Collaborative Opportunity for The 

Ralph H. Johnson VA Medical Center and the Medical University of 

South Carolina to share facilities 

and resources

Field Hearing

before the

sUBCOMMITTEE ON hEALTH

OF THE

Committee on

Veterans’ Affairs

House of Representatives

one hundred ninth congress

first session

September 26, 2005

hEARING HELD IN cHARLESTON, sc

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-24

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800

Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001

u.s. government printing office

washington : 2007

23-803.PDF
Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

 Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

 Terry Everett, Alabama Bob Filner, California

 Cliff Stearns, Florida Luis V. Gutierrez, Illinois

 dan burton, Indiana Corrine Brown, Florida

 Jerry Moran, Kansas Vic Snyder, Arkansas

 richard H. baker, Louisiana Michael H. Michaud, Maine

 Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

 Jeff Miller, Florida Dakota

 John Boozman, Arkansas Ted Strickland, Ohio

 Jeb Bradley, New Hampshire Darlene Hooley, Oregon

 Ginny Brown-Waite, Florida Silvestre Reyes, Texas

 Michael R. Turner, Ohio ShellEy Berkley, Nevada

 Tom Udall, New Mexico

Jim Lariviere, Staff Director

Subcommittee on Health

 Henry E. Brown, Jr., South Carolina, Chairman Michael H. Michaud, Maine

 Cliff Stearns, Florida, Vice Chairman Ranking

 Richard H. Baker, Louisiana Bob Filner, California 

 Jerry Moran, Kansas Luis V. Gutierrez, Illinois

 Jeff Miller, Florida Corrine Brown, Florida

 Michael R. Turner, Ohio Vic Snyder, Arkansas

Jeffery D. Weekly, Subcommittee Staff Director

(II)
CONTENTS

September 26, 2005

 Page

1

 1

45

3

4

 55

7

64

17

19

91

21

95

35

136

38

140

100

109

112

114

Collaborative Opportunity for the Charleston (Ralph H. Johnson) VA Medical Center (VAMC) and the Medical University of South Carolina (MUSC) to Share Facilities and Resources .....................................................................................

OPENING STATEMENTS

Chairman Brown ........................................................................ 

Prepared statement of Chairman Brown ..................................

Hon. Michael H. Michaud, Ranking Member ............................

Hon. Steve Buyer, Chairman, Committee on Veterans’ Affairs .

Prepared statement of Chairman Buyer ....................................

Witnesses

Goldstein, Mark L., Director, Physical Infrastructure Issues, 

  Government Accountability Office  .........................................

Prepared statement of Mr. Goldstein ........................................

Riley, Joseph P., Jr., Mayor, City of Charleston, S.C. ..............

McClain, Tim S., General Counsel and Chief Management

  Officer, U.S. Department of Veterans Affairs  .......................

Prepared statement of Mr. McClain ..........................................

Greenberg, Raymond S., M.D., Ph.D., President, Medical

University of South Carolina ..................................................

Prepared statement of Dr. Greenberg .......................................

McGee, Clarence “MAC”, National Legislative Committee 

Member, The American Legion ..............................................

Prepared statement of Mr. McGee ............................................

Dimery, Lyn, National Legislative Committee Member, Veterans of Foreign Wars of the United States ..........................

Prepared statement of Mr. Dimery ............................................

INFORMATION FOR THE RECORD

Appendix A: Strom Thurmond Biomedical Research Center/

 Gazes Cardiac Research Institute ..........................................

Appendix C: Memorandum of Record .......................................

Appendix D: Working Group Membership List .......................

Collaborative Opportunities Steering Group Progress Report .

(III)
(1)

HEARING ON COLLABORATIVE OPPORTUNITY FOR

THE RALPH H. JOHNSON VA MEDICAL CENTER AND

THE MEDICAL UNIVERSITY OF SOUTH CAROLINA

TO SHARE FACILITIES AND RESOURCES

Monday, September 26, 2005

U.S. House of Representatives, 

Subcommittee on Health,

Committee on Veterans’ Affairs,

Washington, D.C.

 The Subcommittee met, pursuant to call, at 9:10 a.m., in the Solomon Conference Room 125, Thurmond/Gazes Research Building, 

Medical University of South Carolina, 114 Doughty Street, Charleston, South Carolina, Hon. Henry Brown [Chairman of the Subcommittee] presiding.

 Present: Representatives Brown, Buyer and Michaud.

Mr. Brown. Good morning. The hearing will now come to order.

As Chairman of the Subcommittee on Health, I am very pleased 

to be joined today by both our distinguished Chairman of the House 

Veterans’ Affairs Committee, Steve Buyer from Indiana’s Fourth District; and the Subcommittee Ranking Member, a Democrat, the Honorable Mike Michaud. We welcome both of you to the low country.

Mr. Chairman, I am truly honored to have you with us this morning, and especially appreciate your strong leadership and willingness 

to work with the Subcommittee on this very important matter. Your 

persistent efforts have always proven instrumental in bringing VA 

and the Medical University together in order to advance discussions 

on collaboration. And for that, I thank you very much.

It is also a real pleasure to have my friend and the Subcommittee’s Ranking Member Mike Michaud here in the low country. Mike 

and I shared a leadership role last year on the Benefits Subcommittee. This year, as I was selected to chair the Health Subcommittee, 

Mike was designated as the Ranking Member on Health and I am 

grateful for that. I think we have a very strong working relationship 

and I was honored to join him recently in his beautiful home state of 

Maine. Now is South Carolina’s chance to return the hospitality we 
2

were shown by Mr. Michaud and his staff. Welcome, Mike, and thank 

you for joining us today.

I would like to remind everyone here today that our purpose is 

simple: We are here to conduct an official Congressional hearing examining opportunities for enhanced collaboration between the VA 

and MUSC. I understand there will be some in the audience who will 

be hesitant to embrace the idea of collaboration here, but we want to 

hear from the experts as to whether or not collaboration can be expanded. To that end, I would remind you -- because this is an official

hearing -- there will not be an opportunity for members of the audience to speak. There will be plenty of time for that and in fact, I plan 

to host a number of public meetings here in Charleston, to hear your 

questions, concerns and hopefully your support once the information 

is shared in today’s official format.

My goal, as the Chair of the Subcommittee on Health, is to improve 

the health care delivery for our veterans and keep it in step with the 

21st Century. Most importantly, I am deeply committed to doing 

what is right for the veterans of South Carolina. And to that end, I 

have worked hard to ensure that the veterans in this state are able 

to access the best and most timely care at a location that is closer to 

their homes. I have worked to expand the Community Based Outpatient Clinic in Myrtle Beach. Dedicated in March of this year, the new 

clinic is more than triple its original size, going from 4,200 square 

feet to 12,800. It includes 16 primary care examination rooms with 

the capacity to be expanded for 24 rooms as needed. The $2.7 million project also includes on-site digital x-ray equipment and 36 additional parking spaces.

 We can look forward to the new outpatient clinic that is being built 

on the Naval Weapons Station in Goose Creek, which is targeted for 

opening in 2008. In the meantime, however, on September 13, VA 

opened a temporary North area VA outpatient facility on the TRIDENT medical center complex.

 Here in Charleston, we have a unique and wonderful opportunity to develop a new and innovative model for delivering the highest 

quality health care to our veterans and set the standard for all other 

areas to follow.

VA and MUSC have a long-standing and strong history of working collaboratively. Facilitated by their physical proximity to each 

other, the two medical facilities already share significant amounts

of medical staff and research activities. In fact, some 243 physicians 

who hold faculty appointments at MUSC now treat veteran patients 

at VA Medical Center. Of those, about 125 to 150 do so on a regular 

basis, along with another 85 MUSC residents at any given time. This 

represents over 95 percent of VA’s physician staff at the hospital.

Nine years ago, Senator Thurmond took the lead and was instrumental in creating the building where we are holding our hearing 
3

today. The Thurmond/Gazes Biomedical Research Center is shared 

by the VA and the Medical University and houses the research efforts 

of both institutions. It is widely claimed as a highly successful model 

that has served to set a national precedent in the area of collaboration.

In addition to the existing relationship in research, VA and MUSC 

are already engaged in a significant effort in the area of clinical services. In fact, the VA medical center currently purchases roughly $13 

million in specialty medical services. The relationship exists, now we 

want to see if it can be expanded in order to improve care and at the 

same time, reduce the need for both organizations to purchase expensive, duplicate equipment and infrastructures. All these factors 

make this an ideal time to further explore such an option. And that 

is what we are doing -- exploring.

I want to assure all of you here today, especially all the local Veterans’ Service Organizations that are so important to the process, that 

this is not about VA losing control of the care for veterans or destroying VA’s ability to meet veterans’ unique needs. It is about advancing 

an already successful partnership in order to provide the veterans of 

South Carolina the highest quality of specialized inpatient care in 

the best and most up-to-date facilities. The bottom line is we are not 

interested in collaboration for collaboration’s sake, we are interested 

in improving the clinical services provided to veterans through new 

and innovative delivery models.

  I am confident that the panels we have assembled here today will

help us better understand how a mutually beneficial collaborative

agreement can be crafted and how the many complex and critical issues can be effectively worked out.

I now yield to Mr. Michaud.

 Mr. Michaud. Thank you very much, Mr. Chairman. I want to 

thank you for your kind hospitality and I really appreciate being in 

Charleston. It is a beautiful and hospitable city and I want to thank 

you for the little tour this morning. Last night when I arrived actually Chairman Buyer gave me a little tour driving in from the airport. 

So it is great to be here.

 This is a very important hearing this morning. For several years, 

the VA has been working the Capital Assessment Realignment for 

Enhancement Service process. CARES is a very important effort by 

the VA to realign the VA infrastructure with the current and future 

needs of our veterans.

  As we found in the field hearing in the State of Maine last month,

the CARES process to expand access to care for veterans in Maine 

has been stalled because of lack of funds. The CARES plan and decisions recommended collaboration ventures between the VA and the 

Department of Defense as well as other entities. Collaborations are 

appropriate because they have the potential to enhance our service 
4

for our veterans. That is one thing we have got to keep in mind, 

whatever we do on the Veterans’ Affairs Committee, we want to make 

sure that it benefits the veterans, not only in South Carolina but nationwide. 

And I look forward to the hearing today to hear how VA can establish a model process to resolve the complex and important clinical, 

fiscal, legal and governance issues involved in the joint construction

and operation of ventures between the VA and other health care organizations. So I want to thank all the panelists for your testimony 

today and look forward to hearing it.

I yield back the balance of my time, Mr. Chairman. 

 Mr. Brown. Thank you, Mr. Michaud. It was really an experience 

for me to go to Maine, it was my first trip up there, and I know dealing with rural health care for veterans is a big issue that we have got 

to address, and particularly in areas as big as Maine and with such 

a few people. I think it is what, 1.1 million people I think living in 

Maine?

 Mr. Michaud. That is correct.

 Mr. Brown. And what is it, 400 miles long or something like that.

Mr. Michaud. It is almost 28,000 square miles in my Congressional 

District alone.

[Laughter.]

 Mr. Brown. So anyway, we have unique problems as we deal with 

the health care delivery for veterans, particularly trying to take the 

health care delivery to the veterans. It was some great sharing experiences up there and I am glad you are here today. Sorry you cannot 

stay but just a short while.

 We really are fortunate to have the Chairman of the Committee, 

Congressman Steve Buyer. Congressman Buyer is not certainly a 

stranger to this area, having graduated from the Citadel. He has 

family connections and we call him the seventh member of our Congressional delegation.

[Laughter.]

 Mr. Brown. But anyway, Congressman Buyer, we are certainly 

glad to have you and we welcome an opening statement from you.

 Mr. Buyer. Thank you, Mr. Chairman and Mr. Michaud.

 First of all, I want to thank both of you for your leadership. More 

importantly, let me thank you for taking time away to go down to the 

Gulf area to check out the facilities, the damage to our VA Hospitals 

in New Orleans and Biloxi, Gulfport. I want to thank you for that. 

  We are in a very important mission in Congress, trying to find out

exactly what were the facts and what went wrong. More importantly, 

we will have to analyze that VISN and the Secretary is doing that has 

really not been told enough, how well the VA responded. In the press, 
5

Mr. Chairman, you often hear about the federal response. Well, that 

is such an over-statement, because I saw the Coast Guard saving 

thousands of lives. I think they are part of the federal government. 

I saw the VA do remarkable and heroic and courageous acts, and the 

first convoy of relief came from Jackson, Mississippi into the Gulfport

area. So I look forward to talking with both of you when you return 

from your trip.

