Transcripts For CSPAN Key Capitol Hill Hearings 20240622

At the v. A. Have any accountability or any responsibility at all for this happening . If so, how much . Of course we do. As was laid out in the last hearing on the same subject just a few weeks ago, there are many reasons that we are where we are. I think we all share some of the response ability. We have a new program called the Choice Program. We have seven different ways of providing in the community. Im sorry. Did you want to interrupt . My time is limited. You have described with the layout of the land is. Is going to show you what accountability we half. Ok. Do you have any role in this . One of the things you learn is to have no excuses. One of the things that baffles me this case is we are dealing with a Computer System that is over 30 years old call the fms system. It is written in a language i wrote in 1973. We have got to change the Management System of the financial of this enterprise. Our i. T. Budget is about 50 of what a Health Care System i. T. Budget is. We have got to fix that. At the same time, we have got to improve our management of the Financial Systems. Were going to work harder to do that. At the same time, it would help if we had flexibility rather than line items we cannot move around. Every time one of these issues comes up on an almost weekly basis, we year please for more money or more flexibility or some like that, we never get to the bottom of what causes it in the first race. That is what were trying to get to the bottom of. I thought is pretty clear in what caused it. They are giving them too much care. When Congress Passes a law here is my real problem here. You said there is no other option except for an emergency supplemental by congress. He will start closing down operating rooms and hospitals all over this country and with a 60 billion healthcare budget theres no other way for you go around this problem than to tell them they cannot come into the operation room after a certain date . What i taught about was using part of the 10 billion that has been appropriate i congress for care in the community to pay for care in the community. You are appropriated money for care in the community. I yield back. Thank you, mr. Chairman. Thank you, mr. Secretary, for your continued leadership to write the ship. I appreciate it. I do think that stability is part of the solution. It is not the panacea, but it is heart of the solution. Clearly we need to be more enabled to serve veterans and to serve them appropriately and in the way that they deserve it. Closing hospitals is not a choice as far as im concerned. We have an i. T. System that cannot track spending and cannot reconcile a budget in a timely way. I think you have alluded to this in your testimony. I would argue that there has been an increase in demand from our veterans. They also argued that the v. A. Is pushing more resources out the door than they have in the past. That is a good thing. It needs more veterans are being served really. You have mentioned areas that we need to improve upon. You have mentioned i. T. Better management of checks and balances. I think before we move forward in any way shape, or form, we need assurances that these kinds of things will get. Will get next. We cannot hope and pray the next time that we will be at her off. We need assurances that these will be fixed and we will know in a timely way where we are. We will know exactly where we are in terms of money that is spent and what the balances are. Share with us the specifics and when you think these things will be fixed so we dont approach another school year with the same kind of calamity that we are facing today. Thank you. I want to reiterate that we do own these problems. We want to fix these problems. I dont want to give any different kind of impression. The starts of getting the right in place. We have our assistant secretary for the office of information and technology. She was the i. T. Leader. I have been working to recruit her for many months in almost the day i was confirmed. We have got to get the right leaders in lace. I think we have them. We need benchmark operations which we are doing. We have got to replace it. Until we do, have got to take root force effort to make sure we do a better job of keeping track of our budgets and keeping you in warmed of them. One of the issues here was when you passed the choice act, you demanded that we account for care the community and the different ways that we were doing it previously. You asked us to centralize that. Im sure you get in order to keep the chill of that money and make we werent spending it for something else. That exacerbated the situation. We tried brute force to try to keep that accounting will so we could understand what was going on. There is no question we have got to do a at her job. Better job. That is part of the solution. I dont have a lot of confidence having served on this committee for 2. 5 years that the va you have asked us for additional money for an i. T. System yet. I assume that will potentially come. It provides the tools necessary that we would need to be able to have a timely thats timely data. Is there something that you are working ons the city . This is a hype your before us high priority for us. We have got to Work Together to go to one with paper the community and making the i. T. System would be easier. Thank you. I yield back. Thank you, mr. Chairman. Thank you for being here this morning. I think you have a ready sisi history of what was going on here. I thank you for the history of what was going on here. I completely agree with that. What im most concerned about is the fact that you didnt do more about the situation in till two weeks ago . All of a sudden it is like a crisis. From my perspective, i was hoping you have a plan to reform the v. A. And make it all good. I havent really seen you about the reform process going on. Im disappointed with the shortfall. Why didnt we know more about this in advance . What is the story with that . I want to draw your attention to this. This i gave you on june 5. This was about placing the denver facility. At that it was important at the time we publish this to give you a heads up on the work were doing to transform va. If you turn to the back this book, the last 56 pages are all about the transformation of the the a. We sat down those members of congress who are interested and went into the detail. We would love to take you through the details. It includes some of the most outstanding ceos in the country that are helping us. If he is going to the largest transformation in its history. Every member on the committee has 56 pages of what is going on. Were happy to spend more time with you. We would like to be a part of it. We like to have hearings of what were doing to transform in the future. Our first knowledge of it was in the middle of may. At the time we had a meeting with both the senate and house appropriations. We mentioned three issues that are emerging. When was hepatitis c. One was denver. The third was the cost of hearing in a community. At that time it that we could solve the problem by putting more veterans into the Choice Program and therefore not as much on our internal community budget. We also thought we could use unspent money from previous years to do it. We couldnt solve the problem. Anytime you have budget line items where you are inflexible and moving items from one item to another, you have unspent money. When we to be the government of that money is to allow flexibility between accounts. In prior years, the last five years sitting on treasury and as those obligations are expensed the obligations and funds they get you obligated i think for the last years there is about i had another question. I heard there is an issue. It is not what it should be. Could you give me a situation of eight with that . Our collections this year are up significantly. I havent refreshed that figure in my head. I would say it is not 7 higher than we had anticipated. Were working hard to improve collections. A lot our patients who have insurance are at a gap coverage. Explanation of benefits. We are not a medicare provider. We are working hard to collect every penny that we can. Out of time apparently. Thank you. A lot of that money that is left was used quite late to a for the continuation of the denver project, wasnt it . I document the money in the treasury . That money is in the treasury. It is not available to us. We cannot use that money. We thought we could. It is money that essentially becomes the obligated as expenses come in. Sometimes there are new expenses for whatever might have happened in 2014 and that money is used in that year. That was not available to us. We had hoped it would be. I was a staff person who had that cryptic conversation in june. We thought we had a plan. We are a victim of our success. We have gotten many more veterans care. Where did you find that money for denver . The money for the denver project we talk about for this year came from the current year budget and not from the previous years budget. Facebook. That is where you also listed a possible solution of taking that 1 across the board cut. It is not a good idea. Apparently at that time you thought you could. That is correct. There is a lot of gnashing and hair pulling today. We cannot let hospitals close. We have to look for some kind of flexibility. Over the difference between care in the Community Programs that have not been consolidated and choice come it seems to me there is little difference in those aside from contract is and some naming. They are really about. The community. Is that accurate . That means it is not that big of a problem . Yes it your statement is accurate and sensible. In execution, it is incredibly complex. What youll find is that with seven different programs. There are different Payment Methods and different exclusion amounts. I was traveling with a senator who brought in dividers about me about every program we had except for one. I knew the reimbursement rate for that program was higher. Because we have different reimbursement rates, we have different providers encouraging one program over another. With we proposed is to bring all of those together under one program. Make it easier for the veteran and that the a employee. Doesnt that mean that the flexibility that you need from the Choice Program to that consolidated community would it sense . Yes, maam. Lets am trying to help you here. Thats exactly right. There is one very were to point. Our Community