veterans housing on the site of the old clinic. We are awaiting the decision as to what is going to happen with the new clinic so if you could update us on that process it would be helpful. Once again, the synergy is being created with existing facilities preserving additional beautiful architecture close to the own private medical centers is what i hope is a new chapter of the va. Third point, i have become aware and a little involved with a Charitable Organization called project hero. You are under the secretary ale and has given an understanding that the va directors can partner with this organization using recreational activity, bicycling primarily, to be integrated in the va services. There is metrics on this already showing improved health care outcomes, lower cost, extensive wellbeing, drops in suicide. I wanted to highlight that for you because i think this is someone of it programs consistent with what i said earlier and developed because of compassion and initiative by the private sector looking to partner with the va and we have great opportunity here. Thank you. I think just briefly on your three points, the project in omaha, nebraska is exactly what i think we are looking to do in the va which is do things differently. In this case, we are going to build the new facility. It is going to be good for veterans and taxpayers. This is going to leverage the federal dollars that we could not do in the past. If it wasnt for your leadership and support getting this through it would not be happening. I think this is a transformative model. We have four other sites authorized after omaha, nebraska we can do. So i hope other Committee Members are listening. We have a list of 20 sites eligible for this. I think this should become the way we build a future, modern Health Care System. Thank you for your leadership on that. On lincoln, we are moving forward with a new clinic there. It should be awarded this fall and through the whole build and design process, even though i pushed really hard probably the opening gate is going to be in early 2020. It take as while to do this but it is well underway and toward the top of our list. On your third point about project hero, you know, one of the great things about the va is that it defines health care much broader than physical illness. It defines it as physical, psychological, social, economic, and an example of using sports and Adaptive Sports to help people get better and have a sense of wellbeing is something frankly va taught me a lot about. This is a great example. We are very supportive of this is the work around the country like this and thank you for being this to our attention. Thank you. This time we will move into the second round of questions and i will start. Dr. Shulkin, in the page of the fy 18 skinny budget, there is a va request for 2. 9 million in new mandatory funding to complete the Choice Program after the 10 billion the program exhausted in january. Does this indicate the administrations intent to fund from mandatory funding . Yes. Next question, being an appr appropriator, we send out our budget antenna on alert and you announced you intend to provide emergency Health Services to veterans with other than honorable discharges and testified in the senate you are interested in expanding carrier assistance to veterans before the post9 11 era. How do you plan to fit the added cost into the budget when you are struggling to cover expenses for your current va patients . Chairman, you know, maybe this doesnt fit into the budget but basically i dont care. I sat in a session that was organized by members of congress, members of the house, where there was a young man who sat right into the rotunda when he said he had been deployed to afghanistan six times and on his return he found out his wife left him and he took off across the country to find him and he was declared a wall and other than honorable. You could see he was suffering from severe mental and emotional disorders. He went to a va and shows up at a va and says i am here because i need help. I am suicidal and the va says you are not a veteran. He had served our country six times, six tours. That is not acceptable. When we say there are 20 veterans taking their life every day we know it is this group that is among the highest. No one wants to help them. Well, i am not going to just sit by. So, i dont know want more money for this. We are going to find a way to help these people and connect them with Community Resources and get them help because that is the right thing to do. I am going to find the way to do that because i think this is our that is a very compelling story and i am glad you are taking that initiative. And i am sorry, chairman, what was your other question . Caregivers. Yes, caregivers. The Caregivers Program is really, really important. We were authorized to do that for post 9 11 veterans and there have been tremendous success. We frankly didnt get this program right. We have been issuing in some areas up to 90 revocation of caregivers we had authorized. Something is wrong there. We just issued a national suspension of revoking caregiver status and are now on a pause where we will look at what are the right policies in order for veter veterans to get access to caregivers. It is our intent to bring this to pre9 11 caregivers. The most Vulnerable Group is the elderly veterans. The worst situation is when somebody is in their home and has to leave their home to go to a nursing home. Most veterans and people dont want that and secondly it is the most expensive way to care for elderly people. If we can keep them in their homes with caregivers we should do that. We are looking at how we use the current money and potentially come up with even better policy than what we have today. We are going to be announcing that in probably the next couple months. The vas schedule system has been a concern to you, i know. We understand you are on a dual tract to modernize it and piloting a commercial system and