I also am pleased to see that there is such a high level of interest 

in this initiative in this room here this morning, because improving 

how we deliver health care to veterans here and across the nation 

is extremely important, especially at a time when we are at war. I 

think everyone here would agree that health care is becoming such 

an important issue in all of our lives, and for South Carolinians and 

particularly veterans of South Carolina, you have a real champion 

in Henry Brown. Henry and I shared a special moment earlier this 

year when both of us had the opportunity give a memorial address at 

Normandy. As we toured the cemetery and the battlefields of France,

even a World War I cemetery, Henry wanted to be in close proximity 

of his father and where he had served, and I got to see a very sensitive and compassionate side of Henry that motivates him in the service of veterans on this Committee. 

I also want to thank the VA’s General Counsel, Tim McClain, for 

his involvement on behalf of Secretary Nicholson, for coming down 

here earlier. Your personal involvement here is extremely important. I would also like to thank Mr. Mountcastle and Dr. Greenberg 

and the respective teams of dedicated professionals for their interest 

in the welfare of veterans at the Charleston VA facility and in this endeavor which you are presently working on. Your willingness to consider the possibilities that some may view as controversial -- change 

always frightens some people and new ideas can generate emotion. 

But your willingness to step forward and do this investigation is extremely important. 

 One of the major concerns I think veterans here in Charleston, in 

the low country, could have is, are they about to “lose their identity” as a VA Hospital to the University Hospital. These rumors have 

made their way to Washington. Even unfortunately I think the term 

“land grab” has been used. I think these types of words have a basis 

in malice, they are slanderous. These are words that are used by 

individuals who are ignorant. Ignorant, not that they are not very 

smart people, they just do not know what it is about yet. So it sort 

of frightens them, so they use certain words. And this hearing is extremely important because it will be able to dispel some of the myths, 

it will be able to lay out the processes, the methodology that is being 

used here. So these types of misplaced words that are being used by 

some are completely unfortunate.

I have learned in the political arena, Mr. Chairman, that people 
6

will do those kinds of things. But the facts and using cost/benefit

analysis and doing what is in the interest of our veterans and how we 

improve the delivery of health care are extremely important. 

And as I look at the federal dollar and I look at Charleston, what the 

Medical University is doing here, they are doing it because of the use 

of federal dollars, of HUD grants. So this is a very large federal project that is going on here on the peninsula. So when you think about 

the federal dollar and how we are bettering health care delivery and 

services and access here on the peninsula for your citizens here, Mr. 

Brown -- and there is a history of collaboration and excellent working 

relationship that Mr. Mountcastle has with Dr. Greenberg -- how do 

we improve that as we have an ongoing construction project?

I want to thank the CARES Commission, because they have encouraged these two parties to work together. Those negotiations got 

stalled and now they are back on track and I think this is pretty exciting. All you have to do is look around at this building we are sitting 

in, and as you mentioned, Mr. Chairman, it’s state of the art, cutting 

edge. These are pretty exciting terms to use, and to think that South 

Carolina is at the tip of the spear to do that. Only one word I could 

use to describe that and that would be pride. When I toured this facility this past summer, I could sense that and I could feel that.

 So I have complete faith in the veterans who also have the pride 

in their services at the VA facility. They will see what we are endeavoring to do here and how it will increase their access to care 

and decrease waiting times and at the same time reduce the federal 

outlay. That is what is extremely important here because of our responsibility also to the taxpayer. This throw-back of old that I am 

going to build my own hospitals wherever I want, my own fiefdoms

and mausoleums, I think is in a different age.

I want to thank you for calling this hearing, Henry. I look forward 

to the witnesses and I will have some questions as we proceed.

 Thank you, I yield back.

 Mr. Brown. Thank you very much, Mr. Chairman, I really do appreciate you coming and being with us this morning.

  Our first witness this morning is Mr. Mark Goldstein. He is Director of Physical Infrastructure Issues at the U.S. Government Accountability Office.

 The Committee has requested GAO, the agency responsible for 

review and investigation of federal property, to examine issues surrounding the opportunities for VA and MUSC to enter into a joint 

venture, and provide the Committee with a report and recommendation.

Mark, glad to have you with us this morning and we look forward 

to your testimony.
7

STATEMENT OF MARK L. GOLDSTEIN, DIRECTOR, PHYSICAL

INFRASTRUCTURE ISSUES, UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE

 Mr. Goldstein. Thank you very much. Good morning, Chairman Brown, Chairman Buyer and Ranking Member Michaud. I am 

pleased to be here to provide a preliminary findings on the possibility of VA and MUSC entering into a joint venture for a new medical 

center in Charleston. 

As you know, VA has for many years developed and maintained 

partnerships or affiliations with university medical schools to obtain

medical services for veterans and to provide training and education 

to medical residents. Today, VA has affiliations with 107 medical

schools. These affiliations, one of which is MUSC, help VA fulfill its

mission of providing health care to the nation’s veterans.

In addition to partnering with university medical schools, VA manages a diverse inventory of real property to provide health care to 

veterans. However, many of VA’s facilities were built more than 50 

years ago and are no longer well suited to providing accessible, highquality, cost-effective health care in the 21st century. To address 

its aging infrastructure, VA in 1999 initiated the Capital Asset Realignment for Enhanced Services, or CARES, process. In February 

2004, the CARES Commission, an independent body charged with 

assessing VA’s capital assets, issued its recommendations regarding 

the realignment and modernization of VA’s capital assets necessary 

to meet the demand for veterans’ health care through 2022. At that 

time, the Commission recommended replacing VA facilities in Denver 

and Orlando. But the Commission did not recommend replacing the 

VA facility in Charleston. However, the Commission did recommend 

that VA promptly evaluate MUSC’s proposal to jointly construct and 

operate a new medical center with VA in Charleston, noting that such 

an arrangement could serve as a possible framework for partnering 

in the future. In responding to the Commission’s recommendations, 

the Secretary stated that VA will continue to consider options for 

sharing opportunities with MUSC.

My statement today will cover three things: (1) the current condition of the Charleston facility and the actions VA has taken to implement CARES; (2) the extent to which VA and MUSC collaborated on 

the proposal for a joint medical center; and (3) some of the issues VA 

should consider when exploring the opportunity to participate in the 

joint venture.

 Our preliminary views are as follows:

(1) The most recent VA facility assessment and the CARES Commission concluded that the Charleston facility is in overall good condition and with some renovations can continue to meet veterans’ 
8

health care needs into the future. VA officials attribute the facility’s

condition to VA’s continued capital investments. The CARES Commission recommended renovation of the nursing home care units as 

well as the inpatient wards in order to meet the need of the projected 

veterans’ population in the Charleston area. To maintain the facility’s condition over the next 10 years, officials from the VA facility in

Charleston have identified a number of planned capital maintenance

improvement projects, including repairing expansion joints, making 

electrical upgrades and adding a parking deck for patients. VA officials estimate that the cost of these planned maintenance and improvement projects will total about $62 million.

(2) VA and MUSC collaborated and communicated to a limited extent on a proposal for a joint venture medical center over the past 

three years. In November 2002, the President of MUSC made a proposal to the Secretary of VA to participate in a multiphase construction plan to replace and expand its campus. Under MUSC’s proposal, 

MUSC would acquire the site of the current VA facility in Charleston 

for part of its expansion project and then enter into a joint venture to 

construct and operate a new VA facility on MUSC property. Although 

there has been some discussion and correspondence between VA and 

MUSC since 2002 on the joint venture proposal, collaboration has 

been minimal. For example, before this summer, VA and MUSC had 

not exchanged critical information that would help facilitate negotiations such as cost analyses of the proposal. As a result of the limited 

collaboration, negotiations over the proposal stalled. However, VA 

and MUSC recently took some initial steps to move the negotiations 

forward. Specifically, VA and MUSC established four workgroups to

examine critical issues related to the proposal.

(3) The MUSC proposal for a new joint venture VA Hospital presents a unique opportunity for VA to explore new ways of providing 

health care to Charleston’s resident now and in the future. However, 

it also raises a variety of complex issues for VA. These include the 

benefits and costs of investing in a joint facility compared with those

of other alternatives such as maintaining the existing facility or considering options with other health care providers in the area; legal 

issues associated with a new facility, such as leasing or transferring property; contracting and employment; and potential concerns 

of stakeholders. The workgroups established by VA and MUSC are 

expected to examine some, but not all of these issues. In addition, 

some issues can be addressed through collaboration between VA and 

MUSC while others may require VA to seek legislative remedies. It 

is important to note that GAO has stated over the past few years that 

federal agencies, including VA, need to re-examine the way they do 

business in order to meet the challenges of the 21st Century.

 To address future health care needs of veterans, the VA’s challenge 

is to explore new ways to fulfill its mission of providing veterans with
9

quality health care. The prospect of establishing a joint venture 

medical center with MUSC presents a good opportunity for VA to 

study the feasibility of one method to achieve this goal. This is just 

one of several ways VA could provide care. Nevertheless, determining whether a new facility for Charleston is justified in comparison

with the needs of other facilities in the VA system, as well as other 

budgetary claims, is also important. Until all the relevant issues 

are explored, it will be difficult to make a final decision on whether a

joint venture is in the best interest of the federal government and the 

nation’s veterans.

In conclusion, Mr. Chairman, I would like to thank the VA, MUSC 

and the Committee staff for their assistance in this portion of our 

review. I would also like to thank GAO’s team for its contribution to 

this effort.

I would be pleased to answer any questions that you or members of 

the Subcommittee have.

[The statement of Mark Goldstein appears on p. 64]

 Mr. Brown. Well, thank you very much for your testimony and we 

do have a few questions we would like to ask.

Number one, my question would be, what are the key issues that 

the VA needs to explore in examination of the joint venture proposed 

to adequately evaluate whether such an opportunity is in the government’s best interest? What do you think would be the real selling 

point to make this project work?

 Mr. Goldstein. I think there are a number of issues, Mr. Chairman. And let me first say that I do think that MUSC and VA are

certainly now on the road to exploring the issues. The workgroups 

that have been set up in clinical areas and financial and legal and

governance I think are definitely on the road. We saw the interim

report on Friday. We have not had a chance to really analyze it, but 

just even looking at it quite briefly you get a sense that there is some

progress going on. The clinical services area specifically seems to

have really begun to grapple with the hard issues that they face. So 

I think we have definitely seen some strong progress very recently in

the willingness and the incentive of the two groups to move forward 

and do this. 

 Having said that, I think from our view, the challenges that will 

most -- that need most addressing certainly include the governance 

structure, especially if there ends up being a joint governing board of 

some sort. That is an area that may take some assistance from you 

all in terms of legislation to make certain kinds of changes. It is too 

early to tell, of course, at this point, but the governance structure is 

going to be critically important trying to understand who is accountable for what, who is responsible for what, particularly when it comes 

to providing quality care for veterans, to make sure that VA can still 
10

maintain its mission and be sure to have the accountability that the 

American public and Congress expects them to have in achieving 

those goals.

I think the property and the associated transactions still clearly 

need a lot of work. They are going to have to decide whether or not 

this is something where property would be purchased by VA, whether 

it would be leased, whether you could go into an enhanced use lease, 

whether you could share property of some sort. Legal teams are going to have to look through this. There are obviously some complications and restrictions in many of these areas. Capital leases require 

certain kinds of budget scoring issues back in Washington. There are 

a lot of issues there as well that take time. Stakeholder input, I think 

that would be an area where we have not seen so far the workgroups 

at this point get input and they may want to do that from employees, 

from the Veterans’ Service Organizations as well. Those voices certainly need to be heard in this. Meaningful measures to determine 

the joint venture’s utility, how will they know what success is. I think 

that is extremely important as well. Obviously the cost analysis, so 

they can determine cost versus benefits. The clinical services group

has begun that, but there is still a long way to go and obviously you 

have got to find some way to ensure that the information that feeds

into the cost analyses is being appropriate and accurate and valid by 

all parties, that it is transparent. I think that is very important. And 

then finally, I think a difficult issue they will have to grapple with is

sharing health care information. 

In the work that we have done recently I believe for this Committee where we have taken a look at resource sharing between DoD and 

VA, we found that one of the things that came up repeatedly in the 

16 places that GAO visited, one of the biggest challenges was sharing 

health care information and making networks work.

 So those would be the initial observations.

 Mr. Brown. I think that is a challenge for us too, as we look for a 

seamless transfer between DoD and the VA, that is another issue but 

it is an issue we have got to address.

