Logically say they probably require ratification. And if they require ratification, one could make an argument that they perhaps were not proper. Okay. Ill allow a colleague to pursue this, because if they choose because im out of time and for the record will ask mr. Williamson what is noble about the cost of purchasing this care without contract 7 billion do we know it or is it noble . But i realize i dont have time now. Well ask this question for the record and yield back to the chair. Thank you, mr. Orourke. Now five minutes. Thank you mr. Chairman. I am aiming this in the direction of mr. Murray and boyle. Not sure which. Theres a business in my district that supplies specialized shoes. Diabetic shoes and to vets through the va. However this business didnt have a contract. In november of 2014 11 notified them that the custom orthotic appliance and related Service Released a request for proposals. The business filled out the paperwork, denied for not meeting minimum technical requirement of having a certified, not podiatrist but padorthist on staff. Who sets the requirements for the contracts . The main va office and second question is since this business did not have a contract, how do you think the va was paying them for the Services Provided . Well doesnt matter. Ill take that. Okay. One, ill need to explore more the specifics of this case, but the requirements, if it was done by 11, done by the local Contracting Office that supports visen 11 and work for me and my organization. They probably worked closely with the prosthetic folks in that visen or at that Medical Center to develop the requirements. It is not set by the central office, i dont believe, in this particular case. Now, i dont know about the contract situation, or not, but it is possible they were being bought under the micropurchase threshold,s 3ds,000 by the local prosthetic folks with the government purchase card. And i get my follow jum question to that, the owner did say they would receive a purchase order that would have a credit card number on it and Expiration Date and couldnt purchase more than one set of shoes or inserts per time. My question is when talking about this particular organization serviced about 200 veterans in my district, and now can no longer do that. There really is no competitor, and when businesses that are highly specialized at service veterans, get stuck in this cycle, in the va between, in theyre not setting rules. Theyre responding to an organization saying, yes, well join with you in partnership to pray specialized care. So its harmful to the folks on the other end of this trying to comply getting an rfp in. Mail saying now you have to sign up for this. Theyve been providing this for a couple years already and get thrown out because they didnt have a minimum certification, but it was okay and fine as long as they were being paid through the credit card number and the purchase order. It just dont you see an inequity in that, trying to keep Service Providers even available . They have no idea what youre doing and whats complicit and not complicit. I understand. Sounds like if they were doing repetitive orders with a purchase card, that is a split requirement, a logistical discernment. 3,000 in this case a far based contract, should be, in place. You can check this out for me if i give you the info the personal info . Happy to do so yes. I appreciate it. I yield back mr. Chairman, thanks. Thank you. Ms. Rice you are recognized for five minutes. Thank you, mr. Chairman. I feel like i missed something here. Im trying to figure out why maybe mr. Murray you can answer this question. By is there such a reluctance to apply far regulations, when talking about nonva care . If you can give that answer succinctly, because i have a lot of other questions. I dont sense theres a reluctance at, you know, the Leadership Levels. In fact, the Leadership Levels that i see, pc3 choice, provider agreements, seem to be the preferred approach for providing care in the community. That specific if you want to delve into this i think that chief acquisition officer, head of contracting activity for the Health Administration might have some sense for why this is true or could be true in the field. All right. One of the things that we try to address and try to do it with the lechs strags request that came in, were not known as being the most streamlined and easiest to deal with. Brad street numbers, vendors have to do this, apply for federal contract wage statutes. Theres a lot of additional arktivety to do business with the government. We tried to recognize with the legislation, an order of precedence. We want to start deliver and provide care in our va Medical Centers. Next is with contracts. Next with agreements. Our last preference would be what has been termed the individual authorizations. So we want to the have that as really kind of the backstop as we go through this priority hierarchy in providing care, we see that as the, the least preferred option but one we dont want to take away from approximately 400,000 veterans that are being served by some of those small providers. Mr. Giddens, its become a 7 billion backstop. Right . I dont know all seven of that, all seven, i believe is for overall fee and some happened through far and nonfar. The problem i dont have the breakout. The problem is that theres no comprehensive auditing that has been done. I guess mr. Williamson, if you could i mean what what i see a pattern of is either gao or Inspector General saying heres a problem. Heres how you fix it. And a intentional or negligent failure on the part of the va to take recommendations and actually implement them. So can you just tell us what youve recommended, the va do, and where they are still lacking . Well, of course, as you know, we put va on our high risk list very recently and part of the justification for that was that they are not implementing many of the recommendations. In fact, over 100 recommendations weve made that va has not implemented just in the Health Care Area alone. So so there are 22 recommendations, and i dont want to use all your time up but let me