Reestablish our integrity. I think we can do that, and i think we can salvage a system which does provide good care, and we can make that system provide timely access. I am stunned that you would call this, with all the information thats come out, and i dont think were at the bottom of all this yet, that you would call this a good system. I think its absolutely stunning. And i think that the Veterans Administration is the most mismanaged agency of the federal government, and i think that it is not has not been there to serve those who have served this country, but the leadership of the va has been there to serve themselves, and weve had testimony from this committee about all the bonuses, all the bonuses, despite the incredible bureaucratic incompetence and cultural exception. Thats all you seem to be capable of doing is writing checks to yourself. Mr. Chairman, i yield back. Mr. Kirk ps. Kirkpatrick, yo recognized for five minutes. Thank you, mr. Chairman, and i want to thank you and mr. Mishu for continuing to have these hearings. I dont feel like weve gotten to the bottom of this. Mr. Lynch, youve been here a number of times, and toipt foi focus on the scheduling delays. Thats the problem were trying to get to the bottom of. The Committee Heard there are five reasons for scheduling delays, that there was an unexpected surge of new patients. There was not enough funding, obsolete facilities and obsolete technology, a lack of patient extenders in personnel, a lack of consistent policy across the system. But that just further describes a problem. And my question is, why . Why did the va not anticipate a surge in new patients . We know that we have an aging population. Why did the va not have funding when weve given them all the funding theyve requested. Were starting to think as a committee that this is a systemic problem, but were still not getting to the bottom of the why. Can you answer that for me . I think part of the reason may be relatively selfevident. We were not getting good data from the system. We didnt have a good measure of those patients that were waiting but why . Why . Were just i think we know why. I think weve acknowledged that the system was not honest. We were not getting the information we needed. We had Performance Measures that were misguided, and we need to reform that so we have accurate information, and we can resource our system appropriately based on demand and capacity. I think we have the tools to do that. I think we have the information to do that. We need to assure that our data is accurate. We are working very hard to do that. We are making demands on both our visiting directors and medical directors to make sure the practices in their clinic are according to policy. We acknowledge that we are probably going to have to have an independent third party confirm that information is accurate. Because at the moment, we have to verify to you, we have to justify to the American Public that our information is real and accurate, and we can provide timely care, and we can give the information that we need to assess the capacity. I appreciate your answer, but i still feel like were not getting to the bottom of this. And let me just say, why is the va so slow . Why are they so slow in responding to mr. Waltzs office . Why have they been so slow in responding to this committee . Just why, why, why . Is it because there arent enough it is not correct. I think we do have to work with this committee, and we do have to work with congress if were going to build a better va system. And we do need to give you the information that you need. Dr. Lynch, let me ask one other is it a system that can innovate . Yes. I think it is a system that can innovate. And i think we have shown that we can innovate in the past. Particularly in response to crisis. If you rolook back in the mid1980s, there were concerns about Surgical Care in the va. The va acquired a Risk Assessment model that has now become the model in the private sector. In the 1990s, the va was criticized and the va noin vain with the Electronic Health record. I think we have an opportunity here in va to respond to this crisis with an innovative model of staffing, of assessing demand and capacity that can become a standard for the industry as well. Please do it. I yield back my time. Well, if i could just add one thing to what you just said. I think all your questions are critically important, but right now we are focused 100 on trying to get veterans into this system and using all the tools available at our disposal. There will be time for the why questions and the much tougher analytical questions that all of you are asking about how do we finetune capacity and demand, but right now the number of veterans waiting is an emergency, and that gets the highest priority. That does not mean anything else is off the radar screen. And i just have to say in response to the innovation question, i did have the pleasure and opportunity of visiting 1, which happens to encompass the state of maine, and some of the innovations theyve employed up there is really terrific. I think our challenge is figuring out how to spread it and see the successes weve seen in surgery and other areas. Thank you, dr. Clancy. Dr. Winthrop, youre recognized for five minutes. Thank you, mr. Chairman. As we sit here and talk about all this, i think a lot of times as people are watching, it almost seems like were talking about patients as though theyre monopoly pieces. When mr. Walsh brings up the point of the possibility of getting surgery within 48 hours but its six weeks until they can get their preop work done at the va, its disappointing that that surgeon cant make something happen sooner or that there is nowhere to go, that these types of things arent corrected. Im sure these have gone on for years. Theres a lot of things were hearing tonight, and you share our concerns. When did you start . When i got here i went to the general three times saying i would be willing to go into the clinics, to go into the ors. I come from private practice. I trained from a va, and to discuss why it is so much slower, why there are so many fewer patients being seen. Never got a response, never got action on that. You talk about rvus, and for people at home, they probably dont know what those are. Relative value units. A new patient has a higher value than an established patient. A short procedure has fewer value units