Transcripts For CSPAN2 Key Capitol Hill Hearings 20140717

It continues to be sluggish and i cannot give you a reason why that occurred. We are aware that mortgage credit is very tight for a wide range of borrowers and that maybe part of it. We hear about supply constraints builders are facing but i have to say i am surprised. What more do you think the fed can do to help stimulate recovery in the housing sector both for those homeowners who are upside down in the values and those to help new people qualify for homes. Housing prices are continuing to increase. And they have increased substantially and in the markets that saw the worst booms and bust that is the case. So in nevada there are a large fraction of homeowners underwater but if you look at the numbers just the increase in house prices we have seen and i think that is in part reflecting or monetary policy, maybe fewers barrowers are under water. The numbers have declined and i know the Las Vegas Area was one of hardest hit areas. I think we will see greater progress eventually in the Housing Market but there are many impediments they face in the aftermath of the foreclosure problems during the crisis and things havent settled out there. Acting va secretary sloan gibson testified that the Veterans Affairs department has lost the trust of the nations veteran and American People because of widespread medical delays. That hearing is next. And Senate Republicans blocked the democratic bill that would have forced companies to provide Birth Control to their employees regardless of religious belief. It would have negated the recent hobby lobby decision. And doug elder makes questions on the economy and budget at a house hearing later on. July 20th marks the 40th anniversary of the first lunar landing. We talk about the life of the first man to walk on the moon surveillance Transparency Act saturday night at 10 p. M. Eastern. Acting va secretary sloan gibson talks about the changes underway since taking the temporary position in may after Eric Shinseki was forced to resign because of medical delays. Robert mcdonald will become the next secretary if approved by the committee. The committee is chaired by Bernie Sanders of vermont. Lets get to work. Good morning. Welcome, everyone, to what i think will be an important and productive hearing. We look forward and welcome mr. Sloan gibson who is the acting secretary for the department of Veterans Affairs who will be discussing with us what he has been doing and what i perceive to be an active six weeks since you have held that position and we also look forward to hearing from him as to what he perceives the problems facing the va in the months and years to come. I would want to mention to the members of the committee that next week on the 22nd we will be holding a conformation hearing for Bob Mcdonalds the president s nominee for the secretary of va. Last week not last week, last month, despite a partisan environment here in congress, 93 senators put their differences aside to vote in favor of a significant piece of legislation which we hope addresses many of the immediate problems facing the va. It an issue that senator mccain and all of us in the room worked hard on this and i want to thank you for your support. It is my hope that will be completed by the time we leave for the august break. It is clear to all of us that the va faces many, many challenges and they are welldocumented. The concerns that i have that have been well publicized is that we have many veterans unable to access va care in a firearm timely manner, we have accountability issues and we find unacceptable people manipulated data in terms of wait times and people have treated whistle blowers with contention and people have lied and that is not acceptable and we want to hear from mr. Gibson to hear what he is doing to address those problems. But the issue i want to focus on is while we are determined to do everything we can to make the va, which is a huge intuconstitution providing 6. 5 million veterans with health care, we want to do everything we can to make that agency efficient and accountable, there is another issue we have to address that is part of our responsibility and that is what are the real needs facing the 22 million veterans in the country. And how as a congress are we responding to those needs. Number one, the va has to be accountable, efficient and we have to address many of the internal problems we have all heard in the last several months. Secondly, we have also got to ascertain what the problems facing the Veterans Community and their families are and do everything we can to make sure the va is in the position it needs to be to address the problems. Let me mention some of them. Of the 2 million men and women who served our country and put their lives on the line studies suggest that 2030 percent are coming home with ptsd or tbi. That means those wars have created 500,000 mentally wounded American Veterans and as a result very Serious Problems regarding suicide and this committee will be dealing with that issue in connection with ptsd, substance abuse, inability to hold on to a job, divorce, emotional problems for the kids. When you deal with posttraumatic stress disorder is isnt just the soldier it is the wife and kids. The number receiving special Mental Health is up from 900,000 to 1. 4 million in fiscal year 2013. This means in fiscal year 2013 over a quarter of those receiving were being treated for Mental Health conditions. In other words, va currently provides 49, 315 outpatient Mental Health appointments a day a day 49,000 Mental Health outpatient appointments a day. Imagine the challenge if we had endless supplies of money and adequate numbers of doctors in this country this would be a republic. That is the cost of war. Ensuring timely access to medical care is critical for the veterans and their loved ones. The suicide is a tragedy beyond words and not easy to deal with but we have to address it. Like most americans, we are all concerned about these waiting periods and i know mr. Gibson is going to be talking about that in his testimony. But let me go through the numbers to understand the scope. 46,000 veterans are on list waiting to be scheduled for medical pointments. 8,000 have waited over 120 days. We could have an argument, but i dont think there is much, whether 14 days is an appropriate number, i think that was overerly ambitious. When you have over 8,000 veterans waiting over 120 days to receive an appointment and that is 120 days before they are told they will be seen that is not acceptable. 600,000 veterans have an appointment that is more than 30 days from the date the appointment was requested or desired. That is not acceptable. The numbers are staggering and that is an issue obviously that we are addressing right now and we will hear from mr. Gibson as to how he is going to go forward with that. I think the goal of every member of this committee and i would hope and expect every member of congress and the American People is that the veterans of the country and people who suffered so much deserve Quality Health care and deserve it in a timely manner. What i look forward to hearing from mr. Gibson about is the needs of the va in achieving that goal. We are talking about a Staggering Number of veterans coming home with ptsd how many doctors do you need and how many will you get them . How many primary care physicians do you need . How many specialist do you need . If the goal is to provide health care in a timely and Cost Effective manner we need answers from the va and i hope we get some today from mr. Gibson. Needless to say the other issues i know members of the committee are going to be asking is what actions the department has take to know reprimand employees who have lied and manipulated data, what are they doing to make sure it doesnt occur again, what are they doing to deal with other areas that have been identified by other organizations. Let me give the mike to senator burr, the Ranking Member. Thank you, senator and welcome secretary gibson. Since the last hearing, there have been several developments on the scheduling issues and the problems. The va is taking steps to address the culture that has been identified by several independent sources. These changes will not happen overnight and this committee must provide the oversight to ensure the changes occur and are effective. Even with the steps va has taken, there will continue to be reports and allegations regarding va facilities and workers. These reports will not only highlight critical areas of needed reform, but identify the magnitude and breath of the systemic issues facing the va. The ongoing internal evaluation by the va as well as investigations being conducted by Inspector General and counselor are essential to rebuilding Veterans Trust and stakeholders and employees. The role of the office of special counsel and the Inspector General are more crucial now than ever before. Both offices are essential in identifying systemic issues facing the va and i would like to highlight a few critical reports that have been released since the last meeting. At the time of may 15ths hearing there were several stakeholders who didnt race to make judgments since the phoenix reports were regulated. And since the report there has been a secret wait list and other things. The ig identified 1700 veterans waiting for appointments and were not included on enelecan electronic wait list. They found this wasnt an isolated event. The ig has received numerous allegations regarding mismanagement, inappropriate hiring decisions, sexually harassment and bullying behavior by mid and senior level managers. These allegations seek to the culture that has taken deep root throughout the entire department. The office of special council released a statement on va whistle blowers and sent a letter to the president and described the office of medical inspect inspectors consistent use of harmless errors, i quote. This is there defense. Where the department acknowledges the problem but claims patients were not their cares were not affected. The letter details ten pages of agregious care where they dismiss potential patient harm. Two veterans were admitted in one case to an inpatient Mental Health care and didnt receive evaluations for more than seven years after being