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THE STATE OF VA HEALTH CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

JULY 16, 2014 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

BERNARD SANDERS, (I) Vermont, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BLUMENTHAL, Connecticut 

MAZIE HIRONO, Hawaii 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

MIKE JOHANNS, Nebraska 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

STEVE ROBERTSON, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

JULY 16, 2014 

SENATORS 

Page 

Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont ........................ 1 

Prepared statement .......................................................................................... 3 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 5 

Prepared statement .......................................................................................... 7 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington ........................ 8 

Isakson, Hon. Johnny, U.S. Senator from Georgia ............................................... 9 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 10 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 11 

Hirono, Hon. Mazie, U.S. Senator from Hawaii .................................................... 13 

Johanns, Hon. Mike, U.S. Senator from Nebraska ............................................... 13 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 39 

Submitted report in Appendix ......................................................................... 79 

Heller, Hon. Dean, U.S. Senator from Nevada ..................................................... 43 

Prepared statement .......................................................................................... 43 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 47 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 49 

WITNESSES 

Gibson, Hon. Sloan D., Acting Secretary, U.S. Department of Veterans Affairs; accompanied by Philip Matkovsky, Assistant Deputy Under Secretary 

for Health for Administrative Operations, Veterans Health Administration ... 15 

Prepared statement .......................................................................................... 18 

Response to request arising during the hearing by: 

Hon. Johnny Isakson .................................................................................... 28 

Hon. Mark Begich ......................................................................................... 42 

Hon. Dean Heller .......................................................................................... 46 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 52 

Hon. Richard Burr ........................................................................................ 58 

Hon. Jon Tester ............................................................................................. 70 

Hon. Mark Begich ......................................................................................... 74 

Hon. Richard Blumenthal ............................................................................ 76 

Hon. John Boozman ...................................................................................... 76 

Hon. Dean Heller .......................................................................................... 78 

APPENDIX 

Begich, Hon. Mark, U.S. Senator from Alaska; report dated May 2003 from 

the President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans ...................................................................................................... 79 

Wounded Warrior Project; prepared statement .................................................... 105 

(1) 

THE STATE OF VA HEALTH CARE 

WEDNESDAY, JULY 16, 2014 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:02 a.m., in room 

SD–G50, Dirksen Senate Office Building, Hon. Bernard Sanders, 

Chairman of the Committee, presiding. 

Present: Senators Sanders, Murray, Tester, Begich, Blumenthal, 

Hirono, Burr, Isakson, Johanns, Moran, Boozman, and Heller. 

OPENING STATEMENT OF HON. BERNARD SANDERS, 

CHAIRMAN, U.S. SENATOR FROM VERMONT 

Chairman SANDERS. Let us get to work. Good morning, and welcome to everyone to what I think will be a very important and productive hearing. We welcome Mr. Sloan Gibson, the Acting Secretary of the Department of Veterans Affairs, who will be discussing with us what he has been doing in what I perceive to be 

a very active 6 weeks on the job. We also look forward to hearing 

from him as to what he perceives are the problems facing the VA. 

I want to mention to the Members of the Committee that next 

week, on the 22nd, we will be holding a confirmation hearing for 

Bob McDonald, the President’s nominee for Secretary of VA. 

Last week despite a very partisan environment here in Congress, 

93 Senators put their differences aside to vote in favor of a significant piece of legislation which we hope will address many of the 

immediate problems facing the VA. It is an issue that Senator 

McCain and I and all of us in this room worked very hard on, and 

I want to thank everybody for their support. It is my hope that the 

conference we are having with the House will be completed by the 

time we leave here for the August break. 

It is clear to all of us that the VA faces many, many challenges, 

and they are well documented. It is well known that we have 

many, many, many veterans in this country who are unable to access VA care in a timely manner. We have significant problems in 

terms of accountability. All of us find it totally unacceptable that 

people have manipulated data in terms of waiting times; people 

have treated whistleblowers in a contemptuous way; people have 

lied. That is unacceptable. We want to hear from Mr. Gibson in 

terms of what he is doing to address those many problems. 

The issue that I want to focus on is that while we are determined 

to do everything that we can to make the VA—which is a huge institution, providing 6.5 million veterans a year with health care— 

efficient and accountable, there is another issue that we have got 

2 

to address that is also part of our responsibility. That is, what are 

the legitimate needs, what are the real needs facing the 22 million 

veterans in this country, and how as a Congress are we responding 

to those needs? 

So, first, the VA has got to be accountable. It has got to be efficient. We have got to address many of the internal problems that 

we have all heard in the last several months. 

Second, we have also got to ascertain what the problems facing 

the veterans community and their families are and do everything 

we can to make sure that the VA is on the kind of position that 

it needs to be to address those problems. Let me just mention some 

of them. 

Of the 2 million men and women who served our country, put 

their lives on the line in Afghanistan and Iraq, studies suggest that 

20 to 30 percent have come home with PTSD or TBI. Simply stated, that means those wars have created some 500,000 mentally 

wounded American veterans, and as a result, very serious problems 

regarding suicide—and this Committee will be dealing with that 

issue in connection with PTSD—substance abuse, inability to hold 

onto a job, divorce, emotional problems for the kids. When you are 

dealing with PTSD, it is not just the veteran. It is the wife, it is 

the kids. 

Since fiscal year 2006, the number of veterans receiving specialized mental health treatment has risen from just over 927,000 veterans to more than 1.4 million in fiscal year 2013. This means that 

in fiscal year 2013 over a quarter of those receiving care at VA 

were being treated for mental health conditions. 

In other words, VA currently provides 49,315 outpatient mental 

health appointments a day. A day. Forty-nine thousand mental 

health outpatient appointments a day. Imagine the scope of that. 

And imagine the challenge. 

If we had an endless supply of money, if we had an adequate 

number of psychologists and psychiatrists in this country—which 

we do not have—this would be a very daunting tast. And yet we 

are where we are. That is the cost of war. 

Ensuring timely access to high-quality mental health care is critical for our veterans and for their loved ones, and the stakes are 

high. As I have said, we are all aware—and I know Johnny 

Isakson, among others, has taken a hard look at suicide—it is a 

tragedy beyond words, not easily dealt with, but it is one that we 

have got to address. 

Like most Americans, we are all concerned about these horrendous waiting periods, and I know that Mr. Gibson is going to be 

talking about that in his testimony. Let me just go through the 

numbers to understand the scope of the issue that we are dealing 

with. 

More than 46,000 veterans are on lists waiting to be scheduled 

for medical appointments. More than 8,000 of them have waited for 

more than 120 days. Now, we can have an argument about whether 14 days was an appropriate number. I think it was not and that 

it was overly ambitious. We do not have the resources to deal with 

it. But I do not think there is much argument that when you have 

more than 8,000 veterans waiting over 120 days to receive an appointment date. That is unacceptable. 

3 

More than 600,000 veterans have an appointment that is more 

than 30 days from the date that the appointment was initially requested or from the date that was desired. That is not acceptable. 

The numbers are staggering, and that is an issue obviously that we 

are addressing right now, and we will hear from Mr. Gibson as to 

how he is going to go forward with that. 

I think the goal of every Member of this Committee—and I would 

hope and expect every Member of Congress and of the American 

people—is that the veterans of this country, people who have suffered so much, deserve quality health care and they deserve it in 

a timely manner. What I look forward to hearing from Mr. Gibson 

is some straight, honest talk about the needs of the VA in achieving that goal. 

If we are talking about a staggering number of veterans coming 

home with PTSD or TBI, how many mental health workers do you 

need? And how are you going to get them? Because that is tough. 

We do not have enough doctors in this country. How many primary 

care physicians does VA need? How many specialists does VA 

need? 

If the goal is to provide quality, timely health care in a cost-effective manner, we need some answers from the VA, and I hope we 

will begin to get some of them today from Mr. Gibson. 

Needless to say, the other issues that I know that Members of 

the Committee are going to be asking are: what actions the Department has taken to reprimand employees who have lied or manipulated data? That is something that nobody on this Committee tolerates. What has the Department done to ensure that such manipulation no longer occurs? What has the Department done to improve 

other areas of concern identified by the Inspector General, the 

GAO, and other auditing organizations? 

So with that, let me give the microphone over to the Ranking 

Member, Senator Burr. 

[The prepared statement of Chairman Sanders follows:] 

PREPARED STATEMENT OF HON. BERNARD SANDERS, CHAIRMAN, 

U.S. SENATOR FROM VERMONT

Good morning and welcome to what I think will be a very important and productive hearing. We look forward to hearing from Mr. Sloan Gibson, Acting Secretary 

of the Department of Veterans Affairs, who will discuss with us what he has been 

doing in the last six weeks since he assumed that position, and what he sees as 

the major challenges facing VA in the future. 

First, I would like to take a brief moment to discuss the status of the Conference 

Committee. 

CONFERENCE COMMITTEE

Last month, despite a very partisan environment here in Congress, 93 Senators 

put their differences aside to vote in favor of a significant piece of legislation, which 

Senator McCain and I worked very hard to craft, to address the very serious problems currently facing VA. 

I am confident that my colleagues on the Conference Committee will also put 

their differences aside and come together to provide much needed access to health 

care for veterans in a timely manner, and give the Secretary the ability to hold dishonest or incompetent senior officials accountable and the resources needed to increase capacity at VA medical facilities around the country. 

I am pleased that, in reality, there are more similarities than differences between 

the House and Senate bills. We have been making significant progress in the last 

month and I believe that we can reach an agreement very soon. Millions of veterans 

4 

are counting on us to do so. We can’t afford to make them wait any longer for the 

care and services they have earned and deserve. 

With that said, I would like to discuss, what I believe, are the biggest issues facing VA health care. 

VA HEALTH CARE

VA’s challenges are well-documented. As any organization would, it faces significant challenges in providing timely and high-quality health care to millions of veterans all across this country. That’s why it’s important we have some context as we 

begin today’s discussion. VA is the largest integrated health care system in America. 

• VA operates over 1,700 points of care, which include 150 hospitals, 820 CBOCS, 

and 300 Vet Centers. 

• In fiscal year 2013, VA provided 89.7 million outpatient visits. 

• VA conducts approximately 236,000 health care appointments per day. 

Overall, according to veterans that I talk to in Vermont and around the country, 

according to the national veterans’ organizations that represent millions of veterans, 

and according to a number of independent studies, VA does a good job at providing 

quality health care to veterans—once they get into the system. In fact, they have 

been doing some cutting edge work in a number of areas—including tele-health and 

CAM. 

But the simple reality is that the problems they face are staggering. 

MENTAL HEALTH

Of the over 2 million men and women who served in Afghanistan and Iraq, studies suggest that 20 to 30 percent have come home with PTSD or TBI. Simply stated, 

that means the wars have created some five hundred thousand mentally wounded 

American veterans and, as a result, very serious problems regarding suicide, substance abuse, inability to hold on to a job, divorce and emotional problems for children and family members. 

Since FY 2006, the number of veterans receiving specialized mental health treatment has risen from just over 927,000 veterans to more than 1.4 million in FY 2013. 

This means that in FY 2013, just over a quarter of those receiving care at VA were 

being treated for mental health conditions. 

In other words, VA currently provides 49,315 outpatient mental health appointments a day. During the last four years (FYs 2009–2013), VA outpatient mental 

health visits have increased from 14 million a year to more than 18 million. 

VA has noted on numerous occasions that it anticipates its need to provide mental 

health services will continue to grow for the next decade as current military operations come to an end. 

Ensuring timely access to high-quality mental health care is critical for our veterans and their loved ones. The stakes are high. Statistics show that on average 

22 veterans a day commit suicide—that’s more than 8,000 veteran deaths a year. 

Even one veteran suicide is too many. 8,000 suicides are absolutely unacceptable. 

While many individuals with mental illnesses do not commit suicide, it is clear 

the consequences of failing to properly address and treat mental illness are serve. 

ACCESS

I, like most Americans, have major concerns about the inability of veterans in various locations across this country to access care in a reasonable period of time. According to a recent VA audit: 

• 46,236 veterans are on lists waiting to be scheduled for medical appointments, 

8,126 of them have waited over 120 days to receive an appointment—that’s 120 days 

before they are told when they are going to be seen; and 

• More than 636,000 veterans have an appointment that more than 30 days from 

the date that the appointment was initially requested or from the date that was desired by the patient. Of that amount, nearly 360,000 veterans are waiting between 

31 and 60 days, nearly 180,000 are waiting between 61 and 90 days, and more than 

40,000 veterans are waiting more than 120 days for their appointments. This 

doesn’t account for how long new patients have been waiting on lists, so a new patient who waits for an appointment that is scheduled more than 30 days from when 

he or she asked for it may have also waited 120 days, just to receive that appointment. 

This is unacceptable. VA must do much more to improve access to the VA Health 

Care System. We have a moral obligation to provide veterans with the timely access 

to the health care they need. 

5 

A lot of attention has been given to the provision in the bill that allows veterans 

to access outside care. That provision in important because it will immediately bolster VA’s capacity to address veterans’ health care needs. 

However, the simple truth of the matter is that the VA needs more doctors, more 

nurses, more mental health providers and, in certain parts of the country, more 

space for a growing patient population. VA’s ability to provide timely care both now 

and in the future must be strengthened by building capacity within the system. This 

is done by ensuring VA has the resources, including physical space and the health 

care providers and support staff necessary to provide such care. 

I think I speak for everyone on this Committee when I say we need more details 

on your current initiatives to address access issues, such as: 

• How has the Department’s Accelerated Access to Care Initiative improved the 

care and services VA provides veterans and how long does the Department intend 

to carry out expanded care options under this initiative, such as evening and weekend appointments; • When does the Department estimate it will roll out its updated scheduling system; and • Has VA completed all the recommendations in the IG’s interim report on Phoenix. 

In order to address the issue of long wait times, the Department and Congress 

must work together. It is important that you keep us abreast of your initiatives and 

maintain close communication with the Members of this Committee. 

ACCOUNTABILITY

Further, it is beyond words that some employees have lied or manipulated data. 

These issues must be dealt with immediately. The Department must take swift action to hold those who may have manipulated data or failed to carry out their duties 

accountable for their actions. 

Today I would like to hear: 

• What actions the Department has taken to reprimand employees who have lied 

and manipulated data; • What has the Department done to ensure such manipulation no longer occurs; 

and • What the Department has done to improve other areas of concern identified by 

the IG, GAO, OSC, and other auditing organizations? 

I believe it is important for the Department to create an accountable, safe, and, 

transparent culture for its employees. Only then would we be able to prevent these 

egregious actions. 

WHISTLEBLOWERS

Finally, I have been deeply troubled by the recent Office of Special Counsel reports that detail deliberate retaliation against the brave VA employees who seek to 

improve the care and services veterans receive by exposing deep flaws within VA’s 

system. 

I will not accept honest whistleblowers—who want to improve the system—being 

silenced or having their concerns ignored. VA must have zero tolerance for the actions outlined by the Office of Special Counsel in recent weeks. 

During today’s hearing, I would like to hear what the Department has done to 

prevent such retaliation from occurring. 

CLOSING

With that, I look forward to hearing Acting Secretary Gibson’s plans to address 

the critical issues I have highlighted. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Mr. Chairman; and Acting Secretary 

Gibson, welcome. 

Since our last hearing, there have been several developments related to the scheduling irregularities across the VA and its negative impact on patient care. The VA has begun to take the necessary steps to address the systemic problems and the corrosive 

culture that have been identified and substantiated by several 

6 

independent sources. However, these changes will not happen overnight, and this Committee must provide the critical oversight to ensure those changes occur and are effective. 

Even with the steps VA has taken to improve access for many 

veterans, there will continue to be reports and allegations regarding VA health care facilities and workers. These reports will not 

only highlight critical areas of needed reform, but identify the magnitude and the breadth of the systemic issues facing the VA. The 

ongoing internal evaluation by VA as well as investigations currently being conducted by the Office of Special Counsel and the 

VA’s Office of Inspector General are essential to eliminate employees and rebuild not only veterans’ trust but also the trust of 

stakeholders. 

To undertake the needed reforms within VA, the role of the Office of Special Counsel and the Inspector General are even more 

crucial now than ever before. Both offices have been essential in 

identifying systemic issues facing the VA. I would like to highlight 

a few critical reports that have been released since the last 

hearing. 

At the time of the May 15th hearing, there were several stakeholders who did not want to rush to judgment until the allegations 

surrounding Phoenix had been substantiated. Since that hearing 

the IG released an interim report regarding the allegations of 

scheduling irregularities and a secret wait list at the Phoenix VA 

health care system. Not only did the IG substantiate scheduling 

irregularities and a secret wait list at Phoenix, but the IG identified roughly 1,700 veterans who were waiting for appointments and 

were not included on an appropriate electronic waiting list. 

The IG found that scheduling irregularities are a systemic issue 

across VA’s health care system and that this was not an isolated 

event. Additionally, the IG has received numerous allegations regarding, ‘‘mismanagement, inappropriate hiring decisions, sexual 

harassment, and bullying behavior by mid- and senior-level managers at this facility.’’ These allegations speak to the corrosive culture that has taken deep root throughout the entire Department. 

Within a 3-week period, the Office of Special Counsel released a 

statement on VA whistleblower reprisals and sent a letter to the 

President regarding VA’s lack of responsiveness to OSC requests. 