I noticed in your report, you said that I guess in the next several 

years, the hospital, although it is in sound condition today, would 

need some $62 million worth of upgrades or, you know, renovations. 

If in fact a new facility was constructed, how much of that savings 

would be incorporated into the new construction?

 Mr. Goldstein. The VA has said that they would plan to spend 

roughly $62 million over the next 10 years to renovate this facility 

in line with CARES. I could not tell you exactly how much could be 

say transferred or used if they were to build the new facility, nor do 

I know at this point because we have not finished our work yet, Mr.

Chairman, about how this might compare to two other facilities in 

the system. When it comes to the standard maintenance that they 
11

are providing for the facility, it is at about two or three percent of 

operating costs I believe. So it is fairly low, but you could certainly 

take a look at the $62 million and specific projects and many of those,

assuming you were going to build a new facility, could be I suspect 

foregone. You would have to obviously take a look at the facility and 

work with the facility’s assessment reports of the facility and try and 

determine what are real priorities that need to be done even as you 

were to move to a new facility, what had to be done and what could 

be deferred.

Mr. Brown. Right.

Mr. Goldstein. But that is certainly something that is do-able.

 Mr. Brown. Thank you very much.

Mr. Michaud, you have questions?

 Mr. Michaud. Yes, thank you, Mr. Chairman. Once again, I really 

appreciate you having this hearing down here and for your continued 

fight for veterans, Mr. Chairman.

I have got a couple of questions. How does the joint venture being 

explored in Charleston fit into the CARES process and VA’s capital

planning process?

 Mr. Goldstein. Congressman, the VA facility here in Charleston 

fits in several ways. One, as you know, when the CARES Commission made its recommendations, it recommended that two facilities 

be completely replaced in the near future, in Denver and in Orlando. 

But it also put 48 capital projects on the table that were consistent 

with the CARES program as well. Charleston does not fit directly

into those at this point in that they did not recommend a new facility 

here per se, nor does it make that list of 48 immediate capital projects, I think it is to 2010 I believe.

 But in the CARES report, it was indicated, it was requested and 

the Secretary did agree to take a look at Charleston with respect to 

determining whether or not there were greater sharing opportunities 

and whether or not a joint venture could be pursued. And so it does 

fit in that context, and certainly that is exactly what is occurring. I

mean I would add, you know, we have talked a lot over the last couple 

of years about the need for VA to go through the CARES process and 

I think it is going to ultimately be very beneficial. The process, like

any of these kinds of processes, is not static in that obviously changes 

occur that require VA to look at other things. So while the process is 

not set in stone, you use it as a guidepost, if you will, as benchmarks 

to go forward. Obviously VA is going to have to consider changes, it 

would seem to me, based on what is occurring in the Gulf. There are 

going to be some needs there too.

 Mr. Michaud. In your experience, looking at VA efforts to use leasing or other options for collaborative ventures, does VA have a consistent set of criteria and process to explore or evaluate these opportunities in both a comprehensive manner as well as a time sensitive 
12

manner?

 Mr. Goldstein. Shortly after MUSC made its proposal to VA, VA 

did take a look at the project and developed scenarios and some preliminary cost analyses and responded fairly quickly. Then a year later, Congress asked them to do it more formally through a feasibility 

study, which was more recently updated. So from a time perspective, 

I think VA has moved fairly well on its own initiative. I think where 

there has been some concerns is in communicating successfully with 

MUSC on how they might make this collaboration work.

  With respect to any of the specific leasing or owning or sharing

arrangements, we have not looked in detail at them. It is a little premature until they kind of come up with a more specific approach and

framework for how they will do it. To examine the cost in abstract 

we decided was probably not something that we would pursue at this 

point.

 Mr. Michaud. With all the governance, clinical and legal issues 

which the workgroups are currently exploring, do you think they can 

all be resolved or will there be some ongoing, continuing problems or 

concerns that would have to be addressed?

 Mr. Goldstein. I think there will certainly be challenges for years 

to come. I mean I think that the information technology challenge 

will take years to work out, whatever it is that is decided. It is hard 

to accomplish even under the best of circumstances for organizations 

that do not have sort of separate overseers, the federal government 

on one side with its peculiar needs to serve the veteran population 

and protect privacy and handle information in certain ways. I think 

that is a very large challenge that will take a long time. I think the 

governance structure could take a long time, not in setting it out, 

but in smoothing it out probably and getting through its wrinkles. It 

would be a fairly unique approach if indeed they were to create say 

a joint board that managed it and reported to VA and MUSC, and 

obviously that is one where Congress would need to be involved. So 

I think some of these will take a fair amount of time to resolve; yes, 

sir. 

 Mr. Michaud. My last question. In the initial stages of what you 

have heard so far as far as this joint venture, what will it cost the VA 

to implement it -- a rough figure.

 Mr. Goldstein. Again, I think it would be determined on what 

approach they end up taking. The VA says that a new replacement 

facility would be about $185 million, but it is unclear what that facility would include at this point and again, how it would be structured. 

It might not cost that much. Obviously it could cost a lot more. If 

you look at the replacement cost for Denver, it is roughly $600 million 

from what I saw. So that is a lot of money.

 Mr. Michaud. So anywhere from $100,000 to 600 -- I mean $100 

million to $600 million?
13

 Mr. Goldstein. That is possible. You know, we have not looked at 

it, so I am hesitant to even give you a ballpark, but on the other hand, 

GAO issued a report not long ago when we looked at a facility that VA 

and DoD had collaborated on and VA decided not to build a new facility and instead to work through building new outpatient clinics, and 

that cut the cost for them in half, from about $100 million to about 

$45 million. So I think that is possibly a ballpark; yes, sir.

 Mr. Michaud. Thank you very much. Thank you, Mr. Chairman.

 Mr. Brown. Thank you, Mr. Michaud.

Chairman Buyer.

 Mr. Buyer. To follow up on Mr. Michaud’s questions, it is pretty 

early in the process for you to even give a professional judgment as to 

what you estimate the cost could be, would that be accurate?

 Mr. Goldstein. Yes, sir. That is why I hesitated. That was a rough, 

you know, building a hospital is going to be in certain parameters, 

but it does depend on what you put in it and how you structure it.

 Mr. Buyer. I have read your preliminary findings. Would you restate for me what your present charge or mission is? What are you 

presently analyzing, so when I get a final report from you, it is going

to be based on what?

 Mr. Goldstein. We are looking at three things at the request of 

the Committee. One which is how the -- specifically the condition of

the facility here and what its needs would be. Two is whether or not 

MUSC and VA are working effectively and the kinds of things they 

are doing to determine whether a joint effort is feasible for them to 

go forward with. And third is a little different from the testimony 

where we are talking about, you know, some challenges; to see also 

whether or not there are some lessons that can be learned, both here 

in Charleston as well as in Denver for VA in deciding whether these 

kinds of efforts ought to be developed more widely.

 Mr. Buyer. For the purpose of open disclosure here, when Denver 

first started on this initiative collaboration, it caused people to pause

and say well, this is rather interesting, what exactly are they doing. 

And at that moment is when Henry Brown also approached me and 

said you know, Steve, that is something we could also do in Charleston, we should examine that as a possibility. And do not hold me to 

this, but it has got to be three and a half, four years ago, we came 

down here, we met with Dr. Greenberg. At that time, I came down 

because the Navy had an interest in building something, and at that 

time MUSC was thinking about doing something, and the VA is always talking about building something. I said wait a minute, this is 

a lot of federal dollars. So when we look at the peninsula, if you take 

community health centers, Medicare, Medicaid, VA, TriCare, medical 

treatment facilities for the military, it is a lot of federal dollars here. 

And at that time, I had mentioned and suggested, you know, if you 

want to build a billion dollar campus, do it more up on the north side. 
14

The other would be to MUSC that, why do you not get in tough with 

the same firm that is doing the consulting with regard to Denver? 

And that is what they did. So that has been an initiative on the inside that has been working.

I also then, observed what was occurring in Denver -- there was a 

complete breakdown in leadership personalities there between the 

VISN director and the hospital director of the university. When you 

go out there, I want you to take a look at that a little bit more for the 

Committee, about where they went in the process and what went 

wrong, and the lessons learned that can be helpful to us here.

 Mr. Goldstein. In fact, we are going out there next week, so we 

appreciate the insight.

 Mr. Buyer. Oh, that is wonderful, because there are those who are 

against collaboration no matter what, even though they do not know 

anything about it -- I am against it -- you are always going to have 

that -- I am against it. And some feel that well, if all I have to do is go 

into the veterans’ community and spin up the veterans and tell them 

how bad it is going to be for them, therefore, it will fail here because 

that is what they did in Denver. I believe that is false, based on all 

the personal knowledge that I have. So I am interested for you to ask 

those questions when you are out there, because I know how it went 

down, but I want to hear it from your investigation, okay?

 Mr. Goldstein. Sure, we will be happy to.

 Mr. Buyer. The other is with regard to CARES. CARES was a 

snapshot in time, was it not?

 Mr. Goldstein. That is correct, it anticipated being updated over 

time.

 Mr. Buyer. Correct. So as I noted in your report, OMB and GAO

have identified benefits cost analysis as a useful tool for integrating

social, environmental, economic and other effects of investment alternatives when making a decision. Is that correct?

 Mr. Goldstein. Yes.

 Mr. Buyer. The quote “other effects” right now on the conscience 

of the nation is weather -- hurricanes. So we know now its powerful 

effect in the Gulf and as a result two members of this Committee are 

going to go down and have a look at it. We saw what happened to 

the VA facility in Gulfport. We know we have got serious problems 

with that VA hospital in New Orleans, whether or not we can return 

to that facility.

I am anxious to get into this with the next panel, but I want to keep 

it on your conscience that Charleston is at sea level, right?

Mr. Goldstein. Yes, sir.

 Mr. Buyer. So if we are going to be building a VA facility, right 

now, as you do your report, I would like to know about this present 

VA facility and maybe we can get into it with the next panel what 

it is built to withstand. And as we move forward in any form of col-
15

laboration, if in fact a decision is made to build the facility and we 

have shared arrangements with Charleston, what do we need to do 

to harden it against what, Category 4, Category 5? As we examine 

those construction projects, Mr. Michaud, Mr. Brown, you know, you 

are going to have to look at those effects of the hurricane, because 

the country is not going to be too happy if we are going to make these 

multi-hundred million dollar investments and we have not taken 

that into account.

 The other thing I want to reiterate is that yes, CARES did not include Charleston in the 48 projects across the nation, but it did cite 

the potential of joint venture between VA and MUSC as a possible 

framework for future partnership, is that correct?

 Mr. Goldstein. Yes, sir, that’s correct. And the Secretary did agree 

to look at sharing opportunities. 

 Mr. Buyer. You said that this could be a model that could be leveraged. Could you expand on that a little bit?

Mr. Goldstein. Sure. I think obviously what we need to pursue understanding whether it could be a model is better information, which 

the workgroups and however else they decide to pursue this will get 

for the Committee and for VA and MUSC to determine. But I think 

what is required is some specific criteria that would help all the organizations, all the stakeholders whether or not this can be a model. It 

certainly is not GAO’s place to determine what those criteria would 

be, but there needs to be a framework that would include whether 

or not this can be successful and what success would mean for joint 

ventures of this nature, so VA could determine here are opportunities 

that we can pursue and the climate is right and the kinds of measures and situations are right. We have seen this before, this fits into

our model, therefore, we could pursue it with little risk. 

 Mr. Buyer. There is a reason that we have asked the GAO to come 

in. It is because even though CARES gives us encouragement for the 

VA to move toward a joint venture, explore the possibilities, it got 

stalled. There was not the best of communications between the VA 

and MUSC, and MUSC to VA. How do we encourage that, how do we 

keep it going?

 You are our independent set of eyes on this process as we develop 

a model and then as the model is developed, in doing the cost benefit

analysis -- because it has to be mutual, it has to be in the mutual 

interest of the Medical University, and it has to be in the mutual 

interest of VA.

And the next panel will explore that, but there is a fear on our 

standpoint. Our fear is that we want to build a model that is successful and that is the reason we have GAO in, because not only are we 

going to attempt to build this model, but what are the right benchmarks, measurements of success, how do we make these determinations in the decision-making process?
16

 So, Mr. Chairman, I want to thank you for getting GAO involved 

in this process. I think it is extremely important and we are going 

to have an ongoing dialogue as we oversee this process. And I think 

your willingness and your leadership on this -- I think is pretty exciting to challenge anew, because innovation can always be frightening 

to the defenders of status quo.