admitted to the facility. Another case in the letter describes how doctors copied previous provider notes in more than 1200 patient medical records instead of recording current readings forpations. The culture at va and the lack of management and accountability is no longer going to be tolerated. Secretary gibson you have taken several actionable steps in the last month and a half and i commend the work you have done. However, what happened over the course of the years is a blemish on the vas reputation and much more work will be needed to repair that damage. As the va continues to move forward in improving veterans access to care and changing the culture that has taken deep root within the department this committee has a lot of work to do and needs to take an active, vigorous oversight role to make sure the problems identified over the last several months as a host of ig reports come out they are appropriately addressed and they are not allowed to happen again. Again, secretary gibson, thank you for being here and mr. Chairman i yield. Senator murray. Mr. Chairman, thank you for holding this hearing. This is a critical time for the department. The va is scheduling with systemic parties and there are openings in positions and veterans are waiting too long for care. Secretary gibson i really appreciate you stepping up during this crisis. The department need strong leadership right now. Rob neighbors review identified several of the issues which we have been discussing here for some time. A corrosive culture has developed in the department and one that is unworthy of many va dedicated providers that do only want to help. Lack of communication is a problem at all levels and va needs more providers, more space and modern it systems. As we continue to work in the Conference Committee to craft a final bill i hope an agreement is reached so we can send it to the president and make the changes so the veterans get into care and we create transparency and hold people accountable. The bill will be an important first step but as more is found we will need additional steps and we cannot lose sight of many other pressing issues. Too many veterans die by suicide, Sexual Assault victims need help, the va has to make progress in eliminating Veterans Homelessness and clearing the backlog. I appreciate your help and finally building the Veterans Home where hundreds of areas will have access to longterm care they need now. As i have said repeatedly, when the nation goes to car it also commits to taking care of the veter veterans when they return. They are a cost of the war. We know several soldiers will need care for several decades and others come years after the service ended. I am looking to hear about solutions to the systemic problem and smart ways to stregthen the va longterm because they need to be for the veter veterans right away. I yield to senator isakson. Thank you for expecting this responsibility. You are a brave and cure ageious man. We have many problems and i want to quote a paragraph here. I remain concerned about the departments willingness to address the whistle blower problems may have had on the health and safety of veterans. The office of inspector has consistently used the term harmless error as a defense where the department acknowledges claims have been uneffe uu unaffected. The letter goes on to delinate cases where Veterans Health suffered because of the Agency Looking the other way. I have become personally convinced this begins and ends with the Senior Leadership of the va for years to overlook manipulate with the numbers and making things look better. I think congress is to blame somewhat for not looking inside. The pervasive culture of cooking the books for personal benefit, such as pay raises, is absolutely inexcusable. Lastly, i hope in your remarks, which i am looking forward to, you have will address the memo written on august 6th, 2010 that talked about the problems we are now discovering. This was four years ago. How could that letter have gone totally unlooked at by anybody in the va and the problems we are trying to fix lasted four more years because there was a culture of looking the other way when there was criticism or accou accountability questions. While i appreciate your work i am not convinced the va has changed at the Senior Leadership and the management of Veterans Administration and health care. A vote has been called so a number of senators are going to leave. Tester, murran and johanns and then the senator will return. I want to thank sanders and burr for their work on this committee. Access to health care for veterans didnt pop up overnight. We have been working on this for years. Solutions must be based on good information and hopefully the conversation today will be straightforward and frank so week we can get down to solutions. It will require folks on the ground in washington that last well beyond the media span. Veterans deserve better than having the folks jump on the latest crisis or two and nen you never hear about it again. They want answers and solutions and they want the benefits that they have earned not press releases. I am approached by veterans every time i go home whether it is the Grocery Store or service station. They are direct and straightforward and give me the best view of what is going on at the va. This friday i am holding another round table to hear from veterans about the va and the services they are getting and the difficulties along with their good things as well. There is a lack of Service Providers and i am looking forward to hear from the va on they action and their followup. The whitehouse has completed review on impacts to access to care and the va provides high Quality Health care once the veteran is in the door. It found out the Scheduling Technology is outdated at 30 years old. And they need doctors, nurses and Health Care Professionals. Physically space is needed and inappropriately trained personal. The Senate Passed a bipartisan bill that will address issues impacting access to timely medical care at the va and it passed by 93 votes and we seldom get 93 votes for anything in the United States senate. We are in the fourth week and there is not much to show for it yet. Those questions would be good to get answered today, too. Some members of the Conference Committee are balking at the cause. We just shipped 800 folks off to iraq and i didnt hear anyone talk about cost. Back in 2003 when he invaded iraq i wasnt hear but i never heard anybody talk about the cost. These folks went to war, they performed incredible well, some came back missing arms and legs and some cake back with mental illness. Health problems they didnt have when they left. It is frustrating when i come from a state where we are 22 doctors down to hear folks on the Conference Committee say what we need to do is schedule more patient for the doctors. That the solve the problem. That will not solve the problem. We need more Health Care Professionals on the ground and i look forward to hear from you. It is important to get our arms around that as a committee so we can provide the accountability that need to happen within the va to make sure the veterans get the care they deserve. I am very concerned this Conference Committee will end up taking a step backwards for the veterans care. That can not happen. Veterans deserve better. We need to step up to the plate and give them the resources they need and hold them accountable. They demonstrated our best in the field and we need to demonstrate our best as leaders with the va. I will yield to senator morran. Thank you for joining us and having a conversation with me by phone several weeks ago. It has been one of the experiences that i have had in recent years with the va is just no ability to convey the concerns of kansas veterans. We have the ability to convey that information to the department but no Response Time and time again so i appreciate the fact you took time to have a telephone conversation with me. I am going to present to you a letter that i have compiled addressed to you. I heard the testimony from the house Veterans Affairs and the topic was about whistle bow blowers and what i discovered is that many kansans and many employees at the department of affairs are giving me stories of problems within the va and they are declined to present that information to a whistle blower as a whistle blower in a formal way because of fear of retrobution and concern about their future and employment. So we will provide you an outline of things we consider challenges in the home state of kansas. I indicated several months ago i have been a member of the Veterans Committee since coming to congress. 14 years in the house and 6 in the senate. And there have been challenges at the va also and what is different today that occurred overtime is the recognition the va was shrugging its shoulders and no attention to problems and that resulted in veterans telling me they had no faith in the veterans of Department Affairs to provide the services they are entitled to as military men and women of our country. I fought a change in leadership at the Veterans Affairs is required. It is now taking place and i look forward to meeting mr. Mcdonald this afternoon in my office but what i know is that only changing the secretary, only changing the top leadership is insufficient to solve the problems that exist. I look forward to working with you with your time at the department of Veterans Affairs are the results we can all be proud of and the commitments we make are kept to our veterans. Most of the conversations with veterans affair, i think there have been nine, dealt with rural issues. I want to explore that with you in your testimony today. But i am very anxious to hear about the steps that you are taking to change the nature so it doesnt matter if you are urban, suburban or rural veteran i want to Veterans Affairs department to be different than it has been and then i will be happy to get to the issues we face in a rural state like ours. Change is necessary. I want to do everything i can to make certain the department of Veterans Affairs has to tools necessary. But i need the commitment from the department of Veterans Affairs that the resources they are provided and tools they are given will be used in a costeffective and caring and compassi compassi