In this letter, the Office of Special Counsel described the Office of 

Medical Inspector’s, or OMI’s, consistent use of, ‘‘harmless errors.’’ 

This is their defense, where the Department acknowledges the 

problem but claims patients were not—their cases were unaffected. 

The letter details ten cases of egregious patient care provided by 

VA facilities in which the OMI substantiates errors in patient care 

but dismisses potential patient harm. In one case, two veterans 

were admitted to an inpatient mental health ward at the Brockton 

VA facility and did not receive comprehensive evaluations for more 

than 7 years after being admitted to the facility. 

Another case in the letter describes how a pulmonologist copied 

previous provider notes in more than 1,200 patient medical records 

instead of recording current readings for these patients. 

I want to be crystal clear. The culture that has developed at VA 

and the lack of management and accountability is simply reprehensible, and it will no longer be tolerated. 

7 

Secretary Gibson, you have taken several actionable steps in the 

last month and a half, and I commend the work that you have 

done. However, what has happened over the course of years is a 

horrendous blemish on the VA’s reputation, and much more work 

will be needed to repair that damage. 

As VA continues to move forward in improving veterans’ access 

to care and changing the culture that has taken deep root within 

the Department, this Committee has a lot of work to do. The Committee needs to take an active, vigorous oversight role to ensure 

that the problems that have been identified over the last several 

months—and, I might say, over the next several months as a host 

of IG reports come out—are effectively and appropriately addressed 

and they are not allowed to happen again. 

Again, Secretary Gibson, thank you for being here. Mr. Chairman, I thank you and I yield. 

[The prepared statement of Senator Burr follows:] 

PREPARED STATEMENT OF HON. RICHARD BURR, RANKING MEMBER

Good morning, Mr. Chairman. I would like to welcome and thank Acting Secretary Gibson for being here. Today, the Committee is holding a second hearing on 

the state of VA healthcare. 

Since our last hearing, there have been several developments related to the scheduling irregularities across the Veterans Health Administration and its negative impact on patient care. VA has begun to take the necessary steps to address the systemic problems and the ‘‘corrosive culture’’ that has been identified and substantiated by several independent sources. However, these changes will not happen overnight and this Committee must provide the critical oversight to ensure these 

changes occur and are effective. 

Even with the steps VA has taken to improve access for many veterans, there will 

continue to be reports and allegations regarding VA healthcare. These reports will 

not only to highlight critical areas of needed reform, but identify the magnitude and 

breadth of the systemic issues facing VA. The ongoing internal evaluation by VA, 

as well as investigations currently being conducted by the Office of Special Counsel 

and VA’s Office of Inspector General, are essential to rebuilding not only veterans’ 

trust, but also the trust of stakeholders and employees. 

To undertake the needed reforms within VA, the role of the Office of Special 

Counsel and the IG are even more crucial now than ever before. Both offices have 

been essential in identifying systemic issues facing VA; I would like to highlight a 

few critical reports that have been released since the last hearing. 

At the time of the May 15th hearing, there were several stakeholders who did not 

want to rush to judgment until the allegations surrounding Phoenix had been substantiated. Since that hearing, the IG released an interim report regarding the allegations of scheduling irregularities and a secret wait list at the Phoenix VA 

Healthcare System. 

Not only did the IG substantiate scheduling irregularities and a secret wait list 

at Phoenix, but the IG identified roughly 1,700 veterans that were waiting for appointments and were not included on appropriate electronic wait lists. The IG found 

that scheduling irregularities are a systemic issue across VA’s healthcare system 

and this was not an isolated event. 

Additionally, the IG has received numerous allegations regarding (quote) ‘‘mismanagement, inappropriate hiring decisions, sexual harassment, and bullying behavior by mid- and senior- level managers at this facility.’’ These allegations speak 

to the corrosive culture that has taken deep roots throughout the entire Department. 

Within a 3 week period, the Office of Special Counsel released a statement on VA 

whistleblower reprisals and sent a letter to the President regarding VA’s lack of responsiveness to OSC requests. In this letter, the OSC describes the Office of Medical 

Inspector’s consistent use of (quote) ‘‘a ‘harmless error’ defense, where the Department acknowledges problems but claims patient care is unaffected.’’ 

The letter details ten cases of egregious patient care provided by VA facilities in 

which the OMI substantiates error in patient care but dismisses potential patient 

harm. In one case, two veterans who were admitted to an inpatient mental health 

ward at the Brockton VA facility didn’t receive comprehensive evaluations for more 

8 

than seven years after being admitted to the facility. Another case in the letter describes how a pulmonologist copied previous provider notes in more than 1,200 patient medical records instead of recording current readings for these patients. 

I want to be crystal clear; the culture that has developed at VA and the lack of 

management and accountability is simply reprehensible. And it will no longer be tolerated. Secretary Gibson, you have taken several actionable steps in the last month 

and a half. I commend the work you have done; however, what has happened over 

the course of years is a horrendous blemish on VA’s reputation. And much more 

work will be needed to repair the damage. 

As VA continues to move forward in improving veterans’ access to care and changing the culture that has taken deep roots within the Department, this Committee 

has a lot of work to do. The Committee needs to take an active, vigorous oversight 

role to ensure the problems that have been identified over the last several months 

are effectively and appropriately addressed, and they aren’t allowed to happen 

again. 

I thank the Chair, and I yield back. 

Chairman SANDERS. Thank you, Senator Burr. 

Senator Murray? 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, thank you so much for holding 

this hearing. As we all know, this is really a critical time for the 

Department. The VA is still struggling with major systemic problems. There are many vacancies in key leadership positions, and 

most importantly, veterans are still waiting too long for care. 

Secretary Gibson, as we talked about yesterday, I really appreciate your stepping up during this crisis. The Department needs 

strong leadership right now because the VA is facing serious challenges. Rob Nabors’ review identified several of these issues which 

we have also been discussing here for some amount of time. A corrosive culture has developed in the Department, one that is unworthy of VA’s many dedicated and talented medical providers who 

only want to help veterans. Management failures and lack of communication is a problem at all levels of the VHA, and VA needs 

more providers, more space, and modern IT systems. 

As we continue to work in the conference committee to craft a 

final bill, I hope an agreement will be reached so we can send it 

to the President and start making the changes needed at VA so 

veterans get into care, we create transparency, and hold people 

accountable. 

The compromise bill will be an important first step. As more reviews are done and more problems found, we will need to take additional steps. 

And while we continue working on these problems, we cannot 

lose sight of many other pressing issues. Too many veterans still 

die by suicide each day. Sexual assault survivors still need help. 

The VA has to continue to make progress toward the commendable 

and even more challenging goals of eliminating veterans’ homelessness and reducing the claims backlog. 

On a positive note, Secretary Gibson, I really appreciate your 

help in finally getting the money to build the Walla Walla State 

Veterans Home. We have been working on this, as you know, for 

a very long time, and now hundreds of veterans in that area will 

be able to access the long-term care that they need. 

As I have said repeatedly here in this room, when the Nation 

goes to war, it also commits to taking care of the veterans when 

9 

they return home. Their needs are a cost of war, and we will provide for them no matter what. We know many veterans will need 

VA care for several decades to come. Others will come to the VA 

for the first time many years after their service has ended. So 

today I am hoping to hear about solutions to these systemic problems and smart ways to strengthen the VA for the long term, because the VA does need to be there for our veterans, ready to help 

right away every time. 

Thank you, Mr. Chairman, and I yield to Senator Isakson. 

STATEMENT OF HON. JOHNNY ISAKSON, 

U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Thank you, Senator Murray. 

Secretary Gibson, thank you very much for accepting this interim 

responsibility. You are a brave and courageous man. And while I 

am encouraged by some of the serious steps you have taken, I am 

still not satisfied. We have tremendous problems as indicated by 

the letter from Special Counsel Lerner to the President of the 

United States, from which I want to quote one paragraph, ‘‘I remain concerned about the Department’s willingness to acknowledge 

and address the impact of these problems’’—meaning the whistleblowers’ problems—‘‘may have had on the health and safety of veterans. In particular, the VA Office of Medical Inspector has consistently used the term ‘harmless error’ as a defense where the Department acknowledges the problem but claims patients have been unaffected. This approach has prevented VA from acknowledging the 

severity of systematic problems and from taking necessary steps to 

provide quality care to veterans.’’ 

The letter goes on to delineate specific cases where veterans’ 

health suffered because of the agency looking the other way. 

I have become personally convinced that this begins and ends 

with the failure of senior leadership in VA for years to overlook or 

to look over the manipulation of numbers, to make things look better than they really were, to hope that Congress would not come 

look. I think Congress is partially to blame for not coming and 

looking enough. 

You know, I learned when I was raising my children that if parents come every now and then, open the bedroom door and look inside, you have a better behaved kid than if you never look inside. 

I think some of the departments of the VA are exactly the same; 

and the pervasive culture of cooking the books for personal benefit, 

such as pay raises, is absolutely inexcusable. 

Last, I hope in your remarks, which I am looking forward to, you 

will address how the memo that was written by Mr. Schoenhard 

on August 26, 2010, that delineated specifically many of the problems we are now discovering—this was 4 years ago. I don’t know 

how a memo to senior VISN leaders across the network and to senior management could have gone totally without follow-up by anybody in the VA. The problems that we are now trying to fix lasted 

4 more years within the VA because there was a culture of just 

looking the other way when there was a criticism or accountability 

in place. 

So, while I appreciate very much your willingness to come forward as a citizen and take on this interim responsibility, and I apVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
10 

preciate the steps that you have made, I am not satisfied yet that 

the VA’s culture is any different than it has been. We are going to 

have to see to it that the culture of the VA changes and we have 

accountability from top to bottom, but in particular, in the senior 

leadership and management of the Veterans Administration and 

Veterans Health Care. 

I will now yield to—— 

Senator MURRAY [presiding]. I will just say that a vote has been 

called, so a number of Senators are going to be leaving. We will go 

to Senators Tester, Moran, Hirono, and Johanns, and by then the 

Chairman will return. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. All right. Thank you, Senator Murray, and I 

want to thank Senators Sanders and Burr, even though they are 

not here, for their work on this Committee. 

Access to health care for our veterans did not pop up overnight. 

This is a topic that many of us have been working on for years. Solutions must be based on good information. You cannot make good 

decisions without good information. And hopefully the conversation 

today will be straightforward and frank so we can get down to 

some solutions. 

It is going to require tough decisions. It is going to require some 

creativity. It will require focus and engagement from folks on the 

ground and in Washington that lasts well beyond the media span. 

Veterans deserve better than to have folks jump on the latest crisis 

or two and then you never hear about it again. They want answers. 

They want solutions. They want the benefits that they have 

earned, not press releases. 

I am approached by veterans every time I go home, whether it 

is in the grocery store or at the service station. They are direct, 

they are straightforward, and they give me the best view of what 

is happening on the ground with the VA. In fact, this Friday I am 

going to be holding another roundtable, this time in the capital city 

of Helena, MT, to hear from veterans about the VA and the services that they are getting and the difficulties they are having, along 

with the successes. 

Since our last hearing on VA health care, the VA conducted a nationwide audit. They found that the biggest obstacle to timely medical care at the VA is the lack of service providers. It is a lack of 

service providers. I am looking forward to hearing from the VA on 

this audit and the follow-up actions moving forward. 

Since our last meeting, the White House has also completed a review on issues impacting access to care. This review echoed what 

we have already heard, that the VA provides high-quality health 

care once the veterans get in the door. The review also learned that 

the VA’s scheduling technology is outdated—I believe 30 years old. 

It is secondary to the need for additional resources such as doctors, 

nurses, and other health care professionals, physical space, and appropriately-trained administrative support personnel. 

Since our last hearing, the Senate also passed a comprehensive 

bipartisan bill that would address some major issues impacting access to timely medical care at the VA. It passed by an overVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
11 

whelming 93 votes. We seldom get 93 votes for anything in the 

U.S. Senate. 

Right now we are conferencing that bill. We are in the fourth 

week. There is not much to show for it. Those questions would be 

good to get answered today, too, because I think some members of 

the conference committee are balking at the cost. Look, we just 

shipped 800 folks off to Iraq. I did not hear one person talk about 

cost. 

Back in 2003, when we invaded Iraq, I was not here, but I certainly never heard anybody talk about the cost and making sure 

that there were offsets for that cost. 

Look, these folks went to war. They performed incredibly well. 

Some of them came back missing arms and legs. Some of them 

came back with mental health conditions that they did not have 

when they left or health problems they did not have when they left. 

It is very frustrating from my perspective coming from a State 

where we are about 22 doctors short to hear folks on the conference 

committee a few weeks back say, ‘‘What we need to do is we need 

to schedule more patients for the doctors. That will solve the problem.’’ That will not solve the problem. We need more health care 

professionals on the ground. 

And, Sloan, I hope to hear from you today on those issues about 

what those deficiencies are, because I think it is critically important that we get our arms around that as a Committee so that we 

can move forward, so that we can provide the kind of accountability 

that needs to happen within the VA to make sure that ultimately 

the veterans get the care they deserve. 

I will tell you something right now. I am very concerned that this 

conference committee will end up taking a step backward for veterans’ health care in this country. That cannot happen. Veterans 

deserve better. They have earned the health care. We need to make 

sure we step up to the plate, give VA the resources they need, and 

then hold them accountable for the job that they do. Veterans deserve our best. They have demonstrated their best in the field. We 

need to demonstrate our best as policymakers and you folks as 

leaders of the VA. 

With that, I would yield the floor to my friend, Senator Moran. 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Thank you very much. 

Mr. Secretary, thank you for joining us. Thank you very much 

for having a conversation with me by phone several weeks ago. I 

appreciate that outreach. It has been one of the experiences that 

I have had in recent years with the VA that leaves me feeling that 

I have no ability to convey the concerns of Kansas veterans. We 

have the ability to convey that information to the Department, but 

receive virtually no response time and time again. So, I appreciate 

the fact that you took the time to have a telephone conversation 

with me. 

I am going to present to you today, or shortly, a letter that I 

have compiled addressed to you. I heard the testimony from the 

House Veterans’ Affairs Committee last week in which some of the 

topic was about whistleblowers and the apology that the DepartVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
12 

ment made. What I have discovered as a result of what has transpired over the last several months is that many Kansans, veterans 

in particular, but also many employees of the Department of Veterans Affairs, are presenting me now with stories of problems within the VA, and they are reluctant, in fact, disinclined, to present 

that information as a whistleblower in a formal way because of fear 

of retribution and concern about their future and their employment. 

So, Mr. Secretary, we will be providing you an outline of things 

that we still consider significant challenges and problems in my 

homestate of Kansas. 

I indicated several months ago that I had been a member of the 

Veterans Committee since I came to Congress, 14 years in the 

House, 4 years in the Senate, and there have always been challenges at the VA. There are always challenges in health care. What 

seems to me to be different today, Mr. Secretary, and it has occurred over time, is the recognition that the VA, in a sense, was 

just shrugging its shoulders, no real attention to problems, and 

what that resulted in, then, were veterans telling me that they no 

longer had faith in the Department of Veterans Affairs to provide 

the services that they are entitled to as military men and women 

of our country. 

So, I thought a change in leadership at the Department of Veterans Affairs was required. It is now taking place. I look forward 

to meeting Mr. McDonald this afternoon in my office. But, what I 

know is that only changing the Secretary, only changing the top 

leadership is insufficient to solve the problems that exist. 

So, I look forward to working with you during your time at the 

Department of Veterans Affairs to see that the results are things 

that we all can be proud of and that the commitments that we have 

made to our veterans are kept. 

Most of my conversations with Secretaries of Veterans Affairs— 

I think there have been nine of them in my time—have dealt with 

rural issues, and I want to explore that with you today in your testimony. First, I am very anxious to hear about the steps that you 

are taking to change the nature—so it does not matter whether you 

are an urban, suburban, or rural veteran—that the Veterans Affairs Department is something different than it has been over the 

last several years. Then I will be happy to get to the issues that 

we face in a rural State like ours. 

Mr. Secretary, as we know, change is necessary. I want to do everything I can to make certain that the Department of Veterans Affairs has the tools necessary. It has been my commitment since I 

came to Congress, but I need the commitment from the Department of Veterans Affairs that those resources that they are provided, the tools they are given, are going to be used in a cost effective, compassionate, and caring way, and that there is an attitude 

at the Department of Veterans Affairs that there is no higher calling than to take care of the men and women who served our 

country. 

Thank you, sir. 

Chairman SANDERS [presiding]. Thank you, Senator Moran. 

Senator Hirono. 

13 

STATEMENT OF HON. MAZIE HIRONO, 

U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you, Acting Secretary Gibson, for being 

here, and thank you, Chairman Sanders and Ranking Member 

Burr, for our continuing focus on the issues and challenges facing 

the VA. 

When the issues relating to wait times first arose over a month 

ago, the situation was described as an emergency. There was a 

sense of urgency. And, I want this Committee and this Congress 

to continue to be motivated by the sense of urgency and to continue 

to recognize that this emergency needs to be addressed, because 

there is every potential for other issues to come to the fore and for 

Congress to be distracted, important as these other issues may be. 

We owe it to the veterans to stay the course. 

I share the sentiments of the Chairman and many of the Members’ statements this morning that we need to hear from you your 

short-term solutions for addressing the issues at hand and over the 

long term to address the systemic problems and challenges facing 

VA. 