 Mr. Goldstein. Thank you, I appreciate your comments, sir.

 Mr. Buyer. I yield back.

 Mr. Brown. Thank you, Mr. Goldstein, for coming and giving us 

this great information and we look forward to continuing dialogue as 

this process moves along.

 Mr. Goldstein. Thank you, Mr. Chairman.

 Mr. Brown. Thank you. 

 Before welcoming the second panel -- and we are glad to have you 

all here this morning, but Mayor Riley, the great Mayor of this City, 

was going to come and have opening remarks but he has had a death 

in his wife’s family and so he was late coming. He is on the scene and 

we would like to give him just a moment to welcome everybody to the 

City of Charleston.

 Where is Mark? Mark, I was going to recommend that you stick 

around for a couple of days and sort of get a good view of the lay of the 

land here. It is hard to see Charleston in a day.

 He should be here shortly. But before he comes, I will go ahead and 

introduce the panel and at least we will have that little part taken 

care of.

  Our second panel is officials from the Department of Veterans’ Affairs and the Medical University of South Carolina. Representing 

VA is the Honorable Tim McClain, VA General Counsel. He serves 

as the chief legal advisor to the Secretary and the Department. In 

January 2005, Secretary Nicholson designated Mr. McClain as the 

interim Chief Management Officer. As CMO, Tim is also responsible

for, among other things, the Department’s finance policy and operation of the real property asset management. With him is Mr. Mountcastle from the VA Hospital here and we are really glad to have you 

on the panel. The other members are Mr. Raymond S. Greenberg 

who became the eighth President of the Medical University of South 

Carolina in 2000. He has authored about 150 scientific publications

and Dr. Greenberg is nationally recognized for his research on cancer 

and he has served on many national scientific advisory boards. And

with him is Mr. Moreland from the VA Pittsburgh Health Care System.

 Gentlemen, I welcome you here, but before I give you a chance to 

give testimony, we have our great Mayor from the City of Charleston. 

Mayor Riley, if you would just say a few words, we are grateful to 

have you.
17

STATEMENT OF JOSEPH P. RILEY, JR., MAYOR, CITY OF

CHARLESTON, SOUTH CAROLINA 

 Mayor Riley. Thank you very much, Mr. Chairman, members of 

Congress, members of the Committee, members of the staff, ladies 

and gentlemen. I apologize very much for being late today.

My dear mother-in-law passed away this weekend. She was like 

my mother and an extraordinary woman, one of the most extraordinary people I have ever met. So I have been in the other part of the 

state, the funeral is tomorrow. But I left in dark, many miles away, 

to come down here today because of the importance of this meeting 

and in part because of her feelings about this, which I will explain to 

you right away.

My father-in-law was a veteran, her husband. She was widowed 

in 1978. He fought for our country in World War II, he was in the 

Army during the Korean Conflict. And in the later part of his life,

he needed and received wonderful care from the Veterans’ Hospital 

system in our country.

 So a few months ago, when there was an article in our newspaper 

about the possibility of the Veterans’ Hospital -- a new Veterans’ Hospital -- being constructed as a part of the Medical University of South 

Carolina Hospital, she called me. She was living here then and she 

said what a great idea, isn’t this wonderful, what a marvelous thing 

for the veterans. She was calling as the spouse of a veteran seeing 

the possibility here of our veterans, those who risk their lives and 

give their health and have their future longevity diminished in the 

service of our country, that they have the very best, the best that is 

possible.

And to me, Mr. Chairman and members of the Committee, that is 

what this is about. Beyond -- which I will speak about briefly -- the

importance to Charleston and the Medical University of South Carolina, it is an opportunity -- and the care at the Ralph Johnson Medical 

Center is extraordinary. I like going in that place, the feel, the throb, 

the spirit of all the people from the volunteers pushing the carts to 

the senior staff is absolutely extraordinary. But for the veterans to 

have the opportunity in this new world class medical hospital complex, to have their own independent, named, separate yet connected, 

veterans’ hospital with link to the best that is available in the world. 

If that veteran, if one of my father-in-law’s colleagues or someone like 

him needed the best heart care, the best cancer care, the best whatever care, it is right down the hall in this wonderful system.

 When we started working with the Medical University and they 

looked at the possibility of building their new 100-year plan someplace else other than right here. We worked with them because we 

saw, from the City’s standpoint, the opportunity to create a world 

class medical campus right connected in the historic part of our City. 
18

And we together laid out the plan of the system of hospital buildings 

wonderfully gracing the streets and with a wonderful form, yet connected so that you would have this series of hospital buildings along 

Courtenay Street connected with this extraordinary medical university campus. And it was then seeing the potential of making the VA 

a part of this.

 So we really dropped everything we were doing almost from a planning standpoint, got together with Dr. Greenberg and his wonderful 

staff, with our neighborhood, with the people and redid our zoning 

ordinances, did our plans, did our height ordinance -- Congressman, 

you went to the Citadel, as I did -- to respect the wonderful quality 

of the built environment in Charleston, but to make it fit too, so we

came up with this fabulous plan for this wonderful new medical campus with the VA with its independence, with its visibility, with its 

separateness, yet connected to what we know is going to be one of the 

great medical centers in our country.

 So on behalf of my dear mother-in-law and lots of people like her 

whose loved ones depended upon the care of the Veterans’ Administration, we wholeheartedly endorse this opportunity which we believe can become a new national model for the future for how the VA 

can give even greater, more splendid care to those who risk their lives 

for our country.

 Thank you very much.

 Mr. Brown. Mr. Mayor, thank you very much for coming and certainly extend my sympathies to Charlotte and the family.

 Mayor Riley. Thank you, sir.

 Mr. Brown. We are grateful for your service and your leadership in 

this City. Is it 28 years now?

 Mayor Riley. I am in my 30th.

[Laughter.]

 Mayor Riley. Time flies when you are having fun. I was very young

when I was elected.

 Mr. Brown. You are still very young and I know that you and I 

both will have a long career. Anyway, we are grateful for your involvement in this and we are certainly grateful that you would take 

your time to be with us this morning and we certainly look forward to 

continuing dialogue with this panel.

 Thank you. 

 Mayor Riley. Thank you, Mr. Chairman.

 Mr. Brown. Mr. McClain, we will recognize you and you may begin.
19

STATEMENT OF THE HONORABLE TIM S. MCCLAIN, GENERAL COUNSEL, DEPARTMENT OF VETERANS’ AFFAIRS

accompanied by MICHAEL E. MORELAND, DIRECTOR AND

CHIEF EXECUTIVE OFFICER, VA PITTSBURGH HEALTH

CARE SYSTEM and WILLIAM A. MOUNTCASTLE, DIREC-

 TOR, RALPH H. JOHNSON VA MEDICAL CENTER; 

 RAYMOND S. GREENBERG, M.D., PRESIDENT, MEDICAL

UNIVERSITY OF SOUTH CAROLINA accompanied by JOSEPH

 G. REVES, M.D., VICE PRESIDENT FOR MEDICAL AFFAIRS

AND DEAN, COLLEGE OF MEDICINE and W. STUART

 SMITH, VICE PRESIDENT FOR CLINICAL OPERATIONS AND

 EXECUTIVE DIRECTOR, MEDICAL UNIVERSITY HOSPITAL

AUTHORITY

STATEMENT OF THE HONORABLE TIM S. MCCLAIN

Mr. McClain. Thank you very much. And first of all, thank you

for calling this hearing. Ranking Member Michaud, thank you and 

Chairman Brown for your leadership in this aspect. This Subcommittee is very, very important. Health care obviously is one of our 

main businesses; in VA with over 170 facilities, we are the largest integrated health care network in the United States. Chairman Buyer, 

thank you so much for those kind comments about the VA and the 

response to Katrina and Rita. I know that you went down and toured 

the VA facilities after Katrina in New Orleans and Gulfport and have 

seen the devastation there, especially in Gulfport, which essentially 

looked like the insides of the building had gone through a blender. 

It completely gutted buildings including drywall. There was a chapel that I believe you went into that had no pews. There were pews 

before the storm and it was completely denuded of pews; and other 

things like sinks and things were deposited in the chapel -- tremendous devastation.

 We appreciate the support especially for our fourth mission and the 

fourth mission is emergency response, and also the kind words. VA 

is continuing today to respond to Katrina and to Rita and we have, 

as many government agencies do, a 24 hour command center, if you 

will, to respond to these types of issues. Probably before 9/11, we 

could not have responded as we did, but through the leadership of the 

Secretary and General Kicklighter who set up our response team, it 

has been exemplary I think and it all is owed to the employees of VA. 

So thank you, sir, for those comments.

And also I think we have something which is a real step forward as 

a start. We are sitting here today with President Greenberg and we 

are here to testify together as to what we are doing here in Charleston 

and how we intend to move forward. And thank you for the opportunity, and as we sat here in this particular room I think on August 
20

1 for our meeting, it was your impetus, Chairman Brown and Chairman Buyer, that we actually had to get down to the hard work and 

the hard work being that we actually sit there and open the books and 

show each other where we are going and what we are doing and how 

we intend to get there. Thank you very much for that opportunity. 

 Through the leadership on the VA side; Bill Mountcastle, he is the 

Director here at the Ralph Johnson VA Medical Center, the Undersecretary for Health, Dr. Perlin, asked Mr. Michael Moreland to come 

in. He is the Director of the VA Pittsburgh Health Care Center and 

has direct experience in these sort of collaborative efforts in pairing 

with an affiliate in order to get a bed tower built in Pittsburgh, and

so Dr. Perlin asked Mr. Moreland to come in. And I think it has been 

a very, very good relationship so far.

 Following our meeting on August 1, dozens of dedicated health care 

professionals -- financial, legal experts, construction experts -- from

VA and MUSC began meeting to explore the most advantageous future relationship of the two public entity health care delivery networks. 

Like many Veterans’ Affairs Medical Centers, the Charleston 

VAMC has a very close relationship with its affiliate. Successful collaboration between VA and the Medical University has been very 

successful for many years. This collaborative relationship recently 

included the signing of an enhanced use lease which allowed MUSC 

to begin construction of their phase one facility. As the planning 

for MUSC’s other major construction projects unfold, there may be 

additional opportunities to partner in the care of South Carolina’s 

veterans and also could include active duty service members and dependents from the Department of Defense.

 The Collaborative Opportunities Steering Group has begun its work 

and is developing opportunities for a new model for future collaboration in the short term and the long term. The group is reviewing opportunities for enhanced collaboration that could occur in the short 

term perhaps for inclusion in MUSC’s current construction, and in 

the longer term. All options must be fairly evaluated before taxpayer 

dollars are committed to any major construction project. Should the 

Steering Group develop proposals to embark on a joint construction 

project at Charleston, it will have to be in concert with VA’s CARES

decisions and the Department’s long range construction goals, as normally are published in our five-year capital plan. We also have to

be mindful of the potentially heavy financial impact of Hurricanes

Katrina and Rita and in that vein, we have to also take into account 

the possible increased construction costs that this may countenance 

along with an increase in materials, such as steel and concrete and 

labor and such. So there may be increased costs, not only in Charleston, but across the United States.

 The Steering Group has produced an interim report and it has been 
21

presented to the Committee and is available here today. And I would 

like to ask that that report be made a part of the record, along with 

my full written statement. 

 Mr. Buyer. [Presiding] It will be made part of the record, with no 

objection.

 Mr. McClain. Thank you, sir.

[The material referred to appears on p. 114]

Mr. McClain. While VA is very optimistic about the potential for 

a federal-state model, we are also realistic enough to know that we 

will keep an open mind and explore all options for our veterans before committing any scarce taxpayer dollars. We hope that the Department of Defense will consider joining our planning efforts. The 

President’s Management Agenda has placed a very strong emphasis 

on VA-DoD sharing and our staff has been directed by the Secretary 

to identify every opportunity for joint health care operations with the 

various components of DoD.

  Whatever options the group puts forward, we are confident that

by continuing to work together to assure a mutually beneficial plan,

VA can enhance care to veterans while building on its collaborative 

relationship with MUSC.

Mr. Chairman, that concludes my statements and the panel will be 

glad to answer any questions. 

 Mr. Buyer. Thank you very much, Mr. McClain.

 Dr. Raymond, you are now recognized. 

[The statement of Tim McClain appears on p. 91]

 Mr. Buyer. Dr. Greenberg, let us just wait a second, without recessing the Committee. 