upgrading the existing system. It seems like these efforts might lack a unified strategy. Why invest in two systems simultaneously and will the schedule system be tinkered with in the electronic overhaul . On the surface, i agree it makes no sense to invest in two different paths. We awarded a product called mass. That is the system we think meets our solutions and that is the one we are implementing. We are working on a pilot site to create the interfaces so we can do that. The rollout of that across a system as big as ours is going to take several years. In the meantime, we had developed an internal system, one of the frankly last i hope we ever develop, but it is already developed with taxpayer dollars and we did an evaluation in the month of february. We rolled it out to eight sites. It is actually working. It is much better than what we had right now. So as an intermediate stop gap measure we are rolling it bought across the country because it has been developed and it will help in the intermediate period of time until we get a commercial off the shelf system up. Thank you. I would like to recognize the Ranking Member for five minutes in the second round. Thank you, mr. Chairman. I want to focus on military quality of life because at that hearing in march when we had an opportunity to meet with the singer commissioned officers we discussed the marines united scandal which we discussed in my office yesterday. Many of the victims of that really horrific social media site are now veterans. I have met with a number of them as have many of the women members and i would like to know what the va is doing to provide them with the necessary care and support they need because these are women who have had, without their permissions, nude photos posted and been subject to extreme humilitation with regard to the military sexual trauma system that the va has. How have you let veterans know this service is available and what outreach have you had some the va has an expansive system for treating military sexual trauma. We have worked with the secretary of defense so that the va is a place people can go confidentially and get treatment. Men and women can come intogy va center and there is not a connection of record specifically, what kind of outreach are you doing to not only make sure that victims of Sexual Assault in the military are aware of those services but also specifically victims of the marines united scandal . Right. With we met in your office, you suggested that that is something we should be doing. I dont believe we have done that. I agree with you it is something we should be doing and as a result of our conversation we are putting together a plan for that specific outreach so thank you for that suggestion. You are welcome. We have, you know, female veterans that are committing suicide at a rate of six times that of women civilians. And you know, identifying ways and implementing strategies to address the unique Mental Health needs of women is critically important. I would appreciate it if you and your staff would follow up with us on that. The other question i want to touch base on is what i mentioned in my opening remarks and that is the openings, the really significant and serious openings you have in all your Senate Confirmed positions. You mentioned you are going to make an adjustment in how you fill those positions. But i am wondering if there are any problems the administration is facing in identifying candidates for those positions. Are you having trouble filling them . In particular, i find it extremely troubling the secretary for health, assistant secretary for information and Technology Given the Serious Problems we have talked about here, and the chairman of the board of veterans appeals are all positions that remain empty. What is the timeline for filling those and do you have candidates that you are considering and are you having trouble filling them . Well, appreciate your concern about that. I am very impatient and of course i want my team in place. We have obviously very good career acting professionals that are handling this now but i want permanent people in place. The under secretary for health and under secretary for benefits, i am not sure if you are aware, it is mandated we form commissions to search for those positions. The under secretary for benefits met ten days ago and are recommending candidates for me to see and recommend to for president. And the other Group Going Forward in the next two weeks. For cio, i met a number of candidates and we are vetting them now trying to move forward with an offer. At the board of veteran appeals we are trying to vet a candidate also. So, i hope that, you know, these processes having gone through it myself, my own vetting process 13 months, it takes too long. We are looking to move through this as soon as we possibly can. Thank you, mr. Chairman. I will have one in the third round so i appreciate it. This time i would like to recognize the gentlemen from florida for five minutes. Thank you. Mr. Secretary, i want to say your office is watching this hearing and already got with my office regarding some of issues we were discussing with our constituents and i want to give a shout out to mary kay in lake city and if you are still watching i have another issue for you to work on. That is with regard to a lot of my district is very rural. You know, i do have some of the coast but a lot of the people that live in the district live in the countryside. One of the issues they complain about with the Choice Program is there is long wait times, they are receiving complaints about long wait times for va appointments, referrals, payments, through the Choice Program and the payment and reimbursement process to the providers is difficult probably acerbated because it is rural. You know, obviously in that situation, smaller hospitals and clinics. And many of the providers that are technically participating in the Choice Program are refusing to accept choice patients because