I, like so many of my colleagues, have been visiting with the veterans in my State, frankly, long before the particular crisis arose. 

And, of course, they have shared with me their concerns about the 

lack of doctors, the changeover of doctors, and those are some of 

the practical considerations that they have raised with me. 

So, most of us—I think all of us—have had the opportunity to 

talk with veterans in our communities one-on-one and we have a 

commitment to make sure that we continue to stay the course. 

That, to me, is the most important thing that this Committee can 

do, and I thank the Chairman for not allowing us to move on to 

other matters that may be pressing, but what could be more pressing than to make sure that our veterans receive the care that they 

need and deserve. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Other members will be filtering back, but I 

would like to hear from the Acting Secretary now. Customarily, we 

give 5 minutes, but you will have more time. This is a serious discussion and we want you to have the time you need to make your 

case and we want the Members here to have the time they need 

to ask you their questions. 

All right. Senator Burr suggests that we should wait a few minutes to make sure that other Members get back here, so let us take 

a very quick recess. [Recess.] 

Let us reconvene, and Senator Johanns, I think we are ready for 

you and your opening statement. 

STATEMENT OF HON. MIKE JOHANNS, 

U.S. SENATOR FROM NEBRASKA 

Senator JOHANNS. Thank you, Chairman Sanders and Ranking 

Member Burr, for convening another very important hearing to address issues at the VA. It is critical that we continue to have these 

oversight hearings to do everything we can to hold VA’s feet to the 

fire and make sure that accountability is there. 

We know some things now that we did not know at the last hearing. We know for a fact that VA’s wait list manipulation and access 

14 

to care issues is, in fact, systemic. Report after report has confirmed this. In fact, 77 facilities are currently under investigation 

by the VA Inspector General. That is an astounding number. And, 

I believe the scheduling problems are the tip of the iceberg. Now 

we have allegations of whistleblower retaliation and improper payment of claims. The cancer does not seem to stop, but it must be 

stopped. 

While I appreciate your efforts, Secretary Gibson—I think you 

have done some things and they are recognized and acknowledged—but I think we would all acknowledge there is so much 

more to be done. 

There has to be accountability for wrongdoing or these issues will 

continue and the Senate will have more hearings, not only next 

week or the week after, but in 5, 10, 20 years from now. 

There is a serious lack of leadership from the top. The White 

House needs to have a more visible role in addressing the crisis. 

We, collectively, have the ability to fix this agency. We just have 

to find the will and the common ground to do it. All of us have to 

be a part of the solution. 

In May, during our last committee hearing, I encouraged the expanded use of non-VA care to get urgent treatment to those veterans that were languishing on both secret and official waiting 

lists. The bill recently passed by the Senate gives greater flexibility 

and treatment options for veterans faced with long wait times or 

lengthy travel. The ‘‘choice card’’ injects much-needed competition, 

in my opinion, into the process, and it demands of the VA that they 

get their act together. 

The accountability and transparency pieces of the legislation are 

not only important, they are critical. The notion that employment 

should be tied to performance might seem elementary to most people, but this has not been happening at the VA. There have been 

several instances in which senior VA executives who were involved 

in mismanagement or negligence were not reprimanded, but instead received bonuses and positive performance reviews. 

Shameful. 

And, while Senior Executive Service employees can be disciplined 

and fired under current law, it is a very long and very drawn-out 

process. Again, that does not work. 

The Secretary needs the authority this bill provides to cut 

through bureaucratic red tape and, most importantly, to hold individuals responsible. We have to root out the culture of corruption 

that is contributing to nearly all of VA’s most pressing issues. 

It is a huge challenge, but we can and must get the VA back on 

track and focused on their core mission of providing quality health 

care to our veterans. They deserve nothing less. 

Thank you, Mr. Chairman. I yield back. 

Chairman SANDERS. Thank you, Senator Johanns. 

Now, I want to take this opportunity to welcome Mr. Sloan Gibson, Acting Secretary of the VA. Thank you very much for joining 

us to give us an update on the state of health care at the Department of Veterans Affairs. We look forward to hearing your 

testimony. 

15 

Secretary Gibson is accompanied by Mr. Philip Matkovsky, the 

Assistant Deputy Under Secretary for Health for Administrative 

Operations. 

Your prepared remarks will be submitted for the record. 

Secretary Gibson, please begin. 

STATEMENT OF SLOAN GIBSON, ACTING SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PHILIP MATKOVSKY, ASSISTANT DEPUTY UNDER SECRETARY 

FOR HEALTH FOR ADMINISTRATIVE OPERATIONS, VETERANS HEALTH ADMINISTRATION 

Mr. GIBSON. Mr. Chairman, forgive me if I dispense with the traditional niceties and get straight to business. As has been recounted this morning, we have serious problems. Here is how I see 

the issues. 

First and foremost, veterans are waiting too long for care. 

Second, scheduling improprieties were widespread, including deliberate acts to falsify scheduling data. 

Third, an environment exists where many staff members are 

afraid to raise concerns or offer suggestions for fear of retaliation. 

Fourth, in an attempt to manage performance, a vast number of 

metrics have become the focal point for staff instead of focusing on 

the veterans we are here to serve. 

Fifth, VA has failed to hold people accountable for wrongdoing 

and negligence. 

And, last, we lack sufficient clinicians, direct patient support 

staff, space, information technology resources, and purchased care 

funding to meet the current demand for timely, high-quality health 

care. Furthermore, we do not have the refined capacity to accurately quantify our staffing requirements because, historically, we 

have not built our resource requirements from the bottom up. We 

have instead managed to a budget number. 

As a consequence of all these failures, the trust that is the foundation of all we do, the trust of the veterans we serve and the trust 

of the American people and their elected representatives, has eroded. We will have to earn that trust back through deliberate and decisive action and by creating an open, transparent approach for 

dealing with our stakeholders to better serve veterans. 

To begin restoring trust, we focused on six key priorities. Get 

veterans off wait lists and into clinics. Fix systemic scheduling 

problems. Address cultural issues. Hold people accountable where 

willful misconduct or management negligence are documented. Establish regular and ongoing disclosures of information. And, finally, 

quantify the resources needed to consistently deliver timely, highquality health care. 

Here is what we are doing now. VHA has reached out to over 

160,000 veterans to get them off wait lists and into clinics and 

made over 543,000 referrals for veterans to receive care in the private sector, 91,000 more than in the comparable period a year ago. 

This is in the last 2-month period. And, I would point out here that 

for each of those referrals, on average, they result in seven visits 

to a clinician. 

VHA facilities are adding more clinic hours, aggressively recruiting to fill physician vacancies, deploying mobile medical units, 

16 

using temporary staffing resources, and expanding the use of private sector care. We are moving rapidly to augment and improve 

our existing scheduling system while simultaneously pursuing the 

purchase of a commercial off-the-shelf, state-of-the-art scheduling 

system. 

I have directed medical center and VISN directors to conduct 

monthly inspections in person of their clinics to assess the state of 

scheduling practices and to identify any related obstacles to timely 

care for veterans. To date, over 1,100 of these visits have been conducted. 

We are putting in place a comprehensive external audit of scheduling practices across the entire VHA system. We are building a 

more robust continuous system for measuring patient satisfaction, 

which I believe will be central to our measurement processes in the 

future. 

I have personally visited ten VA medical centers in the last 6 

weeks to hear directly from the field on the actions being taken to 

get veterans off wait lists and into clinics. I leave later today for 

Albuquerque and El Paso. 

The inappropriate 14-day access measure has been removed from 

all individual employee performance plans to eliminate any motive 

for inappropriate scheduling practices. In the course of completing 

this task, over 13,000 performance plans were amended. 

Where willful misconduct or management negligence is documented, appropriate personnel actions will be taken. This also applies to whistleblower retaliation. I am sure we will talk about that 

further. 

I have frozen VHA central office and VISN office headquarters 

hiring as a first step to ensure that we are all working to support 

those delivering care directly to veterans. 

VHA has dispatched teams to provide direct assistance to facilities requiring the most improvement, including a large team on the 

ground right now in Phoenix. 

All VHA Senior Executive Performance Awards for fiscal year 

2014 have been suspended. 

VHA is expanding our use of private sector health care to improve access. 

I sent a message to all 341,000 VA employees and have reiterated during every single visit to VA facilities that whistleblowers 

will be protected. We will not tolerate retaliation against whistleblowers. 

I have conducted over a dozen meetings and calls with senior 

representatives of VSOs and other stakeholder groups to solicit 

their ideas for improving access and restoring trust. 

I have named Dr. Carolyn Clancy Interim Under Secretary for 

Health. She will spearhead our immediate efforts to accelerate veterans’ access to care and restore the trust of veterans. 

Dr. Jonathan Perlin, a former Under Secretary for Health at VA, 

currently on leave of absence from his duties as Chief Medical Officer and President of Clinical Services for Hospital Corporation of 

America, has begun his 2-month assignment at VA as Senior Advisor to the Secretary. Dr. Perlin’s expertise, judgment, and professional advice will help bridge the gap until VA has a confirmed 

Under Secretary for Health. 

17 

Dr. Gerald Cox has agreed to serve as Interim Director of the Office of Medical Inspector, a Navy Medical Officer for more than 30 

years and the former Assistant Inspector General of the Navy for 

Medical Matters. Dr. Cox will provide new leadership and a fresh 

perspective to help restructure OMI and ensure a strong internal 

audit function. 

As we complete reviews, fact finding, and other investigations, 

we are beginning to initiate personnel actions to hold those accountable who committed wrongdoing or were negligent in discharging their management responsibilities. To support this critical 

work, Ms. Leigh Bradley has begun a 4-month assignment as Special Counsel to the Secretary. Ms. Bradley is a former General 

Counsel at VA and most recently a senior member of the General 

Counsel team at the Department of Defense, where she had direct 

responsibility for the ethics portfolio for DOD. 

Before I conclude, let me briefly address the need for additional 

resources. 

I believe that the greatest risk to veterans over the immediateto-long-term future is that additional resources are provided only 

to support increased purchased care in the community and not to 

materially remedy the historic shortfall in internal VA capacity. 

Such an outcome would leave VA even more poorly positioned to 

meet future demand. 

We have been working closely with the Office of Management 

and Budget for several weeks to develop the request for funding. 

While the amounts under consideration are large in the context of 

VA’s size, scope, and existing budget, they represent moderate percentage increases in annual expenditures. Furthermore, a substantial portion of the funds required are non-recurring investments in 

space and information technology that would not be reflected in 

long-term run rates. 

Resources required to meet current demand, covering the remainder of fiscal year 2014 through fiscal year 2017, total $17.6 

billion. These funds address only the current shortfalls in clinical 

staff, space, information technology, and purchased care necessary 

to provide timely, high-quality care. 

In closing, we understand the seriousness of the problems we 

face. We own them. We are taking decisive action to begin to resolve them. The President, Congress, veterans, VSOs, the American 

people, and VA staff all understand the need for change. We must, 

all of us, seize this opportunity. We can turn these challenges into 

the greatest opportunity for improvement in the history of this Department. I believe that in as little as 2 years, the conversation can 

change, that VA can be the trusted provider of choice for health 

care and for benefits. 

If we are successful, who wins? The growing number of veterans 

that turn to VA for health care each year. The 700,000 veterans 

who are currently diagnosed with post-traumatic Stress Disorder. 

The million Iraq and Afghanistan veterans that have turned to VA 

for health care since 2002. And, the average veteran who turns to 

VA for health care who is older, sicker, and poorer than average 

patients in the private sector. These are the veterans who will win 

when VA becomes the trusted provider of care and benefits. 

18 

1http://www.va.gov/health/access-audit.asp 

That is what and where we want to be in the shortest time possible. Our ability to get there depends on our will to seize the opportunity, to challenge the status quo, and to drive positive change. 

I appreciate the hard work and dedication of VA employees, the 

vast majority of whom I continue to believe care deeply about the 

mission, want to do the right thing, and work hard every day to 

take care of veterans. As well, I appreciate our partners from the 

veterans service organizations, our community stakeholders, and 

dedicated VA volunteers. 

Last, I deeply respect the important role that Congress and the 

Members of this Committee play in serving veterans, and I am 

grateful to you for your long-term support. I am prepared to take 

your questions. 

[The prepared statement of Mr. Gibson follows:] 

PREPARED STATEMENT OF HON. SLOAN D. GIBSON, ACTING SECRETARY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

Chairman Sanders, Ranking Member Burr, and Distinguished Members of the 

Senate Committee on Veterans’ Affairs, thank you for the opportunity to discuss 

with you the Department of Veterans Affairs (VA) health care system. We at VA 

are committed to consistently providing the high quality care our Veterans have 

earned and deserve in order to improve their health and well-being. We owe that 

to each and every Veteran that is under our care. 

As the Chairman noted in May 2014, the Veterans Health Administration (VHA) 

operates the largest integrated health care delivery system in the United States. 

VHA has over 1,700 sites of care, including 150 medical centers, 820 communitybased outpatient clinics, 300 Vet Centers, 135 community living centers, 104 domiciliary rehabilitation treatment programs, and 70 mobile Vet Centers. VHA conducts 

approximately 236,000 health care appointments every day and approximately 85 

million appointments each year. Over 300,000 VHA leaders and health care employees—many who also are Veterans—strive to provide exceptional care to nearly 6.5 

million Veterans and other beneficiaries annually. 

The Chairman also noted in May 2014 that there are things that VA does very 

well, and there are areas that need improvement. My testimony today will provide 

some updates on a number of actions that the Department has taken since the last 

hearing in May 2014. 

We know that unacceptable, systemic problems and cultural issues within our 

health care system prevented some Veterans from receiving timely care. That 

breach of trust—which involved inaccurate reporting of patient wait times for appointments—is irresponsible, indefensible, and unacceptable to the Department. We 

apologize to our Veterans, their families and loved ones, Members of Congress, Veterans Service Organizations (VSO), and to the American people. We can and must 

solve these problems as we work to earn back the trust of Veterans. 

NATIONWIDE DATA ON ACCESS TO VETERANS HEALTH CARE

At VA, our most important mission is to provide the high quality health care and 

benefits Veterans have earned and deserve—when and where they need it. In midApril, VA began a nationwide Access Audit to assess the integrity of our scheduling 

practices, the adequacy of training, compliance with policy, and proper use of systems. As a result of the audit, we now know that in many communities across the 

country Veterans wait too long to receive care. 

As of July 8, 2014, VHA has reached out to over 160,000 Veterans to get them 

off wait lists and into clinics sooner. Also, between May 15 and June 30, 2014, we 

have made over 430,000 referrals for Veterans to receive their care in the private 

sector. VA made roughly 351,000 referrals during this same time period last year 

in 2013, an increase of roughly 79,000. As we continue to address systemic challenges in accessing care, we are providing regular data updates1 to enhance transparency and provide the immediate information to Veterans and the public on improvements to Veterans’ access to care. We are fully committed to fixing the problems we face in order to serve Veterans better. We know that we must not only reVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6621 Z:\ACTIVE\071614.TXT PAULIN
19 

store the public’s trust in VA, but more importantly, we also must restore the trust 

of our Veterans who depend on us for care. 

Following the release of results from VA’s nationwide Access Audit, along with facility level patient access data, I personally visited VA medical centers in Fayetteville, NC; Gainesville, FL; Baltimore, MD; Washington, DC; Columbia, SC; Philadelphia, PA; Augusta, GA; and Jackson, MS, to gain a clearer understanding of the 

extent of the problems that we face. 

The following actions have been taken in response to the nationwide Access Audit 

findings and data: 

• Removing 14-Day Scheduling Goal 

VA has eliminated the unrealistic 14-day access measure from all employees’ 

performance plans. This action will eliminate incentives to engage in inappropriate scheduling practices or behaviors. As of July 3, over 87,000 performance 

plans have been reviewed and over 13,000 performance plans have been amended, including over 3,500 front line schedulers. 

• Mandated Site Inspections 

Medical Center Directors and VISN Directors are responsible for ensuring 

Veterans receive timely, high quality healthcare. As of June 17, every Medical 

Center Director has been conducting in person visits to every clinic. Site inspections include observing daily scheduling processes and interacting with scheduling staff to ensure all policies are being followed. In addition to monthly reviews of VHA facilities nationwide, VISN Directors will also conduct similar visits to at least one medical center within their area of responsibility every 30 

days, completing visits to all medical centers in their network every 90 days. 

This action ensures leadership knowingly accepts accountability for the integrity of scheduling practices. As of July 9, 683 site inspections have been completed. 

• Establishing New Patient Satisfaction Measurement Program 

VHA immediately began developing a new patient satisfaction measurement 

program to provide real-time, robust, site specific information on patient satisfaction, including satisfaction measurements of those Veterans attempting to access VA health care for the first time. This program will include input from 

VSOs, outside health care organizations, and other entities. 

• Holding Senior Leaders Accountable 

Where audits identify concerns within a medical center clinic, VA will trigger 

administrative procedures to ascertain the appropriate follow-on personnel actions for specific individuals. We will hold people accountable where misconduct 

is found. 

• Ordering an Immediate VHA Central Office and Veterans Integrated Service 

Network (VISN) Office Hiring Freeze 

VA has redirected its focus and resources to staffing at the facility level to 

increase personnel who can directly serve Veterans. 

