Is, if we are better at providing highquality and timely care, thats going to affect veterans coming to the v. A. They will come to us more if they can get care more timely. So having a bottomup planning approach and working with our Medical Center leadership and our Network Leadership to give us a bottom up operating plan of what their financial requirement is in the out years will also help us be better prepared to adjust for where were succeeding and when we succeed. And someone said that weve given the v. A. Everything they have requested. Now, i guess institutional memory should be important because i remember in 2007 and 2008, it was the first time the veterans were able to get the budget that they requested for budgeting. That was under president barack obama. I know im the only one that remembers that, but you know, its important to remember how you got where you are. As we move forward. You need to remember that many of us talk the talk, but we didnt walk the walk or roll the roll, so i think the walk or roe role. I think thats important for us to remember how we got where we are. And v. A. , yes, were having problems but were not to the point that we need to destroy the system, and i feel very strongly about that, and i dont want to be the only one saying that the v. A. Shouldnt i mean, i think we should work with Community Partners and Community Stakeholders and how do you feel about that . We have Teaching Hospitals that we should partner with. We could share equipment, but i still want v. A. To be in charge. Yes, maam. As i travel around and visit v. A. Medical you just returned Foreign Policy grainsville . Yes, maam. And after Medical Center after Medical Center im impressed with the academic affiliations we have with local partners in the communities and all the benefits, all the many benefits, the extraordinary care thats being allowed to be made available for veterans, the expert staff, clinical staff that were able to recruit in part because of those because of those strong affiliations. Its one of our opportunities to continue to pursue. Thank you very much and thank you for your service. Yes, maam. I yeel the balance of my time, sir. You got 42 seconds. Dr. Rowe, you are recognized. Thanks very much, mr. Chairman and thank you, mr. Secretary for being here today and thank you for your service in this tough time. I agree with your Opening Statement. Ive said this in the very beginning. One of the problems the v. A. Has that it did have was lost of trust, and i think ms. Brown brought up the point a minute ago that a previous secretary and ive said this the very beginning, what the mow toe should be of the v. A. Is we work for the veterans. I dont wok for the v. A. I work for the veterans. That cultural change will help. One of the things im just not sure about having more people is going to solve the problem because when i came on this committee five and a half years ago, there were quarter of a Million People that work for the v. A. , 250,000 people and the number i saw in your testimony is 341,000. Thats more people that work for the v. A. Than any city in my district. Its huge, and im just not convinced in getting bigger is going to solve the problem. I think Getting Better will solve the problem and getting more efficient will solve the problem, but i dont think getting larger may make the problem worse. I honestly believe that. And when you see an office go from 800 people to 11,000 thats mind boggling to me, that that many more people could be needed when you dont have that many more employees. So i think i think you are looking internally. I truly believe that. A question i have is you mentioned accountability, has anyone been held accountable yet and terminated . There were three actions that were announced dealing with phoenix back about two months ago. Theres an additional individual thats been placed an executive manager who has been placed on a leave of absence. Has anybody that doesnt have a job that had a job . There is its called being fired. I understand what being fired means and im learning the hard way how you do that in the federal government. And so tougher. It starts when when you create this massive base of information thats documented. We just got i got the end of june, i got the first results from the ig, finally released on one location. A thousand pages of transcripts of sworn testimony and in the midst of all of that, there still wasnt all the information needed so we had to dispatch additional investigators to go take additional testimony. We reviewed all of that. We pull email traffic, and then we go through the process of i have to delegate authority for a proposing official and a deciding official and they have to review all the information. There are two things going on right now in the accountability space. Let me interrupt you because my time is short. Youve just made my point. When you were in the private sector, did you have to go through a thousand pages and do all this to fire somebody . No. The answer is no, you didnt. So creating more inefficiencies in there, i think more people making this bigger, before we trim it down and make it better is not the right direction, and i want to very briefly, i dont have a lot of time left, but were going to have to try to have make decisions, Big Decisions in the next week or so that involve a lot of money, the taxpayers money and its 17 billi billion. Ive asked every time do you have enough money to carry out your mission. How will i know that this is enough money . Because ive voted for every single budget. Thats one of things im never apologize for up here is to spend money on our receipt veterans. I absolutely would never do that. We would not have this country the way that it is, the way i enjoy and grown up if it were not for the veterans of this nation. Thats not an issue, but i dont want to take the money that hard working people including veterans go out and pay taxes and not spend it wisely. So can you tell me how this 17 billion