compassiona compassionate way. Thank you, sir. Senator hirono. Thank you secretary gibson and chairman sanders and Ranking Member burr for their continuing focus on the issues and challenges facing the va. When the issues relating to wait times first arose over a month ago the situation was described as an emergency and there was a sense of urgency and i want the committee and congress to be motivated by the sense of urgency and recognize this needs to be addressed because there is every potential for other issues to come to the floor and congress to be distracted. We owe this too veterans to stay the course. So i share the sentiments of the chairman and many of the member statements this morning that we should hear from you for Short Term Solutions and addressing the issues at hand and over the longterm to address the systemic problems and challenges facing the va. I like so many colleagues have been visiting with the veterans in my state frankly long before the particular crisis arose and of course they have shared with me their concerns about lack of doctors and the change over of doctors. Most of us, i think all of us have talked with veterans in our communities oneonone and we have a commitment we will stay the course. That is the most important think the committee can do and i thank the chairman for not allowing us to move on to other matters that maybe pressing but what could be more pressing than making sure our veterans receive the care they need and deserve. Thank you, mr. Chairman. Other members will be filtering back but i would like to hear from the acting secretary now and customarily we give five minutes but you will have more time. This is a serious discussion and want you to have the time to make sure case and the members to have to time they need to ask you the questions. Senator burr suggest maybe we should wait a few minutes so lets take a quick recess here. [in recess] lets reconvene and senator johanns we are up to you. Thank you, chairman sanders and Ranking Member burr for convening another important hearing to address the issues at the va. It is critical we continue to have the oversight hearings to do everything we can to hold the vas feet to the fire and make sure accountability is there. We know things we didnt know at the last hearing. We know that vas wait list manipulation to care issues is systemic. Report after report has confirmed this. 77 facilities are currently under investigation by the va Inspector General. That is an astounding number. I believe the scheduling problems are the tip of the iceberg. Now we have allegations of whistle blower retaliation and improper payment of claims. The cancer doesnt seem to stop. But it must be stopped. While i appreciate your efforts, secretary gibson, i think you have done some things and they are recognized and acknowledged, but i think we would all acknowledge there is so much more to be done. There has to be accountability for wrongdoing or the issues will continue and the senate will have more hearings the week after and even in five to ten years from now. There is a serious lack of leadership from the top. The whitehouse needs to have more of a role to fix the crisis. We collectively have to ability to fix the agencies we just have to find the will and Common Ground to do it. We have to all be part of the solution. In may inencouraged i encouraged the use of non va care to get treatment for those veterans that were on the secret and official waiting list. The bill recently passed by the senate gives greater flexibility and Treatment Options for veterans with long wait time or travel. The choice card injects muchneeded competition in my opinion into the process and demands of the va that they get their act together. And the accountability and transparency pieces of the legislation are not only important they are critical. The notion that employment should be tied to performance might seem elementary to most people but it hasnt been happening at the va. There have been instances in which senior va members were not reprimanded but received bonuses and positive performance reviews. Shame full. And senior employees can be disciplined and fired under current law it is a long and drawn out process. That doesnt work. The secretary needs the authority this bill provides to cut through the bureaucratic red tape and hold individuals responsible. We have to rid out the corruption that is contributing to the vas most pressing issues. It is a huge challenge but we can and must get the va back on track and focus on the core mission of providing Quality Health care to the veterans who deserve nothing less. Thank you, senator. I want to take the opportunity to welcome sloan gibson, acting secretary of the va. Thank you for joining us to give us an update on the state of the health care at the department of Veterans Affairs. He is here with mr. Philip matkowsky the asis assistant deputy. Secretary gibson, please begin. Mr. Chairman, forgive me if i dispense with the traditional things and get straight to business. As has been recounted we have Serious Problems. Here is how i see the issues, first and foremost veterans are waiting to long to care. And second, scheduling acts were widespread. And third an environment exist where many Staff Members are afraid to raise concerns or offer suggestions for fear of retaliation. Forth, a vast number of vocal points for staff are not focused on the veterans we are here to serve. Fifth, the va has failed to hold people accountable. And last we lack physicians, space, staff, Information Technology and perchase care funding to meet the current demand for Timely Health care. Furthermore we dont have the capacity to quantify the staffing because we have not built resources from the bottom up. We have instead managed to a budget number. As a consequence of all of the failures the trust that is the foundation of all we do, the trust of the veterans we serve and the trust of the American People and their elected representatives has eroded. We will have to earn that trust back through deliberate and Decisive Action and by creating an open, transparent approach to deal with veterans. To begin restoring trust we focused on six key priorities. Get veterans off the wait list and into clinics. Fix systemic scheduling problems, address cultural issues, hold people accountable, establish regular and ongoing disclosures of information, and finally quantify the resources needed to consistently deliver timely, high Quality Health care. Here is what we are doing now. Vha reached out to over 160,000 veterans to get them off wait list and into clinics and made over 543,000 referrals for veterans to receive care in the private sector. 91,000 more in the period a year a ago. And i would point out for each referral on average they result in seven visits to a clinician. Vha facilities are adding more clinic hours, aggressively recruiting to fill spots, deploying mobile medical units. We are moving to augment and improve our scheduling system and buying a commercial off the shelf state of the art scheduling system. I have directed people to conduct monthly inperson inspections to identify any related obsticals to timely care for veterans. Over 1100 to date have been conducted. We are putting in place an ex ternal audit of scheduling across the entire system and building a robust situation to measure Patient Satisfaction which i believe will be central to measurement processes in the future. I have visited 10 va centers to hear from the field on the action to get the veterans off the wait list and into the clinic. I leave later today for two locations in new mexico. They are eliminating any motives for scheduling practice and over 13,000 performance plans were amended in the process. Where willful misconduct is documented action will be taken and this always applies to whistle blower retaliation. Hiring is a first step to ensure we are all working to support those delivering care to veterans. Vha dispatched teams to provide direct assistance to facilities requiring the most improvement including a large team on the ground right now in phoenix. All vha senior executivexecutiv for 2014 have been suspended. Vha is expeneding the use of private Sector Health care to improve access. I sent a message to 341,000 to veterans and reiterated that whistle blowers will be protected and we will not tolerate retaliation against whistle blowers. I named dr. Carry for the secretary of health and she will spear head the immediate access for veteran care and restore the trust. A former Health Secretary is on leave of absence from chief medical officer and president of Clinical Services for Hospital Corporation of america has begun his two month stint as senior secretary advisor. He will help bridge the gap until there is a confirmed secretary for health. Dr. Jerry cox is serving as interim of medical am specter. A navy office for 30 years and the former assistant inspector of the navvy for medical matters. He will ensure a strong internal audit function. As we complete reviews and fact finding, we are beginning to initiate personal allegations to those who were doing wrong. Ms. Bradley is a formal General Council at va and a Senior Member of the general coun council team at the department of defense and had direct responsibility for the ethics portfolio. Let me address the need of Additional Resources. I believe the greatest risk for the veterans over the immediate and longterm is Additional Resources are provided not to remedy the historic shortfall of va capacity. Such an out come would leave va more poorly positioned. We have been working with the office of budget for several weeks to request refunding. While the amounts under the consideration are large under the context of scope and represent moderate expenditures. They are nonreoccurring and wouldnt be reflected in longterm rates. Resources to meet the demand for fiscal year 20142017 total 17. 