they know they will have to wait a long time to get paid themselves. So, some providers that dont accept the choice patients will only do so if the veteran agrees to pay were the services upfront and that leaves the veterans in that same bind they were in before choice which is either face the excessive wait times at the va facility with no option to obtain Immediate Care elsewhere without paying out of pocket first. And obviously that is not the point. Or that is not what we are looking to do. So, i mean, you as a doctor can probably appreciate, you know, with these people that want to take the Choice Program and help the veterans but they know it will take forever to be reimbursed and can you pay me first and we will deal with getting reimbursed later. The oig criticized the va monitoring for these contracted and reported there are no measures to ensure the contractors pay in a time playma playmaly matter. How are you implementing the oigs recommendations . There is an area of significant risk for us that monitoring and it is critical. What we have done is we have done multiple contract modifications to get medical records in order to get paid. We are improving our payment cycles through the Choice Program but it is not perfect by any means. We have to get better at the auditing and we are working on doing that so this is a significant risk for us in that we offer the redesign of the Choice Program, or choice 2. 0, we want to eliminate the complexity of this process. The private sector and do all the things we want to get right in choice 2. 0. Thank you. I would like to recognize the gentlemen from ohio mr. Ryan. Thank you, mr. Chairman. Nice of all you pennsylvania guys to let an ohio guy participate. Ive seen programs like project welcome home troops for they do a lot of breathing exercises with these veterans that are having informative effects of their post medic stress system and another one they use, a lot of videos online that you can watch these vets are on ten12 prescription drugs after going through some of these therapies that are traditional, going down to twothree mets which is a huge savings for us and youre giving the that the tools to function and get a job and be productive members of our society. I want to make sure as we move with the Choice Program that these evidencebased programs are covered by the Trace Program back yes. These types of services and providers are part of the Trace Program and were expanding the networks so we have more access for those types of providers. Right. The other issue is were talking about dealing with the appeals process. We had this conversation yesterday, but the legislation currently is not going to affect the hundreds of thousands, 500,000 people who are already caught up in the stagnant appeals process. So, i say this not to you, because of artie said to you but to members of the committee and the public, i think its a point for us to figure out how we can help you start to reduce this backlog. How do we get more appeals judges may be out of retirement to get into this program and were working on legislation to do that so if your department can provide us with the necessary metrics we would need to figure out how many retired appeals judges from the board of appeals that we need to get back in the system, even on a parttime basis to start getting to this backlog. If you can make that. I appreciate that suggestion. 470,000 backlog claims right now. Even after legislation is passed and we fix the process Going Forward we still have that backlog. I appreciate your offer to work with us and to see if theres a way to help with that. We worked up some numbers and id be glad to share with you in the congressman womack. Great. Thats an important step to try to dig into this 470,000 numbers with the appeals where some are 30 years in the making. For every additional piece of evidence, paperwork they add, it slows up the process and weve got to make a concerted effort, congressman womack i wont still this term but they were talking about a surge for judges to help dig through this. So, thank you again, for all your help. Mr. Taylor from virginia is recognized for five minutes. Thank you mr. Chairman. Ip sheet this has been a great day. A lot of questions answered and information given. Couple things. On the budget. You mentioned that the demand was not fully funded and i know youre looking for agencies and id like to just briefly touch on all that. First i want to applaud you for taking the stand and helping veterans that may have been dishonorably discharged and some of thats because of the effects and stresses that they had on their own personal lives from war, quite frankly. That being said, even in our own mba, when we walk through it and we noticed and asked questions and certainly saw that there were folks that were being treated there that may not be eligible via the system currently. So, in a couple of areas in the email it talks about how there are a couple of areas where you have these veterans that are honorable and veterans that have no issue but when they need a Knee Replacement thats not serviceconnected that theyre not eligible for, they may be getting treatment they are in the va and is a huge cost with zero reimbursement from medicare , medicaid or private insurer or rubbermaid that might be. One of the things we send in their and im not sure if theres a study for it now if you exasperate that across the whole va system, thats a significant dollars. Veterans knowingly or not knowingly, not politically popular thing to say but im a veteran and i dont care. If you know you was retreated there then you dont get treated there because youre taking away from other veterans that should be treated. That being said we want to take care of people as much as possible but im fearful that in a Political Climate that may be the va seen folks that shouldnt be there. They should be using their own private insurance. Has there any studies or looking into that to figure out