Care programs are used to call purchase care. There are a lot of in those programs now that are not covered by choice and will require statutory change to fix that. The longterm care is not covered by choice right now. Can you work with us to look for them . Absolutely. Were working on 13 things that we think need to be changed and have made a commitment to sit down with the staff to make sure that we can address those. One last thing. I notice you are all looking that means veterans and sit at the table drive four hours into los angeles will drive eight or 10 hours to separate cisco . San francisco . This is something we are very concerned about. Thank you. Where are trying to simplify it. We want to make sure it gets that are for veterans and not worse. Thank you. Is there lingers that could combine all of this . Were not yet provided the consolidated language. Thank you. The nonva care money is of a discussion of the department of Veterans Affairs where the choices at the discretion of veterans. Thank you, mr. Chairman. I appreciate the topic of consideration day. This is a difficult discussion for me. I had great hope that we would move forward. The most massive shortfall in the a history. When did you know that we had the shortfall . What i said was around the middle of may. If i understand the items ultimately to percent over the budget amount . We have got it problem. Is that a normal manner . It is not coming to attention a list it is 50 over budget . Your essay tried to resolve the issue as quickly as you can. There is a 10 billion source of funds. What were talking about is i do know that. I would like to know why you lowballed the estimates. New gaming projected theyd be 25 you came in and projected theyd be 25 less. They are actually coming in as 1. 5 dollars over. 1. 5 billion dollars over. Let me give you these figures that you provided. This will 2014, actual spending. He said really need 1. 9 . You are surprised to come in. You will spend more than your spending and 2014 . You come here later and say not only to be cut, we are going to add. That is what i dont understand. [talking over each other] wycoff information as quickly as we could. We are here today. Cracks and would like an explanation of why the project to a reduction in this line item , but now youre saying you want an increase over last year . Im not familiar with information you have. I would be happy to look at it. Here is my concern. You said that you do support va choice. We hear from others in the department that you have many employees were not supportive of choice. Somehow it came in well under budget. What you want the next years budget you decided not do that. You decided to come in and request what we wouldnt do for you earlier. I dont know if they lowballed purposely were created a severe mistake. That is what i dont understand. You are wrong on that. That is what you put in the legit. Budget. We would hope it would offset some of that. Out of the 3 billion that is 80 . That is not the numbers you provided to the committee. One last thing, for everybody here that has never happened. You know that is not true. I want to know for the record how many employees have actually been fired . Is it only to . I think we have seen over the weeks that we have made progress. To our retired. We have got over 100 investigations. Lastly, we saw an announcement that the fbi has indicted someone. These investigations do take time. The good news is that they are coming to fruition. I think over 1300 people have been terminated. We take this very seriously. That is why we night of our 17 members and new Leadership Teams at our Medical Centers. The leadership is changing. I hope we have a change in culture and performance. That is why we had 7 million more appointments this year than last year. Thank you. We do have an outstanding question in regards to the people you say have been terminated. How many were probationary . Are still waiting. We will get you the answers as could the as we can. Unfortunately our systems are selected the Financial Systems. Thank you very much. I appreciate being with us here today. I will try to focus on issues that i think may be causing some confusion in the question of Community Care. They had redefined what has been viewed as nonv. A. Care to include other programs. Community nursing homes. Home health care. I just want to be realistic given the age of demographics. Betsy to 5000 Vietnam Veterans. Just so that we understand Going Forward. Longterm if we are making a commitment to shorten the time frame for waiting to provide reader access and to hire more professionals, i want to understand the exact we but it is, this umbrella of Community Care, and how we expect to meet this need in pay for the need Going Forward. Going forward. So we, under the legislation, were required to centralize all these programs under the chief Business Office and to centralize those fundings. Required by whom . By the choice legislation. So we did that and when we did i mean, we always called them purchased care, really, when i came into it years ago it was pcare. But we were calling it nonv. A. Community care and we said when 20 of our care on a cost basis is out in the community its not nonv. A. Care anymore, it is v. A. Care so we call it v. A. Community care. Were trying to change how we talk about it and the mindset in the organization about what were trying to accomplish so you are correct. That bucket of things includes both outpatient and inpatient care that you normally think of as the purchase care stuff that we do. It also includes our nursing home care, our state home care, home care, camp v. A. Those list of things are this and im happy to get you the detailed list of those and the breakout financially of whats being spent in each of those. Is it the your proposal Going Forward that we would consolidate all of those into one program that we on capitol hill referred to as choice, but it could also be referred to as community . We have all these programs and we also have, as the secretary said, seven different ways of acquiring those services through sharing agreements through contracts, p. C. 3 arch, all these things. I think our proposal and we really want to sit down with the staff and jointly hammer out what a future state might look like. I think that the Choice Program is a good program. I think that if we can figure out how to make that model work across all of these Community Care benefits so that we have a more unified and structured way where we have one billing system, one way to authorize the care one way to get information back, the same kinds of providers that can provide those services, then i think we would be much better off because we could actually explain it not only to other people but to ourselves. And then let me understand when that was consolidated under the choice act to a central, presumably here in washington . Or is it located somewhere else . The c. B. O. , the chief Business Officer is here but we have pieces of that office in atlanta and denver and so when that was consolidated it sounds like there was an inadvertent result in that you no longer had the information that is very regional. I know in our area these are individual decisions and as the secretary mentioned, the reimbursement rates, whether a particular clinic, a particular nursing home, a particular Home Care Program is going to accept this rate, enter into a contract, have we is it fair to say that inadvertent congress wrote it that way, is it fair to say thats created a problem . I think you hit the nail on the head. So i think that these programs typically most of the outpatient care, the bulge of it, the nursing care, state homes, all that stuff was managed locally by a Medical Center, they had a budget for it and clunky Information Systems but they were able to keep track on it. When we centralized that, maybe we should have anticipated some of the problems but we didnt and i think that we lost a lot of intelligence about the obligations that were being made and because you have the authorizations in one system and you have the obligations in a different system and at a time, quite frankly, when we have unprecedented volume of care that were buying in the community so maybe we should have anticipated those things but i think it was an unintended consequence and we did not expect this to happen. So and i appreciate your candor and this is something that we also have it own on our side of the table, having drafted the legislation that way. I think we were probably anticipating a better data system which clearly we have a problem with but this is not unique to the v. A. , that the federal government makes authorizations and obligations and then ends up having to pay the piper. So our balance here as members of this committee is meeting the needs of the v. A. And the veterans all across our districts in every corner from el paso to about pittsburgh, my northern most town in New Hampshire on the Canadian Border but the question becomes Going Forward how do we reintegrate that vital local information and my time is well up. I apologize, mr. Chair. I apologize. I was watching his clock and i thought i was on the way down, i was on the way back up. Excuse me. Was there a question that needed to be answered . Mr. Chairman, i think the answer is, were going to work with you to develop that legislation that integrates all the different ways of Community Care. Ms. Brown has a statement. I just want a follow up to that question because once we pass the choice and we move how we have the counter system, youall caught the problem because when youall reviewed it and you was looking at the requisitions coming in, it wasnt adding up so thats when youall went in and do an individual audit. Can you explain that. Yes thats exactly correct. So back when the First Quarter ended, we were it was clear that we had about a 40something percent increase in the authorizations but we were on plan with our 7. 