and thats 17,000 million dollars, where im from, thats a lot of money. A lot of money where im from too. How is it going to be spent and can i know is that it will be spent wisely and would it be better to not take some of that money, but to veterans who want to, if a veteran says i would like to go see my doctor outside, just let that veteran do that, would that not be cheaper, the infrastructure is already out there, the hospital is already out there. We had those folks out there a week and a half ago today who expressed the desire to do that, and they had the capacity to do that. Would it be more easier and more efficient to just do that . One of points made earlier was the fact that veterans are pleased with the care they go, once you get it, its hard to get it. I agree they are pleased with the care they get in the private sector for the most part. The other thing thats been interesting to me is weve been working down these lists and we call veterans who have been waiting out for care, we ask them do you want us to refer you to community . Sometimes the answer is yes. But oftentimes the answer is no. I want to wait. I had a sergeant in my office this week. But he call the v. A. To cancel his appointment. He was open hold for two hours. Two hours. He walk around his office doing his job, and then later, when he was when he had an appointment, you all have done something, ill tell you at that because he said he got eight different phone calls from eight diven people about his appointment. Now, is that efficient or is that inefficient . It doesnt sound very efficient to me, sir. I yield back. Thank you very much. Mr. Secretary, is there a storage of doctors at the v. A. And if so, what areas are the shortages in . I would say the short direct answer is, yes, there are shortages and there are shortages in primary care and Specialty Care and Mental Health all three. Mental health is a big percentage of the shortage. I heard theres a problem referring people to specialists. What are the v. A. s most successful recruitment tools and does the v. A. Need stronger tools for recruitment . I think we have a number of very strong improvement tools. One of the areas where we have done a lot of work is in surgery. The Surgery Program has actually made significant use of infomatics to look at practice, process and to identify deficiencies. That program runs nationally and is able to actually support both at the regional level, recruitment one of the areas that had come up before, would we look to have a Tuition Reimbursement and other kinds of authorities like that provided and i think looking at costs, those are valuable, and i think we need to look at extending those. Recruitment is that kind of recruitment, Tuition Reimbursement, presupposes that theres a supply thats adequate to recruit from. We know that doctors are more likely to stay in practice in a place where they completed graduate and medical School Education. Gmes seem like one of the best recruitment tools the hospitals have. Is the v. A. Ewing gmes effectively. I think we are. Where we have developed a strong academic affiliate, we have a good pipeline of quality providers who want to work in the v. A. They understand our mission. They love our mission and they come to work for us. Would you welcome funding to expand the v. A. s gme program. I know the v. A. Has normally been 10 to 12 of graduate School Education, with medicare and medicaid have been taking 98 . Weve been frozen since 1996. I think that is contributing to a storage of doctors generally. I have to look at that. Conceptually, he would support t but i need to look at the details. Do you think if we were to increase the number of graduate medical School Education slots at the v. A. I think so. Would the current fee basis system, has the lack of interoperable between the electronic records between the v. A. And nonv. A. Been a problem . Is the requirement that we have, we have the responsibility to maintain continuity and coordination of care. It has, congressman takano. I think in some of our contract options, we have the ability to Exchange Electronic data. Thats written into the contract. Heres the thing. I think manufacture many of us support the idea of nonv. A. Access, given our emergency situation, both public and private, we support that. A lot of us on the democratic side. But the concern about the solution thats the focal point of the funding, is the continuity . We are looking alt one of major contracts we have today to look at further making the data that we share back and forth computable. Today it is not computable. When we have individual authorizations for fee care, it will come sometimes in paper and we scan it. So we need more interoperability to make outsourcing for feasible. The interim ig said in the long run the best efficiencies for the v. A. Are going to be own its own doctors and to keep care within its system. No system really, whether you are private or public, wants to outsource of out network care. Theres usually a huge charge to go out of network. I think the v. A. Has same sort of situation. In this emergency situation, we want to make sure that there is couldnntinuity of care. We think in terms of extraordinary geography, technology and demand. Clearly in a period rhine of extraordinary demand that were dealing with as we accelerate care to veterans waiting too long. Extraordinary geography, theres going to be communities where we cant justify building. Were going to have to provide timely and appropriate care for those veterans. There are going to be occasions where very highly specialized procedures that were going to want to refer them out. We want to maybe set the parameters so it really is possible and really does work. Correct. Mr. Chairman, i yield back. Thank you very much, mr. Florez. In your testimony, you said, quote, we will work hard to earn your trust, unquote, we being the v. A. And your trust being the trust of congress. Your background and my background are fairly