6 billion. These funds address only the current shot short falls in staff, space, technology. We are taking the action to own the problems we face. The president , congress, veterans, the American People, vsos and va staff all understand the need for change. We must, all of us, seize this opportunity. We can turn these challenges into the the greatest opportunity for improvement in the history of this department. I believe in as little as two years the conversation can change. That va can be the trusted provider of choice tr Hilary Clinton and benefits. If we are successful who wins . The growing number of veterans that turn to va for health care each year. The 700,000 veterans who are currently diagnosed with ptsd. The million iraq veterans that turned to the va since 2002. And the average veterans who turns to the va who is older, sicker and poorer than average patients in the private sector. These are the veterans who win when va becomes the trusted provider of care and benefits. That is what and where we want to be in the shortest time possible. Our ability to get there depends on our will to seize the opportunity, challenge the status quo, and drive status change. The vast majority of whom i believe care about the mission and want to do the right thing and work hard to take care of the veterans. I appreciate your partners, Community Stakeholders and volunteers. I respect the role the members of the committee play in serving veterans and i am grateful to you for longterm support. I am prepared to take your questions. Well, mr. Acting secretary, thank you much for not dealing with nisities and dealing with realities. I understand we are talking in a broad sense about two very serious problem areas. Number one, i trust every member of the committee understand we have an immediate crisis. That we have hundreds of thousands of veterans on wait list and those folks must get the medical care they need in a timely manner and am i pleased to see you have acted aggressively in that area. But if i understand you correctly the second point you made it is important to put out the current fire unless we effectively deal with the longterm capacity issues facing the va we will be back here year after year with similar type problems. You mentioned the number. And i want you to get into some detail. What are we talking about . How many in phoenix, other areas of the country there are long waiting periods. The goal of this committee is to end those waiting periods so veterans get quality care in a timely manner. Lets start off with personal. How many doctors, how many nurses, how many other types of medical personal do you need to achieve that goal . Be as specific as you can and how much is that going to cost . Mr. Chairman, of the 17. 6 billion approximately 10 mill billion is allocated for purchase care and hiring additional staff. The blend of that will change over time as we ramp up that capacity and we are successful in hiring people. Is it fair to say that to the degree that we stregthen the va we become less dependented on expensive care . It is absolutey true. Continue. I interrupted you. That 10 billion is allocated in a portion to purchase care probably more on the front end than the back end as we are successful in hiring. Our ability to develop highly refined bottom up estimates of physician requirements is limited. Our best estimates at this time is that this would closing this gap requires hiring 10,000 additional clinical staff. Those are divided among primary care, Specialty Care, and Mental Health care. Of the 10,000, roughly 1500 are physicians and others are nurses and Nurse Practitioners and other direct patient support staff. You talked about space. Yes, sir. I trust you are not talking about building some las vegastype expensive building. What is the relationship between space and the emergency that we currently have in terms of waiting periods. I will tell you, mr. Chairman, in every Medical Center i visited except one and that is augusta, the number one problem is space. Fayetteville, North Carolina is growing at 7. 8 annual rate and when it takes five years to get a building on the ground it doesnt make long to fall behind. So where we are today as a department is we are behind in the in terms of the space required today to serve patients. There are 6 billion in the 17. 6 billion that is designed for infrastructure. Do you have those projects . There are i will ask phillip to go into some details. There are 77 lease projects for Outpatient Clinics that would add about 2 million square feet and 4 million appoiappointment and minor construction and occurring maintenance that would add 4 million additional outpatient visit slots there. We have heard time and time again that the dysfunctional for the appointments at the va is due to an outdated computer situation. Can you say a word on how you will deal with that . There are four parallel issues. 11 existing defects in the system being patched as we speak. There are four different interfaces in the process of making it easier for schedulers to access and provide the opportunity for veterans to access the schedule. On the 11th of july we led a contract for the existing system that will remedy maybe many of the most problems we make it hard to deal with and parallel with all of that we are pursuing the acquisition of a off the shelf state of the art system that is probably two years down the road in terms of having that functionality in place which is why we are pursuing. Let me conclude. If we dont have the resources at the va to address the issues with the ptsd folks, space issues, what happens in years to come . The wait times just get longe longer. We dont meet any standard of Quality Health care. I have committed to the president , veterans, the staff at va i will not hold back for asking for resources because we have not been managing to requirements as department. This would never happen in the private sector. You would fail as a business if you did this. I am not holding back now and wont in the future. But i told these folks that worked on the number i dont want a penny in there we cant justify. Not one cent. Senator burr. Mr. Chairman, thank you. And secretary gibson, i commend you, again. You have sort of made us go back and ask about numbers because it hasnt been that long ago we wrote off 127 million for the new software to do scheduling and then there is the 14 billion in the construction and maintenance account that means projects are on a 710 year timeline. So it is good to see one that va has a sense of urgency and that omb is recognizing the reality of the set of needs. I have a set of questions for you but i want to send them to you and ask you to respond and i would ask for all members to have an opportunity. Without objection. I want to focus on data integrity. The little rock va Regional Office, we are concerned how quickly the number of Regional Offices with allegations is growing. They removed all provisional rated claims from its pending in inventory. This process misrepresented the actual workload of pending claims and progress toward eliminating the overall claim backlog. The office of Inspector General team sent to Philadelphia Regional Office determined that there were significant opportunities for Regional Offices to manipulate and in put incorrect dates of claims in the electronic record data integrity related to timeliness of claims processing. Then there is this exchange that took place you remarked in your Opening Statement they have self reported a decrease in the national backlog by more than 50 since march 2013. Do you trust those numbers . At this point, i would say, no. We have a lot of work ahead of us to address the allegations that we just received which all seem to focus on data integrity and need to be looked at carefully. I do not want to say a trust in. In the end of the hearing, one of the things you said in your opening, and that struck me was that some of the success may be comprised by data integrity issues. Anything that the secretary has said tonight that alleviates those concerns that he raised in your Opening Statement simply responding know. Also, on the issue of whether the Quality Metrics are reliable , the General Accounting Office provided this testimony, and prior work we documented shortcomings in va Quality Assurance activities and more recently concerns have been raised about the lack of transparency related to changes in the agencys national accuracy rate for disability claims. In several basic areas they are not following general statistical procedures. That looseness in their methodology translates to numbers that are inaccurate and and helpful in terms of looking at trends over time in terms of performance accuracy and or comparing relative performance. That is not good metrics. Simply, the Inspector Generals office testified that they continue to identify a high rate of errors and Regional Offices processing claims decisions. Now, undersecretary hickey was the one that testified from the va. And despite her testimony, which was preceded by the Inspector General, the gao, the va put out a press release the very next day entitled va takes action to ensure data integrity of disability claims in which said va touts it as reduce the backlog, the number of days it takes to process claims and has improved their rate to over 90 percent. Now, listen, you said that you have to regain the trust of the committee. I think we agree with you. Let me ask you, how smart was that press release . Did you sign off on that press release . How can numbers that were refuted by the people that were actually doing the investigations of va facilities, how can they reviewed the numbers and the next day that va come out with the same numbers and talk to them . Senator, i think, as you have noted, trust is the foundation of everything that we do. Where there are questions about data integrity i think we have got to look deeply. There are a number of issues that have been raised. I could sit and go through and take an item or two, but the fundamental issue remains. Theyre is there are questions about whether or not we have good data integrity. Just as we are undertaking independent reviews, we need to take those. So this has been under way. Much of it initiated by members of this committee with the Inspector General, the General Accounting Office. You have acknowledged the shortcomings on the fee age a side. This is fresh, this week. And still that press release of stress is that the va will continue to publish these performance data is on its website. Senator, i would tell you that i come into this organization and look at the transformation over the last two to three years and a fine anybody to show