than a long procedure, those types of things. So when people hear that, they know what were talking about. When did you start looking at the rvus . The rvus, i believe, became part of our evaluation process after the oig report in late 2012. So just in the last couple years. And thats been around for a while as some type of measure. But my question is, are you measuring how many rvus per patient, per day, per month, per provider, per facility, per visit . Yes, sir, we are. Sg well, that would be nice, because if you could pick one visit and give me that information tomorrow, i would appreciate seeing how you go about doing that. I would be very curious. And dr. Benechek brought up a very good point when he said how much are you spending for rvu . So if you take all this money youre spending on these patients and tally up how many rvus that have been built up, how much are you spending per rvu . Because i can tell you medicare knows how much they spend per rvu because its already established. So your budget is out there. Youre measuring rvu but not how much youre spending per rvu, and i think thats key. And i also think its key that you look at how many patients a doctor is seeing each day or a facility is seeing each day. Theres more than one way to measure these types of things. In our practice, if one doctor is seeing 60 patients and a similar doctor is seeing 30, were talking to the one with 30 and see how we can help them get that up and continue the quality that they have to have. But when youre comparing to yourself, i dont think youre getting anywhere, and thats part of the problem. So my next question is, when you talk about doing these evaluations of profficiency, who is doing this . If its someone in the va system their whole life, they dont know what theyre measuring, they dont compare to successful, Healthy Health care systems. So who is doing this currently . Right now its being done by dr. Carter mecher and eileen mor moran. Are they in the private sector . Have they been in academia . Where have they been in their careers that makes them qualified to do this . I dont know dr. Mechers history. I know hes met with the physicians on this committee, so i think you have talked with him. I think he does have a good handle and a good understanding of the rvu system and productivity. I think he has some very innovative concepts of how we can use that to resource our system and to look at rightsizing the number of physicians and the capacity that we have. And thats helpful, but i would definitely look at someone who has had Great Success in these areas and they exist throughout our country, without a doubt. We are speaking to kaiser and a continue of leaders from private sector systems, and if you had other suggestions, we would be all ears. And those are good suggestions, and i would also suggest that you encourage the president and the senate to confirm someone who has some administrative experience in the private sector in these areas. I think it would be a great benefit to our veterans and to our country. And lastly, i do want to point out that the cincinnati va, and i represent that area, has been flagged. I have asked for why they were flagged and have not received my notification yet as to why. Certainly somebody knows why, so i hope we get that very quickly as well. I look forward to seeing one of those reports on the rvus as well. I yield back. Thank you. Ms. Custer, youre recognized for five minutes. Thank you very much, mr. Chairman, and thank you, dr. Lynch and dr. Clancy for being with us this evening. I think what all of us are trying to do is be helpful. I think our chair opened the hearing asking how can Congress Help you . And our challenge is that this whole process feels like a rubiks cube. Every time we think weve got a peace and order and we think we understand what the problem is, is it not enough physicians, then we offer to help on that, but maybe thats not the problem, its a space problem. If its not a space problem, its the support staff and the list goes on and on. Im very fortunate to have experience with the d. A. In new hampshire. My fatherinlaw got very excellent care within that system, but obviously the concern that we have is that that be replicated for every veteran around the country. So the focus of my comments is, how do we ensure access to high quality care at a cost that the taxpayers can afford for every veteran . I spent 25 years in the private sector on policy issues. I know this isnt easy, this conundrum of high quality care, access and cost. Sometimes a wobbly threelegged stool. But in your case, it seems that the problems of scheduling and wait time data has called into question the whole basis for your staffing and capacity calculations. And i think, dr. Lynch, you just mentioned this. Youre trying to match supply and demand, but you dont have an accurate picture on the demand side, and so trying to determine what the staffing model would be is of limited use. And when you tell us the average is a physician seeing 10 patients a day, does that include the data that weve heard in this committee of 50 noshows . Is that actually a physician that has 20 slots per day but only 10 patients walk through the door . And we want to help you with this. We want to get the policy right. We have legislation that were offering this week. It will be bipartisan, thats about getting residents involves, give you greater capacity. We would be happy to help talk about what the state issues, but how can you help us with where to start helping you . Congresswoman, i think we can start by trying to give you the information that you ask for. And i apologize if you have not seen that. We have provided a briefing to members of this committee on the productivity model that we have. I acknowledge that until we can assure the accuracy of our scheduling data, that information is going to be flawed. Although i am confident that i think we do have reasonable information on productivity, and we can begin to use the productivity information to begin to look at what we need in the way of additional staffing to increase the efficiency of physicians, or, in those practices that are very efficient, who we may need in the way of additional physicians. So i think we have a start. But i think we need to gather more data. I think we need to have accurate data on access before we can come to a final answer. And then if we