6 billion dollar expenditures for purchased care in the community. When we sat down and said somehow this doesnt make sense i could think of a lot of reasons why it might actually make sense but we didnt really know and we felt like we needed to look at this so we did, in january and february, look at that. It took us a while to understand exactly what the problem was going through this system. And then once we did that we had to sit town and reconcile millions of authorizations by hand to understand the magnitude of the problem, and it wasnt until really late april that we understood that, the magnitude of that problem. We put a plan together which we thought was going to resolve the situation. And as i said, the pillars of that plan started getting pulled out kind of from underneath us and it wasnt really until may the middle of may, when we said, look, the plan is not viable and we dont really know thou fix this problem without driving more of the care really through choice and accessing choice dollars for their intended purpose which is to buy care in the community. Thank you. I do think its important to note that just prior to folks finding out that this was an issue, we swept somebodys got a cell phone on that needs to be turned off. We got 150 million that we swept out of the v. A. To give to denver, is that correct . I believe so. I dont know for sure. So you anyhow that there was a shortfall coming but you thought it was critical that you go take 150 million and give to denver rather than allocate it to the shortfall . Mr. Chairman, i wouldnt have sequenced it that way. I think the action on denver predated this understanding that was discussed. I mean please understand that every every tool was being pulled out of the tool box to do away with even to the point where we had Medical Center directors voluntarily reducing their salary budgets, their compensation budgets. We had employees willing to give up compensation in order to meet this need of veterans in the community. Maybe some bonuses, too. Mr. Secretary, good to see you. Thanks for being here today. The problem that i dont understand with this, this is what i dont get, is that it seems like it keeps coming back to this issue of perception. You come today, you talk you have all your stats, your tables and your graphs and those kinds of things and we over here want solutions as badly as everybody else is because were fighting for veterans in our district and fighting in a bipartisan manner and doing everything we can legally through a legislative process but what we have been up to since you were here scholastmultiple thargs go on every other day in this place weve looked at to continue whistleblower retaliation systematic failures, management in philadelphia and Oakland Denver cost overruns, waste fraud and abuse and i have been involved and every time your i. T. Chief has been here and we talked about this, as well earlier, getting answers from the i. T. Department, do you need any money to upgrade what you have . Nelson mandela no, we dont. Do you have what you need and what you have needed to keep up . Yes, we do. Do you have, you know, domain issue thats been encrypted . No, we dont. So thats what we have been up to and what the American People have been up to is we have been sitting here asking questions since the last time we met personally in a body like this and i think the issue of trust and this issue of verify becomes dominant in my mind because my fear is that, you know, i love the issue of flexibility. I sit with another member im on the Armed Services committee. We did that with the d. O. D. They needed to move funds. We understood that but there was also a history we could track that was very transparent, very open and the American People saw it, as well, that there was a verifiable need. My concern is back to some of the other points folks made is what will be the guarantee today when we leave here and were going to continue our pursuit of all this oversight of Everything Else that goes on in the v. A. That the American People hear about, as well, and i sit here today shocked thinking we just heard about this crisis and is there anything other, number one, than the threat of shutting down medical facilities to take care of our veterans, is there anything else that can be done number one and number two if the flexibility of funds is the answer, where is the guarantee . Are we going to be looking for a marker that can you say in six months heres what youre going to see and i guarantee it, i put the power of my Office Behind it . I think the only guarantee i can give you is one that were putting the right leaders in place and that those leaders are leaders who are trustworthy and we have to earn your trust. I think thats the strongest guarantee i can give you. I understand and i appreciate that and with all due respect, i accept that as your answer. I guess the problem is this, that we have been at this longer than youve been at the table and we are still celebrating the day that you came. I apologize for everything that happened this morning. And your confirmation was a year ago and i think in some areas youve been incredibly helpful but i guess my concern is this, when we talk about being flexible and moving funds and we dont see and were the eyes and the ears for a quarter of a Million People each of us, thats what we hear and see and when we still get the information back and we still sit here in hearings and dont have the verification on 1300 people whether theyre probationary, whether theyre full employees, we dont see the shake, rattling and rolling of your side and those are the kind of things that i want to see, you know. It wasnt too long ago that veterans were dying because of intolerable kinds of instances that were exposed here in this place through media about what was happening to our veterans. I wanted to see people go to prison. There were people that died that will never be accounted for again and the gross abnormalities were happening at the hands of the administrators and i would think that with the 1300 people terminated the f. B. I. Investigations and those kinds of things that maybe we wouldnt have as many hearings as weve had but we still have instances of offense against wilvet blowers, i. T. Issues that the American People shake their head at, billions of dollars spent, no reforms, nothing is working and we still sit here today and i feel bad. I wouldnt say nothings working. More than a year ago we had virtually 300,000 people on wait lists. Today we have seven million more completed appointments. We have wait times on an average that are five days for specialty, four days for primary care, three days for Mental Health. I defy you to find another medical system in the country that has that. I mean, we are here and we are all for shining light on what were doing because we think it makes us better. And we appreciate your partnership to do that. Just like we appreciate your i dont want to make light here today of the fact that this is an easy decision and i dont want the American People to think, in the state of indiana where i live, 2. 5 billion is more than real money its shocking money and we toss that around like were asking for a little amount of money but im asking for a guarantee and for somebody someplace to stand up and say never again on my watch, never again on the secretary of defenses watch or anybody elses or this president will we tolerate whats happened and i want a guarantee that says heres what history says, were still having hearings on massive amount of issues. Thats what history says. I want a guarantee Going Forward that this will stop and the final question i have for you is when did the president know there was a crisis in the v. A. . I think the president s been working on a crisis in the v. A. For a long time. When did the president know about this budget crisis . First discussion i had with the president was the crisis that we have. When did our president know about this hearing were having today that were 2. 5 billion. Did you tell the president . Of course. I told chief of staff, sure. When did you do that . In june . I dont remember. May, when it started happening . Ok. I knew about the middle may so it was probably around that time. I appreciate it. Thank you mr. Chairman. I do have information, mr. Secretary, that your office did provide to us regarding terminations and i have 958 were probationary perminations out of that number. Mr. Orourke. Thank you, mr. Chairman. Thank you mr. Secretary dr. Tuchschmidt, for your answer, your testimony and service to the country. I had a town hall meeting this saturday and as with almost every town hall that i have, it was dominated by concerns about access to the v. A. And primarily Mental Healthcare access which seems to reflect your own recent rankings as of july 1, out of 141 Mental Healthcare systems within the v. A. , el paso ranks 141st, were dead last. One of the veterans who came up, wonderful young man, incredibly patient and polite, said that that friday, the day before, hed had a Mental Healthcare appointment that had been scheduled for some time at 9 00 a. M. At 7 30 a. M. He was called to inform him that his provider would not be available and somebody would call him back to reschedule that appointment. No one called him back so he came to the town hall to let me know. I immediately called gail graham, interim director, and she got him an appointment this week and hes going to be seen but i tell you that anecdote because even though were ranked the worst in the country for access, you show us at about 17 days. When i asked the veterans in my community and we did a statistically valid survey of veterans in el paso about access with margin of error under 4 , they tell me that it takes about 64 days on average to see someone so i just want to register this note of concern especially given the wait time scandal we had last year that i dont think v. A. Statistics and reporting on wait times reflect what veterans actually experience and when i asked veterans as opposed to the v. A. I get a very different number. And so i just want to register that with you and i want to thank you for your commitment to turning the situation around in el paso. It could not be a graver crisis. Mr. Secretary, you said your Worst Nightmare is a veteran not able to get access to healthcare because we havent provided flexibility. I think the Worst Nightmare for veterans and theyre currently experiencing that in el paso is despite record funding theyre unable to get access to see somebody and fully 34 of the veterans we surveyed could not see a provider at all for Mental Healthcare access whether it was 16 days, 60 days 34 accounted accounted could not get in at all so i want to be sure we look at the numbers and make sure they reflect reality as veterans are experiencing. I would suggest we do that. Lets get your numbers and our numbers together and understand the basis of your research and basis of our numbers and see if we can sort through it. Obviously we have work to do in el paso. You and i and others have been working