me any major part of the federal government anywhere that is transformed that much in that amount of time. I think it is amazing looking at it from a private sector perspective, much less in the context of the federal government agency. There is room to improve. We have got to restore trust. The 100 percent provisional ratings were pulled out. My recollection a round numbers, its about 12,000. That may not be exactly right, but the backlog is down 350,000. So i get it. We need to make sure that the data integrity is there, but i am not going to pull back from standing by that department and the good work that has been done we cannot have back and forth between ing. We have to embrace the findings. I appreciate the chairmans lenience. I am not sure you are embracing those findings. It concerns me because these are veterans that are waiting for their determination is to be made and in some cases it involves overpayments. And it just strikes me and now realize this is a vha hearing. It strikes me that we could have testimony like we had on monday night and turn around and put out a press release stating the same numbers the next day when every one of the investigators found that those numbers could not be trusted. This is an area of great concern big, if not bigger because the budget is the biggest budget. Thank you, mr. Chairman. The va has removed the wait time criteria from the performance contracts. I do understand the need to be wary of creating incentives for people to gain game the numbers, but we have a serious accountability problem. How will you hold a network and Medical Center directors accountable for wait times if it is not in a performance contract . I think the first that we have to do is get to integrity in the data. So the idea behind polling that at this stage of the game was to eliminate any questionable motivation. Understood. I think as we move forward what we are going to find is that average wait times are a very poor gauge firm timeliness of care for a large, integrated health system. You dont really find that in that private sector. It is one of the reasons we are boosting our Patient Satisfaction measurement activities because i think Patient Satisfaction is going to become central. The veteran needs to be seen today, we have failed that veteran. You are looking for different ways i think we will be looking at different ways to evaluate timeliness of care, a combination of Patient Satisfaction, veterans waiting too long and seeing that number coming down steadily. And then as we have the system could ability to do things like you see in the private sector, metrics like the third next available appointment which gives you some gauge of the capacity of the system to be able to handle that veteran as they come in. Today at least we are able to look at same day appointments. Roughly in the primary care area we see about 100,000 veterans on the same day basis every single month in primary care. Thats coming to me, suggests that there is capacity being maintained to take care of that veteran who cannot wait 14 days or 21 days or 30 days. Okay. Health care from the private sector does play a Critical Role in making sure that veterans get the care in a timely fashion. There are drawbacks to the care that the va has been trying to overcome like not being able to get medical records returned to the department and a little ability to see the quality of care. If congress were to expand the authority for 90 for health care, what steps would be necessary . I will ask philippe to jump in here in a moment. One of the Biggest Challenges we have with purchase care in the community is maintaining continuity of care for the veteran. The ability to get information, medical information, medical record information back and forth is a vital part of this. Ensuring the quality of care. I would tell you if the floodgates open it will present the department with challenges, but the fact remains we are right now referring out roughly a quarter of a million referrals every month to purchase care. As i mentioned before, every one of those referrals on average will result in roughly seven appointments. That is an awful lot of activity. Last year 15 million visits to non va providers over the course of the year added to the 85 million Outpatient Clinic visits. 100 million outpatient visits per year that we are managing. It is already a very large number and a challenge for us. But if we open the floodgates it would be an even bigger challenge. Senator, the one thing i would add is purchasing care in the community does not absolves loss of the requirement and responsibility to coordinate care in addition to the assurance that we can send both send and receive clinical data. There is just the handson coordination required to make sure an appointment has occurred, the veteran knows where to go, the family is involved, all the rest of that. For a look at the cost of care alone, we are missing a big responsibility. We look at how we do this and expand, we have to look at those issues and get them right or we will create a bigger problem for the future. Finally, va has had a lot of difficulty hiring providers for a number of reasons including the that is lower than the private sector and a long, as you mentioned, cumbersome hiring process and hiring in shortage areas in health care anyway. Because we know there is a National Shortage as well. Now va does a lot of training for doctors and nurses and works closely with a lot of universities. What more can that va do to help build the Health Care Workforce necessary to meet the needs of the department and our country . That is a great question, maam live. One of the significant opportunities where we can work collaboratively. Maybe tuition payment programs or reimbursement programs, ways that we can encourage that. We rely heavily upon our academic affiliations as a source for new conditions. We are doing things from my compensation standpoint as well where we have flexibility to appeal to meet the local markets. That is part of the reason for a backlog as well. We cannot ignore that side of it yes, maam. Thank you very much, mr. Chairman. Thank you, senator murray. Following up with a question about referrals and the private sector, i wrote this down from your statement. He said 543,000 referrals for private care. What percentage of those would you guess or Mental Health referrals . Fifth. Im sorry. I could hasten a guess, but i will take that one for the record. The reason i ask that question is to my got into the atlantic va in august of last year when we had two suicides and a drug overdose. When we dug they were using a Community Based provider. Va with see the patient, refer them to the communitybased provider with no followup. And in that time when the person was determined to be at risk, in two cases they took their own life because they did not get timely service. I think there was an interesting observation about coordinated care. As we expand private options and Veterans Health care, which we may or may not do. I hope we do. Care coordination will be one of the secrets to making that work, not just in reducing wait times but the quality of care or increasing the quality of care for veterans, particularly with the number of Mental Health people coming forward. That will be an ongoing process, one that will have to be coordinated and monitored. The memorandum. In may when secretary shinseki and dr. Peters were here and ask them both the question had they seen it. Dr. Peters said he had and the secretary said he had not. I think both of them told me the truth. I dont think he ever saw it because i think the Senior Leaders did not let him. I think my experience is it lies at the highest levels of the Veterans Administration that insulated leaders from the problems. Why else would a memorandum written four years ago that we are discovering now and 2014 not have been acted on . The last sentence of the third paragraph says these practices will not be tolerated. It does not say look at this when you get a chance and delineates each of the programs. You are an interim director, secretary. You will be handing off this presumably to of mr. Macdonald. What are you doing to put in place the type of affirmation transfer and conduits that will see to it he does not become a rookie victim of what a distinguished general was in terms of mr. Shinseki. I will let my old friend are will not let my friend become a rookie victim of anything. Let me interrupt. I am not being tried when i ask this question. I understand. For four years va has indicated its leader. I will tell you from my personal perspective i have learned to never have all my information filtered through a couple of people. So from the first day that i got to va asserted reaching down the organization to get additional information. I think your sense is an accurate one. Historically they have operated in an insular organization. Part of what we have been doing is dismantling a lot of those barriers. Since my first day as acting secretary, every single morning at 9 00 a. M. We have something called access stand up. Senior leaders from across vha and the department up in our integrated Operations Center and bore into data are round access to care. This status, what are we doing, many contacts, appointments, the wait times, the status on many of these different initiatives i have alluded to in my Opening Statement. It is just part of what were putting in place. This young guy right here and as said before if i was half as smart as philippi would be darn smart. He has been doing an awful lot of the work to put in place the kind of Management System the youre talking about some of the and not just relying on by chance the information filters out that we have dashboards in place to help us identify whether where there is scheduling malpractice from a productivity opportunities for us so bring more productivity out of a particular clinic, that we are able to identify those things and in tandem requiring Medical Center directors to get out in their clinics so that they take direct ownership for the consequences. The first sentence in a memo that provided that direction was , Medical Center directors are directly accountable for their quality of care and the timeliness of care delivered. That was the first sentence. That