• Increasing Transparency by Posting Access and Patient Wait Time Data TwiceMonthly 

VHA is now posting regular updates to the access data released at the middle 

and end of each month at VA.gov. The first one of these was on June 9, 2014. 

These twice-monthly data updates will enhance transparency and provide the 

immediate information to Veterans and the public on Veterans access to VA 

health care. 

• Initiating an Independent, External Audit of Scheduling Practices 

I directed that an independent, external audit of system-wide VHA scheduling 

practices be performed. We are working with an outside private entity to conduct the audit and anticipate initiating these audits early next fiscal year. 

• Utilizing High Performing Facilities to Help Those That Need Improvement 

VHA will formalize a process in which high performing facilities provide direct assistance and share best practices with facilities that require improvement 

on particular medical center quality and efficiency performance measures. 

• Suspending Performance Awards 

VA has suspended all VHA senior executive performance awards for fiscal 

year 2014. 

• Enhancing Non-VA Care 

VHA is employing guidelines for using private sector care to improve access 

to health care for Veterans who are or who may experience excessive wait times 

for primary, specialty and mental health care. VHA is now operationally monitoring the effectiveness of our sites use of non-VA care to ensure Veterans are 

receiving their timely care. 

• Quickly Bringing in Veterans for Care 

20 

VHA facilities are improving access to health care for Veterans by: adding 

more clinic hours to evenings and weekends, recruiting to fill physician vacancies, deploying mobile medical units, using temporary staffing resources and expanding the use of private sector care. 

SCHEDULING SYSTEM UPDATES

VA recognizes that its medical appointment scheduling system is antiquated and 

we are replacing it through an acquisition process. VA hosted pre-solicitation ‘‘Industry Day’’ meetings with technology vendors on June 18 of this year to discuss the 

Department’s upcoming scheduling system acquisition. This Industry Day presented 

an important opportunity for VA to communicate directly with potential vendors on 

all aspects of the upcoming scheduling system acquisition. The Industry Day served 

as a face-to-face platform for exchanging information about business needs, industry 

best practices, and challenges specific to VA’s scheduling system. We recognize the 

need to develop lasting, long-term reforms, including a complete overhaul to replace 

the outdated technology for our scheduling system. Bringing an innovative scheduling product into our world-class electronic health record system is a crucial part 

of providing the scheduling staff in our facilities with the necessary tools to succeed. 

VA’s scheduling technical requirements are complex and require clear, well-articulated communication to ensure comprehensive understanding by industry and potential vendors. VA conducted a live scheduling system architecture question-andanswer session to ensure potential solutions seamlessly interface with VA’s Veterans Health Information Systems and Technology Architecture electronic health 

record. The information shared during the Industry Day will provide VA with a better understanding of what needs to be included in the upcoming scheduling system 

solicitation, with the ultimate goals of receiving solid proposals and reducing time 

to field new technologies. 

WHISTLEBLOWER PROTECTIONS

At VA, we depend on the service of VA employees and leaders who place the interests of Veterans above and beyond self-interest, and who live by VA’s core values 

of Integrity, Commitment, Advocacy, Respect, and Excellence. On June 13, 2014, I 

sent a message to all VA employees regarding the importance of whistleblower protection and met with employees at VA medical centers across the country to reemphasize that message. I reminded all 341,000 of our employees in messages and during site visits to VA facilities around the country that we must protect whistleblowers and create workplace environments that enable full employee participation. 

Intimidation or retaliation—not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion, or report what 

may be a violation in law, policy, or our core values—is absolutely unacceptable. 

Following the recent release of the Office of Special Counsel’s (OSC) recommendations to President Obama, I directed an immediate review of the Office of the Medical Inspector’s (OMI) operation, process, and structure. After I was briefed on this 

review, I determined a clear need to revise the policies, procedures, and personnel 

structure by which OMI operates, and I directed a restructuring of the organization. 

As long-term restructuring moves forward, I have appointed an interim Director of 

OMI from outside the current office to assist with transition, and VA has suspended 

OMI’s hotline and is currently referring all hotline calls to Office of Inspector General (OIG). On July 2, 2014, I met with Carolyn Lerner, Special Counsel of the 

United States Office of Special Counsel. VA has begun the process of completing the 

OSC 2302(c) Certification Program and is focused on ensuring protection from retaliation for employees who identify or report problems. Special Counsel Lerner and 

I identified ways to streamline the organizations’ work together to ensure whistleblower protection during the course of an OSC investigation. 

SUMMARY

VA has also recently initiated the process of selecting the next Under Secretary 

for Health of VHA—one of the most important jobs in government today. VHA’s new 

leader will be a change agent and deliver necessary reforms to provide our Veterans 

timely access to the world-class health care that they have earned through their 

service and sacrifice. 

These are just a few of VA’s actions to improve Veteran’s access to high quality 

health care. There is always more work to do, and VA is focused on continuous improvement to the care we provide to our Nation’s Veterans. I appreciate the hard 

work and dedication of VA employees, our partners from VSOs—important advocates for Veterans and their families—our community stakeholders, and our dedicated VA volunteers. Just two weeks ago, I met with the leadership of 26 Military 

21 

and Veterans Service Organizations (MSOs and VSOs) to reaffirm VA’s commitment 

to work together to address the unacceptable, systemic problems in accessing VA 

health care. During this meeting, I updated the organizations’ representatives on 

VA’s work to restore Veterans’ trust in the system and on VA’s progress in reaching 

out to get Veterans into clinics and off of waiting lists. I appreciate MSOs and VSOs 

for being VA’s valuable partners in serving Veterans and continuing to improve the 

Department, and I solicited their ideas on how VA can improve Veterans’ access to 

care and services. 

I also respect the important role Congress and the dedicated Members of this 

Committee play in serving our Veterans. I look forward to continuing our work with 

Congress to ensure Veterans have timely access to the quality health care they have 

earned. 

Again, thank you for the opportunity to appear before you today and for your unwavering support of those who have served this great Nation in uniform. 

Chairman SANDERS. Well, Mr. Acting Secretary, thank you very 

much for not dealing with niceties, for dealing with realities. 

As I understand it, we are talking, in a broad sense, about two 

very serious problem areas. Number 1, I trust that every Member 

of this Committee understands that we have an immediate crisis, 

that we have hundreds of thousands of veterans on wait lists, that 

those folks must get the medical care they need in a timely manner. I am pleased to see, Mr. Acting Secretary, that you have 

moved aggressively in that area. 

But, if I understand you correctly, the second point you made is 

that while it is important we put out the current fire, unless we 

effectively deal with the long-term capacity issues facing the VA, 

we are going to be back here year after year with similar types of 

problems. 

You mentioned the number, and I want you to get into some detail. What are we talking about? 

Let us just start off with personnel. How many doctors, how 

many nurses, how many other types of medical personnel do you 

need to achieve that goal? Be as specific as you possibly can—and, 

how much is that going to cost? 

Mr. GIBSON. Mr. Chairman, of the $17.6 billion, approximately $10 billion is allocated for a combination of purchased care and hiring additional clinical staff. The blend of that will change over time 

as we ramp up that capacity, as we are successful in hiring people, 

yes—— 

Chairman SANDERS. Is it fair to say that to the degree that we 

strengthen the VA, we become less dependent on expensive contract care? Is that a fair statement? 

Mr. GIBSON. It is absolutely a fair statement, Mr. Chairman. 

Chairman SANDERS. OK. Please continue. I interrupted you. 

Mr. GIBSON. So, over the 3-plus-year period of time that $10 billion gets allocated—a portion to purchased care, probably more on 

the front end than on the back end as we are successful in hiring. 

As I mentioned in my opening statement, you know, our ability 

to develop highly-refined bottom-up estimates of specific physician 

and clinician requirements is pretty limited. Our best estimates at 

this time is that this would—that closing this gap would require 

hiring approximately 10,000 additional clinical staff. Those are divided among primary care, specialty care, and mental health care. 

And, of the 10,000, roughly 1,500 of those are actually physicians. 

Others are nurses and nurse practitioners and other direct patient 

support staff. 

22 

Chairman SANDERS. You talked about space. 

Mr. GIBSON. Yes, sir. 

Chairman SANDERS. I trust that you are not talking about building some Las Vegas-type expensive buildings. What is the relationship between space and the emergency that we currently have in 

terms of waiting periods? 

Mr. GIBSON. I will tell you, Mr. Chairman, in every medical center I visited except one, and that is in Augusta, the number 1 constraint that they are operating under right now is space. Fayetteville, NC, for example, is growing their patient population at a 7- 

percent annual rate. And, when it takes us 5 or more years to get 

a building out of the ground, it does not take long to fall behind. 

So, where we are today as a Department is we are behind in 

terms of the space required today to serve patients, that there are 

$6 billion included in the $17.6 billion total that is designed for 

infrastructure. 

Chairman SANDERS. And, can you tell us what are those 

projects? Do you have them? 

Mr. GIBSON. There are—I am going to ask Philip to go into some 

of the details—there are eight major projects there. There are 77 

lease projects for outpatient clinics that would add about two million square feet and roughly four million appointment slots. And 

then there are both minor construction and non-recurring maintenance that would add several million—roughly four million, in 

round numbers—additional outpatient visit slots there. 

Chairman SANDERS. We have heard time and time again that the 

dysfunctionality in terms of appointments for the VA has something to do with a significantly outdated scheduling system. Can 

you say a word on that? 

Mr. GIBSON. There are actually four parallel tracks underway 

right now dealing with the scheduling system. There are 11 existing defects in the system that are being patched as we speak. 

There are four different interfaces that are in the process of 

being developed to make it easier for schedulers to access and to 

actually provide the opportunity for veterans to be able to directly 

access their schedule. 

On the 11th of July, we let a contract for major enhancements 

to the existing scheduling system that will remedy many of the 

most egregious problems that we have right now that make it hard 

to deal with. 

Then, parallel with all of that, as I mentioned in my statement, 

we are pursuing the acquisition of a commercial off-the-shelf, stateof-the-art system. That is probably 2 years down the road in terms 

of actually having that functionality in place, which is why we are 

pursuing these other tracks in parallel. 

Chairman SANDERS. All right. Let me conclude. I have gone over 

my time. If we do not have the resources at the VA to address 

issues like hundreds of thousands of folks coming home with PTSD 

and TBI, space issues, what happens in years to come? 

Mr. GIBSON. The wait times just get longer. We do not—meet 

any acceptable standard of timely and consistent quality health 

care. It is—you know, I have committed to the President, I have 

committed to veterans, I have committed to the staff at VA, I will 

23 

not hold back asking for resources because we have not been managing to requirements as a Department. 

This would never happen in the private sector. You would never 

stand for it. You would fail as a business if you did this. It makes 

no sense and I will not—I am not holding back now and will not 

hold back in the future. 

But, I have also told these folks that have worked on these numbers, I do not want a penny in there that we cannot justify, not one 

cent. 

Chairman SANDERS. OK. I have gone over my time. 

Senator Burr. 

Senator BURR. Mr. Chairman, thank you. 

Secretary Gibson, again, I commend you. You have made all of 

us go back and sort of ask about numbers because it was not that 

long ago that we wrote off $127 million for that new software program to do scheduling, and I think that was the second time. 

And the $14 billion-plus that we have got currently in the construction and maintenance account, that means that projects are 

on a 7, 8, 10-year timeline. 

So, it is good to see, one, that VA has a sense of urgency; two, 

that OMB is recognizing the realities of what the needs are. 

I have got a set of questions for you, but I intend to send those 

to you and ask you to respond to them. 

I would ask unanimous consent that all Members have an opportunity to do that, Mr. Chairman. 

Chairman SANDERS. Without objection. 

Senator BURR. Sloan, I want to focus for just a few moments on 

data integrity specifically at VBA. 

I want to give you some examples of testimony provided by the 

Office of the Inspector General and the General Accounting Office 

in a House hearing on Monday night. 

The Inspector General made these statements; all quotations: 

‘‘We have concerns that VBA’s performance goals are not 

realistic and comprised by data integrity issues.’’ 

‘‘We are receiving numbers of serious allegations regarding mail mismanagement, manipulation of dates of claims 

and other data integrity issues in the Baltimore, Philadelphia, Los Angeles, Oakland, and Houston VA Regional Offices, and today, we received an additional allegation regarding the Little Rock VA Regional Office. We are concerned at how quickly the number of regional offices with 

allegations is growing.’’ 

‘‘VBA removed all provisional rated claims from its 

pending inventory. VBA’s process misrepresented the actual workload of pending claims and its progress toward 

eliminating the overall claims backlog.’’ 

‘‘An Office of Inspector General team sent to Philadelphia Regional Office on June 19, 2014, determined that 

there were significant opportunities for regional offices to 

manipulate and input incorrect dates of claims in the electronic record. Incorrect application of date of claim comprises data integrity related to timeliness of claims processing.’’ 

24 

Then there is this exchange that took place between Congressman Bilirakis and the Assistant IG, Linda Halliday. 

Mr. Bilirakis said, ‘‘You remarked in your opening statement 

that VBA has self-reported a decrease in the national backlog by 

more than 50 percent since March 2013. Do you trust those 

numbers?’’ 

Ms. Halliday’s response was, ‘‘At this point, I would say no; I 

cannot trust those numbers. I think we have a lot of work ahead 

of us to address the allegations we have just received. They all 

seem to focus on data integrity, and they need to be looked at very 

carefully. So, I do not want to say I trust them.’’ 

Near the end of the hearing, Congressman O’Rourke asked Ms. 

Halliday, ‘‘One of the things you said in your opening comment 

that struck me was that some of the success may be comprised by 

data integrity issues. [Is there] anything that Secretary Hickey has 

said tonight that alleviates those concerns that you raised in your 

opening statement?’’ 

Ms. Halliday simply responded, ‘‘No.’’ 

Also, on the issue of whether VBA’s quality metrics are reliable, 

the General Accounting Office provided this testimony: 

‘‘In prior work, we have documented shortcomings in 

VA’s quality assurance activities; and more recently, concerns have been raised about the lack of transparency related to the changes in the Agency’s national accuracy rate 

for disability claims.’’ 

‘‘In several basic areas, they are not following general 

statistical procedures. That looseness in their methodology 

translates to numbers that are not accurate and are not 

very helpful in terms of looking at trends over time, in 

terms of performance accuracy rates and/or comparing offices in terms of relative performance. That is not good 

metrics.’’ 

Simply, the Inspector General’s Office testified that they, ‘‘continued to identify a high rate of errors in regional offices’ processing 

of claims decisions.’’ 

Now, Under Secretary Hickey was the one that testified for the 

VA. And, despite her testimony, which was refuted by the Inspector 

General, the GAO, VA put out a press release the very next day, 

entitled ‘‘VA Takes Action to Ensure Data Integrity of Disability 

Claims,’’ in which the VA touts that it has reduced the backlog by 

55 percent and has reduced the number of days it takes to process 

claims and has improved their accuracy rate to over 90 percent. 

Now, listen; you have said that you have got to gain the trust 

of the Committee, of the veteran, of the country, and I think we 

agree with you. 

Let me ask you, how smart was that press release? Did you sign 

off on that press release? 

And how can numbers that were refuted by the people that are 

actually doing the investigations of VA facilities, how can they refute the numbers and the next day VA come out with the same 

numbers and tout them? 

Mr. GIBSON. Senator, I think, as you have noted, trust is the 

foundation of everything that we do, and where there are questions 

25 

about data integrity I think we have got to bore into those very 

deeply. 

There are a number of issues that have been raised there. I could 

sit and go through and pick at an item or two, but the fundamental 

issue remains that there are questions about whether or not we 

have got good data integrity there. And just as we are undertaking 

independent reviews in the VHA side, we will undertake those in 

the VBA side. 

Senator BURR. But, Mr. Secretary, they have been underway, 

much of it initiated by Members of this Committee, with the Inspector General, with the General Accounting Office. 

And you have acknowledged the shortcomings on the VHA side. 

This is fresh. This is this week. And, still, that press release 

stresses that the VA will continue to post these performance data 

on its Web site. 

How does publicizing suspect data increase the integrity and the 

trust that you—— 

Mr. GIBSON. Senator Burr, I would tell you I come into this organization from the private sector. I look at the transformation that 

has been wrought in VBA over the last 2 to 3 years, and I defy 

anybody to show me any major part of the Federal Government 

anywhere that has transformed that much in that period of time. 

I think it is amazing, looking at it from a private sector perspective, much less doing it in the context of a Federal Government 

agency. 

There is room to improve there. I got it. 

We have got to restore trust there. I got it. 

They pulled the 100 percent provisional ratings out, and those 

did not get counted in the backlog. I got it. 

My recollection, round numbers, is it was about 12,000. I may 

not have that exactly right. 

The backlog is down 350,000 in round numbers. 

So, I get it. We need to make sure that the data integrity is 

there, but I am not going to pull back from standing by that Department and the good work that has been done. 

You know, we cannot have back and forth between IG. IG has 

findings, and we have got to embrace those findings. 

Senator BURR. Well, I appreciate the Chairman’s leniency here. 

I am not sure you are embracing those findings, especially in 

comparison to how you have embraced the VHA findings. 

It concerns me because these are veterans that are waiting for 

their determinations to be made. In some cases, as the IG and 

GAO have pointed out, it involves overpayments—overpayments 

that are due the American taxpayer, that are due back to the VA, 

to help fund other things. 