[Brief pause.]

 Mr. Brown. [Presiding] I apologize for having to leave during your 

presentation, but I had a chance to read it last night and we thank 

you for your presentation and we will hear from Dr. Greenberg and 

then we will open it for questions I guess when both panel members 

are concluded.

 Dr. Greenberg, thank you very much for being here today.

STATEMENT OF RAYMOND S. GREENBERG, M.D.

 Dr. Greenberg. Thank you, Mr. Chairman, Chairman Buyer, 

Ranking Member Michaud, it is an honor to be invited to present testimony this morning and it is a special privilege to share our thoughts 

again and host you on the campus of the Medical University of South 

Carolina. 

 First and foremost, we are here to tell you how much the Medi-
22

cal University values its relationship with veterans and with the 

Veterans’ Administration. South Carolinians, as we have already 

heard this morning, have served our nation in the armed services 

with pride and with distinction. Many have suffered serious health 

consequences from their service and it is a privilege for us to be able 

to help care for these veterans as a partner with the Veterans’ Administration.

 Our relationship with the VA is deep and it is long-standing. We 

work as colleagues with the VA in every aspect of our mission. In 

clinical care, virtually all of the attending physicians at the Ralph 

Johnson Veterans’ Administration Medical Center are MUSC faculty 

members. In the education arena, all of the physicians-in-training at 

the Charleston VA Medical Center are in MUSC residencies. With 

respect to research, many of the most productive scientists at MUSC 

are investigators in the VA system. In fact, the facility in which we 

are meeting this morning, as has already been mentioned, is a very 

tangible symbol of our collaboration. The Strom Thurmond Research 

Building is owned by the Medical University, but half of the laboratory space is leased to the VA to conduct its scientific work. This

joint research building, now in operation for more than eight years, 

is one of only a handful of such facilities in the country. It works and 

it works well. We believe that the exact same type of success can be 

achieved by coordinating facilities in the clinical arena.

  Now before proceeding further, let me emphasize here that the first

priority in considering any linkage between the Medical University 

and the VA Hospital is to better meet the health care needs of veterans. It is our position that any arrangement that does not improve 

health care for veterans is not a good arrangement for anybody. Let 

me repeat that -- it is our position, the Medical University’s position, 

that any arrangement that does not improve the health care of veterans is not a good arrangement for anyone involved.

In that light, let us advance the case for closer coordination of hospital facilities. First, both the Ralph Johnson VA Medical Center and 

the Medical University have aging hospitals. Both have been maintained admirably, but the fact remains that they were designed 40 

to 50 years ago and as a result, cannot accommodate the size and 

complexity of current state-of-the-art medical equipment. Therefore, 

they are not the best environment for delivering state-of-the-art care. 

Recognizing those limitations, the Medical University has begun the 

stepwise process of replacing its hospital, the first phase of which is

under construction across the street, as you can see from the steel going up, and as Chairman Buyer mentioned, financed by the Department of Housing and Urban Development. The immediate adjacency 

of this site to the Ralph Johnson VA Medical Center makes it feasible 

to build facilities in a cooperative way.

 We have already heard about the devastation of Hurricane Katrina 
23

on the Gulf Coast and it is a warning of what could happen in Charleston. The Ralph Johnson VA Medical Center is built on low-lying land 

adjacent to a tidal river in a hurricane prone coastal area. It also sits 

in a city with a history of destructive earthquakes. This facility was 

designed prior to current standards for wind, flood and earthquake

resistance. Let us not allow the disaster of Hurricane Katrina to be 

revisited in this particularly vulnerable setting.

 Third, building coordinated facilities would allow sharing of infrastructure, such as expensive operating rooms and imaging equipment. 

By avoiding duplicating this infrastructure, money could be saved 

on both sides and be redirected back into providing more services to 

veterans. Everybody in this room is well aware of the spiraling costs 

of health care and anything -- anything -- that can be done to reduce 

costs is something that warrants our support and encouragement.

 Fourth, we believe the quality of care will be improved by colocating facilities. For example, in certain specialty areas where the 

Medical University is nationally recognized, such as the treatment 

of digestive disorders, the Ralph Johnson VA could be designated as 

a VA Center of Excellence so that veterans would not have to travel 

from their homes in South Carolina to more remote specialty centers such as Atlanta. From the VISN level, a center of excellence in 

Charleston would allow consolidation of some services here, avoiding 

duplication elsewhere.

Let me state emphatically that this is not a proposal for the Medical University to “take over”, in quotes, the operation of the VA. We 

do not want to take over running the Veterans’ Administration Hospital, we do not think that is appropriate. Quite to the contrary, 

we want to preserve all of the current advantages of a dedicated VA 

hospital, while saving the federal government money and increasing 

service capabilities. Any coordination of facilities should be guided 

by principles to protect the interests of veterans and those who serve 

them.

 First, there would be a dedicated veterans’ tower so that veterans 

would not be housed interspersed in with other patients.

 Second, the VA Medical Center identity would be displayed prominently on its facility.

 Third, veterans will be guaranteed to have equal or preferred access to any and all shared facilities, as they do now.

 Fourth, the dedicated employees of the VA Medical Center would 

be given every consideration in any integration of staffing.

 There is no existing model for what we are proposing, so we cannot just simply go out and copy what has been done elsewhere. The 

hard work of exploring this opportunity has begun, as has already 

been alluded to, by the VA and the Medical University. We have had 

meetings on a weekly basis, they have been highly productive and 

there has been, I believe, a tremendous spirit of cooperation demon-
24

strated on both sides. As we have already heard alluded to, there 

have been four working groups organized around clinical integration, 

governance, finance and legal matters. An oversight group has been

established to set the general direction. The interim report that has 

already been alluded to and now entered into the record of this meeting demonstrates the progress that has taken place.

Again, Mr. Chairman, I thank you for the opportunity to be with 

you this morning.

[The statement of Raymond Greenberg appears on p. 95]

 Mr. Brown. Thank you very much, Dr. Greenberg and we are grateful for this dialogue and feel like it is a good opportunity to explore all 

the issues to be absolutely sure that the veterans are the benefactor 

of more timely health care and better quality of health care too.

I would like to ask a question to both of you, if I could, and Mr. McClain, if you would answer first and then we will get Dr. Greenberg’s

reaction. How would the proposed joint venture improve access to 

health care to veterans in the future and which services and how?

Mr. McClain. Rather broad question, Mr. Chairman. 

 Mr. Brown. I will leave it to your discretion.

 Mr. McClain. I am not sure I can fully answer that question at this 

time. As you are aware, we are at a place where we are still learning 

about MUSC and I think they are learning about us and no decision 

has been made one way or the other as to how this should look. But 

certainly we have to address -- whatever comes out of the steering 

group has to address three things as far as VA is concerned -- quality 

of health care, access to health care and improved cost.

And so that is how we are looking at, and I know that is how Dr. 

Greenberg is looking at it also, but we are simply not far enough 

along, as I understand it -- now Mr. Moreland, Dr. Greenberg and Mr. 

Mountcastle have been involved in these weekly meetings and I have 

not, and Dr. Greenberg may be able to address that a little bit more 

succinctly than I can.

 Mr. Brown. Okay, Dr. Greenberg, you want to give it a shot and 

then I will have another question. 

 Dr. Greenberg. Well, very briefly, Mr. Chairman, I think that I

agree with Mr. McClain that we are still early enough in the discussions that we cannot get a definitive answer, but I think we could give

some suggestions where in principle access could be improved.

 One issue that has been adequately demonstrated over the last few 

weeks is that in emergency situations, we do not have within the 

VA system and within the larger health care system, surge capacity 

for dealing with emergency situations, whether manmade or natural 

disasters. We were asked to provide hospital beds for evacuees from 

the Gulf area. It was very difficult to find that capacity within our

hospitals, as I am sure it was within the VA system. We have done 
25

everything we can to make health care efficient and that leads to taking extra beds out of capacity.

I do believe this proposal would allow building some surge capacity 

into the Veterans’ Administration system and to use those beds effectively by leasing them on an interim basis to the Medical University 

to occupy.

I also think another area where access could be improved is very 

specialized services and very specialized medical equipment where it 

does not make sense for the VA to purchase equipment on its own because they do not have enough volume to justify it. If they were part 

of a collaboration, they would have access to PET scanners, radiation 

therapy facilities, advanced robotics in operating rooms and so forth.

 So I do believe there are opportunities but I certainly agree with 

Mr. McClain that we are still at a very early level of exploring those 

potentials.

 Mr. Brown. Mr. McClain, what are the primary legal issues and 

what obstacles do they pose to pursuing a joint venture? I know this 

is new ground, what do you see the obstacles from the legal side?

 Mr. McClain. It is certainly potentially new ground because we 

are looking for a new model in this case. And potentially we are looking at -- and there is a legal appendix to the report itself and it really 

begins to address -- it is the progress report of the legal workgroup 

beginning on page 11 -- and it begins to address those particular issues and I would have to start first with real estate, as to if we were

to move, where would that be, how do we acquire the property, what 

interest do we acquire in the property, the type of financing that we

are talking about. Also if there is any sort of sharing of facilities, 

what does the agreement look like and if there is any sharing of staff, 

what the agreement looks like. So there are a tremendous number of 

legal issues that could come into play -- employment law, real estate 

law, appropriations law. And we have a very, very experienced legal 

working group that is prepared to address each of those questions as 

they are raised by the steering group.

 Mr. Brown. And if I might ask both of you that same question, how 

are the committees coming along and when do you project you might 

have some interim report. 

 Mr. McClain. Dr. Greenberg.

 Dr. Greenberg. Let me start. It has already been alluded to in the 

GAO report that there is not a history of great communication between the entities and I think that has to do somewhat with the complicated organizational structures that are involved here. But since 

you and Chairman Buyer came down here and really charged us to 

work together in a collaborative way and organize the four working 

groups, and since the Undersecretary designated Mr. Moreland to 

help coordinate that effort, I have to tell you it has been a totally different dialogue between the parties. We have been talking in these 
26

workgroups on a weekly basis. It has been a very constructive dialogue. We have learned about some interesting things that have been 

done elsewhere, such as in the Pittsburgh situation and in New York 

State and I have to tell you, I am very grateful for your influence in

helping get the dialogue really started.

 Mr. Brown. Thank you both of you very much.

Mr. Michaud, do you have questions?

 Mr. Michaud. Yes, I do, Mr. Chairman.

  Dr. Greenberg, if the VA is unable to make a final decision on the

joint venture in time for the university to move forward with phase 

two, will the university still be able to secure the funding that it needs 

for the project?

 Dr. Greenberg. Mr. Michaud, we of course are working very hard 

on our separate plan and we have a financial feasibility study which

indicates that we should be able to move forward independently. Obviously our desire is to not foreclose any opportunities to collaborate. 

As Chairman Buyer alluded to, early on people seemed to think that 

we were particularly interested in the land.

 Our Board of Trustees in choosing to build on this site -- and Mayor 

Riley alluded to the fact that we were evaluating other locations -- 

determined that the 16 acres that the Medical University currently 

owns is adequate to build all phases of the Medical University facilities. So we believe that we could certainly build a stand-alone facility. We just think it makes much more sense to work in partnership 

with the VA.

 Mr. Michaud. And as I stated in my opening statement, I think it 

is important to be able to collaborate everywhere in any way that you 

can to have, you know, that synergy. I guess this question is also for 

Dr. Greenberg and Director Moreland.

As co-chairs of the steering group, how do you plan to involve the 

local Veterans’ Service Organizations, and employees in the working 

group in this process.

 Mr. Moreland. At this point, again, it is very early in the process and so we have really been meeting together to have something 

to communicate. What we have decided is that our communication 

right now is to let people know that we are working together, we are 

working in a cooperative spirit, we are working to explore options. 

And that is really all we can communicate right now. I think in the 

future, we will need to sit down and talk about how to pull other 

people in to gain input from others. We have not gotten to that point 

yet, but that would be something we would certainly look at in the 

future.

 Mr. Michaud. But is it better in the initial stage to have everyone 

that is going to be involved in this upfront? I am not talking about 

a huge group, but planning the process and looking at some of the 

testimony, there are a lot of questions out there from the VSOs and I 
27

am sure the employees as well. So why not involve them in the initial 

process to help ease it? Because part of the problem I think as Chairman Buyer mentioned, there is a lot of concern out there, and is it not 

best to deal with it upfront?

 Mr. Moreland. I think we will take your comments back for feedback and we can sit down and discuss that and look if there are ways 

that we can advance our time line on getting other input.