is part of ensuring that we have that kind of accountability and, frankly, is part of the culture change. It. My time is up, but with that endorsement i have to ask this question. You are not leaving when secretary stone leaves, are you . I am not going anywhere either. I am talking about make sure he is at the right hand. There are a lot of good people building a lot of good tools. One of the things we have a team working on now is to take that memo and actually developed tools that allow us to mind gated to look for those patterns. Give us as we are looking at art timeliness data secretary gibson has directed us to go look at and integrity score against it and read it. Are there certain questions . If they persist have an audit. Thank you both very much. Thank you. And you are right. There are a lot of good people at the va and a lot of them delivering damn Good Health Care on the ground. When need more of them and to get rid of the bad apples. You said you have a concern about purchase care trumping va capacity. I assume that is during this Conference Committee and other times. We will put more emphasis on purchase care and not enough emphasis on va capacity. Have you been able to do any sort of cost analysis . Is it more expensive, less expensive . There are instances where we have taken what we would consider to be the mix of patients and the types of services we provide and compare them to private sector models. Sometimes we do it for communitybased Outpatient Clinics. As a general rule it tends to be more expensive. There are two different types of contract options. They both have their problems. I come from a state where quite frankly the frontier in a lot of areas of private care mayor may not solve the problem, but it looks attractive. If it breaks the budget of the va and we dont get Better Health care in the private sector, which both of those are up for debate can age can be a problem. That is why i agree with your capacity issue. Want to talk about an issue called project project march. It has worked well, not been perfect, but worked well. Can i get any assurance that it will not be prematurely shut down before it is reauthorize . The discussion that we had the other day was exactly to that issue. My commitment is, to the extent i have the authority there is some question, but we will not end a program that is providing access to veterans until we have their robust replacement in place so that there is no lapse in care for the veterans being served. That is my commitment. That is good. I think the project definitely works and it allows you to have control of those medical issues moving forward, which is a big concern. Can i ask you, what do you say to folks that say the va work shortages are a myth and the real problem is medical personnel is just not working hard or fast enough . I will start and probably pass it to philip for a wrapup. I think when you looked i mentioned earlier in my opening remarks, older, sicker, people were. When you look at the typical va patient. When you Start Talking panel sizes, Specialty Care, you have to take into account the very different Patient Population that the va is dealing with. The number of primary care patients that a Commission Sees at va is in all likelihood going to be different than what you see in the private sector. Secondly, there are oftentimes factors, for example space. We talked about that earlier. I think the average in the private sector for primary care is to and have treatment runs for a primary care provider. And i do not know that we have good data on what that looks like a cross va but i strongly suspect we do not have those resources. In the case of Specialty Care, one of the places we are significantly under a leveraged addressed and these numbers in this request is on average one support person for every Specialty Care provider. That compares to a goal or target of three and a half to one. We are under leveraging Specialty Care providers and as a result they are not seeing as many patients as they ought to be able to. We get these differences. I am convinced we will see productivity enhancement, but it means we have investments to make to be able to deliver. That meets the needs of the veterans that to not have access to the va . What i am saying is, i was told, for instance, va montana has 22 slots. Productivity can probably take care of some of those. Maybe, maybe not. But my point is that if we are 22 short, it becomes an issue of if they would be happy. Take a moment and summarized the process we have been going through. We did accelerating care. We pushed up productivity data. I may touch on panel size a little bit. But we sometimes miss the comparative Patient Population when we do that. We are looking at productivity, comparing it internally. Hi, productive facilities, looking at how they get there. Part of it is smart use of support staff and part of it is just monitoring productivity. Some can be covered internally and some will require Additional Resources. We ask every facility to look at productivity numbers. We use that as the basis to a accelerate care. Thank you very much. Chairman, thank you very much. You have used the word trust. I never asked for a cabinet secretarys resignation. This is the first. We were indicating that there was the problem with the culture , a systemic problems. It was my sense that all of that was true. I was somewhat comforted in the position, but actually very concerned by what i heard the secretary say on the day he announced his departure which was something to the point that he had been surrounded by people whose views he trusted that he should not have. The scenes that we were right. If the secretary cannot trust the people that he or she must deal with on a day to day basis. I want my comments to be brought and not provincial. Appreciate the senator from montana, but i want to use that as an example of why i have had difficulty in trust and the department of Veterans Affairs. I dont mean this in a personal way or to suggest that i am personally offended. Handicapped by the sense that i have had fact that the department of Veterans Affairs does not trust us, does not share information, is not honest , and most importantly has rarely responded to issues raised. Again, this is not a personal concern of mine. It is not that i am personally offended, but when a veteran in kansas brings an issue to me and i raise it, i think we should be able to expect an on asphalt, fair, and timely response which has not occurred. My ability to trust the department of Veterans Affairs has been significantly handicapped. An example of that is this program. It says if you live long distances from i va hospital outpatient facility you can access at home by the Veterans Department giving you the ability to do that paying for the service. That is a Pilot Program. Five across the country i kept asking how what was going. Is it working . How are veterans are they letting it . Is the Technology Work . We get virtually no answers. Finally, at a hearing with secretary shinseki this program is about to end. Its threeyear Pilot Program is coming to a conclusion, although we are pleased to know you have the authority to extend it. Secretary shinseki in march of this year indicated to me and would have an answer to my question by sunset, his words. Never had an answer yet. Then in march and incidently one of the things i have learned since then is that in the spring of 2012 year after the Pilot Program got started the wichita va is interested in promoting this program to rural veterans and were instructed by dca you cannot recruit and market. My concern is we have created a program that someone at the department of Veterans Affairs is not like so they are out and about trying to make certain they prove it does not work. For someone at the va to tell folks in kansas, dont market this, dont encourage veterans to participate suggests that they wanted a failure. I become more suspicious as i learned this. On march 26 of this year a National Program director directed the five Pilot Programs to notify veterans the program was going to a conclusion. At the same time in fact, in april, a week or so later, a senior staff at the va the shores my staff and Committee Staff that we are continuing to assess the program. Subsequently we learn the memo has gone out. Ten days later, to weeks that we are assured. That makes me suspicious five about the inability to get the report promised by the secretary of Veterans Affairs by sunset i wonder what is going on in march. Then june of this year we discovered there was an email ready to be sent terminating the program. I, including some on this committee and ask that not to be the case. We are told justintime. This and russian send button was not pushed. A series of things have caused us have great doubts about who is telling us what, what the truth this. In a more fundamental way, programs authorized by congress, then theyd be easily undermine to my personality not apparently like the suggestion we have made, not a suggestion, the law we have passed finally, our telephone conversation. I appreciate you reiterating what you just said, but that is the circumstance of find myself and as someone who is a supporter of veterans and theyre for a supporter of the department of Veterans Affairs Whose Mission it is to take care of veterans across our country in state. Just a quick comment i alluded in my opening remarks to an openness and transparency. I think that is central to maintaining trust and the position we are in right now of reestablishing trust. This is one of the central cultural issues that we must deal with as an organization. I would tell you that there is i used the word insular earlier to describes the particular vha, as i find it, coming into the department. I think that is the case. Over the last six weeks i have been pushing information out the door as fast and hard as i can. I prod behindthescenes for responses to congress, and we have got a lot of work to do in that regard to earn the trust back. Is, sir. Okay. Thank you. Senator. Thank you. We know there are capacity issues at the va, and i would like some clarification on comments or statements you made. Did you say that based upon your assessment of the capacity issues that you would need 10,000 additional staff . At think you were talking about that is correct. Over two and a half billion that you would be requesting. That is correct. Yes, maam. I know that sounds like a huge number. There are 300,000 people in vha alone. So additional staff and i know you broke it down to how many doctors and within the specialties. So is that for the emergency situation we have now, or is this an assessment that reflects your longterm staffing needs . There was a reference made in one of the Opening Statements earlier about the findings of the field audit. The number one cause for scheduling difficulties was that there were not sufficient providers lots to be able to schedule patients into. So what were talking about here my comment earlier we have not historically manage requirements. We have managed to a budget number. Basically we took a budget number and did what folks thought they could do, and the veterans on the being the shock absorber in that process. Meanwhile, if you look at your true needs youre saying that you would need to hire 10,000 additional staff. Yes, maam. That would of course depend upon the appropriations that we provide. Yes, maam. If you were to have the appropriations to hire 10,000 people, how long do you think it would take for 10,000 people to be hired . One of the things i did hear about the hiring in va is that it takes a long time to hire a doctor. I hope that in your review you are also looking at your hiring process is because it should not take a long time, whatever that means. That is one question. And then, to hire 10,000, do you have any sense of how long this would take should you get the money from us . A couple of comments. One, every single Medical Center i visit i hear from rankandfile staff that it takes too long to hire. Staffing practices is one of our areas of concentration. My guess is there are some things we will find is just a function of being in the federal government, regulation and statute we must follow. My guess is we will find a large portion of that is selfinflicted, and we have got to clear that stuff away so that we can hire more expeditiously. Second, round numbers to i would say in vha we probably hire 30,000 people every year anyway. Nine of 10,000 sows like a huge number. Its about 3 percent of staff, maybe a little less. But recognize that some of these are in places like primary care positions and Mental Health providers. We know, and you all know that those are tough to find. So it will take time for us to be able to hire. Quite frankly, the other problem even if we could go out and hire them all tomorrow, we dont have a place to put them all. In some instances we will have to deal with space issues in tandem with this. We may be able to do there are provisions in here for what are called the emergency leases. I authorize some of these when i go out to the field where someone has found clinics based that is local that can be occupied quickly. 10,000 square feet, Something Like that. I dont mean to interrupt you, but my time is running out. Yes, maam. You are addressing the length of time it takes. If you are hiring 30,000 people every year, there are probably some retention issues that you also probably ought to be addressing. 10 turnover. Well. It is relatively low. You mentioned that in response to a question when the ig has findings from embracing those findings. Since the problems and challenges that the va has a longstanding, i wonder whether you have a process or someone in that va who provides a response to the ig findings. Should you be providing a report to congress to respond to the ig finding so that we also can provide the kind of oversight that we should provide as to what is happening at va . There are responses. Unless i am mistaken, i believe those responses are shared. Is that correct . Yes. So there are responses. What i would tell you is that i dont believe that those have always done the visibility and detention. Some of the examples surrounding the office of the medical inspector in those reports, quite frankly, i dont think those are getting the attention they deserve. As we look at overhauling processes, part of what we have to do is make sure the issues that need to be elevated of the way to the office of the secretary are, in fact, being elevated. Where someone says we have taken care of this issue, we know what has been done and confirm that. Mr. Chairman, just one more item. I was told by the veterans i have been talking with, many of them live in rural areas. I was told that even if they got vouchers to go out to get private care that the doctors on the big island would not take veterans, so we would not help them. Have you heard that concern . I would tell you, there are issues of around primarycare closeknit Community Contract that we have got was two Different National providers for Specialty Care, and we do find instances where i think we have room for improvement. A new program Just Launched earlier this year, and i cannot think we are executing it as well as it needs to be. There are discussions going on this week, today with the leaders of those two programs to make sure that we address those issues. I get that feed back from staff and from veterans as well when i am out of a field. The main thing is you are addressing that issue. Yes, maam. Thank you. Thank you, senator. Mr. Chairman, thank you. Mr. Secretary, in your requests for of lot more money one of the things that you mentioned was the facilities and the idea behind that is some of these may improve productivity and hopefully that results in Better Services to veterans, that sort of thing. You mentioned that there were eight facilities that would be construction projects. How did you pick those . I know of a list of there. If you have a need for a facility, new hospitals, making its way of the list, do you just pick the top eight . If you want to toss it over to philip matkowsky, that is fine, too. I am guard to toss this one, if i could, please. This is we have a backlog of Major Construction projects. This is the Major Construction, not a minor distraction or nonrecurring maintenance. Theyre is a prioritized ranking system that has rated safety and security as the highest. Seismic corrections where we have deficiencies if there were an earthquake the building would crumble, those have to be fixed. There are a number of those. We also have longstanding space shortages. Every single one of our facilities as a space shortage in terms of meeting patient need visa not abstract numbers. There is not enough space. The vast majority of the va projects are sinless, louisville , american lake, san francisco, palo alto, west l. A. , long beach. For the most part they high prioritized items because of structural deficiency. Some to have patient care for Additional Space with this top aide be the same topic as the list of 20some projects that are out there waiting to make their way . It is from that list. Yes, sir. With a match if i took that list and matched it with what you just describe for me . If you talking about the 26 or 27 major leases . Not leases. I think youre talking about the historical projects that were ranked. It would match, and it would match against that list for the most part. Yes. For the most part. What is the most part missing here . For the most part, just to give you a direct answer, the ability to complete a project given the size of the required funding it would fit in whereas somewhere else that might only be 20 percent of that project. That is what i mean. At the Committee Hearing in may 1 of the things i talked about and other members did, too, the expanded use of non va care to deal with the urgent treatment issues. You know, this is not an academic issue. It never was. It very definitely is not today because we know that people died on the va waiting list. We know that throughout the system the list was gained intentionally and dishonestly. To the detriment of veterans. Now, there are a lot of ways of handling that. Mr. Secretary, let me be candid with you. I have sat on this committee now nearly six years. Other members of hot water. This committee has been, i think, very, very generous to the va. And i kind of find it remarkable republicans, democrats, liberals, conservatives, when general shinseki came in and it was kind of like, what do you need, general . And it was almost like we would salute when he said what he needed an out the door he would go with more money. How was the promise of reducing better. Here is my concern. This sounds so similar to what we have heard over the years, i need more money. I need to be bigger, faster, grander, a bigger bureaucracy, hire more people and on and on and on. I think what you need personally is competition i think if someone were biting at your backside because they were providing better care, faster care, honest waiting lists people would go, holy smokes. If we dont put our act together we will lose out on this. If we dont see more patients touring the day we will lose out on this. Let me ask you, what am i missing here . I think i do not know what you are missing. And know that millions of veterans turned to va for their health care. As a number of folks have mentioned, an awful lot of veterans continue to believe they get great care, access to care is a challenge for many, particularly for new patients, but theyre is a lot of great care being delivered every single day. I am out of time. You know, i hear this, but at the end of the day these veterans fight for our freedoms. Why dont they have the freedom to make their own choice about their health care . Maybe they say, by golly, i love the va. I will stay with the va until the day that i died. Maybe they say, that hospital 20 minutes down the road for i am at is just simply a better situation for me than the hospital that is 250 miles from our am at with a long waiting list. I am totally out of time, and i do not want to impose on the chairmans patients, but i just think that you guys need competition. Kaj feel very, very strongly about that. If you cannot clean up your act then, guess what, you lose a help. That is what i think you need. I dont think you need more billions and billions of dollars so thank you. Thanks you, senator. You will have a modest amount of additional time. Thank you very much, mr. Chairman. Thank you both for being