It just strikes me—and I realize this was a VHA hearing—it 

strikes me that you could have testimony like we had on Monday 

night and yet turn around and put out a press release still stating 

the same numbers the next day when every one of the investigators 

found that those numbers could not be trusted. 

So I will work with you. It is an area of great concern. It is as 

big, if not bigger, a problem than the VHA because the budget is 

the biggest budget at the VA. 

I thank the Chair. 

26 

Chairman SANDERS. Senator Murray. 

Senator MURRAY. Thank you, Mr. Chairman. 

Mr. Secretary, the VA has removed wait time criteria from the 

performance contracts of network and medical center directors. And 

I do understand the need to be wary of creating incentives for people to game the numbers, but we also have a serious accountability 

problem. 

How will you still hold network and medical center directors accountable for wait times if it is not in their performance contract? 

Mr. GIBSON. I think the first step that we have got to do is get 

integrity in the data, and so the idea behind pulling that out at 

this stage of the game was to eliminate any questionable 

motivation. 

Senator MURRAY. Understood. 

Mr. GIBSON. I think as we move forward what we are going to 

find is that average wait times are a very poor gauge for timeliness 

of care for a large integrated health system. You do not really find 

that out in the private sector. 

That is one of the reasons we are boosting our patient satisfaction measurement activities because I think patient satisfaction is 

going to become central. Even at a 14-day standard, if the veteran 

needs to be seen today, we have failed that veteran. 

Senator MURRAY. So you are looking for different ways to—— 

Mr. GIBSON. So I think we are going to be looking at different 

ways to evaluate timeliness of care. It will be a combination of patient satisfaction. It will be a combination of veterans that are 

waiting too long and seeing that number coming down steadily; and 

then, as we have the system capability to do things like you see 

over in the private sector, metrics like the third next available appointment, which gives you some gauge of the capacity of the system to be able to handle that veteran as they come in. 

Today, at least, we are able to look at same-day appointments. 

Roughly, in the primary care area, we see about 100,000 veterans 

on a same-day basis every single month in primary care. That, to 

me, suggests that there is capacity that is being maintained to take 

care of that veteran who cannot wait 14 days or 21 days or 30 

days. 

Senator MURRAY. OK. Health care from the private sector does 

play a critical role in making sure that veterans get their care in 

a timely fashion, but there are some drawbacks to that care that 

VA has been trying to overcome, like not being able to get medical 

records returned to the Department and very little ability to see 

the quality of care that is provided. 

If Congress were to expand the authority for non-VA health care, 

what steps would be necessary to address those kinds of problems? 

Mr. GIBSON. I am going to ask Philip to jump in here in a 

moment. 

One of the biggest challenges we have with purchased care in the 

community is maintaining continuity of care for the veteran. So, 

the ability to get information, medical information, medical record 

information, back and forth is a vital part of this—ensuring the 

quality of care. 

I would tell you if the floodgates open it will present the Department with challenges. 

27 

But the fact remains, right now we are referring out roughly a 

quarter of a million referrals every month to purchased care. And, 

as I mentioned before, every one of those referrals, on average, will 

result in roughly seven appointments. That is an awful lot of 

activity. 

Last year, 15 million visits to non-VA providers over the course 

of the year plus the 85 million outpatient clinic visits that we have 

is 100 million outpatient visits a year that we are managing. 

So, it is already a very large number and a challenge for us, but 

it would be—if we open the floodgates, it would be an even bigger 

challenge. 

Anything to add there, Philip? 

Mr. MATKOVSKY. No, sir. 

Senator Murray, the one thing I would add is purchasing care in 

the community does not absolve us of the requirement, the responsibility, to coordinate that care. 

In addition to the assurance that we can both send and receive 

clinical data, there is just the hands-on coordination required to 

make sure that an appointment has occurred, that the veteran 

knows where to go—— 

Senator MURRAY. Right. 

Mr. MATKOVSKY [continuing]. That their family is involved, all 

the rest of that. 

If we just look at the cost of the care alone, we are missing a 

big responsibility. 

Senator MURRAY. So when we look at how we do this and expand 

that, we have to look at all those issues as well and get them right, 

or we are just going to create a bigger problem for the future. OK. 

Finally, VA has had a lot of difficulty hiring providers for a number of reasons, including pay that is lower than the private sector 

and, as you mentioned, a very long, cumbersome hiring process 

plus the challenge itself of hiring in shortage areas in health care 

anyway because we know there are national shortages, as well. 

Now VA does a lot of training for doctors and nurses and works 

very closely with a lot of our universities. 

What more can the VA do to help build the health care workforce 

that is necessary to meet the needs of the Department and our 

country? 

Mr. GIBSON. That is a great question, ma’am. 

I think one of the significant opportunities—and the Chairman 

and I have talked about this before—are opportunities where we 

can work collaboratively there, maybe tuition payment programs or 

tuition reimbursement programs, ways that we can encourage that. 

We certainly rely very heavily on our academic affiliations as a 

source for new clinicians, and we are doing some things from a 

compensation standpoint as well, where we have got some flexibility to be able to meet local market—— 

Senator MURRAY. OK. I am very interested in that because I 

think that that is part of the reason for a backlog as well. 

Mr. GIBSON. Yes, ma’am. 

Senator MURRAY. I mean, there is a variety of reasons, but we 

cannot ignore that side of it. So I am interested in hearing more 

of that. 

Mr. GIBSON. Yes, ma’am. 

28 

Senator MURRAY. Thank you very much, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Murray. 

Senator Isakson. 

Senator ISAKSON. Following up on Senator Murray’s question 

about referrals, in particular to the private sector, I wrote down 

this from your statement. You said you all had recently made 

543,000 referrals for veterans for private care. 

What percentage of those would you guess were mental health 

referrals? 

Mr. MATKOVSKY. I am sorry. I could hasten a guess, but I would 

take that one for the record. 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. JOHNNY ISAKSON TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. From May 15, 2014 to July 30, 2014, VHA made approximately 541,000 

outpatient referrals. Based on the identified category of care, there were 8,454 referrals that were for mental health services. 

Question 2. What is VA doing to ensure coordination of care for mental health patients? 

Response. It is the responsibility of the Veteran’s treating clinician(s) to lead coordination of care for a Veteran receiving mental health care in the community, in 

coordination with clinic administrative staff, Health Information Management Service, and the facility staff responsible for the business (clinical and administrative) 

processes related to Non-VA Medical Care Coordination (NVCC). 

The NVCC model is a system of business processes that standardize front-end 

business processes and improve patient care coordination VA-wide. 

In the NVCC model, the Veteran is notified of the approval of non-VA medical 

care and contacted to identify availability, preferences, and needs. Once this information has been obtained, the non-VA medical care provider is contacted to schedule an appointment for the Veteran. The appointment is then captured in VistA. 

The Veteran and non-VA medical care provider are sent the authorization and the 

appropriate release of information form, to ensure the medical records are received 

by VA. 

After the appointment date, the Veteran is contacted to verify that the authorized 

non-VA medical care has been received. If the Veteran missed or did not attend 

their medical appointment, VA staff will work with the Veteran to reschedule the 

missed appointment. NVCC staff will then work with the non-VA medical care provider to obtain the required clinical documentation. The documentation will then be 

scanned into the appropriate system, and uploaded to the Veteran’s electronic medical record. If additional review and follow-up action is required from the referring 

VA provider once the clinical documentation is received, an alert will be sent to notify the VA provider of the required action. 

At the Atlanta VAMC, in particular, since 2013, VHA has greatly consolidated the 

number of contract providers it utilizes for mental health services, from 26 to 5, to 

ensure there is greater coordination of patient care. 

Senator ISAKSON. The reason I ask that question is I got into the 

Atlanta VA starting in August of last year when we had two suicides and a drug overdose. 

When we dug down, they were using a community-based provider for mental health. VA would see the patient, refer them to 

the community-based provider, with no follow-up between the referral and the appointment. And, in that period of time, when the 

person was determined to be at risk for themselves and their own 

life, in two cases they took their own life because they did not get 

timely services on the referral. 

I think Mr. Matkovsky made an interesting observation about coordinated care. 

As we expand private sector options in veterans’ health care, 

which we may or may not do—I hope we do in terms of the legislation going forward—care coordination is going to be one of the seVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
29 

crets to making that work, not just in reducing wait times but increasing the quality of care to the veterans, particularly with the 

number, as Chairman Sanders said, the number of veterans seeking mental health care coming forward. 

That is going to be an ongoing process. It is going to be one that 

is going to have to be coordinated and monitored. 

My question is, did you ever see the William Schoenhard memorandum? 

Mr. MATKOVSKY. Yes, Senator. 

Senator ISAKSON. In May, when Secretary Shinseki and Dr. 

Petzel were here to testify, I asked them both the question, had 

they seen it? 

Dr. Petzel said he had seen it and read it, and Secretary 

Shinseki said he had not. 

I think both of them told the truth. I do not think Secretary 

Shinseki ever saw it, and I do not think he ever saw it because the 

senior leadership of the VA did not let him see it. 

My experience of a lot of these problems lies at the highest levels 

of the veterans administration and veterans medical services that 

insulate the leadership of VA from the problems that they had. 

Why else would a memorandum written 4 years ago, describing 

what we are all discovering now in 2014, not have been acted on? 

The last sentence of the third paragraph says, ‘‘These practices 

will not be tolerated.’’ It does not say, ‘‘Look at this when you get 

a chance.’’ 

And it delineates each of the programs just like the testimony 

that the whistleblowers gave the other night in the House hearing. 

You are an interim secretary. You are going to be handing off, 

presumably, to Mr. McDonald, who I understand is a well-qualified 

individual. 

Mr. GIBSON. Yes. 

Senator ISAKSON. What are you doing to put in place—the type 

of information transfers and conduits—that will see to it Mr. 

McDonald does not become a rookie victim as a distinguished general did, in terms of Secretary Shinseki? 

Mr. GIBSON. I am not going to let him. I am not going to let my 

old friend become a rookie victim of anything. 

More fundamentally—— 

Senator ISAKSON. Let me interrupt. I am not being trite when I 

ask this question. 

Mr. GIBSON. No, no, I understand. 

Senator ISAKSON. For 4 years the VA insulated its leader, in the 

case of Secretary Shinseki. 

Mr. GIBSON. I would tell you from my own personal perspective 

I have learned to never have all my information filtered through 

a couple of people, and so from the first day that I got to VA I 

started reaching down in the organization to get additional information. 

I think your sense is a very accurate one. I think, historically, 

VHA has operated a fairly insular organization—not fairly, a very 

insular organization; and I think part of what we have been doing 

is dismantling a lot of those barriers. 

Since my first day as Acting Secretary, every single morning at 

9 a.m. we have something called Access Standup. We have senior 

30 

leaders from across VHA as well as senior leaders from across the 

Department. We are up in our integrated operations center, and we 

are boring into data around access to care: 

What is the status? 

What are we doing? 

How many contacts? 

How many appointments? 

What are the wait times? 

What is the status on many of these different initiatives that I 

have alluded to in my opening statement? 

It is just part of what we are putting in place. 

I would have to say this young guy right here—I have said before, if I was half as smart as Philip, I would be darn smart—he 

has been doing an awful lot of the work to put in place the kind 

of management information that you are talking about so that we 

are not just relying on, by chance, that information filters up, that 

we have got dashboards in place that will help us identify where 

there is scheduling malpractice. That is in place right now, where 

there are productivity opportunities for us to wring more productivity out of a particular clinic, that we are able to identify those 

things, and then, in tandem, requiring medical center directors and 

VISN directors to get out in their clinics so that they take direct 

ownership for the consequences. 

The first sentence in the memo that provided that direction was, 

‘‘Medical center directors and VISN directors are directly accountable for the quality of care and the timeliness of care that is delivered by VA.’’ 

That was the first sentence, and it was in there because I wrote 

it. 

That is part of ensuring that we have got that kind of accountability, and frankly, it is part of the culture change for the organization. VHA is not used to operating that way. 

Senator ISAKSON. Well, my time is up, but with that endorsement of Philip, I have to ask this question; Philip, you are not leaving when Secretary Sloan leaves, are you? 

Mr. GIBSON. I am not going anywhere either. I am going to stick 

around. 

Senator ISAKSON. I am talking about in the leadership. Make 

sure he is at the right hand of Mr. McDonald. 

Mr. MATKOVSKY. There are a lot of good people building a lot of 

good tools. 

One of the things that we have a team working on right now is 

to take that memo and actually develop tools that allow us to mine 

data to look for those patterns, to give us a risk score at the timeliness data that we are looking at. 

So, as we are looking at our timeliness data, Secretary Gibson 

has directed us to place an integrity score against it and rate it. 

Are there certain questions? And, if the questions persist, then 

have an audit come in, take a look at it, and manage it. 

Senator ISAKSON. Thank you both very much. 

Chairman SANDERS. Thank you, Senator Isakson. 

Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. 

31 

You are right; there are a lot of good people in the VA building 

tools and there are also a lot of them delivering some damn good 

health care on the ground. We need more of them, and we need to 

get rid of the bad apples that are in that bunch. 

Mr. Sloan, you said that you have a concern about purchased 

care trumping VA capacity. I assume that is during this conference 

committee and other times, where we will put more emphasis on 

purchased care and not enough emphasis on VA capacity. 

Have you been able to do any sort of cost analysis on providing 

care for veterans outside the VA? Is it more expensive, less expensive, about the same? 

You can kick it over to Matkovsky if you would like. 

Mr. MATKOVSKY. There are instances where we have taken what 

we would consider to be the mix of patients that we would be serving—veteran patients—and the types of services we would provide, 

and we compare them to a private sector model. Sometimes we do 

it for a community-based outpatient clinic, sometimes larger. 

As a general rule, it tends to be more expensive. 

And there are two different types of contract actions that we 

have used: capitated models and fee-for-service models. They both 

have their problems. 

Senator TESTER. OK. I come from a State where, quite frankly, 

it is a frontier in a lot of areas. And the private care may or may 

not solve the problems, but it looks pretty attractive. 

If it breaks the budget of the VA, though, and we do not get better health care in the private sector, which I think both of those 

are up for debate, it can be a problem. That is why I agree with 

your capacity issue with the VA. 

In the meantime, I want to talk about an issue that Senator 

Moran worked on, and that is Project ARCH. I think it has worked 

well. It has not been perfect, but it has worked well. 

Can I get any assurance from you that ARCH will not be prematurely shut down before it is reauthorized? 

Mr. GIBSON. The discussion that Senator Moran and I had the 

other day was exactly to that issue. 

My commitment is we will not, to the extent that I have got the 

authority—there is some question there—but we will not end a program that is providing access to veterans until we have the robust 

replacement in place so that there is no lapse in care for the veterans that are being served in Project ARCH. 

That is my commitment to Senator Moran. It is my commitment 

to you and the veterans that we serve. 

Senator TESTER. That is good. I mean, I think the Project ARCH 

definitely works, and it definitely allows you to have control of 

those medical records too as you move forward, which is a big concern when we start going to the private sector. 

Could I ask you, what do you say to folks that say the VA’s work 

shortages are a myth and that the real problem is the medical personnel are just not working hard enough or fast enough? 

Mr. GIBSON. I will begin, then I will probably pass it over to Philip for a wrap-up. 

I think when you look—I mentioned earlier in my opening remarks, older, sicker and poorer, when you look at the typical VA 

patient. 

32 

First, you start talking panel sizes or RVUs when you are looking at specialty care. You have to take into account the very different patient population that VA is dealing with. So the number 

of primary care patients that a clinician sees at VA is, in all likelihood, going to be different than what you see in the private sector. 

Second, there are oftentimes factors that bear on their ability to 

see. For example, space, as we talked about that earlier. 

I think the average in the private sector for primary care is two 

and a half treatment rooms for a primary care provider. And I do 

not think we have good data on what that looks like across VA, but 

I strongly suspect we do not have those resources. 

In the case of specialty care, I would tell you one of the places 

we are significantly underleveraged—and it is addressed in these 

numbers in this request—is, on average, we have one support person for every specialty care provider at VA. That compares to a 

goal, or a target, of three and a half to one in primary care. We 

are underleveraging our specialty care providers, and as a result 

they are not seeing as many patients as they ought to be able to 

see. 

So, we get these differences in comparison to the private sector. 

I am convinced we are going to see some productivity enhancement, but it also means that we have got some investments to 

make to be able to deliver those. 

Senator TESTER. Will that productivity enhancement meet the 

needs of the veterans that do not have access to the VA? 

In other words, what I am saying is that I was told, for instance, 

VA-Montana has 22 slots short on docs and nurses are significantly 

higher than that. Productivity can probably take care of some of 

those docs—maybe, maybe not. 

But, my point is that if we are short 22 docs, it just means harder work for the doctors there, it becomes an issue of are they going 

to be as happy with the VA. Nine out of ten say they are happy 

with the service now—the ones that get through the door. 

Mr. GIBSON. Let me ask Philip to take just a moment and summarize the process that we have been going through across VA. 

Senator TESTER. Yes, that is fine. 

Mr. MATKOVSKY. When we did accelerated care, one of the things 

we pushed out was productivity data for specialty care. I may touch 

on panel size a little bit because I think there is some criticism 

there, but we sometimes miss the comparative patient populations 

when we do that. 