 Mr. Michaud. Mr. Greenberg, we heard earlier from the GAO when 

you look at the maintenance costs and the $62 million I think, what is 

the maintenance costs on your existing facility, what portion of your 

budget, is it two or three percent similar to the VA?

 Dr. Greenberg. I think it is probably in that range. We have about 

a $650 million a year operating budget in our hospital, which is compared to the VA at about $150 million, so we proportionately spend 

more in absolute dollars, but percentage-wise it is probably in a very 

similar range.

 Mr. Michaud. Playing the devil’s advocate, and as I stated, I think 

it is really great to collaborate. It is very important, but also with 

the addition of Hurricane Katrina -- and I want to thank the VA for 

your quick response in that effort -- but playing the devil’s advocate, 

looking at the GAO report, it talks about the facility being in good 

condition, while some renovations definitely will help out. There are

a lot of questions from the veterans’ groups that have not been answered and I am sure with the working group, they probably will be 

addressed. When you look at the CARES process, they have already 

made their recommendation, we had a hearing earlier in the State 

of Maine, and CARES recommended I think five additional clinics in

Maine that would actually cost about $5 million.

Now, as a member of Congress when we look at the GAO report 

saying that this is in good condition, how can we go back, not only 

in Maine, but other areas where CARES has recommended some additional facilities, to go back to them and say well, we are going to 

spend millions and millions of dollars here and yet we have not taken 

care of something that is actually ready to go under the CARES process? I guess I will ask Mr. McClain first and then if you could respond as well.

 Mr. McClain. Mr. Michaud, thank you for the question. Obviously any model that results from this collaboration needs to go back 

to VA and all of the other criteria need to be applied to it, from, as 

I mentioned, our five-year capital plan, our CARES funding, those

sorts of things are all going to be applied to it and looked at through 

our capital investment process. And the idea, as I understand this, is 

to work with one of our very, very close affiliates to see if we can come

up with a national model that can be rolled out across the United 

States that is a model that will ensure quality, ensure access and 

save money. And the jury is still out on that. We do not know the 
28

answer to that yet.

If it is simply a type of model that is a one-off, in other words, 

it works in Charleston but not anywhere else, I am not sure where 

that fits into our national planning. And so we would really like the

model to be able to -- if there is one -- to roll out nationally and save 

us money in multiple locations, not just Charleston.

 Dr. Greenberg. Mr. Michaud, if I could just add briefly that as

someone who runs a hospital, I think you have to look at what is the 

capital outlay and then what are the operating costs over time. Running an older hospital is an inefficient vehicle in the long term. And

I do believe that there can be cost savings over the next 20 years in a 

newer facility with new equipment and shared utilization of it.

 So you are absolutely right, if you only look at capital investment 

up front, it may look like it is not a good financial deal, but if you look

at it in the context of what are you going to be investing over the next 

20 years in the operating expenses, I think you might come to a different conclusion.

At the same time, let me say that we are just beginning that kind 

of financial analysis now, so we cannot bring you definitive numbers,

but I think that where you will find the cost-savings is over the longer

term.

 Mr. Michaud. If I might, Mr. Chairman, a follow up question actually to Mr. McClain. Does that mean that the proposals under the 

CARES process, that actually looks currently at a much smaller level 

where hospitals are willing to, you know, work for these clinics, are 

going to be put on hold?

 Mr. McClain. No, sir, I would not say that. 

 Mr. Michaud. Glad to hear that.

[Laughter.]

 Mr. Michaud. Thank you very much, Mr. Chairman. 

 Mr. Brown. Mr. Chairman. 

 Mr. Buyer. Mr. Moreland, I want to thank you for accepting the 

challenge, and I would like to hear from you your comments on the 

testimony that you have heard so far.

 Mr. Moreland. It has been a pleasure to come down here and meet 

the wonderful people in Charleston, South Carolina. I have spent 

some time in the south, living there and now I live in Pittsburgh, 

which is not exactly the south, and I have enjoyed coming down and 

meeting the people here. Dr. Greenberg and his staff have been great 

to work with and I think we are making really nice progress in understanding each other, making sure that we can start to move toward 

understanding each other’s financial situations, because they are just

a tad different, and making sure that we can make some move in that 

direction.

 We both understand -- and I think Dr. Greenberg said it very clear-
29

ly -- we both understand that at the end of the day, we may not find

something that works, but if we do, it will be something that will be 

better for veterans, improve access, improve costs. So we are really 

putting very sharp pencils to paper to work together to try to find

something that could be a good model for us.

 So I think we are making good progress. The workgroups are very 

energetic. We have conference calls every week and we have been 

down here just a couple of times. We have been talking earlier to 

the side, we will have a conference call again this coming Wednesday 

morning. So I think we are making good progress, sir.

Mr. Buyer. I have heard two words here this morning used that 

I will link with a preposition. The two words have been “synergies” 

and “excellence”. It is synergies for excellence, that is where I think 

we are going, so I am putting it together with a preposition.

 So when you think about synergies for excellence, I think that is 

what our pursuit really is and from my standpoint, gentlemen, I want 

to make sure that we have some form of a veterans’ preference, a 

pavilion, a place where they can go and they have their comraderie, 

their own identity. I know some veterans are saying, you know, I 

want to make sure that I am with my comrades and that they are 

given preference. And that is what Dr. Greenberg has talked about. 

So those are meeting some of our objectives.

 But in order to create the synergies of excellence to take our health 

care to the cutting edge, it is not only that it benefits us, in order for

synergies of excellence to work, it benefits the population as a whole. 

And for the fact that we cooperate here with a research facility and 

press those barons of science to benefit all of our society, this is pretty

exciting as an endeavor. So I want to thank both of you.

I noticed that you have a memorandum here from Dr. Perlin signed 

by Michael Cussman that went to you, Mr. Moreland, this is the 

charge memorandum.

Mr. Moreland. Uh-huh.

Mr. Buyer. Dr. Greenberg, have you seen this?

Dr. Greenberg. Yes.

Mr. Buyer. I noticed on number four, that with regard to the steering committee, you are supposed to have coordinated a communication plan for dealing with outside groups. Has that plan been developed yet?

Mr. Moreland. Yes, in one of our meetings, we actually put together a two-page, I believe it was, discussion point about how to communicate and like I mentioned earlier, that plan basically instructed all 

of us on the group and our staff about how to communicate where we 

are right now. And that is, like I said earlier, probably not as fully 

developed as it will be soon, but it did discuss going out and communicating.

Mr. Buyer. So it would be the goal that two parties are working 
30

in collaboration and it is not yet clearly defined, so that both parties

have mutual trust in good faith and the two of you work cooperatively 

in reaching out to the community at large. Would that be accurate, 

the spirit of this memorandum?

Mr. Moreland. Yes.

Mr. Buyer. Dr. Greenberg, is that your understanding? 

Dr. Greenberg. Yes, absolutely.

Mr. Buyer. All right. So if an invitation came from whoever, that 

the two of you would make an appearance together -- or if not the 

two of you, you would try and make sure that the views are equally 

reflected.

Mr. Moreland. I am not sure if I will respond to exactly the question, I’m trying. The intent was to make sure the communication is 

the same, not that we would be together at all times.

Mr. Buyer. I understand that. 

Mr. Moreland. Okay.

Mr. Buyer. I understand that. I guess the reason I make that 

point is that I am pretty much aware that some have some concerns, 

some are antagonistic because they disagree with what is going on 

here, and some perceptions were created in the veterans’ community, 

not as a whole, but in a small piece. And it is very unfortunate, because how can something not yet defined be delivered. So you end up

with inaccurate perceptions.

 So I want to make sure I ask the questions on how we deal with our 

stakeholders, and I think that is extremely important. And I think 

that our Ranking Member also recognizes that by his question.

Mr. Mountcastle, I want to make sure that you still agree with this 

statement. At the ceremony that opened this facility, you said “It is 

hard for individual entities to build separate buildings, but focusing 

on a team research approach and the competition for research dollars, the biggest players will find the biggest strength in collaboration.” You said that. Do you still believe that? You said that back in 

1996. Do you still believe that today?

 Mr. Mountcastle. Yes, I do.

Mr. Buyer. Oh, excuse me, when did you say this? 2003. Do you 

still believe that today?

Mr. Mountcastle. Yes, I do. 

Mr. Buyer. Okay. Let me ask about labs for a second. I hate to 

jump into the weeds, I know all of you are doing this.

Mr. Moreland, what are you doing in Pittsburgh that is helpful -- as 

you take the Pittsburgh overlay and introduce that to Dr. Greenberg, 

how is that helpful to him? If you take your overlay and his overlay, 

what do you see?

Mr. Moreland. Well, what I have been working with Dr. Greenberg about is looking at successful ventures in other places, like Pittsburgh, but there are multiple other places where there are examples; 
31

not necessarily as a model to move here, but as an example of success. 

We have talked about taking examples of success, and as you mentioned, use those to build a synergy for even better success.

 So, for example, there have been situations where the VA Pittsburgh and there are others like that, has bought high-tech, high-cost 

equipment, retained ownership of that piece of equipment but placed 

it into another organization’s building like a university or even a private community hospital, having that community hospital operate, 

maintain and use that equipment. Veterans always get preference 

to get to that piece of equipment but we use a piece of that volume, 

as Dr. Greenberg described, we use a piece of that volume. In exchange for the use of that equipment, I would get free services from 

that entity. So for example, place a PET scan into the University of 

Pittsburgh, I get free PET scans for the life of the equipment, but the 

University of Pittsburgh gets to use the excess capacity and they use 

that for their patients and their revenue generation. It is a win-win 

for me because I do not have the operational costs and the maintenance costs of that piece of equipment; yet, I am getting a reduction 

to my operating expenses by getting free PET scans. It is a win-win 

for the university because they get a piece of equipment that they did 

not have to spend $2 million to purchase, but they are able to give 

me the free scans because using that excess capacity allows them to 

generate additional revenue. So each of us wins.

 So what we talked about is doing things like that and even bigger 

things, but that is an example. So we are prepared to move forward 

on some of these smaller things as proof of concept, to show that, yes, 

it can work; yes, it can be a good thing for veterans, be a good thing 

for the community. I am glad you mentioned the community. I did 

another arrangement with a private community hospital, they did 

not have the funds to purchase high-tech equipment, we did, but they 

were willing to run it, so by VA purchasing and maintaining ownership and placing it in the community hospital, it improved health 

care for the entire community, plus veterans.

 So that is the kind of thing that we have been talking about doing 

and getting down and doing our figuring. MUSC now will work with

me to talk about what volume of services they can provide to the VA 

at no cost or dramatically reduced cost in exchange for the use of that 

piece of equipment. That is the details that we are getting involved 

in discussing now.

Mr. Buyer. If I may, Mr. Brown, Mr. Mountcastle, how much approximately in services do you presently purchase from MUSC?

Mr. Mountcastle. About $13.5 million, not counting the residency 

costs.

Mr. Buyer. And if we are to proceed in this collaboration whereby 

the VA builds a facility and somehow we link it with yours, at MUSC, 

since VA likes to say they are the low-cost provider, are you inter-
32

ested in exploring what services you could purchase from the VA?

Dr. Greenberg. That is an interesting question, Mr. Chairman, 

because the operating assumption initially was the VA traditionally 

has purchased services from the university, so it has been kind of 

a one-way purchase agreement. What has come out of the discussions when we started comparing price is that in fact, the VA may be 

cheaper for certain kinds of services than the university, and since 

federal dollars are purchasing health care for many other patients 

through Medicare and Medicaid and so forth, it would be the cost-efficient thing to do to lower the overall cost by purchasing some services 

from the VA where they can offer them at a lower cost; and therefore, 

also build a larger portfolio of services that the VA is able to offer.

 So I have learned in these discussions that this can be very much 

a two-way street.

Mr. Buyer. I think that is the only way this model is going to 

be successful. Even in Washington, I will hear the sounds from the 

bureaucracy that will immediately say well, gosh, we do not want 

the VA to be the cash cow for the medical university, just funneling 

money into it. It is kind of interesting how people will throw out 

phrases, sort of play tennis, you know, bat it away. Sometimes people 

will expend more time and energy to say no, than figure out how to

say yes and learn to do things better, and do things well. 

 So I want to thank the four of you for your work here because we 

have a tremendous opportunity, like the Mayor said, and I am pretty 

excited.

 The last thing, Mr. Chairman, if I may, on labs, what do you do 

now? Do both of you have your own labs?