on that and we know that. Weve submitted a proposal, pilot project, to you and i thank you for reviewing it so quickly, would love to work with you Going Forward to implement that or a better idea if youve got one but we have been at the bottom of the barrel and that translates into care deferred care denied, suffering on the part of veterans and veteran suicides in my community. Ive met with too many surviving families of veteran suicides. This cannot go on. I dont mean to be parochial but ive got to tell you were in crisis and really need your help so whether its our plan that we propose to you or your plan, lets turn this around. Id like to you to talk about i dont disagree with your request for flexibility. I think it makes sense. And i dont know that i would have a problem long term if i knew you were going to be the v. A. Secretary for the next five or 10 years to carry this out. But in thinking about a policy and a set of rules that we played laid down for future secretaries and the v. A. To follow Going Forward, how do we not create a moral hazard in the aurora funding, in the 3 billion shortfall in, future requests from the v. A. That whatever happens at the v. A. And Additional Resources are needed congress will provide them without necessarily getting accountability or safeguards Going Forward that we wont need to plug additional gaps to the tune of billions of dollars. We want to help with that as we put together this proposed legislation we would like to put in the safeguards and restrictions that we think would be necessary regardless of whos in office. We think thats a part of it. I said that in my prepared remarks. The thing weve got to work on is find a better way to predict demand. I talked earlier about the 34 of veterans accessing care and 1 difference being another billion and a half dollars. Weve got to get a handle on that and weve got to Work Together on forecasting what that will be and building that system because remember as i said 2014, the crisis was because of the vietnam era veterans. It was not because of iraq and afghanistan. If we dont get ready for iraq and afghanistan veterans today we wont be ready for them 20, 30 40 years from now as they age. Id like to ask you to consider an idea not my original idea, it was brought by the Summers Family at a hearing we had on survivors of veterans who committed suicide because of lack of access for problems within the v. A. And that suggestion on their part was, as you are referring care out and you said you had a 36 increase in Community Care last year, their suggestion which i think holds a lot of sense is why not refer that care out that is comparable to what the civilian population would need . I use the example of diabetes or the flu or dental care and for those signature disabilities and conditions related to service in combat posttraumatic stress disorder sexual trauma, the v. A. Becomes a center of access for quality of care and outcomes. Any quick thoughts on that suggestion . Patients like to go through the same medical doctor so if you have a primary care physician, you want that primary care physician connected to the specialty physicians. One of the things im trying to work given we are doing Community Care is im trying to improve the understanding of the military culture amongst private sector doctors. We have been working with secretary burwell on this and if somehow weve got to do that because the primary care physician in the private sector has to ask the person, you know, have you served, have you been in the military, because theres a different culture and a different set of questions that need to be canada if asked if they have so we are working on that. I think we agree with your position. I think coordination of care issues says we need to provide as much as the services as we can but there are some things, Mental Health is one of them, that you cannot readily buy in the community and we have to be the center of excels. We have to be able to provide the infrastructure to support those services for veterans. Id like to use this basis for agreement to prototype this in el paso if possible somewhere in the country to see if that works. Why el paso . It comes to mind. I wish a happy birthday to dr. Rowe who is now recognized for his five minutes. Thank you mr. Chairman. And a couple of things. Obviously, mr. Secretary, you are here for the same reasons were here, to provide the highest quality care for veterans that we can provide in this country as they have earned. I think one of the frustrations that ive had on this committee is that we have, as a committee i have been here 6 1 2 years and we keep providing more and more and more money and then we have the v. A. Come back for more money and we see things like thing about in aurora. We beat that horse to death. Moves that cost hundreds of thousands of dollars. I think of a billion dollars goes wasted at aurora that could have provided v. A. Veterans healthcare. I dont know where it went. We had a failed system between d. O. D. And v. A. That spent 1 billion trying to get way before you got here, to try to integrate two healthcare records, vanished, the moneys gone. Thats a waste that i see and no way on this earth would you have allowed that to happen at your shop when you were in no way would i have allowed that to happen when i was the mayor of johnson city, tennessee, where i was or in my own practice, i couldnt have survived doing that and whats happened is that both sides of the aisle want to provide for the care and we feel like were caught in this trap and the chairman mentioned bonuses, all these other things we see, when we go home and talk to our veterans and to mr. Orourkes point, ive got to tell you in johnson city tennessee, these numbers at the Mountain Home v. A. Hospital and they do a fine job, as a matter of fact, i get veterans all the time that tell me how much they appreciate the care they get there. But theres no way on this earth that the primary care is four days and Mental Health is three days and the Specialty Care is five days. I dont know where that information came from. It doesnt exist at our shop, i can tell you and mr. Orourke pointed that out. Not to beat a dead horse but that is a fairytale where i live. I would love to get the information from you as to the veteran, the name, the date, where you believe thats not true because we really do need to make sure that our data is has integrity and the only way we can solve that problem is if we Work Together to make sure we have the right data but we cant anecdotes are helpful but we really need names and dates so we can dig into it. I have a long thick stack of names and dates of people that cant get in. I think thats amazing that you could if this is true, i certainly couldnt do this in my own private practice, i can tell you that, i couldnt meet that criteria an average clinic appointment four days or 5 days. Most doctors are booked up for weeks ahead or at least a month ahead so anyway enough on that. The other thing i wanted to bring up and i think the Choice Program as i understand it, as we envisioned it was was to help get rid of the backlog, not the v. A. Care currently but eliminate backlog. If that program is to continue and it is sunsetted, i think youre right. There ought to be one system in taking a v. A. To outsourced care. It ought to be easy and i talked to several veterans and ill be delighted to let you talk to one of the Veterans Service officers in hawkin county, tennessee that cannot make sense of the Choice Program to this day. His comment was its a joke. I put that in the record, his letter to us and he certainly doesnt mind using his name. The other issue, i think, that disturbed me was when the Veterans Choice Program came out, the first 500 million that was spent and we had a hearing on that, 300 million was administration. I dont understand that. I dont understand why 60 of the money went to the bureaucracy and 200 million actually went to get veterans in to see me as a doctor. Maybe that was needed, i dont know. But that seemed excessive to me. That was the amount required to set up the network. Nevertheless, were trying to maximize the use of that network as much as we can to provide more care to veterans. I think the other thing i would look into and certainly flexibilitys been talked about. Any c. E. O. Needs that to operate their shop. I agree with that. The other thing i want to comment in the last few seconds that i have is morale at v. A. Hospitals is down. Those folks feel beat down and i think there needs to be an evaluation of the morale of the physicians and so forth. The other thing im going to do is bring a bill up very soon as a trial process and a lot of people have done this, when you go to your doctor anymore, not only does the assistant come into the room but another person shows up and that person is the scribe and because of Electronic Health records, a lot of doctors use the scribe to enter the data so they can see more patients. I would like to do a Pilot Program in the v. A. And let scribes come in and see if the physicians that are there, providers, are not more productive. I guarantee you they will be. Ive had friends who work at the v. A. Tell me they could see 25 30 more people. This is a big issue you raise about the scribe. We are piloting a program with scribes. Its uneven right now but were in the process of systematizing. Morale also is a big issue. As ive said earlier, 91 of our Medical Centers with new Medical Center directors, new Leadership Teams. We had a lot of people leave for various reasons and morale is a big issue and v. A. People, a third of which who are veterans, dont want to be called out as somehow different and failing to perform. They really care about veterans and theyre working hard every single day. Yield back. Thank you ms. Rice, youre recognized. Thank you mr. Chairman. Mr. Secretary, i want to make sure i heard you correctly. You said you found out about the extent the shortfall in may. So i believe that you were given information, this committee was given information that the shortfall was actually discovered as far back as either february or actually i think it goes back to even december. Can you explain that discrepancy . No, i cant. I havent heard that. I dont think we knew there was a shortfall. I think what we knew in february that was there was a difference between the increase in authorizations that were up substantially and the obligations for that care which were on plan. So all the data we had in february in february suggested we were on path for our 7. 