Veterans, id like to see im a v. A. Provider even if its in my private practice. We should come over and discuss that. Ive been asking and secretary gibson said, imstaff, supplies everything involved would be important to this entire committee, the cost is not just the paper. Dr. Ruiz. Thank you to the chairman and Ranking Member for holding this hearing when brave young men and Women Volunteer to serve in our armed forces, they swear to support and defend the constitutional of the United States against all enemies foreign and domestic. The Service Members make a promise to their country to all of us to keep us safe and protect our way of life in recognition of that service we promise to care for them when they return. So veterans is served and sacrificed and we must do whatever it takes to hold up our end. Many veterans in my district excluded from the strict requirements ochof the Choice Program dont receive care for what they are authorized because the v. A. Has begun delaying elective care due to the budget short fall and as a physician, i can the tell you that even if a condition arguably does not meet the v. A. s working standards for authorizationing nonchoiced purchase care it may feel painful and very urgent to the patient. Veterans being deprived of health care they earned whether due to unforeseen increases in cost or demand, budget tarry mismanagement at the v. A. Congressional dysfunction, or any other problem outside the veterans control thats completely unacceptable and absolutely critical we stabilize the immediate problem and resume surfing veterans who need Community Care at full capacity prevent any furloughs or facility closures and reform whatever Structural Systems at the v. A. Have failed. You are actively searching for new ways to be able to predict the future needs of veterans. This is a problem due to the success of having 7 million more appointments but as a physician and Public Health expert i understand that you really cant predict to the tee the health needs of a growing population of a system in transition that needs to take risk to identify best practices and understand that some of these practices may fail and therefore we may need to learn from those lessons in order to improve. And your mention before the term management is what this come myth thety has done in the past now youre managing to the requirement and i want to one requirement youre managing to is only one larger piece and complex and whether a veteran gets seen in 30 days is not the same with quality care and respect they need and efficiency of care when they are being seen and thankfully, a lot of veterans rate their care very highly, but so we need to manage to the Veterans Health care needs with efficiency and to the point of measuring how much it cost and efficiency and Percentage Rate of cost due to or the amount of cost due to an increase in 1 of v. A. Care that reflects on the efficiency of the v. A. So i really want to stress those points and my concern here is these claims that were shutting down facilities that its not being and the way its being presented is that youre holding these v. A. s hostage because youre not getting your way and thats absolutely, i know, with the sentiment not true so can you first question can you explain more whats going on in denver and how the this is affecting the care of our veterans in receiving that care and two, one of the concerns is that if you take, if with the this flexibility, which i think its a great idea, if you take money from one pot that you already have for another there is always going to be take aways. So is this a surplus fund is the this what is the take away that is at risk here . The choice care act itself that Congress Approved was to provide care in the community for veterans and there is a 10 billion appropriation that is to expire in three years. What were talking about is care in the community largely there is another half a Million Dollars, half a Million Dollar for hepatitis c drugs. So we would be using money for what it is set aside for, care in the community and that way, you know were using the money that was set aside for, not a new appropriation. Secondly the issue you raised about denver is because we have flexibility of moving money between accounts the accounts that the money came from this fiscal year for denver veterans and and has no enimpact and we got to put that money in the 2016 budget. Budget. Thank you. Yield back. Mr. Costello. Thank you. I would certainly like to associate my comments with those of congresswoman rice and congresswoman ruiz in term it is of frustrations, at least what ill hearing in my district and i want to assure those veterans that i will work at 110 to make sure there is no uninterrupted care for veterans out there and im confident in the leadership. Were going to resolve this so that there is in no way, i want to focus on a couple things that are either in your written testimony or that ive learned that are very very frustrating for me and i want to start with the issue of technology. I want to talk about technology and your use of the term flexibility. So in 2004, the v. A. Received 475 million for their i. T. System. G. A. O. Report comes out and says that there is essentially nothing to show for it. In 2010 congress was going to provide 400 million for another update and the v. A. Pulled the plug on that. You werent around then. I wasnt around then. Its clear in the past the v. A. Identified the need for updated Technology Capacity as well as congress being willing to invest in that. This request relates to the Financial System and to why you have a budget short fall. Sort of what you said in your testimony thus far. But on the issue of flexibility you indicate the quote on page 3, all together over 70 line items are influxble. Freed up they would help us give the v. A. What they deserve. Are you talking about the entire 