We are looking at productivity. We are comparing productivity 

internally. Where we have highly-productive facilities, we are looking at how they got there. Part of that is smart use of support staff, 

but part of it is actually just monitoring RVUs and productivity in 

our appointments that we have available. 

Some of that can be covered internally. Some of it will require 

additional resources. So when we pushed out accelerating care, we 

asked every facility to look at their productivity numbers as well 

as whether or not they could increase them; if they could not, to 

give us a requirement for some non-VA care resources. And we 

used that as the basis to accelerate care. 

Senator TESTER. OK. Thank you very much. 

Thank you, Mr. Chairman. 

33 

Chairman SANDERS. Senator Moran. 

Senator MORAN. Chairman, thank you very much. Again, Secretary Gibson, thank you for your presence today. 

Senator Burr and others, including you, have used the word 

‘‘trust.’’ I have never asked for a Cabinet Secretary’s resignation. 

This is the first time I have ever done that in my time in Congress. 

And we were indicating at the time that there was a problem with 

the culture, systemic problems, lack of leadership. It was my sense 

that all that was true, or I would not have taken the steps that 

I took. 

I was—I do not know—somewhat comforted in the position, but 

actually, you know, very concerned but what I heard Secretary 

Shinseki say on the day that he announced his departure, which 

was something to the point that he had been surrounded by people 

whose views he trusted that he should not have trusted. The reason that there was some assurance to me is it seems to me that 

we were right, there is a culture and a systemic problem if the Secretary cannot trust the people that he or she must deal with on a 

day-to-day basis to provide information. 

I want my comments here today to be broad and not provincial 

just to Kansas. I appreciate the Senator from Montana raising this 

issue of ARCH, but I want to use that program as an example of 

why I, as a Member of Congress, have had difficulty trusting the 

Department of Veterans Affairs. I do not mean this in a personal 

way. I do not mean to suggest that I am personally offended by the 

circumstances that have developed over a period of time. What I 

mean is that my ability to assess what you are doing, to make decisions as a member of the Appropriations Committee, but most importantly, my ability to care for the veterans back home in Kansas 

is handicapped by the sense that I have had that the Department 

of Veterans Affairs does not trust us, does not share information 

with us, is not honest with us, and perhaps most importantly, has 

rarely responded to issues that we have raised. 

Again, this is not a personal concern of mine; it is not like I am 

personally offended. But when a veteran in Kansas brings an issue 

to me and I raise it with the Secretary or anyone else at the Department of Veterans Affairs, I think we should be able to expect 

an honest, fair, and timely response, and it has not occurred. So, 

my ability to trust the Department of Veterans Affairs has been 

significantly handicapped. 

An example of that is this ARCH program. I authored legislation 

that ultimately created a pilot program—it got narrowed down to 

be a pilot program—that says if you live long distances from a VA 

hospital outpatient facility, you can access that at home by the Veterans Department giving you the ability to do that paying for the 

service. That pilot program, five of them across the country in rural 

areas, was created in 2011. I kept continually asking questions of 

the VA: how is it going? Some pride of authorship, but mostly, is 

it working? How are veterans—are they liking it? Is it cost-effective? Does the technology work? And we got virtually no answers 

over a long period of time. 

Finally, at the hearing with Secretary Shinseki—this program is 

about to end. Its 3-year pilot program is coming to a conclusion, although we are pleased to know that you have the authority to exVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
34 

tend it. Secretary Shinseki in March of this year indicated to me 

that I would have an answer to my question by sunset. Those were 

his words, ‘‘by sunset.’’ I never got an answer. 

Then on March 20—and, incidentally, one of the things I have 

learned since then is that in the spring of 2012, a year after the 

pilot program gets started, the Wichita VA is interested in promoting this program to rural veterans, and they were instructed by 

folks in Washington, DC, that you cannot recruit veterans for 

ARCH and you cannot ‘‘market’’ ARCH. 

My concern is that we have created a program that somebody at 

the Department of Veterans Affairs does not like, so they are out 

and about trying to make certain they prove is does not work. For 

somebody at the VA to tell folks in Kansas, ‘‘Do not market this, 

do not encourage veterans to participate,’’ suggests that they wanted failure. So, I became more suspicious as I learned this. 

On March 26 of this year, the national program director directed 

the five pilot programs to notify veterans the program was coming 

to a conclusion. At the same time—in fact, in April, a week or so 

later—senior staff at the VA assures my staff and Committee staff 

that we are continuing to assess the program. Subsequently, we 

have learned that already the memo has gone out telling those five 

pilot programs to notify veterans the program will no longer exist, 

but 10 days later or 2 weeks later, we are assured VA is continuing 

to assess. That again makes me suspicious about the inability to 

get the report promised by the Secretary of Veterans Affairs by 

sunset that I will know what is going on with ARCH. 

Then, in June of this year we discovered that there was an email 

ready to be sent terminating the program. I and several other Senators, including some on this Committee, asked that not to be the 

case, and we are told just in time the ‘‘Send’’ button was never 

pushed. 

So, there were a series of things that cause us to have great 

doubts about who is telling us what; what the truth is. And I guess 

in a more fundamental way, these programs authorized by Congress, can they be easily undermined by personnel at the Department of Veterans Affairs who apparently do not like the suggestions that we have made? This is not a suggestion; this is the law 

that we passed. 

Finally then, our telephone conversation of June 27, I appreciate 

you reiterating what you just said to Senator Tester. So, that is the 

circumstance that I find myself in as someone who is a supporter 

of veterans and, therefore, a supporter of the Department of Veterans Affairs whose mission it is to take care of veterans across our 

country and our States. 

Mr. GIBSON. Just a quick comment. I alluded in my opening remarks to openness and transparency. I think that is central to 

maintaining trust. And the position that we are in right now, reestablishing trust, this is one of the central cultural issues that we 

have to deal with as an organization. I would tell you that there 

is a—I used the word ‘‘insular’’ earlier to describe particularly 

VHA. As I find it coming into the Department, I think that is the 

case. As you know, what I have been doing over the last 6 weeks 

is pushing information out the door as fast and as hard as I can 

push it out. I prod behind the scenes for responses to Congress, and 

35 

we have got a lot of work to do in that regard. We have to earn 

the trust back. 

Chairman SANDERS. Thank you. 

Senator Hirono? 

Senator HIRONO. Thank you. 

We know there are capacity issues at the VA, and I would just 

like some clarification on some comments or statements that you 

made. Did you say that based on your assessment of the capacity 

issues that you would need 10,000 additional staff? I think you 

were talking about some $17.6 billion that—— 

Mr. GIBSON. That is correct. 

Senator HIRONO [continuing]. You would be requesting. 

Mr. GIBSON. That is correct, yes, ma’am. I know that sounds like 

a huge number. There are 300,000 people in VHA alone. 

Senator HIRONO. So is that 10,000 additional staff—and I know 

you broke it down into how many doctors, et cetera, within the specialties, et cetera. So is that for the emergency situation we have 

now; or is this an assessment that reflects your long-term staffing 

needs? 

Mr. GIBSON. There was a reference made in one of the opening 

statements earlier about the findings of the field audit, and the 

number 1 cause for scheduling difficulties was that there were not 

sufficient provider slots to be able to schedule patients into. So 

what we are talking about here, my comment earlier that we have 

not historically managed to requirements, we have managed to a 

budget number. 

So, basically, we took a budget number, and we did what folks 

thought they could do. And the veterans wound up being the shock 

absorber in that process—— 

Senator HIRONO. So meanwhile, if you are looking at what your 

true needs are, then you are saying that you would need to 

hire—— 

Mr. GIBSON. Yes, ma’am. 

Senator HIRONO [continued]. 10,000 additional staff. 

Mr. GIBSON. Yes, ma’am. 

Senator HIRONO. And that would, of course, depend on the appropriations that we provide. 

Mr. GIBSON. Yes, ma’am. 

Senator HIRONO. So, if you were to have the appropriations to 

hire 10,000 people, how long do you think it would take for 10,000 

people to be hired? Because one of the things that I did hear about 

the hiring in VA is that it takes a long time to hire a doctor. So, 

I hope that in your review you are also looking at your hiring processes, because it should not take a long time, whatever that means. 

That is one question. 

Then to hire 10,000, do you have any sense of how long this 

would take should you get the funding from us? 

Mr. GIBSON. A couple of comments. One, at every single medical 

facility I visit, I hear from rank-and-file staff that it takes too long 

to hire. Staffing practices is one of our areas of concentration. My 

guess is there are some of those things that we are going to find 

it just a function of being in the Federal Government, and that is 

the regulation and statute that we have got to follow. But my guess 

is that we are going to find a large portion of that is self-inflicted, 

36 

and we have got to clear that stuff away so that we can hire more 

expeditiously. 

Second, round numbers, I would say in VHA we probably hire 

30,000 people every year anyway. So I know 10,000 sounds like a 

huge number. It is about 3 percent of staff, maybe a little bit less 

than that. But recognize that some of these are in places like primary care physicians and mental health providers, and we know 

and you all know that those are tough to find. So, it will take time 

for us to be able to hire them. 

Quite frankly, the other problem we have, even if we could go out 

and hire them all tomorrow, we do not have a place to put them 

all. So in some instances, what we are going to have to do is deal 

with some space issues in tandem with this. We may be able to 

do—there are actually some provisions in here for what are called 

Emergency Leases. I actually authorize some of these when I go 

out to the field where somebody has found some clinic space that 

is local, that can be occupied quickly—10,000 square feet, something like that—they can go put three patient line care teams in 

there and take care of an additional—— 

Senator HIRONO. Excuse me. I do not want to interrupt you, but 

my time is running out. 

Mr. GIBSON. Yes, ma’am. 

Senator HIRONO. My concern is mainly that you are addressing 

the length of time it takes, and if you are hiring 30,000 people 

every year, there are probably some retention issues that you are 

also probably addressing. 

Mr. GIBSON. It is 10-percent turnover, which, in fact, is relatively 

low if you look at health care organizations. 

Senator HIRONO. That is good. You had mentioned in response to 

a question that when the IG has findings, to quote you, ‘‘we are 

embracing those findings.’’ And since the problems and challenges 

at the VA have been longstanding, I wonder whether you have a 

process or someone in the VA who provides a response to the IG’s 

findings. Should you be providing a report to Congress to respond 

to the IG’s findings so that we also can provide the kind of oversight that Congress should provide as to what is happening at VA? 

Mr. GIBSON. There are responses to those, and unless I am mistaken, I believe that those responses are shared. Is that correct, 

Philip? 

Mr. MATKOVSKY. Yes. 

Mr. GIBSON. So, there are responses. What I would tell you is 

that I do not believe that those have always gotten visibility and 

attention. Some of the examples surrounding the Office of the Medical Inspector and some of those reports, quite frankly, I do not 

think those were getting the attention that they deserved. So, as 

we look at overhauling certain of our processes, part of what we 

have got to do is make sure that the issues that need to be elevated 

all the way to the Office of the Secretary are, in fact, being 

elevated. 

Senator HIRONO. Yes. 

Mr. GIBSON. And that is where somebody says, ‘‘We have taken 

care of this issue,’’ that we know what has been done and we have 

confirmed that. 

37 

Senator HIRONO. I have, Mr. Chairman, just one more item. I 

was told by the veterans that I have been talking with—many of 

them live on neighbor islands, so these are rural issues—I was told 

that even if they got vouchers to go out to get private care, the doctors on the Big Island and Maui would not take veterans so it 

would not help them. Have you heard that concern? 

Mr. GIBSON. I would tell you there are issues around the PC3, 

Primary Care Close to the Community Contract, that we have got 

with two different national providers for specialty care, and we do 

find instances where I think we have got room for improvement. 

PC3 is a new program, just launched earlier this year, and I do not 

think we are executing it as well as it needs to be executed. There 

are discussions going on this week, today, with the leadership of 

those two programs to make sure that we address those issues. 

I get that feedback from staff and from veterans, as well, when 

I am out in the field. 

Senator HIRONO. The main thing, you are addressing that issue 

also. 

Mr. GIBSON. Yes, ma’am. 

Senator HIRONO. Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Hirono. 

Senator Johanns? 

Senator JOHANNS. Mr. Chairman, thank you. 

Mr. Secretary, in your request for more money, a lot more 

money, one of the things that you mentioned was new facilities, 

and the idea behind that is that new facilities may improve productivity and hopefully that results in better services to veterans, that 

sort of thing. You mentioned that there were eight facilities that 

would be construction projects. How did you pick those eight? I 

know of a list out there that if you have a need for a facility, a new 

hospital say, it makes its way up the list. Did you just pick the top 

eight? And if you want to toss it over to Philip, that is fine, too. 

Mr. GIBSON. I am going to toss this one to Philip, if I could, 

please. 

Mr. MATKOVSKY. Sure. We have a backlog of major construction 

projects, and these are in major construction items, not in minor 

construction or non-recurring maintenance. There is a prioritized 

ranking system that typically—not typically—has rated safety and 

security issues as the highest. So seismic corrections where we 

have got seismic deficiencies where, if there were an earthquake, 

the building would crumble; those have to get fixed. So, there are 

a number of those. 

We also have longstanding space shortages. Every single one of 

our facilities has a space shortage in terms of meeting patient care 

needs. I think we need to understand that. These are not abstract 

numbers. There is not enough space. 

But the vast majority of these, the eight projects—they are St. 

Louis, Louisville, American Lake, San Francisco, Palo Alto, West 

L.A., Long Beach—for the most part are safety and security high 

prioritized items because of structural deficiencies. Some of them 

do have patient care for additional space. 

Senator JOHANNS. Would this top eight be the same top eight as 

the list of 20-some projects that are out there waiting to make their 

way? 

38 

Mr. MATKOVSKY. It is from that list, yes, sir. 

Senator JOHANNS. OK. Would they match if I took that list and 

matched it with what you have just described for me? 

Mr. MATKOVSKY. Are you talking about the 26 or 27—— 

Senator JOHANNS. Yes. 

Mr. MATKOVSKY [continuing]. Major leases, or are you talking 

about—— 

Senator JOHANNS. No; it is not leases. 

Mr. MATKOVSKY. I think you are talking about the historical 

projects that were ranked and prioritized. It would match, and it 

would match against that list for the most part. Yes. 

Senator JOHANNS. OK. For the most part. What is the ‘‘most 

part’’ missing here? 

Mr. MATKOVSKY. So, ‘‘for the most part,’’ just to give you a direct 

answer, might be the ability to complete a project given the size 

of the required funding it would fit in, whereas somewhere else 

that might only be 20 percent of that project. That is what I mean. 

Senator JOHANNS. OK. At the Committee’s hearing in May, one 

of the things I talked about—and other Members did, too—is the 

expanded use of non-VA care to deal with the urgent treatment 

issues. You know, this is not an academic issue. It never was. It 

very definitely is not today because we know people died on the VA 

waiting list. And we know that throughout the system the list was 

gamed, intentionally and dishonestly, to the detriment of veterans. 

Now, there are a lot of ways of handling that, and, Mr. Secretary, 

let me just be candid with you. I have sat on this Committee now 

nearly 6 years. Other members have sat on the Committee a lot 

longer. This Committee has been, I think, very, very generous to 

the VA. And I kind of find it remarkable—Republicans, Democrats, 

liberals, conservatives, it has kind of—when General Shinseki 

would come in, it was like, ‘‘What do you need, General?’’ And it 

was almost like we would salute when he said what he needed, and 

out the door he would go with more money, and always made the 

promise that we were doing better. 

Here is my concern. This sounds so similar to what we have 

heard over the years: ‘‘I need more money. I need to be bigger, faster, grander. I need a bigger bureaucracy. I need to hire more people,’’ and on and on and on. 

Personally, I think what you need is competition. I think if somebody were biting at your backside because they were providing better care, faster care, honest waiting lists, et cetera, people would 

go, ‘‘Holy smokes, if we do not put our act together, we are going 

to lose out on this. If we do not see more patients during the day, 

we are going to lose out on this.’’ 

Just let me ask you, what am I missing here? 

Mr. GIBSON. I do not know what you are missing. I know that 

millions of veterans turn to VA for their health care. And as a 

number of folks have mentioned at various points this morning, an 

awful lot of veterans continue to believe they get great care. 

Access to care is a challenge for many, particularly for new patients, but there is a lot of great care that is being delivered every 

single day. The challenge is—— 

Senator JOHANNS. Here is what I would offer, because I am out 

of time. You know, and I hear this. But at the end of the day, these 

39 

veterans fight for our freedoms. Why don’t they have the freedom 

to make their own choice about their health care? And maybe they 

would say, ‘‘By golly, I love the VA. I will stay with the VA until 

the day I die.’’ But maybe they would say, ‘‘That hospital 20 minutes down the road from where I am at is just simply a better situation for me than the hospital that is 250 miles from where I am 

at, with a long waiting list.’’ 

I am totally out of time, and I do not want to impose upon the 

Chairman’s patience, but I just think you guys need competition. 

And I feel very, very strongly about that. And if you cannot clean 

up your act, then guess what? You lose out. And that is what I 

think you need. I do not think you need more billions and billions 

of dollars. 

Thank you. 

Chairman SANDERS. Thank you, Senator Johanns. 

Senator Begich did not make, as I recall, opening remarks, so we 

will give you a modest amount of additional time. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you very much. I like the way you say 

that, Mr. Chairman. 