6 billion estimated expenditures for the year. We questioned that data. Right . Does it make sense why you would have 40 more authorizations, but the obligation rate is not up. That is what we knew in february. It was at that time we sat down and said we have to figure this out. Maybe there is a good estimation, maybe it all makes sense. But it wasnt until april that we understood the problem, and the magnitude of that problem. That sounds like semantics to me. In what way . Sounds like you just dont want to say that word shortfall. Did you have a solution . What i said is i thought we had a solution and told the middle of may. That solution fell apart as we worked the mr. Secretary, if you can put it in 30 words or less the reason for the shortfall, tell me, hep c, just give me an idea. The easiest description is more are coming for care. 7 million more appointments than a year ago. Thats the reason . Thats the reason . Thats the reason. I kind of feel like this is have you seen the movie groundhog day. Once again the committee is , sitting in front of you with members of the va talking. Talking about a crisis in the v. A. , that is a recurring theme. Another request for yet more money. And the most disturbing point to me is a complete and utter lack of accountability. I dont agree with you obviously. Remember, this money is already appropriated. What were asking you to do is to spend money for care in the community. How are you going to pay for care in the Community Next year . What we are asking for is a part of the choice budget. What we have talked about is lets put together an integrated way of doing care in the community. One way to do it, not the seven we have today. Members of the community said they dont understand, our employees have trouble actually executing. So where is the accountability is what i am asking for . There is no part of the shortfall that is related to misuse of funds or potential fraud. Or anything like that . There has been no misuse of funds or fraud. You have done an audit . Have you had somebody do an audit, yes or no . We have had an internal reconciliation. Is that a yes or no . I am not sure that is a good idea. We had 34 for more authorizations in the community. You asked us to make sure no veteran was waiting no more than 30 days for care. We have done that. What i think is disgraceful i , have about 20 seconds left. What i think is disgraceful is for you to insinuate by not giving money nobody on this committee cares about veterans. Hold i am so sick and tired of that insinuation. And i yield back my time, mr. Chairman. Just to be clear, we didnt insinuate that. We all think you care for veterans dramatically. What we are faced with you pass , the laws to give veterans benefits. You pass the budget to pay for those benefits, and we have to execute that. When there is a mismatch between the laws in the budget, it is a difficult opposition. I get letters from all of you every single day trying to give more benefits to more veterans. But we have to have the money to do it. The law also says the secretary must manage within available resources. But the choice act is not a resource that is available to you at this point. Mr. Kaufman. Thank you, mr. Chairman. Mr. Secretary, thank you for your service in the United States army. Although the president id like to think the president chose you in recognition. In proctor and gamble. And we had in this committee, my predecessor on the over sight subcommittee had requested a study of Major Construction products and that was done and published in april of 2013. At that time, it said there were four ongoing projects one in las vegas orlando, new orleans aurora colorado listed as denver. That the average 366 Million Dollars over budget. And that they were each on average about three years behind schedule. We clearly knew there was a big problem. If you and proctor and gamble were to step in and you had an apartment that was that dysfunctional, you would have fired the management team. Straightened it out, spotted off when i look at the v. A. , your core competency is benefits to veterans, health care being a significant part of that. Construction is not a core mission. I would love it if you would reexamine extricating the the a from being involved in construction products. I know we have legislation today that would reduce the amount. I talked to gibson about this, he was at the 250 million figure that would be outsourced to the army corps of engineers. I think we have legislation today of 100 million. One of the problems is that the different investigation boards were supposed to be finished in june. They will not be done in june. They may be done in september. But i just think there is a real concern. We held a the subcommittee Oversight Committee held an investigative hearing in denver on the aurora projects at the state capital. I think it was last year, the chairman was there. Mr. Lamborn was there they stuck to the 604 million figure. That the project could be built for that. Lost in late 2014 on every single count was that this was a plan that could not be built for 604 million. The army corps of engineers is taking over the project. Were talking about shortfall of the day we are talking about a halffinish hospital. Hopefully a little over halffinish. It will cost another 625 million i believe is the figure. Which is more than the initial projected amount to finish. So, i would is really ask you, i mean as a veteran, is not the core competency of your organization. Focus on health care benefits, and to leave as many other agencies in the federal government they do these Major Construction projects. I love your response. Punishment kaufman, we agree in part with you. The only difference between your point of view and hours was what that right level was 250 or 100. I do want you to know that weve taken a lot of steps to improve our construction process. We are doing integrated master planning requiring Major Construction has at least 35 plans designs made prior to scheduling. We are doing very deliberate requirements to control process that we are instituting a project review board, using a project Management System, establishing a v8 activation office. I could go on. These are best practices from the private sector. At the same time, we have also met repeatedly with the association of general contractors. They had boycotted the v. A. We met with them, secretary gibson i did, we took them through all the changes. We asked them for their point of view, if they are missing anything. Theyre helping us redesign. Wherever we end up with legislation, what i can assure you is we are now operating against a new and improved process. What happened in denver, which is really regrettable and awful should never happened. It will never happen again. We have been through this, wound up in the same position. I think 100 million ceiling will be 300 million ceiling, i dont have confidence it will change. I just want to be quick. As we move forward with this construction discussion, when you say General Service or army corps of engineers i know no one likes the word. When i look at the corps of engineers, i know what happened with katrina and that project. We need accountability, i dont care what agency is handling it. I yield back. Thank you, mr. Chairman. Mr. Secretary, you are introducing in my view a new way of talking about contract care with nonv. A. Providers not salaried within the ba. Is that correct . Yes, sir. You are calling this care in the community. On a bipartisan basis we are encouraging cooperating more with the community nonv. A. Providers. I think you are trying to change the culture, so that there is not this enmity not a conspiracy to disappear. That is where i am reading. That is why we changed the name to care in the community. We in the v. A. Own that care even though it is in the community. I have seen others within the the a health testify before the committee the concerns that you do own the care, you are responsible for it there need to be ways in which the contractor and the providers are also accountable. That that care is accountable. I have raise a number of times this issue of health records. You have centralized the billing and payment from the regional areas. You are saying in your testimony from what ive heard, that centralization had a lot to do with driving the shortfall. The misunderstanding that arose from what you knew from the regional billing to the centralized billing. Is that somewhat accurate . The requirement in the choice act to centralize the accounting and billing and administration of the choice act helped make it more obscure for us to figure out what was going on. So when you were in february seeing a discrepancy between the authorizations and payouts, you are not able to figure that out. This centralization of stored was obscuring your cash position . Yes sir, a new practice. My concern, is there any feeling that the centralized authorization has resulted in inappropriate authorizations . The regional offices had problems with records that were paper records being passed back and forth. There were complaints that even registered mail was not being acknowledged. I envisioned stacks and stacks of records that had to be scanned then, there were delays in payments to doctors because of that. Is the centralization improved at all . From what we know, the centralization not just of the choice act but across the payment function of the v. A. Has accelerated our ability to pay bills and you are not worried about the excel or is acceleration, the accountability centralization usually leads to better security. The care is still determined at a local facility level, a clinician seeing a patient, puts in that request. And the authorization is entered at a local level by the Business Office people at that facility into the facility records information, it is transferred to a third party. There is a great deal of umbrage, what is information we have to act on immediately, but the overall narrative i am getting though is more money is being pushed out the door more appropriately. Many more veterans are being served, more are finding out about the superior service. Meaning that you use the example of the Knee Replacement there is no copay. It is a rational decision that a lot of veterans who qualify for both programs are choosing to come to the v. A. , that accounts for, can you give me that number again . The number coming to the v. A. That you had before . It is over 2 million. But what we are talking about is 7 million more appointments in the last year i was looking at the increase. 