what that is costing the va across the system . Absolutely, have looked at this. As you know, the veterans are classified in eight priority groups. The first three generally are serviceconnected, the next three, foursix are generally income related, low income. When you start getting to seven eight, those are people that fall outside of that and currently that is frozen. Not all veterans as you are saying are eligible for care in the va system. We are focusing on those that are serviceconnected and lower income. If i may. Yes. Has there been any review where that may not be the case for smart were focused on the folks that are supposed to be in the system any care but has there been a review across the whole spectrum to figure out and im not trying to say whos fault it is maybe but some of this may not be, they might not know, have we had a report across the system to figure out what those costs are for the va customer back yes, we know exactly how many people are in the priority groups. Not the priority groups, sorry to interrupt you. Its the people who are getting care that are getting treated . Im not aware of any veterans that are getting care that shouldnt be. If they are, we have to address that and stop that. We do check, except in emergency care, Eligibility Criteria when people come in and if theyre not eligible for care we generally are telling them that. Now, maybe youre aware of some situations that id like to understand that better because i think youre correct in your assumption that our care needs to be focus on those that are eligible for care, particularly when we have access issues. I be glad to talk with you more about that. I do want to mention two things. First of all, our policy is for emergency Mental Health care for honorable not dishonorable discharge. Dishonorable discharge. Sorry if i misspoke. I applaud you that their wounds are mental of course and i applaud you for those efforts to the other thing i want to mention is your letter of march 209th we did respond by april 6th so that we made it in the 14 days. There is Additional Information that your office wants on the protocols of the Veterans Crisis who are providing that to you and we want to get that detail to you. Thank you. I proceeded. Thank you mr. Taylor. Were moving to a third round of questioning for those who remain with that, i thought it we touch on a couple issues first. As you know, we included 50 million in the omnibus appropriations bill that will be considered on the floor guess right now for va opioid abuse prevention and treatment. We realize the va has come a long way in opioid management efforts since the. [inaudible] in the candyland situation. What what approach has worked best with opioid dependency and how are you achieving those goals to funding . Thank you for that Additional Support. I can tell you it is money were spent. We seen a 32 reduction of opioid use in the va since 2010. But we have a lot more work to do. This is a good investment. Id say very briefly, the va approach to this and we are leading american medicine in this, i just published an article on this is a multifaceted approach. One is a veterans need to sign an informed consent when they go to opioid. Sadly, we monitor the profile of doctors so they can compare themselves to how other doctors are prescribing. Third, we mandate participation in the state prescription data monitoring programs. Fourth, we do academic detailing where experts go out and educate our clinicians on this. Fifth, we are suggesting strong alternatives to opioids and providing those like complementary Integrative Medicine in our facilities. Id also like to ask you to as it relates to disability claims backlog management issue. We were pleased to learn last year that the va had reached an effect of zero on the size of the disability claims backlog. I know some claims will always be or exceed the target deadline because the va is waiting for the veteran to provide Additional Information but could you bring that number down from 611,000 in 2013. We understand the backlog is creeping back up because of your shift in workload priority from initial claims to appeal cases. We know the caseload needs to be tack load in the management dilemma you face, congress and ryan touch on that a bit but what is your longterm plan to bring a balance between activity on initial claims and appeals workload that the main issue id like to hear about today. I dont think we are where we want to be on this. We have to make continued progress. Were at a hundred thousand disability claims over 125 days and it needs to come down for significant. We are doing a number of changes to our process, one is called the decision ready claims that will allow a veteran to seek a much quicker resolution to the disability claims and give them a choice when they have all their Information Available to do that. Were so advancing our technology , moving toward a paperless system, we have ten sites now that are completely paperless that moves everything through faster and were looking at a number of other alternatives to do that. We do have plans to get that down and were not seeking additional funds to do that. We see it through process improvements. Thank you. Finally, jack kushners white house of American Innovation has apparently chosen va as its first target to reshape the bureaucracy by making it leaner and effective. Has his office fanned out staff to the va to analyze its operations and make suggestions at this point . Smack we are in close contact with mr. Peters office. They have been extraordinarily generous with their time. What theyve really been doing is industry partner servers and best practices in to help the va. I dont think their staff has commented on their substance nor do i think that their intent. If more to identify solutions that already exist in the private sector and bring them in and modernize our system. Thank you for sharing that. All federal agencies have received an executive order to reorganize