similar. We are both c level organizations in private sector organizations. You as chief Financial Officer and me as chief financial and executive officer. In those positions, we were reporting to boards and was responsible for the organizations. Lets say you are the ceo of a organization that has caused funding levels to be higher than were actually used, and those funds were reprogrammed to other purposes without letting the board know, and then you have a Resource Management system that accordingly to your own system is not accurate so in light of that what do you think the boards reaction would be if you go to it and say i need a whole bunch more money, and im only going to give you three pages to explain it . So thats so the first part of the question. The second part is wouldnt it have been much more wise to come and say we need a small amount and were going to many could back to you in a few months and show you what a great job we did with this small amount and then say in light of that we would like to make a larger request because were on the the right track . So thats my first question. Well, i think the sense is that we needed to provide, as the Conference Committee was considering other appropriations, we needed to provide our best estimate of the requirements to meet the current demand. You turned those requirements into a request. And i dont think that was wise. I think it would have been a lot smarter to koom back to us say this is the down payment we need and if we are successful in turning this around and putting Veterans Health care first, then were going to come back for you and ask for x, y, z, but you asked for the whole enchilada at one time. Thats caused a lot of folks to look at that. Lets go into a little bit more granular information. In the Health Care Model that the v. A. Uses, its call the enrolling health care projection model. That takes into consideration a number of components, projected number of enrollees, workload, unit costs for providing the services, in fiscal 11 and 12 the v. A. Used that for the sources for Health Care Budget estimates. In 2014, it expanded the use to develop cost estimates beyond that. Over the years, gao has identify many problems with that since its not a very trustworthy product so thats an issue, and now the administration is asking 17. 6 billion, which is an unwise thing to ask. Here are my questions, you can answer these supplementally hoel before the end of the day. Number one was the chcpm used to clear out the current background lock from the v. A. , why did the ehcph failed to effect the demand on the system, and is there a way it can be adjusted to incorporate wait times . Should we continue to advance appropriate v. A. Health care funding if clearly the method used to predict the funding needed to far in advance is not working . As i said earlier in my testimony, the v. A. Overestimated and then used the funds for other purposes without talking to congress or its board, so the model just goes all over the place. Now you are saying that it needs 16 17. 6 billion. Did you use that . Indirectly. We used unit costs that were derived from the model but we look at appointment wait time and used the data that we had for veterans waiting for care greater than 30 days. Thats different from the model. Everything else was starting looking at the data that we had at the time. Do you know why the ehcpm failed to pringt these estimates in the past . I dont know that it did fail to predict it. I would have to go look at the details the facts say it did fail. Get back to us on that as well as my third question. I yield back. Thank you, very much. Ms. Titus, you are recognized for five minutes. Ms. Titus, you are recognized. Excuse me, mr. Chairman. Well, i think we all agree that the purpose of these hearings and of your proposed reforms is to increase service to our veterans and to their families. These are services that they have deserved and i thank you, mr. Secretary, for being here and all that you propose to make that happen. We have heard of all the many problems and if these problems exist generally for veterans, i think that problems are perhaps even worse for our lgbt and Women Veterans and thats where i would like to address my concerns. I will ask you, mr. Secretary, do you believe that veterans and their spouses should have equal access to federal benefits through the v. A. Regardless of their current state of residency . Yes, maam, i do. Well, i thank you for that answer and i ask you this because last month the v. A. Announced that your agency has exhausted all avenues in the wake of the decision by the Supreme Court in windsor versus the u. S. That struck down doma for giving benefits to our lgbt veterans. Unless congress acts, those veterans who live in states who dont recognize their marriages would be denied access to their earned benefits, is that correct . Thats correct, yes, maam. Thats most unfortunate. Because of that, i recognize that need and after the Supreme Court decision, i introduced hr 2529, thats a very simple bill that would correct that language problem in the statute. We had a hearing on that last march. Nobody came forward to oppose it. We had vsos speaking in favor of it. Nobody is working against it and i will ask you would you support our efforts here in congress to make that change so all our veterans who have all worn the uniform, senkd the United States, could have access to those benefits . Maam, im not familiar with the legislation specifically, but my own policy decisions at the department have been to provide equal benefits to all veterans to the maximum extent permitted by the law. And i thank you for that and our veterans do too. Im sure. As for women, i would like to ask you about that. Some of the recent reports have highlighted some very disturbing statistics about the low quality of care that our Women Veterans face and they are less likely to seek out care. They are often called our silent veterans. But when they do, weve found th