4. 5 million more in Community Care, 2. 5 million in v. A. Care. This was of stored by the change in the choice act and how you do the accounting. I dont like the short notices but we have to act quickly. More importantly, we serve the veterans. The good news is we are serving more and more. And lets keep doing it. Thank you, mr. Chairman. I want to thank you gentlemen both for being here. He spoke today about the increase in productivity, and i think the number you said is every 1 of increase is 1. 4 billion . Is that a number . I may have confused you. That are ands 34 of their care from the v. A. Any increase of one percentage point of that leads to a 1. 5 million increase in budget need. That is different than productivity. With the increase in productivity the v. A. Is different from private practice. When you increase productivity, that is not money coming in. That money going out in most cases, there may be some silos there. Whereas on the flipside, an increase in productivity has more coming in. That is the reality we have to face in this, we ask for more productivity. One question i have, is that increase within the same amount of hours, if you will . In other words, if i increase my productivity because i work saturdays and sundays, that is different because did i increase in the same amount of time . Right, also what we worked at was productivity, disregarding how many more physicians we brought in. As we first shared on the 8. 5 increase in productivity, jim can talk about this more. Jim we have done it, increase productivity a number of ways. One of them is what you suggested. We have evening clinics, weve had a weekend clinics. And particularly those evening clinics have been very popular with younger female veterans, in particular. One of the things we need to focus, again the comparison with private facte practice, how doincrease in the same amount of time . We talked about poor setups and clinics, one room when you need four. The increase in productivity has to be looked at realistically im as well. These are good things to add but if we are not giving the same amount of time, we are hurting ourselves. Jim we are. It is a little bit of both. Increasing productivity during the normal hours, as well as the extended hours. One of our biggest hurdles to improving access is the physical infrastructure we have. If we can use that Physical Plant infrastructure more efficiently by having weekend hours, everybody benefits. I have frustration my first came here, before phoenix broke and Everything Else. I will go into clinics with you. I will go into the operating room with you and tell you why youre not getting more. I think we still need to do that. We have doctors on this committee that would be willing to partake in that process. We talked before about thirdparty payments, people coming to the v. A. I would love to see them as centers of excellence, they dont want to go anywhere else. People from the outside would prefer to go to the v. A. Because of the centers of excellence. We do have veterans that come in and i have other insurance. And i am not sure how this is taking place in a what percentage we are capturing, but maybe we should put that out to people who do claims like that all the time. Take it out and increase the revenue to the v. A. These are things we can do, and as we see more people wanting to go to the ba, especially if they have other insurance collections are up, but we are and value waiting a lot of our Business Offices practices. One of the things were looking at is whether collections is something that should be out i suggest we take bids on what that would look like. We talked about this before, at some point, we have to be able to know what we spend her relative value unit. If we do not know that, we do not know what the cost is compared to when we pay per rvu outside the walls. I do agree with you, care in the community. I agree with that, rather than nonv. A. Care. If i was still in practice seeing veterans, i would like to say i am a v. A. Provider. We have cost data and we should discuss that with you. I have asked about it several times. Secretary gibson said we cannot do that. Im talking everything, not just what you are paying the doctor. I am talking Physical Plant, staff, supplies, everything involved. That would be very important to the entire committee. I think the secretary would understand it is not just paper. Thank you both for being here, i appreciate it. Thank you to the chairman and Ranking Member for holding this hearing. When brave young men and Women Volunteer to serve in the armed forces, they swear to support and defend the constitution of the United States against all enemies foreign and domestic. They make a promise to all of us to keep us safe and protect our way of life. In recognition, we promise to care for them when they return. So veterans have served and sacrificed to uphold their end of the bargain, we must do whatever it takes to uphold our end. Many veterans in my district who are excluded from the strict requirements and the Choice Program are unable to receive care in the community, for which they are statutorily authorized. The v. A. Has already gone delaying elective care due to the shortfall. As a physician, i can tell you that even if a condition does not meet the urgent working standard for nonchoice purchased care, it may still be painful and very urgent to the patient. Veterans being deprived of health care, they have earned whether due to unforeseen increases in cost or demand, budgetary mismanagement at the v. A. , congressional dysfunction or any other problem outside the control is completely unacceptable. It is absolutely critical we stabilize the immediate problem and resume serving veterans who need Community Care at full capacity to prevent any furloughs or facility closures and reform whatever structure systems that have failed. You are actively searching for new ways to be able to predict the way future needs of veterans this is a problem due to the success of have an 7 million more appointments. As a physician and Public Health expert, i understand that you cannot predict to the t the health needs of a growing population. Of a system in transition that needs to take risks to identify best practices and understand that some of these practices may fail therefore we need to learn from those lessons. In order to improve. And you mentioned before the term managed to budget, which we have done in the past. Now you are managing to the requirement. But i want to warn you that the one requirement you are managing to is only one of the larger piece and complex. Whether a veteran gets seen within 30 days is not the same whether they get the quality care, the respect they need, and the efficiency of care when they are being seen. Thankfully, and a lot of our v. A. s veterans rate their care very highly. We need to manage the Veterans Health care needs with efficiency, to the point of measuring how much it costs per rvu. And the Percentage Rate of cost due to the amount due to the increase in amount, that reflects on the efficiency of the v. A. So i really want to stress those points. My concern here is this claim we are shutting down facilities that the way it is being presented you are holding them hostage because youre not getting your way. Absolutely, i know thee sentiment is not true. Can you explain more what is going on in denver. How this is affecting the care . Of our veterans and receiving that care . Two, one of the concerns is that if you take this flexibility which i think is a great idea, if you take money from one pot that you already have for another, there is going to be takeaway. Is this a surplus fund, what is the takeaway that is at risk here . The choice care act itself that Congress Approved was to provide care in the community for veterans. There is a 10 billion appropriation that is to expire in three years. What we are talking about is care in the community largely there is another half 1 million for hepatitis c drugs. So we would be using the money for what it was set aside or, care in the community. In that way, we are using the money for what it was set aside for it is not a new appropriation. Secondly, the issue you raise about denver, because we have an influx of money between accounts, the accounts it came from this fiscal year for denver do not affect the health care of veterans and other locations. So in that sense, denver has no impact. Now, as i said in my prepared remarks, we have to get denver the denver medical complex we have to get that in the 2016 budget. I am concerned about that since the original house budget cut our construction by 50 . Ok, thank you. I yield back. Mr. Costello. I would certainly like to associate my comments with those of the congress andwomen rice and ruiz, what i am hearing in my district i want to assure those veterans in Montgomery County that i will work at 100 and110 to make sure there is no on intrepid care. I am very confident in the leadership, the ranking minority member brown we are going to resolve this. So that there is in no way a diminishment or any interruption in the care for veterans. But i do also want to focus on a couple of things that are either in your written testimony or that i have learned that are very frustrating for me. And i want to start with the issue of technology, and i want to talk about the use of the term flexibility. You received 475 million for the i. T. System, the report comes out and says there is essentially nothing to show for it. In 2010, the vehicle the plug on more money. You were not around then, i was not around then. It is very clear that in the past, the v. A. Has identified a need for updated technological capacity, as well as congress being willing to invest in that. Part i feel of your explanation in coming here with this request relates to the Financial Systems that are in place as being attributable to why you have a budget shortfall. I dont want to put words in your mouth, but i believe that is what you said thus far. But on the issue of flexibility you indicate and i would just quote you on page three, over 70 line items in the budget are inflexible. Freed up, they would help us give veterans what they deserve. The 70 line items. Are you talking about the 170 billion plus budget. . With the choice act, we have given the veteran a choice whether they get their care within the v. A. Or outside the v. A. Very