give you a couple examples. One is, we recommended that va keep track, wait times, for for veterans that went to nonva providers. They have not yet done that. Weve talked to them about it. They still havent done that. Whats the reason for them not having done it . We dont really know. When you ask them you tell them, how i think what theyre looking at. They want to close a case from the time the veteran starts the process of getting an appointment to the time the claims paid. They want to do that in 90 days and they are tracking that. But for some reason theyre reluctant to track the 30 days. Why . Good question. I dont know theyve given us a great answer on that. What would be a good answer . Is there a good answer . They probably dont have the systems to do it. It takes a lot of work. It does. It does take some good data. But thats not a good reason necessarily for not doing it. Mr. Williamson, so youve laid out a blueprint for how the va can improve, whether its tracking wait times, doing better audits to see where these multibillion dollar expenditures are going. And i guess what i and maybe there isnt an answer to this. That it seems to me that you have not been able to get any satisfactory answers as to why youre recommendations have not been implemented, and maybe youre not the right person to answer this, but i dont know if anyone at the va, i havent heard mr. Murray give explanation why. So well i think part of it is that, it always comes back to the same issues no matter what youre, what program youre reviewing in va. The data is often insufficient. The awed mated systems they have in many cases cannot produce the kinds of things they need. And it comes down to a lack of oversight. Both at the local level and at the Head Quarters level, and time and time again, the claims processing problems we found on the Emergency Care for for nonserviceconnected veterans, same thing. The problem is that you there will be no overall cultural shift at the va unless there is meaningful oversight, whether talking about this issue or about how whistleblowers are treated, or anything else. And thats really at the heart of the problem. Isnt it . Comes down to accountability, and its not there. Thank you, mr. Williamson. I yield back, mr. Chair. Thank you ms. Rice. Mr. Lamborn, youre recognized for five minutes. Thank you mr. Chairman rch and i appreciate your leadership in pursuing yet another scandal, basically. Here it is june 1st. Its another month and we have another scandal. And it seems like the whole year been like this and i for one am getting sick and tired of it. Mr. Williamson, id like to ask you for some background in this whole issue. Whether we call the contracts illegal or just improper or noncompliant, what can go wrong when the va doesnt follow the proper procedures as regards these contracts . Mr. Williamson . Youre talking to me . Yeah. Oh, okay. I thought you were from a gao perspective. You know im not a lawyer or a procurement expert either, and im, in listening to what ive heard today from the va witnesses, im a bit confused, because in one hand you know, there are did they say theres no impetus or reluctance to do a farbased for purchased product for va nonproviders i think there is. Otherwise mr. Frye would not have had the difficulty hes had. I think i would i would want to know, i would want to know what a far base system would mean to accessible care for veterans because the end game here is still providing high quality, accessible and Cost Effective care for veterans. And so if a remedy to solve the problem, if a far based if its determined that a far based system should be used here the remedy should, i would want to know how long will it take . In this process, for a person of her contract to be executed. And what the process means. And i would want to know how it affects the accessibility to the care for veterans. Also, one thing we havent mentioned yet is the whole idea of what it would mean for the acquisition workforce. When we did our clinical contract care work, we found that the Contracting Officers and the Contracting Officer representatives who do most of the legwork for the Contracting Officers already are stressed in terms of work load. If you increase that work load you double it tenfold, whatever, whatever it would mean to get a farbased system, then you know what would it mean in terms of budget for hiring new people and so on . I just dont know what a farbased system would do in terms of accessibility and the work force, and thats what we need to know. Whats interesting the gao identified six categories of problems that can arise when proper oversight is not provided by the va. The type of provider care, credentialing and privileging, clinical practice standards. Medical record documentation. Business processes. And maybe the most important to me, access to care. So let me turn now to mr. Frye. Would you agree that those six areas are called into question when proper procedures are not followed . Well, yeah, absolutely and in addition to that, when federal contracts are required and you dont use them there are terms and conditions that are completely missing from the contract. By federal statute, youre required to have terms and conditions. These include the termination for convenience termination for default. The disputes clause. Fair and reasonable price determination. Just a whole host of issues, not not and probably even more important the terms of health care, the safety and efficacy terms and conditions that are required to be followed by these specific contractors, without those contracts, without a contract, without those terms and conditions, the contractor is free to do what he or she wants. Well and thats thats my concern. And, ms. Anderson, in regards to your statement earlier, i have to agree with you. The government is obligated to pay for as much as that are rendered, even if the Proper Foundation wasnt, you know the procedures werent followed in soliciting those services. Thank you for the opportunity to respond to that. We were comparing a farbased contract and what it what it will take to become