their department by december in line with her fy 18 company proposals. Youre acting deputy has seen that the va would like to get started sooner than that. What changes do you expect the va is organized and how it operates before the end of the year . We are underweight with this right now. Although, i dont know all the specific solutions because were still working on it, what you should expect is that were looking at a smaller, Central Office function, more streamlined, were looking to move toward shared Services Rather than silo services, and each of our demonstrations and were looking across federal agencies to see other things that other agencies are doing better that they should be doing for us or vice versa. Whether va should be taking on some of the functions that other agencies are doing. Were working with other secretaries on that. Thank you, secretary. That complete my questioning and at this time i recognize the Ranking Member for five minutes. Thank you, mr. Chairman. I want to just ask you about the Veterans Crisis line. When we went to the dc va hospital, we had a rather confusing conversation with their personnel that made it evident that there were various issues with the decentralized nature of the crisis line it been a National Hotline as well as a hotline at each hospital. So, the it reports that came out highlighted how significant the concerns are and within days of the igs report, the va said the issue had been fixed. Can you explain how fixed it is smart what does that mean what are you doing to ensure that our veterans are absolutely able when they are in crisis because of the risk of suicide been so high are able to get the services they need . I apologize for the confusion there is only one centralized Veterans Crisis line. Each of the medical centers do not have a centralized crisis line. What the ig was referring to was the fact that when the va responders in the Veterans Crisis line receive more calls than they can handle they went to back up centers that were located around the country. Those backup centers are certified, samsara, backup centers they are trained responders as well. Theyre not va responders. We did not think that was satisfactory. Several months ago we went out, hired 200 new responders, had to get them trained, they came online in the early part of 2017 and we opened up a Second Center in atlanta, georgia. Now because of the new responders and the Second Center that is online we are able to handle the calls that that are coming in. We have less than a 1 backup center rollover rate at this point. Thats why we came out and said we fixed that problem. We have many days where we have zero rollover calls, probably in the last two months we average less then ten rollover calls on a given day. We are responding to over 2000 calls a day to veterans in crisis. We typically send out 6065 emergency responses disabled veterans life. When we were at the va hospital here, they described a system that was one that was based with their personnel and one that kicked to the National System when it was after hours. Every va has a Mental Health service. We have Sameday Services available. So if a veteran calls and is in crisis, they will be seen that day or their issue will be dealt with that day. That does happen. Every one of our medical centers has a Suicide Prevention coordinator, many have more than one that is there to deal specifically with followup issues and to address people in crisis on that day. There is only one National Veteran crisis line and thats run out of two locations in upstate new york and one in atlanta. To the all receive the same training. As i was explaining to the congressman, the Veterans Crisis line responders all receive the same training because they are licensed, Healthcare Professionals and the Suicide Prevention corners all receive the same training but different training than the Veterans Crisis line responders because theyre not all credentialed or licensed Mental Health professionals. Okay. Then you mentioned the reorganization and Jared Kushner s office calls, are those goals aligned with yours . Are you waiting for mr. Kushner reorganization recommendation before you begin hiring for. No. No. Again, the American Innovation office is not intended to come in and give assessments and do recommendations. The executive order has asked the department to do that. Thats what were doing. Mr. Peters office is helping us in identifying industry best practice and Strategic Partners that can help us advance the modernization goals. Okay. As i run out of time, on the board of veterans and backlog in the issue of disability backlogs as well, are you aware of online Electronic Technology that exists that previously had contracts with the va that no longer do and that could significantly address some of the backlogs . Id like to follow up with your office so that you can be aware of this technology. I have no preference for any particular contractors, the timeline and story that ive heard about the process that they have gone through me frustrated that we have a massive backlog and a potential avenue to help address it but no way in for a contractor like them to actually be a part of it no, thank you. Thank you, i yield back. Recognize the gentleman from virginia, mr. Taylor. Thank you, mr. Chairman. I wanted to say before i get my question, i have a letter right here so maybe i misspoke in terms of getting the. Answers. Im just glad we were responded. Continue with the budget and i met like i said i understand youre looking for efficiencies and you mentioned 32 of the care being outside of the walls of the va which is 62 increase in two years. What is the office doing in terms of looking at the inside and figuring out, youre asking for the monies to fully fund that in the mandatory budget, that directory is pretty high right what are we looking at terms internally to our we seen complete demand exploding. Yeah, the crisis in 2014 is because we were not being honest about what the real demand is and once we opened up both internal access and Community Access we started to see what the real demand is and were reaching to hope reach a steady state where we wont see continued growth in the way that we have in the past but that we are meeting the Health Care Needs of our veterans and honoring our commitment. Thank you. Back to the 735 underutilized vacant buildings that are out there. You have a cost, rough idea about what you spent. Year on that . Yeah, i have a chart that i the cost of the 435 buildings that are vacant are is 6. 