simplistically, those two budgets cannot be comingled. So i have to predict how that veteran makes that choice. Or come back to you each week i get where he is going you dont always know what the medical need is going to be. I understand there is going to be flexibility with the budget to appropriately address the needs. But i also feel that in a budget of 170 billion, and that is itemized among 70 line items that isnt really that many line items. And in terms of flexibility, the more money we just say, do what you like with it, the more i fear we will get into the issue of 475 million disappearing into an i. T. Budget, i dont like the aspect of shifting things around the other being accountability. We agree with you. In the case were the aim of the budget is exactly the same, i would argue they would be coming on. The next question related to rep. Costello i continue to hear that there is just a reluctance by many to sort of buy in to the Choice Program. Congress last session made a legislative determination that from a policy perspective, the Choice Program was something not only offered, but encouraged through the allocation of dollars. Now, i feel that because some either do not like the program or feel that since there is money left over and it was popular to institute that legislation, that we could shift it elsewhere. He gets back to the issue of accountability and transparency. While you use the term flexibility, i also feel we could be painting a too broad rush when we use the term flexibility for budget purposes losing the accountability that we need and is frankly the source of some of the problems that cause us to be here today. Senator mcdonald we are in favor of caring for the community, and we are in favor of the Choice Program. If you or your veterans are encountering employees that are not in favor, we need to know about it. We are trying to create a culture where we dont care where they get care, as long as they are getting care. Rep. Costello as you talk about a new i. T. System in order to better handle budgeting and planning, in my opinion, mismanagement can be a very visible can be visible and also not visible. On the i. T. Side, it is easy to miss manage things and not really have any ability for those doing oversight to really know about it because it is sort of on the planning side behind the scenes. Moving forward, as you are talking about coming forward with what your needs are going to be for new i. T. Systems, and has to be thorough comprehensive. The ad hoc we need a little bit money here in the year after is not going to work. I think in these to be a comprehensive plan so that we have some confidence that what you are proposing is going to solve problems and over the longterm, reduce costs because run manager perspective, you are going to have more transparency. I yield back. Senator mcdonald we agree and we would love to have our new head of i. T. To talk to you. I think she is going to be terrific for us. She has experiences with dell. We are taking the best of the private sector. I want to thank you for your service, both in the army and in this complicated transition. We are hoping that it turns out well and we are going to do our best to make sure it does. My first question has to do with public and private partnerships. Secretary gibson mentioned that you had spoken about this and you are in favor, can i ask you that question do you feel the v. A. Could benefit from publicprivate partnerships . Senator mcdonald one of our strategies for the transformation is strategic partnerships. We set up an office of partnerships we have a leader. Yesterday when i was in pittsburgh working at the Medical Center, there was a wonderful example. Im that with the chancellor of the university of pittsburgh. We have a Great Partnership there. This is a system that omar bradley set up in 1970 to ensure that veterans get the best care in the country. Those partnerships are absolutely critical to us. Rep. Mcnerney thank you. Taking a look at this graph, it is a straight line. If you divide 7. 6 by 12 you are totally over and you are going to clearly missed the target. Why did it take so long given this kind of information yucca was it not available . Senator mcdonald we went back and reconstructed so that represents our obligations. What we were projecting early on was lower. The obligation that we did the obligation data we had was understated. Rep. Mcnerney how much of the three billion dollars shortfall is to two under forecasting . Senator mcdonald i think we had anticipated that more of the care in the community would have gone through the Choice Program and been paid for out of the money that was appropriated for the program. That program i am not going to sit here and tell you that it is working perfectly because it is not. It is a complex program. Dr. Tuchschmidt it is we have payback done because nobody else in the industry was interested in taking it on. We have business processes that, quite frankly, need improvement. We are working on those things. I think that we have a Choice Program that we and you thought were going to get more care in the community for veterans and make sure that veterans were not waiting over the early days for care. We have not been able and maybe some of it as coulter all but we have not been able to get the volume, the number of authorizations through that program that we had anticipated. That has not stopped us from trying to be faithful to the intention of congress when it passed the act which was, note veteran should be waiting. What we are asking for is to be able to use funds that were appropriated for the purchase of care in the community to the Choice Program to pay for care that we purchased in the community that not through choice but through normal mechanisms because we have oversubscribed those programs. Rep. Mcnerney how soon can we provide the flexibility . So what would require a bill to be passed by the end of august, or by the end of july . Dr. Tuchschmidt the money has been appropriated sen. Mcdonald the money has been appropriated. I assume it is some kind of bill. Rep. Mcnerney we would have to authorize the transfer of those dollars. Can you provide a list of the facilities that will be closed if you do not get that money . How soon can you provide that list . Sen. Mcdonald we have an entire plan which we can share with you. Dr. Tuchschmidt i would just say that when we run out of money, we will move funds around between facilities as best as we can medical services will be the first appropriation that runs out. It will affect every facility in the country. Rep. Mcnerney thank you. Dr. Abraham let me start by saying that you can delegate authority but not responsibility. I know you are ceo of a major firm before you came aboard and i just think that if you had come to the board of directors at the 11th hour, they would be a little incredulous at the shortfall, at the lack of vision. We dont want to disparage that. We understand that everybody in this room has the best the veterans best interests at heart. You and i both know hepatitis c is an insidious disease. I was in my district this weekend and three Vietnam Veterans came up to me and said that they had yet to receive anything from the v. A. Because i understand that is in the pipeline and i understand that the other hepatitis c rows are only approved in 2013. That still gives about two years to formulate plans, delicate how this medicine is going to be divvied up. It has not been done. Can you give me some indication as to when our Vietnam Veterans can expect some hard data as to if they can get treatment . Dr. Tuchschmidt we we have treated over 20,000 veterans this year for hepatitis c. Dr. Abraham how were you delegating which veteran gets treated in which does not . Dr. Tuchschmidt you may be getting a little bit over my head in terms of hepatitis c. We have a severity score based upon whether the veteran has advanced liver disease. Dr. Abraham i guess what i would ask is if you could just give me that information of how the determination is made. Is it viral loads or autopsy results . If you would just place to do that i would appreciate it, so i can give it to my district. Dr. Tuchschmidt i would be happy to give you the information. We have treated over 20,000 veterans with hepatitis see and we continue to treat patients with advanced the vertices and patience who can go out into the community have the Choice Program as an option to do that. Dr. Abraham secretary, you said of the 3 billion you are anticipating, 500 million of that would be designated for hepatitis c treatment . Sen. Mcdonald yes, sir. Dr. Abraham i yield back. Thank you mr. Chairman. With regard to the medical scribes, elaborate on that Pilot Program, because these are great pilot sector t private sector solutions. I had a town meeting that lasted four hours and people were bringing that up last weekend. You want the doctors to focus on medicine. Elaborate on that Pilot Program. Sen. Mcdonald i have heard a lot of this. At every facility i go to there is a different approach. We are pretty consistent in the team of people working with a particular patient. On those teams today, we do not have a scribe. I think what jim was describing was, lets pilot describes so that everybody on that team can be working on the patient and not just entering information into the medical record. Dr. Tuchschmidt i did not come prepared today to expect this question so i will have to take it for the record and get you information about where we are in terms of the Pilot Program. Rep. Bilirakis thank you. Any other Innovative Solutions coming from the private sector that you have implemented in the last year, do you have a council set up of physicians that work in the private sector to get these ideas . Sen. Mcdonald we do. Believe it or not, we have more than 25 Advisory Councils but we have two i would like to tell you about. One is our special medical Advisory Council which is the best medical minds in the country. It is shared by john perlin. He is the chairman of the American Hospital association. He is the chief medical h officer of hca. On my v. A. Work we are doing, we have also set up an external Advisory Council. We have many doctors that are part of that including the head of the cleveland clinic, the former surgeon general. One of the things they are bringing is not only their innovation and ideas but they are taking away our innovations. A couple of weeks ago, we published an article that was picked up in medical journals not broadly at newspapers about the new monte carlo simulation technique we can use to predict suicide. This is a breakthrough. If we can validate this model of predicting suicide, this will be a breakthrough for the v. A. But also a breakthrough for the american public. A lot of what we have seen has been innovations that actually start in the v. A. Part of our 1. 