170 plus billion budget and is that all the line items . Yes, with the choice act weve given the veteran a choice whether they get their care in the v. A. Or outside the v. A. Very simplistically, they cannot be comingled. I got to predict how that veteran makes that choice. Right. Or come back to you each week. I think dr. Ruiz, i get where hes going. Look, the need, you dont always know what the medical need is going to be. I understand there has to be flexibility within a budget to appropriately address the medical needs of the veteran but i also feel that in a budget of 170 billion that if that is itemized among 70 line items 70 line items for 170 billion isnt that many line items and in terms of flexibility, the more money we say oh, here is 700 billion, do what you like with it, the more we get into the issue of 475 million disappearing into an i. T. Budget or oh, that didnt really work out over there and so i dont like the aspect of just shifting things around without there being acontinuebility to congress, i dont think taxpayers we agree with you. If were able to do this, we would Work Together on what are the restrictions and what are the budgets that should be comingled. Comingled. Let me just, next question related to that and youre looking to use choice money and there is and that there is just a reluctance by many in the v. A. To sort of buy in pardon the pun, to the Choice Program. Congress policy not only did we want to offer but we wanted encourage it. Now i feel that because some in the v. A. Since there is money left over and time to institute that legislation we can take it out of the popular programs and shift it elsewhere and again, gets back to the issue of accountability and transparency. You use the term flexibility and i understand why you need it is to be painting too much of a broad brush using the term flexibility or budgeting purpose and lose the accountability we need and havent had and the source of some of the problems that cause us to be here today. Were very much in favor of care in the community and in favor of the Choice Program so if youre, if you or veterans are encountering employees we need to know about it because that would be wrong. I mean, were trying to create a culture where we dont care where the veteran gets care as long as they get great care. Final point here as youre talking about a new i. T. System to better handle budgeting and planning, for my opinion, mismanagement can be very visible, im not suggesting you have mismanagement, it can be visible and not visible and i think on the i. T. Side its easy to mismanage things through the years and not really have any ability for those doing oversight to really know about it. Because its sort of on the planning side behind the scenes. I think moving forward, as youre talking about i presume coming forward with what your needs are going to be for new i. T. System, it has to be thorough, it has to be comprehensive and the ad hawk we need money here and money after and i think it needs to be a comprehensive plan so we have confidence in what youre proposing is going to solve problems and over the long term reduce cost because from a management perspective, you have more transparency and things will be more efficient. I yield back. We agree and would love to have laverne counsel the head of i. T. Come talk. I think shes going to be terrific for us. She has experience as the head of i. D. T for Johnson Johnson and dell. Thank you, mr. Chairman. I want to thank you, mr. Secretary, for your service in the army and secretary in this very complicated transition period and we hope it turns out well and well do our best to make sure that it does. My first question has to do with publicprivate partnerships. Secretary gibson mentioned on a june 25th hearing, you and he had spoke about this and youre in favor can i ask you that question, do you feel the va could benefit from Public Private partnerships . One of the five strategies for my v. A. Transformation to the v. A. Is strategic partnerships. We have a leader of the office and yesterday when i was in pittsburgh working in our medical center, there was a wonderful example. I met with the chancellor university of pittsburgh, dean of the medical school. We have a Great Partnership between the medical provider with the university and with the v. A. This is a system omar bradley set up in 1946, 47 to make sure veterans get the best care. Those partnerships are critical to us. Thank you. Mr. Secretary ive looked at this graph that the v. A. Care and Community Short fall and if you divide 7. 6, its clear youre going to miss the target what took so lock given this information or was this not available in what we protected was lower. We, the obligation data was under stated early in the year that reflects the experience. How much of the 3 billion short fall is due to understand casting . I dont think its under forecasting. I think we had anticipated of the care in the community would have gone through the Choice Program and been paid for out of choice dollars appropriated for the program. That program, you know im you know, its a complex program that was as it was structured is, we have pay back on our contract to get it done because no one else in the intusdustry was interested in taking this on and we have business processes that quite frankly need to improvement and were working on those things. So i think that we had a choice, we have a Choice Program that we and you need to get more care in the community for veterans were not waiting for care. We have not been able to get and maybe some of it is cultural but we have not been able to get the number we anticipated. That has not shopped us to be faithful to the intention of Congress Passing the choice which was no veteran should be waiting. So really what were asking for is to be able to use funds that were appropriated for the purchase of care in the