Mr. Mountcastle. Yes, we do. We each have our own labs, I think 

we actually send some specialty lab tests out to different locations.

Mr. Buyer. And what do you do in Pittsburgh?

Mr. Moreland. We do have our own lab in Pittsburgh as well.

Mr. Buyer. And is this part of your discussions on how you could 

share some of the lab tests?

Dr. Greenberg. An example, Mr. Mountcastle just mentioned there 

are some tests that are now sent to the VA at great distances to be 

analyzed elsewhere, which could be analyzed locally, so not only is it 

a question of cost, but also timeliness of reporting results back.

 On the other hand, some of the more routine laboratory procedures 

may be done more cost-effectively by the VA and so some of the Medical University work could be done by lab support from the VA. So it 

works both ways.

Mr. Buyer. On a personnel question, by percentage how many approximately of the medical staff, doctors, interns in the VA are presently provided by MUSC on a shared agreement?

Mr. Mountcastle. We have -- I think as Dr. Greenberg stated in 

his opening remarks, most all of our physicians do have faculty ap-
33

pointments at MUSC. However, you know, we do have our own funded doctors but they still participate in education and research in a 

collaborative way with MUSC. It would be in the high 90s, I would 

think.

Mr. Buyer. In the high 90s percentile?

Mr. Mountcastle. Ninety percent.

Mr. Buyer. You have already got collaboration.

Mr. Mountcastle. Absolutely.

Mr. Buyer. Mr. Moreland.

 Mr. Moreland. I was going to respond whose doctors they are varies on which side of the street you are on. When I pay 100 percent of 

their salary, I consider them my doctors, even though they have an 

affiliation with the university. And so what I like to say is they are

our doctors, they are physicians that work on both sides of the street. 

And you are right, that is a very high level of collaboration and cooperation with each other.

Mr. Buyer. What are your time lines, present time lines?

Dr. Greenberg. We just produced the interim report that has been 

entered into the record. I must say, having the date of this meeting 

helped dictate bringing that to conclusion. Our hope would be to 

have another interim report about a month from the completion of 

that first one and then hopefully a final report about a month later,

sort of a Thanksgiving present to you, sir.

Mr. Buyer. Well, Thanksgiving comes early.

[Laughter.]

Mr. Buyer. The reason I say it comes early is, you know, Mr. McClain, the Commission has a construction bill that we have to deal 

with pretty soon and that is why I say it comes early, so we need to 

make sure we have some discussions on legislative recommendations. 

If you have got some for us, get them to us. We have some leases out 

there that are coming due and so we need to move on our legislation 

to extend those existing lease arrangements around the country. So 

that is why I say it is coming soon.

 But if you have got any recommendations that need to be incorporated in Mr. Brown’s construction bill that is coming up here real 

soon, please let us know.

 Mr. McClain. Yes, sir. 

Mr. Buyer. And let me thank all of you. This is a heavy lift and 

what you are doing, a lot of people are not going to get a chance to see. 

Banging it out, doing that which is difficult, and when you do that,

you are doing it to improve the quality of care and the access for our 

veterans. Some people may not realize it because they are used to it 

one particular way and therefore, only want it that way. But at some 

point when that is explained, what this endeavor is all about, then 

you can enjoy the fruits of your hard labor.
34

Mr. Chairman. 

Mr. Brown. I thank you all for coming to participate, what a great 

sharing experience you bring to the table. We look forward to the 

report. 

Mr. McClain. Thank you, Chairman Brown.

Mr. Brown. We will now welcome our third panel. But before we 

do that, let us take just an informal break.

[Pause.]

Mr. Brown. Dr. Greenberg, before we start the third panel, the 

Chairman had one further question he wanted to ask you, if you could 

come back to a mic.

Chairman Buyer.

Mr. Buyer. Thank you.

 Dr. Greenberg, as I understand, you have laid out a plan with regard to phases, the VA has indicated a preference for a particular 

phase, which was different obviously than what you had thought 

about, and when you have got two parties who want to work together, 

you want to be a good listener. You have a challenge though, do you 

not, because that preference is the VA would say we would like to 

build that facility is just right across the street here. So it is right 

where I parked this morning, that is your entire recreational area of 

your campus, right? 

Dr. Greenberg. Yes, sir. 

Mr. Buyer. So you have a tremendous challenge in front of you, do 

you not?

Dr. Greenberg. Yes, sir. One of the things that really has not been 

mentioned this morning is in addition to figuring out what we do in a

coordinated fashion, the location is also critical. There are multiple 

potential sites for further building. I think until we know a little 

bit more about (a) whether the VA will build colocated with us and 

(b) what they would build colocated with us, it is hard to select the 

particular site.

Mr. Buyer. And you not going to do a VA land grab now for your 

rec center, are you?

Dr. Greenberg. No, sir, we are not.

Mr. Buyer. You have got, as we explore this, Mr. McClain, you have 

got a value placed on the VA property, you have got a value placed on 

your rec center, all those are some things that you guys have to figure

out. And at the same time, you have got some other planning that 

you would have to do because if you want to do this, you are going to 

have to go out and build that, you are going to have to duplicate that 

somewhere else on your site, would you not?

 Dr. Greenberg. Yes, we would. And as you can tell driving around 

campus, there is a lot of other construction going on, so the number of 

such sites is quite limited at the moment. I wish the Mayor was still 
35

here because one of the things we discussed is building a potential 

replacement that could serve some broader community needs as well. 

So I think that is an opportunity. 

 We were anticipating leaving that towards the end of the multiple 

phase construction process, because of the extra cost of replacing that 

facility which we estimate -- and I hasten to add this is only an estimate -- is probably about a $40 million replacement cost.

Mr. Buyer. Wow, that is a lot.

Dr. Greenberg. Yes, sir. 

Mr. Buyer. And you are going to hold that until the end?

 Dr. Greenberg. That was the plan.

Mr. Buyer. If we are going to go through all this endeavor and 

create these centers of excellence, I do not want that to be a show 

stopper either.

Dr. Greenberg. I mean you have my commitment that it will not be 

a show stopper. Part of it is a question of timing. That facility I think 

was completed in 1994, so it is only about 11 years old at the moment. 

You know, it is a little early to be replacing it today or in the next few 

years, but down the road, if it is necessary to do, it is necessary to do. 

Charleston is an urban environment, there is very little land that is 

not already built on, so almost any site that you begin to look at, you 

have to consider is there a functional facility on it and what are the 

ramifications of removing it.

Mr. Buyer. Thanks very much. Thank you, Mr. Chairman. 

Mr. Brown. Thank you, Mr. Chairman; thank you, Dr. Greenberg.

It is always a special pleasure to welcome the next panel. We are 

guided by the wisdom and the input from those that matter most. 

We have asked two prominent and well-known veterans in this area 

-- Clarence Mac McGee with the American Legion, and Lyn Dimery 

with the VFW -- to let us know their views. And gentlemen, thank 

you very much for coming today. Thank you for your service to this 

great nation and thank you for the freedom that we enjoy to be able 

to hold hearings like today.

Mac, I will start with you.

STATEMENTS OF CLARENCE MAC MCGEE, NATIONAL 

LEGISLATIVE COUNCIL, THE AMERICAN LEGION, AND

LYN DIMERY, NATIONAL LEGISLATIVE COMMITTEE, 

VETERANS OF FOREIGN WARS

STATEMENT OF CLARENCE MAC MCGEE

Mr. McGee. Mr. Chairman, Committee members, my name is Mac 

McGee. My home is in Berkeley County, South Carolina. 

 Thank you for granting me this opportunity on behalf of my fel-
36

low Legionnaires of the First Congressional District. I would like to 

extent appreciation to South Carolina’s First District Congressman 

Brown and the Veterans’ Affairs Committee and the VA Health Subcommittee for their work on behalf of the veterans of this community, 

state and nation.

 The concerns here today are the proposal of the merger of the Ralph 

H. Johnson VA Medical Center and the Medical University of South 

Carolina. 

 The American Legion is the nation’s largest Veterans’ Service Organization with over 2.7 million members who contribute millions of 

hours in volunteer work in the Ralph H. Johnson VA Medical Center and other hospitals around the nation. This financial and volunteer work in the VA Hospital in this community and in VA hospitals 

around the nation to our nation’s aging veterans is unprecedented, 

making our VA system more community friendly and providing a 

needed service. 

I have personally been a member of The American Legion for over 

20 years, serving as Department Commander and on several national 

committees. I presently serve on the National Legislative Committee.

I am a military retiree, having served over 20 years, retiring as a 

senior nonCom. My service to this nation taking me to many places, 

including Vietnam.

 For the past several years, the VAMC and MUSC have enjoyed a 

contractual working relationship to provide services to the veterans 

of this community. The VAMC working with MUSC is not a new 

concept, but we hope that it is a continuation and better experience to 

the veterans of this community and that they will appreciate a better 

medical care delivery system.

 We are pleased to note that the Veterans’ Affairs overall budget has 

increased 40 percent since 2000 and area anticipating future funding 

which will keep pace with the needs of the growing and aging veteran 

population.

A local result of the latest Congressional Supplemental Appropriation, which infused monies into the nationwide VA system, locally 

will soon be seen in the Myrtle Beach, Beaufort and Savannah VA 

clinics through the addition of new administrative personnel that 

will allow clinical personnel to concentrate on giving medical care to 

veterans.

 We are looking at an aging facility at the Charleston VAMC. With 

the uncertainty of future spending priorities forced upon our nation 

by terrorism and natural disasters such as Katrina, this facility will 

not be replaced at any time in the foreseeable future. We as veterans are pleased with any improvement in serving the needs of the 

veterans in our community. To many veterans, the VAMC is their 

only means of obtaining medical care and services. These men and 
37

women have, in many cases, paid with their health. Our responsibility to them is a debt that cannot be paid. To give them the care that 

they deserve, through whatever vehicle, is the right thing to do. The 

proposal offered in cooperation with the Medical University of South 

Carolina sounds good. However, there are concerns that are most often asked by veterans and their dependents -- “Will this remain a Department of Veterans’ Affairs hospital?” Maintaining the identity of 

that facility is important and that assurance, along with ample space 

to transact VAMC and veterans’ business is critical as this transition 

goes forward and we, as veterans, want that assurance from the parties involved.

 Regarding the planned VA clinic that is being constructed in conjunction with the Navy Super Clinic at the Naval Weapons Station, 

veterans want absolute assurance that the VA facility will not be 

taken over by DoD for active duty military in times of emergency or 

perceived emergency, to the medical detriment of veterans.

 The following concerns voiced by veterans are very important: 

 What will be the impact on associated community outpatient clinics such as the VA/Navy Super Clinic just mentioned?

  Where there is a patient load conflict between MUSC and VAMC,

how will protocol be established, by whom will it be established, and 

who will make the decisions. Will it be a collaborative action of the 

Medical University and VAMC?

 Will VAMC have its own pharmacy, especially to be responsive to 

known and growing outpatient needs?

 How will VA co-pay and third party billing be affected?

 Will the new MUSC-VAMC relationship improve the delivery of 

timely medical care? At present, the waiting time at the VA hospital 

is excessive.

 Will VAMC retain its current 83 resident positions?

  Will the supervising physician be Board certified at the VA? This

question arises often.

  The final proposal must constitute a substantial improvement over

the service currently provided the veterans from the low country. 

Current VAMC Charleston contracts with MUSC for specialty services at approximately, I was given $17 million annually. Have we been 

getting our money’s worth to date? How will there be a measured 

improvement to VA patients served as a result of this merger?

Charleston VAMC has greater experience in providing care to veterans and represents a familiarity that we do not want to lose if the 

two are merged. The fear is that VA will be swallowed up by the 

much bigger medical facility and lose its personal touch with the veterans. Will the present VA staff be incorporated in such a manner 

that their experience will continue to convey to their VA patients?

 Our local veterans are apprehensive that services will be reduced 

and health care needs unmet.
38

As the spokesman for the American Legion and the veterans of this 

community and my community, we insist that the proposed merger 

provide all that is included in an improved level of health care to our 

low country veterans who have borne the battles that have given us 

this great nation and our freedom that we enjoy, who now suffer the 

consequences of their service.

 Thank you.

Mr. Brown. Thank you, Mr. McGee.

Mr. Dimery.

[The statement of Clarence McGee appears on p. 136]

STATEMENT OF LYN DIMERY

Mr. Dimery. Mr. Chairman, good morning to you and your committee.