far compliant, and then to mr. Williamson point to what end . What we really, that result in Immediate Care to the veteran. And i i i chaired a work group in july of 2014. And that work group was responsible, tasked with, identifying measures and how do we become far client . We realized after threehour weekly sessions over four months that there are lots of hurdles to overcome. Not the least of which labor issues, consultation with labor. Hiring. Hiring a Contracting Officer workforce, estimate 600, then its a how immediate can we really give the care at that point . Still, we need to go through the hurdles. So we quickly realized that we need to really begin aggressively pursuing legislation, and aggressively pursuing legislation we, working with working with the department of labor. Working with omb working with the department of justice we maam weve embedded in the legislation protections, credential credentialing, quality of care. Okay, maam. Youre getting into another issue that is is a very important issue. The proposal of legislation. My time is way over. I wanted to make the point. No ones arguing that the government should not pay these contracts. Im concerned what gao and mr. Frye identified what can go wrong when the procedures not followed. Mr. Chairman thank you for your inkulgens and i yield back. Now recognized for five minutes. Thank you, mr. Chairman, and first of all, mr. Lebonte, my deepest apologies for you, and what i understand, and you understand, much more clearly is that veterans care is a zero sum proposition. If one veteran doesnt receive the care theyre entitled toened a the best quality then its a failure. So your situation is unacceptable. The thing i encourage you on and as i looked into this, the tort issue. Thats your recourse on this and they will always try and throw barriers up both in the private sector and in the public, but there are a lot of good folks out there that can help with that. So i would hope you would pursue that. Well the efficacy of the tort program is that the va essentially invest gates themselves. I mean their attorney acts as their investigator which is trust me, people win these, and what im saying is, if this was wrong, there are people out there to assist you. There are veteran attorneys that are veterans themselves, that their job is to try and help make this right. Yes, but the va has a sixmonth start to coach witnesses where youre not allowed to file i agree. Its never easy. As youre sitting here listening to this, the issue for you is that all the rest of this is kind of irrelevant. The issue is what happened to you, and i would just say from your perspective, theres two things happening here. Were kind of at the 40,000foot reform discussion here. My advice to you is that go down that road. Pursue that hard, where you can get, redress your what im doing now and witnessing that that program is ineffective as far as va investigating themselves. The va attorney sends the information that i send the attorney investigator to the actual hospital Risk Management coordinator who then tells the privacy officer which records they need to keep, or manipulate or lose and tells the Department Head how to coach their residents to specifically to the legal matter. So i would say to that recourse is ineffective and designed to protect the hospitals reputation rather than actually help the veteran. I wouldnt disagree with you just, my theres folks to advocate with you. Stick with it. Veteran Service Organizations others, so stick with it. Thank you. Im goin to move back to this again, our 40,000 foot, and i appreciate you all being here. And im going to my colleague from new york, ms. Rice, was hitting on this, mr. Wrmsilliamson. Ive seen it before. . O. Puts out 22 recommendations. What is the weights of a j. O. Recommendation. What does that do . Well you are, because the congress is, we report to the congress and the congress provides the leverage we need, and its forums like this that we have that bring those things to light. Exactly. This is why and, again, mr. Murray, i could go down and ask some of these but i dont think it was necessarily even a rhetorical question. I do think youre the wrong person to answer this. Were in this needs to be fixed and somebody needs to deal with this, but this is a much broader issue. Its a reform issue. The va being all things for all people and not to antagonize my chairman, this is the va trying to build hospitals trying to do everything for everybody and ive been saying we need to have that discussion to figure out how do we best leverage both the private sector, the Public Sector our promises to our veterans get quality care and do it in the most costeffective manner . So were here, i would argue, deal wig a very important issue and its very granular and were discussing inappropriate versus illegal and they do matter. The bigger issue here is that if i would ask the questions and again i dont think theyre fair to you, mr. Murmury, is what should the va be doing. How do we fix the contracting . What is the purpose and mr. Frye pointing out the holes in there this is probably not the forum for that. So i appreciate you all being here. I dont question that were all trying to get to the same point, but you heard mr. Lebonte. This is what happens when you break faith. He doesnt believe anybodys going to get good care and we can tell him countless stories of highest Quality Health care dlived in country by a va hospital and that would be irrelevant to him. I dont think well get there in the current system. I feel like, im confident your 22 recommendations will be recommended in two years from now and well be trying to implement them and that is a horrible condemnation on the entire process. They have implemented seven of them. Yeah, and it is. Again, its not because of the motive, to not provide quality care. It goes back to the institutional sdpin and issues on cull cheer were trying to get to. That level over the top makes answering many of these questions very difficult. I thank you, chairman, for your time. Well, again mr. Lebonte, i certainly apologize f