community through the Choice Program to pay for care that we purchased in the community that is not through choice but through the normal mechanisms because we have over subscribed to those programs. How soon do you think we could provide that flexibility. Were asking you to do it before you leave in august, so by the end of this month. So it would require it would be passed and signed into law by the end of august or by the end of july. The money has been appropriated so im not an expert on what congress does so i yield to the chairman on that but yes, i assume its some kindof of bill. We would have to authorize the transfer of those dollars out of a finite amount from the Choice Program. Well a painful question. Can you provide a list of the facilities that would be closed if you dont get that money . Or how soon can you provide that list . We have an entire plan together which we can share with you. I would just say that when we run out of money, so we would move fund around between facilities as best we think. Medical services will be the first approachation that runs out. It will affect essentially every facility in the country. Thank you, mr. Chairman. Dr. Abraham. Thank you mr. Chairman. Let me i guess, just start big by saying the old adage in business, you can delegate authority, but never responsibility. Mr. Secretary i know you were ceo of a major firm before you came aboard. I would think if you had came to the board of drejters at the 11th hour like my brown indicated, they, too, would be a little incredulous at the shortfall, the lack of vision so to speak. And we dont want to disparage that. We understand that everybody in this room certainly on this committee and yourself and in this room has the veterans best interest at heart and i do believe that. Let me hit it just from the hepatitis c. You and i both know its an insidious disease. I had three Vietnam Veterans come up to me and say that they had yet to receive anything from the va because i understand thats in the pipeline and i do understand that the help titus drug was only approved in 2013. But still saying that that still gives us about a year and three quarters to formulate plans, delegate how this medicine is going to be divvied up so to speak and it hasnt been done yet. Can you give me some indication as to when our Vietnam Veterans, our iraqi, afghanistan veterans can expect some hard data as to if they are at this point of the disease they can get the treatment . Yes. So we of course, those drugs were not approved by the fda when we submitted our budget for i understand that. So we have a plan. Weve had a plan all along for the treatment of hepatitis c. But when will the veteran he or she know that hey, i can get treatment mow. Weve treated over how are you delegating which veteran gets treated and which veteran does not . So you may be getting a little bit over my head in terms of help titus c. Our hepatologists are managing that. We have a severity score, based on whether the veteran has advanced Liver Disease. If you cant answer if you would just give me that information as to how that determination is made, there are blood tests, their bile load, liver biopsy results. Ive treated hundreds if not thousands of hep c cases id be happy to get you the information. Today, weve treated over 20,000 veterans with hepatitis c today. And we continue to treat patients with advanced Liver Disease and patients who can go out into the community, have Choice Program as an option to do that. And secretary, you had that of that 2. 5 to 3 billion that you were anticipating, shortfall, that 500 million of that would be designated for hepatitis c treatment . For the treatment itself . Yes, sir. Okay. I yield back, mr. Chairman. Thank you, mr. Chairman and thank you, mr. Secretary, for testifying today. With regard to the medical scribes, elaborate on that part of the program. I know in the private sector these are great private Sector Solutions and i know that the doctor will have more time. Its been proven in the private sector that the doctor will have more time with the patient. I had a town meeting that lasted four hours a couple of weeks ago. People were bringing that up. So, you know you want the doctor to focus on medicine. Elaborate on that program, that pilot program. Well we ive heard a lot of this. Ive been to 195 different va facilities and every one i go to theres a different approach. But we are pretty consistent in the operation of a p. A. C. Team which is a patient care team, a team working with a particular patient. I think what jim was describing is lets pilot the scribe so everybody on that team can be working on the patient and not just entering information into the medical record. I didnt come prepared today to really expect this question. So i will have to take it for the record and get you information about where we are in terms of standing up a pilot program. Okay. Thank you. Any other Innovative Medical Solutions coming from the private sector that youve implemented in the last year . Do you have an adviserry council set up possibly to work in the private sector to get these ideas and make yes, we do. We have believe it or not, we have more than 25 Advisory Councils, but we have two that id like to tell you about. One is our special medical Advisory Council which is the best medical mind, i think some of the best medical mind in the country thats shared by the chairman is john kurlin. John is the chairman of the american medical hospital association. Hes the chief medical officer of hca. Hes also a former undersecretary of health. Theyre providing tremendous leadership. On the on the my va work that were doing the transform va, weve set up an external Advisory Council. We have many doctors that are part of that including toby kos grove who is the head of the cleveland clinic, rich carmona a former Surgeon General and a veteran. But i have to t