8 billion in Research Spending that you appropriate and we appreciate it that result in a positive result for the American People. Heres a copy of the article. I would be happy to put in the record. We have more of these breakthroughs coming. Rep. Bilirakis very good. Sir, we need to get the word out on this Choice Program. I know you sent out a car what else have you done to get the word out . I have another question with regard to access. Sen. Mcdonald we have emailed letters to everybody. We have emailed three letters total, first with their card and then a followup. We have a flyer we developed. We have a website dr. Tuchschmidt we have a website that we have just reengineered. We do surveys of veterans who use the Choice Program, asking what they think about the program and one of the biggest issues they have had is with the website and availability of information so we know have a redesigned website that is about to go live it has a live chat on its and that the veterans, why they are looking if they cannot find information they can click the chat button talk to somebody right then so we have really done a lot, we have a set of outbound phone calls to people who initially were actually waiting for care more than 30 days to contact them about the Choice Program. So we have tried to do a a lot of outrage. Rep. Bilirakis sir, my constituents are having trouble getting access to the program. Describe for the benefit of the heroes, describe the scenario. How would it work . Can you describe a reallife scenario . Dr. Tuchschmidt there are two benefits under the Choice Program, one is that you are waiting more than 30 days. If you wait more than 30 days for an appointment, our staff if you call in or while you are checking at a clinic in getting a followup our staff will tell you if you cannot get an appointment within 30 days that the Choice Program is available to you. They have information that they can hand out to the veterans about the Choice Program. At the moment, booking an appointment for the veteran into the v. A. And offering them a Choice Program in making that referral to the third party administrator, the veteran can decide which of those two options they want at any time. We are about to change that program so that what will happen is at the time the veteran asks for an appointment, if we cannot give them an appointment within 30 days, we will ask them if they want an appointment in the v. A. Beyond 30 days or the if they would like to go to the community and in our staff will contact the tpa and get an a pointman for the patient. Will you to do a contract modification to be able to put that program in place but it is coming down the pipe and that should improve i think the coordination and the level of service. If you are in the 40 mile group, what happens today is that the tpa already has your information and you can contact them directly. You dont need to go through the v. A. To get an authorization. Rep. Bilirakis sir, we got to make it easier for the veteran. Sen. Mcdonald we totally agree. Rep. Bilirakis i yield back. We are not going to do a second round of questions unless there is one that is absolutely pressing. With that, you are recognize. Rep bro. Brown i want to thank you for holding this hearing. We have heard a lot of discussion today. It used to be a program fax, just attacks. I want people to understand the facts before they walk out that door. I have seen a lot of people snapping pictures of us making different statements. I want you to give us a list of the facts while we are in this emergency situation and if we do not act before we go home, we are going to have a crisis at the v. A. Everybody needs to understand where we are. This is not anything new. You have been saying it from day one, you need flexibility. And we need to give you the flexibility and then we will hold you accountable. But i need to set up. Act like we dont have 7 million additional veterans coming into the system wait a minute, 7 million additional appointments and 4 million veterans and we have a Community Program that you have taken money from the end used yet he used it where you could but it had limited ramifications how you could use it. Give us the facts before any of us walk out the door. Sen. Mcdonald we will. Thank you. Rep. Brown no, no. I want you to answer it. I want you to sen. Mcdonald ok, what we like to do is get the authorization to use 2. 5 billion from the Choice Program for care in the community and 0. 5 billion for hepatitis c treatment and we would like to get that before the end of the month because we have run out of care in the Community Money in the v. A. Budget and we want to keep our care going for veterans. We think we are in a good place in a sense that more veterans are getting more care, 7 million more appointments this year. Average wait time is three days Mental Health, four days. Primary care, five days. Specialty care admittedly we have issues we have to work on in other parts of the country but we are making progress that right direction. We want to keep it going. Our veterans deserve it. Dr. Tuchschmidt i would like to add that we continue to buy care for patients so they will not wait more than 30 days. When we ran out of money and our budget to do that, we took money out of operations to continue to buy that care. We can probably sit here and debate whether that was a wise decision or that decision. Had we decided not to do that and leave it in operations, we would not be facing any kind of shut down or closure heard but we would have told people in june that there was no more care in the community. You either waited or went somewhere else. We chose not to have that happen but rather to continue to buy care for patients that could not get care through the Choice Program. And so, today, because of that, we find ourselves not having money in the field to be able to make payroll during the month of september. That is really what we are asking today is to be able to use choice money set aside to buy care in the community to pay for care in the community. Rep. Brown the last thing. I know one of the discussions was a problems in certain parts of the country but some of the veterans, particular those in florida, they like the care that they received from the v. A. And i dont personally want to see the a just going to a specialty. We need comprehensive care in certain areas and i know around the country, it is a real problem with getting the comprehensive care of. But when you look at the approval rate of veterans, it is like, what is the percentage . It is of a percent90 7 like the care that they get in the v. A. Sen. Mcdonald that is what the vfw study told us. The other thing that we see is veterans have always had choice. 81 of veterans have multiple ways of getting health care, whether it is medicare tricare v. A. What we are seeing as we improve care is more and more veterans are decided to come to thev. A. I take responsibility for sharing the forecast with you and as we continue to improve care how many more are going to be coming to be a for their care . V. A. For their care . Rep. Brown thank you, i yield back my time. Did i hear you say that in june you are at the point that you were going to have to tell veterans you were out of money and there was no longer the ability for them to have care provided for them in a local community . Sen. Mcdonald through the purchase care program, we started pooling money about 290 million to supplement that pool of money in probably early or middle of june. Is that an accurate statement to say that veterans would not be able to have care provided for them outside of the v. A. . Again, you couched your comment to make it appear that you are going to shut the spigot off in june. There are 9 billion dollars finite dollars, which is why we have been so protective of that money. You are the ones that sent out the notice with the cards saying that it is a temporary program and as you trained the money out of this program, and somebody made a budgeting decision, and you have already said right from are wrongfully you missed. You thought you could weather the storm and just squeaked by but you cant. You got caught. Somebody made a bad decision. Veterans will still get health care in the community through choice. Is that correct . I know there are some restrictions on dental issues and things like that, but you are making it appear with the statement that you just made, that, as of june, you thought you were going to have to start telling veterans they could not receive care in the community. Sen. Mcdonald i think that said that veterans that could not get care through the Choice Program would not would have to wait for care. That is not exactly what you said but i will go back and check the record. Dr. Tuchschmidt i stand corrected. We are at a crisis situation again many of my colleagues have already brought that, you know scaring veterans that hospitals are going to close, though we are not going to be lit a pay their salaries, i think is just that, trying to scare them. We are the ones that will have to make the decision whether or not this money gets allocated and i dont think there is a Single Person that was up here today that advocates anything less than trying to solve the problem that exists out there. What we are asking is when these issues arise internally, the sooner you can inform us, the better off everybody is. We are still not satisfied with where we are with the Choice Program. I dont think you are either. You have made those comments. All hands need to be on deck. With that, i would ask that all members have five legislative days to revise and extend their remarks and add any extraneous material. This meeting is adjourned. [captions Copyright National cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] announcer coming up, john kasich holds a town hall meeting in New Hampshire. And scott walker campaigns in iowa. Later, Congress Talks about the on the next washington journal, we will talk to congressman karlis cabello about the thaw in cuban relations and passing the highway spending bill. Also, commerce and brad sherman on the fifth anniversary of the doddfrank anniversary