could add dr. Benecheks analysis about the cost inhouse and outside the va, because its difficult for us to make that recommendation as to how to make these adjustments. You know, we want veterans to be seen in a timely way, but its not unlimited, you know, the funds that can be put toward this. If it is less expensive within the va, then lets expand your capacity. If its less expensive outside the va, then lets use private facilities, but were not able to measure this at this point. No, but i think that all of the information that youve heard and we look forward to briefing you more on, on the productivity and staffing, will be a huge puzzle piece here that will be foundational to getting to this second order question after the emergency of addressing people waiting in line right now about what kinds of resources do we need. And the issue that dr. Lynch brought up a couple of times about maker by decision at the very local level, because thats where it needs to happen, the answer to that is not going to be thumbs up, thumbs down all the way. Its probably going to be make in some areas primary care, for example, and buy in some other specialty areas and so forth. And a lot of that will be a very dynamic relationship with Community Capacity and so forth. My time is up, but i do have a specific question id like to get to later about women being served in the va, because i think thats a unique situation as well and problematic at best. So thank you, mr. Chair. I yield back. Youre recognized for five minutes. Thank you. Id like to ask a question about the va staffing and productivity standards. The ig that was here a couple weeks ago made an interesting kind of assessment. He pretty much said be careful what you wish for to our committee and this issue of va care. I did some investigation in my state. I learned there are a number of va hospitals, including the one in fort wayne, indiana, va medical center, that are not functioningal fu aling at full. Theyre turning patients away due to lack of physicians or facilities. The va facility is closed. The er is now using criteria over what patients theyll accept and those they will turn away based on their facilities. By paying for nonva care in addition to operating halfempty hospitals, va appears to be paying for two systems of care. So do you know how many va hospitals fit this description . I dont. Could you give me that number . I found the fort wayne one pretty quickly. I think there are facilities that are struggling. They are older facilities. Not always like fort wayne where theyre in larger communities. Sometimes theyre in smaller communities. The population that they support is small and oftentimes its difficult for them to support an icu. Those are difficult decisions, but we need to look at our facilities where they are and we need to ensure that were using them optimally. I guess my followup question would be what the ig warned us about, which is, who is looking at those numbers to figure out for example, in fort wayne, those numbers for prebasis care are skyrocketing every year. Once i looked at that and found out theres no icu and theyre using criteria of who they can take and who they cant take, they may have to send somebody across the street for a riskbased procedure because theres no icu. Who looks at those numbers . Is that statewide or that specific hospital looks at those skyrocketing numbers, and who makes the assessment are we paying for two facilities or are we paying for one . Part of the challenge we have is that based on the volume in some of our facilities, we cannot support an icu. Not because we cant afford it, because we dont have the patient volume to maintain competence. And so theres a balance. And oftentimes its felt that because of the volume and because of the competence, it is better to send these patients into the private sector. I understand your concern, and we do need to look at where our costs are going and how were using our facilities. We do need to look at or is somebody actively looking at this now that all this information is really coming to us from the inspector general. Is somebody ongoing looking at that to see this cost benefit analysis to see what are we paying for . Are we paying for two systems, or is that something youre going to look at in the future . I dont know whether we have an active exercise in place, but we certainly do need to have one moving forward. I just got a note from a constituent that says there must be some kind of cnn program on tonight and that theres a new revelation. It says records of dead veterans were changed or physically altered, some in recent weeks, to hide how many people died while waiting for care at the phoenix hospital. A whistle blower pointed to a new problem in the va scandal. Records were removed so it would not show that patients died while waiting for care. Youve been to the phoenix hospital four times. Are you aware of this revelation . I am not aware of the revelation. I am aware that the ig is looking very carefully at all the deaths that have occurred. I dont know of any attempts to hide deaths, congresswoman. And my followup question, because i imagine this will be big news this morning or big news tonight when all the constituents are watching the news. To echo the comments of the committee, its so hard to take the information seriously that you give us tonight when there are these ongoing investigations by new whistle blowers that theyre taking stickers off of files and removing names still. While weve been doing these hearings a couple months and americans are literally wondering when is this going to stop . This looks like a new revelation tonight. Under all the scrutiny, all the lights, all the spirit of full disclosure, phoenix is still doing this kind of stuff . And you guys have had them under a microscope and youve physically been there four times, and this is new . Congresswoman, i dont know the details of the accusation. Could you provide that to us when were probably going i think the details are up, but could you provide a va answer to that in a timely manner . I will certainly try, as i understand it. Thank you, mr. Chairman. I yield back my time. Mr. Roarke, youre recognized for five minutes. Thank you, mr. Chairman. Dr. Lynch, you mentioned earlier that 312 million has been made available to accelerate access to care for veterans who have been unable to receive it thus far.