Let me, if I can, thank you both for being here. I appreciate it. 

But, you know, it is amazing to me. I have been here now just 

about 6 years, but I am looking at a 2003 report, ‘‘Improve Health 

Care Delivery for Our National Veterans.’’ Are you familiar with 

this report? 

[Mr. Gibson nodding head.] 

Senator BEGICH. If not, you should all read it. But I am really 

doing this for my colleagues, because when I turn to one page 

here—and why I am saying this, this is really part of your point. 

It says, ‘‘Although enrolled veterans technically have access to VA 

health care system, long waiting times for appointments with 

health care providers continue to be problematic for a significant 

number of veterans. As of January 2003, at least 236,000 veterans 

were on a waiting list of 6 months or more for a first 

appointment[...]—a clear indication of lack of sufficient capacity or, 

at a minimum, a lack of adequate resources to provide the required 

care.’’ 

This is not new. It is just they did not get the funding years ago, 

and now we are playing catch-up, because you have also had 1.4 

million net new VA patients. We did not do it. And I say ‘‘we.’’ I 

was not here. Somehow people missed this report. I do not know. 

I would submit it for the record, Mr. Chairman. I think, you know, 

it is like somehow suddenly it is all a new problem, it just occurred 

yesterday. No. It is right here in this report. And because they 

were not funded properly, it built up and new patients were added 

to the list from the Afghanistan and Iraq wars. Maybe people 

missed that. I do not know. Pretty simple, third page of the report, 

not complicated. Done under a different administration. 

So, I want to put that to the record because the issues you are 

bringing up are relevant. 

[The report from May 2003 is in the Appendix under Senator 

Begich.] 

40 

Senator BEGICH. You know, do I think it is a lot of money? Yes. 

Is the money well deserved for our veterans? Absolutely. Because 

if they would have had it here, we might have been recruiting doctors back then, because the problem we are going to have, to Senator Hirono’s question, is hiring 10,000 people. I agree. You have 

got a hiring system that is great. But to get mental health providers and primary care doctors? You do not just turn a switch. 

Every private hospital in this country is behind the curve getting 

doctors. Nurses are backed up. We do not have the capacity to fill 

these. 

So, I want to make this clear because I think there are a lot of 

good bumper stickers being talked about today, and I get it. But 

this is a systematic problem that has been around for a decade or 

more. And yet it is now suddenly—thanks to the VSOs and others 

who have come forward and said, look—they have been fighting for 

this for years. And now we are finally figuring this out. 

I will tell you—and I know the Chairman gets aggravated, not 

aggravated, but he knows I will bring it up all the time, and that 

is—what we are doing in Alaska. We have talked about this. We 

saw this problem. When I came into office in 2009, we said, ‘‘What 

are we doing?’’ We had 1,000 people on our waiting lists in Alaska 

with 120-day wait periods. So, what did we do? We did not go to 

the private sector because, honestly, all of us that go to the private 

sector get a doctor, it is hard enough to get appointments. Do you 

think we are going to add veterans to the system and clog it up 

some more? So what did we do? We looked at our current system 

of Federal tax dollars and how they are being used. Indian Health 

Services delivered by our tribes in Alaska, the federally qualified 

clinics, federally funded. So what did we do? We maximized the resources we have at our fingertips today. 

What is our wait time in Alaska in the Northwest Region? It is 

one of the lowest in the country, because we now have access. As 

a matter of fact, in Anchorage, when you use the qualified Federal 

clinic there and/or the South Central Clinic—and, again, you have 

got to be on the list. You sign up, you get through the system, you 

get on the list. For non-major medical you get same-day care. That 

is pretty significant. 

That is competition that actually works with the tax dollars we 

are all paying. But if we shove it out only to the private sector, 

some magic will happen—and I agree, with the Closer to Care program, as you know, which uses private sector resources. But that 

does not mean it is the panacea, that every veteran is going to get 

care overnight. We have to look at the systematic problems here 

that I know you and I have talked about—this idea and what we 

are doing in Alaska, which I think has been successful. We have 

some problems still. We have some logistic problems, billing problems still. We have some scheduling issues and how to make sure 

the records are transferred properly between Federal agencies and 

so forth, but I know we are going to figure this out. 

Doesn’t that seem like something we should be expanding and 

looking at around the country? I mean, federally-qualified clinics; 

the one reason you have certain pay levels for doctors so you have 

a controlled cost unit. In the private sector you are not going to 

have a controlled cost unit. 

41 

Now, it does mean we will still use private sector resources as 

we are doing in Alaska, along with federally-qualified clinics and 

our Indian Health Services, otherwise known as what we call it, 

the ‘‘Nuka’’ model, which is a very impressive model for the delivery of health care. Don’t you think this is a model that we could 

use to actually go after some of this? 

Again, I did not mean to get so aggravated about this. It just aggravates me when people tell me it is suddenly a new-found problem. People who have been here a lot longer than me should have 

read this report, not necessarily you two. I mean, Congressional 

people. 

Senator BEGICH. Go ahead. Sorry. There is my rant. There was 

a question there. 

Mr. MATKOVSKY. I will try to address it, sir. Very quickly, about 

the model in Anchorage, the Director there actually was a trailblazer for us. He actually established a number of the Tribal agreements with local Alaska Tribes—— 

Senator BEGICH. There are 26 of them now. 

Mr. MATKOVSKY. Yes, phenomenal work that he did. I mean, he 

earned the trust. He literally extended the network of community 

providers into a seamless integrated system up there. It also allowed us to avoid folks having to travel long distances. I mean, the 

norm before used to be folks flying down to Washington State, if 

you recall—— 

Senator BEGICH. Yes, in Seattle. 

Mr. MATKOVSKY [continuing]. So, they were able to stay local. So, 

it is remarkable work by the Director. Some of that has actually 

become sort of a pattern that we have used elsewhere in the country, with local Tribes and with IHS, signing the agreement with 

IHS to extend health care services. But most importantly, with the 

Tribes, in the Dakotas, in Oklahoma, across the country, we have 

Tribal agreements in place where we can reimburse for care. It is 

not perfectly seamless, but it is something that has really taken 

root for us. 

Senator BEGICH. And, you did not need new rules to do that? 

Mr. MATKOVSKY. No, we did not. We used our sharing agreement 

authority. 

Senator BEGICH. Right. 

Mr. MATKOVSKY. We have certain authorities in Title 38 that we 

use, you know—— 

Senator BEGICH. And you can do that, also, with federally-qualified clinics. 

Mr. MATKOVSKY. We can—— 

Senator BEGICH. Yes. 

Mr. MATKOVSKY [continuing]. Under sharing authority. 

Senator BEGICH. Right. In Alaska, we are doing that with a couple which—one just went from a private to a federally-qualified 

clinic to deliver care in Seward, AK, because there is no veteran 

care down there, which is a great example of how you can do this 

with your existing rules. 

Let me ask you, on having the VA utilize—and we talked about 

this or I may have sent a letter to General Shinseki on this—regarding positions that the Indian Health Services use, which are 

some of the Corps being used for their medical delivery system, and 

42 

seeing if the VA can do the same thing. It is actually in the bill 

of how to fund some of these folks. In other words with the Health 

Care Corps, can you tell me if your regulations allow you—I know 

we talked about this briefly; I do not know if you had time to check 

on that. I think this is a resource of over 5,000 medical professionals sitting there, ready to go. 

Chairman SANDERS. Mark, are you talking about the National 

Health Service Corps? 

Senator BEGICH. Yes. I am. 

Chairman SANDERS. Yes. The National Health Service Corps. 

Mr. MATKOVSKY. Yes. I mean, I think we would have to look at 

some credentialing and privileging issues that would allow us to 

credential and privilege and share those authorities to treat in our 

system, as well. I would have to take that back and look at it to 

tell—— 

Senator BEGICH. Can you do that for me? 

Mr. MATKOVSKY. I will. 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. MARK BEGICH TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. VHA has the ability to enter into agreements with other government 

agencies to temporarily assign professionals with critical skills. Inter-Governmental 

Personnel Act (IPA) agreements are one method endorsed by the Office of Personnel 

Management. To date, VHA has not pursued an IPA with the Public Health Service 

as VHA has been engaged in ongoing discussions with them regarding detailing 

medical professionals, particularly for mental health care, to VHA. The discussions 

presently are exploring the creation of an Interagency Agreement (IAA), which 

would define the terms, costs and skills of assigning 100 mental health professionals 

from PHS to VHA temporarily. 

Senator BEGICH. And then the last thing is on—I have a bill 

which Senator Murray talked about, and that is reimbursements 

for doctors in the sense of serving our VA system, and I have a bill 

on mental health providers, psychiatric care, which is a huge gap, 

and doing loan forgiveness. Have you had a chance to look at that 

bill, and if not, can you give us some feedback on that at an appropriate time? 

Chairman SANDERS. Mark, if you will yield to me for a second—— 

Senator BEGICH. Yes. 

Chairman SANDERS. The issues that Senator Begich is raising 

are very important, and that has to do with how we not raid other 

facilities and steal doctors and psychiatrists, but develop more. 

Mr. MATKOVSKY. Right. 

Chairman SANDERS. And, the issues are that you guys have a 

Health Education Assistance Program, which: (A) needs to be reauthorized; and (B) needs to be significantly increased. Right now, the 

maximum you can provide is only $60,000, which does not do anything for somebody graduating $200,000 in debt. That is what you 

are talking about, right, Mark? 

Senator BEGICH. Exactly. As a matter of fact, under ACA, the Affordable Care Act, for other professions, it is up to $100,000 for 2 

years’ service. So, the question is, have you had a chance to look 

at that bill, and do you support this concept? 

Mr. MATKOVSKY. I think we support the concept. We just have 

to look at the funding requirements associated with it. But, in pracVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
43 

tice, it is something that would allow us to recruit and retain highly qualified staff. 

Senator BEGICH. Very good. 

Mr. Chairman, I have some other questions. I will submit them 

for the record. But, I appreciate you allowing me to ask questions. 

It is just very frustrating when I see a report like this and people 

suddenly think it is a newfound problem when it has been around 

for 10 years. We just need to get after it and deal with it, and it 

is going to take years to change it. 

Thank you, Mr. Chairman. 

Chairman SANDERS. OK. Thank you, Senator Begich. 

Senator Heller, you will have additional time, as well, because 

you did not make opening remarks. 

STATEMENT OF HON. DEAN HELLER, 

U.S. SENATOR FROM NEVADA 

Senator HELLER. You know, what I may want to do, Mr. Chairman, is just submit my opening remarks for the record. That way, 

I will go back to having 5 minutes and keep this hearing timely. 

[The prepared statement of Senator Heller follows:] 

PREPARED STATEMENT OF HON. DEAN HELLER

Thank you Chairman Sanders and Ranking Member Burr for holding this hearing 

today. I believe this Committee must continue conducting this vigorous oversight at 

a very troubling time in the Department’s history. It is also important that the Conference Committee works quickly to reach an agreement so Congress can pass a bill 

to help Veterans get the care they need immediately. 

In a short number of months, Congress, Veterans, and the American public have 

had a glimpse into the failure of the VA to provide quality care to Veterans across 

the Nation, and it is disturbing to say the least that many of our Veterans went 

without health care because a few employees decided to cheat the system. 

Every time I am home, I repeatedly hear from Nevada veterans about their individual stories and difficulties they’ve faced with the VA, and many of them are 

doubtful it will ever improve. 

I share their frustration. Our veterans are entitled to a VA system that delivers 

the benefits and care they have earned in a timely manner. But today, the VA is 

not meeting that standard. 

I have a timeline here showing the progression of this scandal, and every week 

there has been a new revelation about failure to provide quality care, another VA 

official resigning due to a lack of accountability, or whistleblowers being punished 

for doing the right thing. 

It is unfathomable so many problems existed at the VA for years and management at some level allowed it to continue. 

That’s not going to be the case anymore, and I expect the nominee for VA Secretary to prove to this Committee that he will bring a dedicated and unrelenting 

approach to fixing this broken agency. 

Veterans in my home state of Nevada are also facing significant problems that 

I expect to be resolved. 

At the Las Vegas VA Hospital, more than 6,700 Veterans were forced to wait 

more than 30 days for an appointment. 

And just last year, a blind female veteran waited nearly 6 hours in the Emergency 

Room before being seen by a nurse or doctor. 

I have spoken with the VA Hospital Director Duff about improving these wait 

times and better meeting the demand of Veterans in the area, and I expect this hospital to provide the best care possible moving forward. 

Over in Pahrump, 6,000 Veterans have waited more than two years for a clinic 

to be built. Despite promises of progress, construction of this facility has not started, 

and VA officials have not even provided a timeline for final approval of this facility. 

Pahrump Veterans have waited too long for this clinic to be built, and I would 

like to see the VA break ground on this facility before the fall so construction can 

begin and Pahrump Veterans can finally receive the care they waited for. 

44 

In Northern Nevada, the Reno VA Hospital is still waiting for a director to be 

hired. As the VA works to bring greater accountability and transparency to its 

health system, I want to ensure any new director is committed to this goal. 

Unfortunately, the challenge with the VA health care system is not the only issue 

facing Nevada Veterans. These same problems with management and accountability 

are also an issue in the Veterans Benefits Administration, which processes the disability claims for veterans. 

The VBA continues to struggle to eliminate the veterans’ disability claims backlog 

as it operates under a 1940s system in the 21st century. 

On a local level, Nevada’s Veterans are facing the worst of the claims backlog. 

Not only does Nevada have the longest wait in the Nation at 340 days for a claim 

to be processed, but the VA Regional Office in my state was recently audited by the 

Inspector General with less than satisfactory results. 

The IG found that 51 percent of disability claims they reviewed were inaccurately 

processed, and many of the problems at this VARO persisted due to poor management. 

The VA has been given enough chances to fix the backlog for Nevada’s Veterans, 

but has failed to produce adequate results. What Veterans need now is for Congress 

to take action to reform the outdated claims processing system. That is why Senator 

Casey and I introduced the bipartisan 21st Century Veterans Benefits Delivery Act 

to address three areas of the claims process: Claims submission, VARO practices, 

and Federal agency responses to VA requests. 

Just as Congress needs to address the quality and timeliness of our veterans’ 

health care, Congress must also work to improve the delivery of their benefits, 

which is why I have continued to encourage Chairman Sanders to re-schedule a legislative hearing so the Committee can consider this important bill. 

Again, thank you Acting Secretary Gibson for testifying today. I look forward to 

hearing about what the VA is doing to improve care and benefits for Nevada and 

our Nation’s veterans. 

Thank you, Mr. Chairman. 

Chairman SANDERS. One of the few Senators who wants less 

time than being offered. 

Senator HELLER. Yes. But, having said that, if I go over, please 

do not cut me off. [Laughter.] 

Having said that, thank you very much for holding this hearing, 

for both the Chairman and the Ranking Member. 

At risk of irritating you, like Senator Begich claimed, you know 

that I will be talking about backlog statistics. I would certainly appreciate a rescheduling of the hearing on the backlog information, 

and I will talk about that in just a minute. 

But, I am looking at the latest statistics; and I want to thank 

both of you for being here, Secretary, and the smartest guy in the 

room, Philip here, for taking some time. But, I am looking at the 

latest average days of completion in the VARO in Reno, which I 

bring up because Reno has the worst VA Regional Office in the 

country. I have been hitting on this and hitting on this, and I think 

it is a management problem. I do not think the rank and file in 

that office are at fault. I truly do believe it is a management problem and I am certainly hoping and have called for changes in that 

particular office. 

The average days to complete now a pending claim is about 340 

days. I have been harping on this for 5 years, and they are making 

slow progress. In 5 years they have reduced it by 10 days. That is 

it. We have gone from 350–351 days down to 340 days over 5 

years—5 years! You have got to imagine, it is pretty frustrating. 

And, I am not frustrated for myself. I am frustrated for every veteran in the State of Nevada that truly needs the help, the benefits, 

and the health care that they deserve. 

45 

On top of that, we had an Inspector General report that found 

that 51 percent—51 percent of the disability claims that were reviewed in this VARO were inaccurate. 

I have to tell you, I appreciate your opening statement, your 

openness and concern for openness. I think that is important. 

Transparency is important. 

Senator Bob Casey and I, because he has similar problems in 

Pennsylvania, worked together. Our staffs worked very, very hard. 

We came up with this VA Claims Backlog Working Group, submitted legislation on that. Are you familiar with the information in 

this—— 

Mr. GIBSON. I would tell you that I am aware of it. It would be 

a stretch for me to say that I am familiar with it. 

Senator HELLER. OK. OK. Fortunately, I will be able to meet 

with the nominee tomorrow—— 

Mr. GIBSON. Good. 

Senator HELLER [continuing]. And get an opportunity for him to 

also address or take a look at it, because I think it is very clear, 

the concerns, the problems that we have. I think this legislation 

does address some of those problems. Legislation is available. 

What is good news is Senator Moran and Senator Tester from 

this Committee are also cosponsors of this legislation. I think it 

would go a long way so that we do not, in 5 years, have a 10-day 

improvement, that, hopefully, in less than a year, we could see perhaps a much greater improvement. 