here. I appreciate it. You know, it is amazing to me. I have been here not just about six years, but i am looking at a 2003 report, improve Health Care Delivery for our national veterans. Are you familiar with this report . If not you should read it when i turn to one page year, part of your point, although enrollment veterans have access said health care they see long waiting times for appointments with Health Care Providers and continue to be problematic for a significant number of veterans as of january 2003. At least 236,000 veterans were on a waiting list six months or more for their first appointment , a clear indication of lack of sufficient capacity or at a minimum a lack of adequate resources to provide required care. This is not new. It is just they did not get the funding years ago, and now we are playing catchup because you have also had almost oneandahalf million net new va patients. We did not do it. I was not here. Somehow people missed this report. I do not know. For the record, mr. Chairman, it is like somehow suddenly it is all a new problem. It just occurred yesterday. No. It is right here in this report. Because they were not funded properly it build up. They knew that patients were added to the list from afghanistan and iraq wars. Maybe people missed that. Again not know. Pretty simple. Third page of the report. Not complicated. Down under a different administration. So i want to put that to the record because the issues you are bringing a par relevant. Joy think it is a lot of money . Yes. Is the money will reserve well deserved for our veterans . Absolutely. The problem we will have is hiring 10,000 people, i agree, you have a hiring system that is great. But to get Mental Health providers and primarycare doctors, every private hospital in this country is behind the curve getting doctors. Nurses are backed up. We do not have the capacity to fill it. So i want to make this clear because i think there are a lot of good bumper stickers being talked about today, i get it. But this is a systematic bomb that has been around for a decade or more and yet it is now suddenly and thanks to the fiascos and others who have come forward and say, look, we have been fighting for this for years. I will tell you and i know my chairman gets aggravated not aggravated, but he knows i will bring it up all the time. We have talked about this. We saw this problem when i came into office in of nine. We said, what are we doing . We know the private sector. All of us get a doctor. It is hard enough to get our appointments. At a veterans to the system and got it up more . We looked at our Current System of federal tax dollars and how theyre being used. Health services delivered by tribes in alaska. Qualified clinics, federally funded. What do we do . We maximize resources at our fingertips today. What is our wait time in alaska, the Northwest Region . Is one of the lowest in the country because we now have access. As a matter of fact, an anchorage when you use a qualified federal clinic there and or the South Central clinic and again, you have to be on the list, up, get through the system and get on the list, for non Major Medical it is in day care that is pretty significant. That is competition that actually works with the tax dollars we are all paying. We shall let out to the private sector. We do closer to care program, as you know, which uses private sector, but that does not mean it is the panacea that every veteran will get care overnight. We have to look at the systematic problems. And now you and i talked about this idea and we are doing in alaska. We have some logistic problems, billing problems, scheduling issues and how to make sure that the records are transferred properly between federal agencies and so forth. I know we will figure this out. But doesnt that seem like something we should be expanding and looking at around the country . I mean, federally qualified clinics, the one reason you have certain pay levels for doctors is so you have a controlled cost unit. Now, it does mean that we will use private sector resources, as we are in alaska along with federally qualified. And our Indian Health services, otherwise known as we call the new model. Dont you think this is a model that we could go after . I mean, again, i did not mean to get so aggravated about this. It is aggravated when people tell me this is a newfound problem. Go ahead. Sorry. There is my rant. There was a question there. [laughter] i will try to address it, sir very quickly, the model in anchorage, the director actually, he was a trailblazer for us establishing a number of trouble agreements with local alaskan tribes, 26 of them now. A phenomenal work that he did. He literally extended the network of Community Providers into a seamlessly integrated system up there that allowed us to avoid folks having to travel long distances. The norm before used to be folks flying down to washington state, if you recall. So remarkable work by the director. Some of that has actually become sort of a pattern we have used elsewhere in the country with local drives and i ags, signing the agreement to extend health care services. Most importantly with the tribes , the dakotas and oklahoma and across the country. We have trouble agreements in place where we can reimburse for care. It is not perfectly seamless, but it is something that has really taken root for us. And you do need new rules. No, we did not. We have certain authorities entitled 38 that we use. You can do that also with federally qualified funding . We can under sharing authority and in alaska we are doing that. One just went from private to a federally qualified connected to libertarian sort, alaska because there is no veteran care down there which is a great example of how you can do this with existing rules. Let me ask you, having the va you lice i sent a letter to general shinseki on this regarding positions, they use for their medical Delivery System and seeing if the va can do the same thing. It is in the bill. In other words, the health care core. You tell me if your regulations allow you i know we talked about this briefly. I dont know if you had time to check on that. This is over 5,000 medical professionals sitting there ready to go. Youre talking about the National Health services. Im sorry, National Health services. We would have to look at credential in an privileging issues that would allow us to grant privileged and share those authorities to tree in our system as well. I would have to take that back and look at it. Can you do that for me . I will. The last thing, senator murray talked about reimbursements for doctors in the sense of serving our va system. I have a bill on Mental Health providers psychiatric care, a huge gap. Have you had a chance to look at that, and if not, can you give us feedback on that at an appropriate time . If you would yield to me for a second. Absolutely. The issues being raised are important and has to do with how we not raid other facilities and steel doctors and psychiatrists but develop more. The issues are that you have a house Education Assistance program which coming a, needs to be reauthorize, and it, the companies to be significantly increased. Right now the maximum is only 60,000. That is what youre talking about. Exactly. It is up to 100,000. You want to try to have you had a chance to read the bill and do you support the concept . We support the concept. We have to look at the funding requirements associated with it, but the practice is something that would allow us to recruit and retain highly qualified staff. Very good. Mr. Chairman, i have other questions i will submit for the record. I appreciate your allowing me to ask questions. Its frustrating when i see a report like this and people think it is a newfound problem, and it has been around for over ten years. We just have to get after it. It is going to take years to change it. Thank you. You will have additional time as well because he did not make an opening remark. What i will do is just submit a opening remarks for the record it that way i will go back to my five minutes and keeping this timely. One of the few senators who once less time. If i go over please dont cut me off. Having said that, thank you very much for holding this hearing, the chairman and Ranking Member. At risk of irritating you, you know will be talking about statistics. I certainly appreciate a rescheduling of a hearing on the backlog information. I will talk about that in a minute. I am looking at the latest autistics. I want to thank both of you for being here. But i am looking at the latest average days of completion. I bring this up because reno has the worst va Regional Office in the country. I have been hitting on this and hitting on this, and i think it is a management problem. And i think the rankandfile are at fault. I am hoping and have called for changes in that particular office, but the average date to complete a pending crime is about 340 days. Have been harping on this for five years. They are making progress. They have reduced it ten days in five years. And you have to imagine, it is pretty frustrating. I am frustrated for every veteran and a state of nevada that truly needs the help and benefits and health care that they deserve. On top of that we had an Inspector General report, 51 percent of the possibility claims that or reviewed were inaccurate. I have to tell you, i appreciate your Opening Statement, your openness, and i think that is important. Transparency is important. Senator casey and i have tea had similar problems in pennsylvania, our staff worked hard. Became up with this claims backlog of working group. I you familiar with the information in this . I would tell you i am aware of it. It would be a stretch to say im familiar. Fortunately i will be able to meet with the nominee tomorrow and get an opportunity for and to also address or take a look at it. I think it is very clear. It does address some of those problems. Begin news is there are cosponsors of this legislation it would go a long way so that in ten years we dont have an improvement and in less than a year we can see, perhaps, a much greater improvement. Then have resulted in domains. We had challenges on the procurement side of that as i think your staff has been briefed over the years and right now we are working