 First, let me thank you for allowing me to speak here today to present the Committee with some questions from my fellow veterans on 

the proposed collaboration of the Ralph H. Johnson VA Medical Center and the Medical University of South Carolina. 

My name is Lyn Dimery. I was born and raised in Horry County, 

in the town of Aynor, South Carolina. 

I joined the United States Air Force after high school and retired 

after 21 years as a non-Commissioned officer, NCO.

I served in Vietnam for 20 months which gave me my eligibility to 

join one of the greatest and oldest wartime veterans organizations in 

the United States, the Veterans of Foreign Wars of the United States 

of America, VFW, and on the 29th of this month, we will celebrate our 

106th anniversary.

 Our membership is over 1.7 million and 700,000 in our Ladies Auxiliary. In the year of 2004, comrades and ladies had over two million 

hours of volunteer service in our communities, the VA hospitals, local 

hospitals, nursing homes and clinics.

 Our organization has been serving the veterans and their families 

for a long time. Our motto is “Help the dead by serving the living.”

I have been a member of the Veterans of Foreign Wars of the United States of America for 25 years. In the year 2000, I had the honor 

of being elected State Commander of our 18,000 members of the Veterans of Foreign Wars of the United States in South Carolina. 

I served the past two years on the National Council of Administration of the Veterans of Foreign Wars of the U.S. I was appointed to 

the Legislative Committee this year by our Veterans of Foreign Wars 

Commander in Chief.

I have been working with veterans, active duty service personnel 

and their families for the past 25 years. During this time, I have 

heard a lot of complaints and concerns from veterans and their biggest concern is veterans’ health care.
39

I am here today to present some questions from veterans who use 

this center, that concerns them on the collaboration of the VA Hospital and MUSC.

 With your permission, I would like to present them at this time and 

hopefully see them addressed in this process.

A. Is this a sharing agreement?

 B. Who is in charge, VA or MUSC?

C. Who is paying for all this and will MUSC pay their share?

 D. Who gets priority, veterans or civilians?

 E. How will returning veterans from Iraq and Afghanistan, will 

they be cared for and what priority will they get?

 F. Will this VA Medical Center lose its name or its identity?

 G. How will community-based outpatient clinics be affected by this 

collaboration?

 H. How will veterans who are currently being seen in communitybased outpatient clinics, who require surgery or inpatient treatment, 

be affected?

Mr. Chairman, thank you and your Committee for your time and 

allowing me to be here and present some of our fellow veterans’ concerns on an important issue as this is to all veterans who use this VA 

Medical Center.

 Thank you and God bless our veterans.

[The statement of Lyn Dimery appears on p. 140]

Mr. Brown. Thank you and thank you too, Mac, for coming and 

being part of this. 

 We have got the ear of all the people that are involved in this collaboration and so I am sure they were taking notes to answer those 

concerns that you might have.

My next question I guess would be to both of you is what is the best 

way for the facilities to communicate to the most important stakeholders as their work continues?

I know you would like to get answers to these questions, but what 

other dialogue could we generate within the veterans community 

that you would feel that you would be a part of the stakeholders and 

part of community group?

Mr. McGee. I think it would be helpful if our State Commander 

and those folks as far as the Legion was concerned were contacted 

and they, through our communications, came right down to our district and to our community. The only concerns that I have heard from 

veterans, and I talk to hundreds of veterans a month, is essentially 

the same thing that both of us have asked, who is going to be in 

charge, how is it going to affect care that veterans receive at the VA 

Hospital. I think if it went through our state, they could disseminate 

it and more veterans would be exposed to it.

Mr. Brown. Okay.
40

Mr. Dimery. I agree with that. In the VFW, like the Legion, we 

have a commander and he is in Columbia. We have nine districts, although they are not in the low country, and if the state headquarters 

gets this information, they could give it to all of the nine commanders 

that we have and then they are responsible for getting that information out to the districts. We have not gotten much information on 

this. 

Mr. Brown. As you might have gleaned from being at this hearing 

today, it is very preliminary and what we are trying to do is to find

out areas we can best collaborate services. So I do not guess they 

have much information to communicate at this point, but we recognize as we move forward that it has got to be very important that you 

have a voice in this because you are the stakeholders. We are doing 

this for you all, we are doing it because we want you all to have better 

quality health care. Not just the ones in this room, but those young 

men and women that are coming back with some very trying times 

and they are going to have to live with one arm or one leg. I was up in 

Bethesda about two months ago and had my appendix taken out but I 

was on the fifth floor with a lot of those young men that were coming

back, and prosthesis is a big item because a lot of them are coming 

back with a lot of parts missing. And so the challenges that we face 

with health care in the 21st century is going to be different from what 

we had in the 20th century. So that is the reason we are looking for 

better ways to deliver this health service. 

 But I do appreciate you all coming and being a part of this.

Mr. Michaud, do you have questions?

Mr. Michaud. First of all, I would like to thank both of you for your 

service to our nation and also for the advocacy for our veterans as 

well. I really appreciate that.

 You have raised several good questions here today and I am sure 

there will be probably additional questions as time moves on. And I 

know last week, the American Legion presented its legislative agenda to the Joint Session of the House and Senate Veterans’ Affairs 

Committee and one key issue that actually they raised was about the 

stakeholders’ input on ongoing CARES studies and I know that is a 

key issue with the VFW as well.

I do know the VA has set up local advisory panels for all of the 

ongoing CARES facility studies. Do you think that would be helpful in this process as well, is my first question. My second question

is I know there are more organizations than American Legion and 

VFW. Does South Carolina have a -- in Maine, we have what we call 

a Commanders Call, the Maine Veterans Coordinating Committee 

for all the VSOs. The commanders will get together and there is one 

individual who is the head of that that actually helps coordinate and 

disseminate that information. Do you have such a group here?

Mr. McGee. I do not think so, but we should have. 
41

 Ms. Milling. Yes, we do. We have an Advocacy Council. The state 

commanders of the service organizations get together. The meeting 

is usually called by the Director of the State Veterans’ Affairs Office.

Mr. Michaud. Thank you.

Like I said, I thought you had a lot of good questions and you heard 

Mr. Greenberg mention this morning and in his written testimony 

that he values his relationships with veterans and I think that value 

should not only take care of veterans when you are in the hospital, 

but before. And hopefully they will include you up front versus near 

the end, because I think any time we can get the information out 

there, if you have questions. That synergy and collaboration that we 

talked about earlier this morning is very crucial. And I think probably some of the opposition and concern out there is just that you do 

not know the answers and I am in hopes that the committee will look 

at that and really make you part of that process and I assume that 

you are willing to participate in that process.

 Mr. McGee. Yes, sir. 

Mr. Dimery. Yes, sir. I think you are very right there. That would 

stop the rumors because right now it is all rumors and you know how 

you get rumors started, and if we get more information, we could pass 

it out at our meetings, like American Legion at VFW, we have conferences, conventions and we have CFAs every month and we could pass 

this on, which I will be passing this on this Sunday, the information 

I have got. That will help us a lot.

Mr. Michaud. I agree.

 That is all I have, Mr. Chairman, and again, I do want to thank 

you for your strong advocacy for veterans and for having this hearing 

here. It is so important.

Mr. Brown. Thank you, Mr. Michaud, and I am grateful that we 

are able to serve, this is our third year now with the Chairman and 

Ranking Member and we have a great relationship. We usually say 

in Washington that partisan politics stops at the Committee room 

door. Veterans issues is not about Republicans and Democrats, it is 

about health care and benefits. And this is what we are about and I

am grateful that we have that great relationship.

And for the lady who stood up, I would like for you, if you do not 

mind, stand back up and give your name so we can have record of 

your input.

Ms. Milling. My name is Alta Milling. I am the State Council President of the Vietnam Veterans of America.

Mr. Brown. Thank you very much.

Mr. Chairman, do you have a question? 

Mr. Buyer. You know, Sergeant Major, Master Sergeant, if you 

look back on our military history, it must have been one heck of a decision when they decided to take the Army Air Corps out of the Army 

to create the Air Force.
42

[Laughter.]

 Mr. McGee. Yes, sir, messed up everything.

[Laughter.]

Mr. Buyer. Now when you go past the humor, the Marine Corps 

said no, they wanted to maintain their own air assets, they wanted 

their pilots and the crew to sweep and to know exactly who the ground 

pounders were. So when I call in fire or you have got to call in fire, I

know you, we know each other. I am bringing it in as close as I can 

and I will be damned if it is going to hit you and you are going to feel 

comfortable I can bring it in without hitting you.

Mr. McGee. I always felt comfortable.

Mr. Buyer. Some guys do not necessarily feel comfortable when it 

is an F-15 flying that fast, they say do not worry about it, I can hit

them and not hit you.

I guess I am really after the word “synergies”, synergies and trust 

and what we feel comfortable with and you can deliver things finally

and that is invaluable, right?

Mr. McGee. It is.

Mr. Buyer. Now we are talking about in life. How do you create 

synergies and make it timely and deliver so it has a real impact on 

people. That is what this is about. 

Mr. McGee. I think information.

Mr. Buyer. And that is what this is about.

Mr. McGee. Information is the key.

Mr. Buyer. I think that is true. I think the questions that both of 

you asked after you met with your veterans were very good questions 

that anybody would ask when you are on the outside not knowing.

 The good thing about Chairman Brown asking us to come down 

here and have this hearing is that this information can get out at the 

same time we give input with regard to ongoing negotiations and discussions. There is nothing easy about what is happening here. We 

want it to be hard and we want it to be difficult because we know that

if they are successful and can build this model and create these new 

synergies, that we improve quality. That is the goal. And I think 

that is pretty exciting.

And I wrote down all the questions you asked quickly as you were 

asking them, and immediately just clicking off in my head, most of 

these you got answered here today.

Mr. McGee. That is true.

Mr. Buyer. So you are able to go back to your comrades and let 

them know what you have heard here today. At the same time, you 

also know that Dr. Perlin issued a memorandum whereby the steering group is to formulate how to communicate with all of you. So 

hopefully in a timely manner that can be done.
43

I noticed you had a question, Sergeant Major, on how will there be 

measurement for improvement. Sounds like the GAO.

[Laughter.]

Mr. Buyer. That is exactly what the GAO’s testimony was about. 

And so Sergeant Major, you hit it right on the head. The same demands that you made over the years in command leadership, the element that makes the difference, is the same thing that GAO has been 

invited to do by Chairman Brown, to create those measurements. So 

when Mr. McClain testified about the five-year plan and how we measure it, we do not know if that is the proper measurement, because 

that is for different types of models.

Mr. McGee. Right.

 Mr. Buyer. So how are we going to properly measure success? I do 

not know, but I am willing to work with them to figure out how to do

it. And there are going to be some hurdles that we have to overcome. 

You know, there are some concerns that the VA may have and there 

are some definite concerns that MUSC has got to have. They just

built a rec facility and all of a sudden the VA goes yeah, but I want 

this property, not that property, we will give you this but you have 

got to build something somewhere else. These are big chess pieces, 

okay, that we are moving across the pavement here. And it all has 

to be done so that it is mutual, right? You have got trust, it makes 

sense for the taxpayer, but more importantly it makes sense for the 

customer. And for that customer, I will share with you that I believe 

that Dr. Greenberg has an equal desire to provide quality services as 

Mr. Mountcastle has in providing them to the VA customers.

 So how do we create the synergy whereby we continue to improve. 

And this is pretty exciting when you can combine some of the greatest 

minds in the country that are here, to do that. Too often, we think 

the expert is in Columbia or is in Charlotte and you have got to go 

somewhere else to look for it. But you know what? We have got it 

right here and so I am very impressed by the staff that I have worked 

with. You have got the best in the country, Dr. Greenberg, and creating these synergies for excellence for Charleston, South Carolina to 

lead the country in a model that is being leveraged -- I will go back to 

the word pride.

 So Mr. Chairman, thank you for your efforts and I want to thank 

my comrades in the Veterans Service Organizations for not only your 

service but your work in caring for the veterans who cannot care for 

themselves. Thank you, and God speed to all of you.

Mr. McGee. Thank you.

 Mr. Brown. Thank you, Mr. Chairman.

I too would like to extend my appreciation to both of you for your 

leadership in the veterans’ community and I look forward to continuous dialogue.
44

 This has been a great sharing experience today. We have got a 

lot of good information. There certainly are a lot of dedicated people 

involved in trying to make life better for our veterans.

 With that, this meeting stands adjourned.

[Whereupon, the Subcommittee was adjourned at 11:32 a.m.]
(45)

APPENDIX
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141