7 million a year, our total cost is approximately 25 million a year for all these buildings. Thank you. Jumping back and i appreciate that thank you. Jumping back to the suicide. You mentioned the two different folks that are trained for suicide. Its my understanding that like him to va theres a call center that mans the Suicide Prevention hotline, is that correct smart. No. The suicide hotline is a National Hotline, during Business Hours the hampton va would be there to assist veterans in crisis. The National Hotline is run out of our upstate new york office and now in atlanta, they have a second office. So Contractor Office as well said they were that call center for the hampton va. Im sorry, the va and in some cases they run a call center, they do not run the crisis line. They run regular calls that come in and want to be asked for appointments or get to certain places three telephone operator. We do run call Centers Across the country but its we only have 1800 number for our Veterans Crisis line and thats run out of upstate new york in atlanta. Im just trying to understand the Veterans Crisis line. If i called hampton say not that im suicidal but it will say dial seven,. It will say welcome and if youre having issues related to suicidal ideation, these better words than not, please dial seven and will automatically be connected to our national Veterans Crisis line. Okay. Thank you. I have no further questions. Thanks for your time. Thank you. I really think that if were having a hard time understanding how Veterans Crisis light works then imagine how veterans must feel. I dont think its clear how it works and what happens from beginning to end, every hour of every day. I think, im glad you have an Additional Service center that has your employees a staffing it but i dont understand the difference between who handles suicide on the Veterans Crisis line and other Mental Health calls i dont understand how it works when youre outside of Business Hours. Im confident that there are different crisis lines that are at local va hospitals because we were told that they had people working at the dc Veterans Hospital that handled that and that it only went to the veterans line when they werent open. You can provide later further clarity it would be helpful. Smack this wouldnt be the first time that ive learned information that then i would agree with you,. [inaudible] i have an understanding thats clear but please lets make sure that its a correct understanding and i do wanted to be clear. There should be no doubt how a veteran gets help when theyre in crisis. Obviously, were not communicating that well enough or if theres a system that i dont understand, i appreciate you raising that and ill get back to you on this. Thank you. Id like to recognize mr. Thornberry for five minutes back thank you, mr. Chairman. Thank you mr. Secretary for listening to me earlier and embracing the transfer of ideas that are kicking off in omaha and in this regard as well, president taylor actually test on the question and others have as well. The excess inventory. The air force is going to say they carry 40 excess inventory and while yours in terms of cost impact much much lower, nonetheless, thats not a good use of dollars. We throw around the word. [inaudible] i highly suggest you do not use that term. What we can do is work with you constructively you have this option to for instance, sell excess buildings to communities around you, look at the types of services which the military is starting to do and its more applicable to bases but nonetheless it might apply to you. It can be contracted or given over to local treaties, landscape maintenance, terry bases, firefighting security as well, these are the types of ideas that go toward the possibility of not pulling forward things that are no longer applicable in an innovative va without running into the difficulties of interacting communities adversely when you close up something. Dont ever use the word bracket because it brings up bad memories and you automatically set yourself up for controversy. I suggest that we call it m isc, miscellaneous, we could work on some acronym. Again, its very consistent with what youre trying to do in terms of updating the va, getting the best value for the dollar and ensuring that old ways of thinking are transformed into new ways of care for veterans. Those are just some final thoughts i had. I know you covered that when i was out of the room more extensively. I wanted to be with that. The other issue is i think you forward to us a list of possible changes, one of which you brought up the other day catch22 about not being able to study things that weve actually mandated you to study because weve meditated you cant study things. Ideas like that while they may be small back to the transformative thing, we look forward to receiving those. Yes, thank you. Seen no further questions, id like to thank everybody for their participation. Thank you doctor scholz, i can see why you are confirmed unanimously. Congratulations again. This hearing stands adjourned in any secondary hearings will control occur after the president s budget meeting in may. Meeting adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] Lawyers Association conference. This is 45 minutes. Come on up. [applause] sorry i didnt intend to make you dance a little. Im very pleased we can start our day off not with a lawyer but someone with a fierce