I want to get on another topic real quickly, if you do not mind, 

and that is an issue that we have in the State of Nevada. There 

is a small city in Southern Nevada called Pahrump. Pahrump has 

about 6,000 veterans down there, and you are shaking your head, 

Philip. I am glad to see that. They have been waiting for a VA clinic for several years now. The Director in Las Vegas, Director Duff 

has approved it. They are now waiting for the national VA officials 

here in DC to get this done. What is the status? 

Mr. MATKOVSKY. I have to get back on the detailed status. We 

have had some issues with, if I may, our lease authorities that we 

have been trying to work through, and I think some folks here may 

be familiar with that, that have resulted in some delays in getting 

leases enacted. We had some challenges on the procurement side 

of that, as I think your staff has been briefed over the years. Right 

now we are working through trying to make sure that we can exercise our lease authority in the current environment. That is the 

challenge we have, sir. 

Senator HELLER. Do you have any timeline for approval of this 

clinic? 

Mr. MATKOVSKY. I do not right now. It is not an issue of approval. It is an issue of actually effecting a lease agreement. 

Senator HELLER. Do you think we can get an answer perhaps by 

this fall or something to—— 

Mr. MATKOVSKY. I will get it to you sooner than fall, sir. 

Senator HELLER. If you would, please—— 

Mr. MATKOVSKY. I will personally go in and look at it. 

46 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. DEAN HELLER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. VA Southern Nevada Healthcare System (VASNHS) has developed 

plans to expand the clinic, which is too small for the Veteran workload in this area. 

• The current clinic is in a modular building which is not feasible for expansion. 

• In May 2013, an Out-of-Cycle SCIP proposal was approved for a new expanded 

Pahrump CBOC. 

• VASNHS has solicited proposals for a larger clinic, which would be built to VA 

specifications and leased back. 

• There are viable proposals which are currently under review in VA’s contracting 

process, with final approval expected in the next few months. 

• The costs of the proposals exceeded the threshold for local approval and will require Secretary Veteran Affairs approval. 

• Once a bid is approved and funds are obligated, the estimated construction 

timeframe is between 12 to 18 months. 

• The current Pahrump CBOC provides primary care, women’s health, mental 

health, telehealth and social work services. The new clinic will expand these services and add space for radiology and pharmacy services. 

Senator HELLER. I want to talk about—I have got just another 

minute here—about the face-to-face audits, reviews, and the problems. We have scheduling. We had an audit. The first phase was 

released on June 9, and this is with the Las Vegas VA Hospital, 

Southwest VA Clinic in Nevada, and they said that it needs further 

review. Do you know if those reviews have been completed? 

Mr. MATKOVSKY. We have referred all of those cases to the Inspector General, and we have prepared a detailed set of briefings. 

I think we are trying to schedule it now with the Committees and 

with Delegations to walk through the audit findings as well as why 

someone would have wound up on a further review list. 

Senator HELLER. OK. 

Mr. MATKOVSKY. I know it has taken us a while to do that. I 

want to apologize for the amount of time. 

Senator HELLER. I just want to make sure there is not a—we 

don’t miss the follow-up. I would not anticipate that you would. 

But, do we have any timeline into when those—— 

Mr. GIBSON. I would tell you, the question there—somebody mentioned earlier that the IG is in over 70 different locations—— 

Senator HELLER. Sure. I am sure. 

Mr. GIBSON. Any location where the IG is working, we are not 

able to go in and do any additional review. We have created Accountability Audit Teams to go into all of those where the IG is 

not, and those are scheduled to be completed, I think, by mid-August. But, in the meantime, we are going to provide some briefings 

on what the findings were and what we know. 

Senator HELLER. Thank you very much. 

Mr. GIBSON. I am going to be in Reno in August. I have to go 

out there to speak. We will get you the dates. 

Senator HELLER. If you would, please. 

Mr. GIBSON. I will make sure these guys get you the dates when 

I am going to be there and I will go visit the RO while I am there. 

Senator HELLER. If you would. Thank you very much. 

Mr. Chairman, thank you. 

Mr. GIBSON. And, last, we appreciate the opportunity to provide 

some technical input on the leasing issue. 

Senator HELLER. Great. 

47 

Mr. GIBSON. I think we have furnished some of that information 

to the staff, Mr. Chairman, which would be very helpful for us to 

be able to move forward. 

Chairman SANDERS. Thank you. 

Senator Blumenthal, you have 8 minutes, and I alert the members that there will be a vote, as I understand it, at 12:20. Senator 

Blumenthal, 8 minutes. 

STATEMENT OF HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you very much, Mr. Chairman. I 

really appreciate your holding this hearing and your leadership, 

along with Ranking Member Burr; and thank you, Mr. Gibson and 

Mr. Matkovsky, for your service to our Nation. 

I think you folks are in a difficult, if not impossible, position, because you are temporarily before us without the head of an agency, 

and my hope is that there will soon be a Secretary of the VA. But, 

right now, in effect, there is an empty desk where the buck should 

stop and I think that situation has to be remedied as soon as possible, and that is on us, not on you. 

Leadership has to include an overhaul, top to bottom, of the people who run the agency. Very simply, my view is that there has to 

be accountability for what is done in the past, but also a change 

in leadership which you are commendably seeking, as well, top to 

bottom, across the country. 

My experience over the last few months has been that the failure 

of the agency to be more responsive and accurate in some of what 

it is saying to the public is actually aggravating its credibility and 

trust problems. Senator Burr raised one instance earlier with the 

press release that he mentioned. I have found that there simply 

have been no answers to some of the questions that I have posed 

in letters to the agency, letters asking for site-specific information 

about the audits that were performed. 

The VA officials locally, and the audits seem to confirm that 

there have been no problems in Connecticut with these delays and 

destruction of documents and manipulation of waiting lists, and yet 

we have found in recent data released by the VA that, in fact, wait 

times have increased over the May-to-July period. In fact, those 

wait times have tripled. What is the meaning of that data? 

So, I have asked not only for the site-specific information resulting from the audit that was performed as a result of General 

Shinseki’s order, but also for an explanation of those wait times, 

and I have yet to receive responses from the agencies that are really complete and satisfactory, in writing, to the questions that I 

have posed. 

Now, I understand you have a lot going on, but I would suggest 

that that kind of responsiveness in providing information is part of 

the mission that is all the more important. It has always existed, 

but it is all the more important now. So, I would like a commitment from you that the agency will respond to my inquiries in 

writing as soon as you are able to do so, and that you will respond 

in the future to the inquiries that I pose. 

Mr. GIBSON. Two quick comments. First of all, the answer is, we 

absolutely will. It might even be more effective for us to arrange 

48 

to come in and deliver a briefing, walk through the wait time data, 

also walk through, as Philip just mentioned a second ago, briefing 

material around the access audits that is being provided. You have 

not had the opportunity to hear other comments, but we have been 

pushing information out the door as fast and as hard as we can 

over the last 6 weeks. That openness and transparency, to your 

very point, is an essential part of earning back trust. 

Last thing. I told the President of the United States when he 

tapped me to be the Acting Secretary, I said, do not expect me to 

behave like the word ‘‘acting’’ is in front of my title. So, if anybody 

has seen any behavior out of me that looked like I was serving as 

a caretaker, please let me know what it was so that I can try to 

explain what maybe you were looking at. 

Senator BLUMENTHAL. Well, I welcome that comment and I second it and support it. 

Can you tell us anything about the ongoing inquiry internally, 

what its status is, when you expect it to be completed, and second, 

about the Department of Justice investigation. I called for a criminal investigation by the Department of Justice with great reluctance and regret, but I do think that criminal responsibility has to 

be applied if there was obstruction of justice, destruction of documents, fraud in reporting, because those crimes, even with an 

agency as important as the VA, or perhaps especially because of its 

very important mission, has to be implemented where necessary. 

Mr. GIBSON. There was a mention earlier of the fact that the IG 

has reviews underway at 70-some locations across the organization. 

I should explain more here. Before the IG goes into any location 

to do any kind of a review for any purpose, they inform the FBI. 

And, at any point during the course of their review of activities 

they uncover evidence of criminal wrongdoing, those routinely get 

referred to the Department of Justice. In fact, there is a Criminal 

Investigation Division of VA’s IG. So, routinely, there are criminal 

investigations undertaken and completed and prosecutions that 

occur as a result of IG investigations. So, it is a routine matter. 

I would tell you, of the 70-some-odd locations that the IG has 

been reviewing, at the end of June I got the first set of reports on 

the first location, so, we have been working. With more than a 

thousand pages of transcripts of sworn testimony, it turned out 

that we actually needed some additional information, so we dispatched an official fact-finding group to go to that particular location. We have reviewed hundreds, if not thousands, of e-mail traffic. And, I expect by the end of this week to have proposed personnel actions on my desk for that—for a number of individuals at 

that one particular location. 

There is nobody that wants to see this process move faster— 

move forward faster than I do. It is painstaking. 

You know, I would say the other general category here of issues 

have to do with the referrals coming from the Office of Special 

Counsel. I have met directly with Carolyn Lerner. We are expecting a substantial number of those to come to us very quickly, and 

we have agreed on some expedited processes that we will work 

through to ensure that the whistleblowers are properly protected, 

and then to launch the appropriate personnel actions in the wake 

of that. 

49 

Senator BLUMENTHAL. My time is about to expire, so I apologize. 

I am not going to have more questions in this setting. I would like 

to follow up on the Department of Justice investigation—I know 

you cannot really comment in this setting about it—and, most important, about protection for whistleblowers. I think one of the unexplored areas here has been the potential for retaliation against 

whistleblowers. I would like to know from you, in the form of a future briefing, what has been done to protect them. 

Just one last comment. There is nothing routine about what happened here. You said that, routinely, the FBI is involved. There is 

nothing routine about what happened here and I think the FBI 

should be fully engaged and the Department of Justice involved. 

Thank you. 

Thanks, Mr. Chairman. 

Chairman SANDERS. Senator Boozman, you will also have additional time. 

STATEMENT OF HON. JOHN BOOZMAN, 

U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Chairman Sanders and Ranking 

Member Burr, for having this very, very important meeting. And 

I want to thank you all for being here. I know that you are working 

very, very hard to try to resolve these things. 

I also want to commend you, Mr. Gibson, for getting out to the 

places that are really struggling, and also the places that are doing 

well, trying to figure out best practices and then, again, why others 

are struggling so much. 

Dr. Perlin, I think, is important in the situation of bringing him 

on as an advisor. I think that was really a very good move. 

In regard to your request as far as additional personnel and 

things like that, is that based on current practice or is that based 

on reforms in the future that are going to significantly change 

things, hopefully? 

Mr. MATKOVSKY. The methodology we used is largely framed in 

the current context, Senator Boozman. So, what we looked at is 

looking at our current appointment volume, looking at our current 

delays in care, forecasting those through the years, and trying to 

attenuate them year on year. So, it is not any subsequent reform. 

It is in our current context. 

Senator BOOZMAN. Right. You know, I had the opportunity to 

serve with Tom Osborne over in the House, the great coach from 

Nebraska. People used to talk to him about winning and he would 

say, ‘‘We did not ever talk about winning. What we talked about 

was doing the little things.’’ And, one of the little things that has 

to be done—which I am a little bit concerned, because you said it 

would take 2 years, though in terms of VA, that is probably more 

like 4 or 5—is the scheduling. 

That is one of the little things. My understanding is they do not 

call people the day before and tell them they have got an appointment. You could cut your ‘‘no show’’ rate significantly just by doing 

that and then taking somebody that is on a backlog and sticking 

them into those slots. That is just common sense practice that is 

done throughout the country with anybody in the private sector. 

So, you have to get the scheduling under control, and there is no 

50 

reason not to do that rapidly, particularly targeting the areas that 

are having problems. You know your facilities that are doing OK 

right now by whatever standards you are measuring. But, it does 

seem like you could put that in place right away. 

Mr. GIBSON. You may have mentioned—missed the comments 

earlier. There are actually four different major initiatives underway on scheduling. One has to do with fixing existing issues. There 

are 11 of those fixes in process right now. There are four separate 

applications under development to make it easier for schedulers to 

interface with the system as well as to give veterans the ability to 

directly request schedules. 

There is a contract that has already been let that will make 

major modifications to the existing scheduling system—was let on 

the July 11—and we expect that to bear fruit in the May through 

August time period next year, to deal with some of the toughest, 

some of the most difficult issues associated with the existing scheduling system. 

All of that is in parallel while we are working to acquire a commercial, off-the-shelf—— 

Senator BOOZMAN. If there are good over-the-counter systems 

right now in place that major medical centers are using without 

any problem at all—that is the basis of medical practice. 

Mr. GIBSON. Do you want to answer this one? 

Mr. MATKOVSKY. Sure. I would agree with you, sir. I think that 

you have two comments. One of them is the underlying system, 

and I think there was a reference made to a prior system effort. 

I do not think we are looking to go build something from scratch 

this time. I think—— 

Senator BOOZMAN. No. I mean—— 

Mr. MATKOVSKY. Right. 

Senator BOOZMAN [continuing]. I would hope not. 

Mr. MATKOVSKY. We are not, no. 

Senator BOOZMAN. I would say that that is something that people 

have been doing for years. I am an optometrist by training, so, 

again, that is the basis of your practice, scheduling. 

You mentioned that you have one assistant per specialist right 

now in the VA system. I think you said two-and-a-half or whatever, 

which might even be a little bit low. What I would like to know 

is what is the relationship between—if you take a major VA medical center and you look at total staffing, you look at the staffing 

that it takes to support that medical center, what is the comparison with a major private entity as far as numbers? 

Mr. MATKOVSKY. I do not have the exact percentages, but if you 

look at the overhead rate in the VA or the indirect rate in the VA 

for support staff, it is considerably lower in each one of our major 

areas: primary, specialty, and mental health. I do not have the specific counts. 

Senator BOOZMAN. As far as the total numbers. I am talking 

about administration, the whole bit. 

Mr. MATKOVSKY. I am looking just at the field costs, not looking 

at everything else for a blended overhead rate. I think we could 

come up with something like that, which would look at a blended 

rate and see where the different overhead and G&A charges come 

51 

in. But, in terms of what we have in our facilities, the labor share 

is lower in the VA for support than it is in the private. 

Senator BOOZMAN. Not as dollars, but people. 

Mr. MATKOVSKY. In terms of people, it is lower in the VA than 

it is in the private sector. What you may be asking, as well, would 

be, could we construct a blended rate that looked at the overall cost 

factors. We could. We have not done that. 

Senator BOOZMAN. OK. I would like to see that. I think that 

would be interesting. 

The other thing is that right now if you go to your Medicare doctor, if you are a veteran and you have a physical with a Medicare 

doctor who decides that you need high blood pressure medicine, 

then you go to the VA, instead of filling that prescription—which 

is a pretty good deal for the veteran—they have to have a physical 

in order for it to be filled. 

Mr. MATKOVSKY. I understand—— 

Senator BOOZMAN. Why is that? I mean, is there any logical reason for that, as well? How many slots would that free up if you 

made that one change? How much money would that save? 

Mr. MATKOVSKY. I am not a clinician, so I cannot in a learned 

way describe why that is the case, but there are certain reasons 

why that would be appropriate and why that does make sense. But, 

I will tell you that we are looking at things like referrals to audiology and where that could obviate—where we could bypass the 

primary care step as an additional item. But, we need to look at 

that carefully, and I think folks are looking at that now, audiology, 

optometry, ophthalmology, maybe some pharmacy, not all pharmacy. We need to be careful. But, we are looking at that, to your 

point. 

Senator BOOZMAN. Now, I can see the scheduled drugs and 

things like that, but to me, it makes no sense at all that if a guy 

that is licensed and taking Medicare dollars, another entity that is 

licensed by the government, why a prescription cannot be filled for 

diabetes, high blood pressure, the vast majority of stuff that actually comes across. Could you look and see how many slots that 

would save—— 

Mr. MATKOVSKY. We will look at that. But, the one thing—just 

one point of caution would be not to over-correct in that direction. 

But, we do have folks looking at the pattern between primary care 

and certain specialty, the pattern between primary and pharmacy—— 

Senator BOOZMAN. How do you mean, over-correct? 

Mr. MATKOVSKY. Just to not be vigilant for pharmacy-filled requests that would be coming in from the private sector. That is the 

only thing that I mean, just to make sure that we are determining 

the appropriateness of certain prescription fills. And, the examples 

that you have given, they seem pretty straightforward, but we just 

need to make sure that those are the only examples. 

Mr. GIBSON. There is a large percentage of veterans that are 

served by both VA and Medicare. 

Senator BOOZMAN. Yes. 

Mr. GIBSON. And, so, part of this is understanding what the second and third order effects are of the kind of change that you are 

talking about. Clearly, one of the impacts would be that it would 

52 

free up primary care slots. Got it. That is a good thing. What are 

the second and third order effects, and that is, I think, Philip’s 

point, about being thoughtful—— 

Senator BOOZMAN. Well, it probably would decrease the backlog. 

Mr. GIBSON. Yes. 

Senator BOOZMAN. I am sorry to run over Mr. Chairman. Thank 

you. 

Chairman SANDERS. We have reached the end of what I think 

has been an important and productive hearing. 

Mr. Acting Secretary, I want to thank you very much for stepping in, clearly unexpectedly, into a very important position in a 

very difficult moment in the history of the VA, and thank you very 

much for the work that you are doing. 

And, Mr. Matkovsky, thank you very much for what you are 

doing. We look forward to working with you in the days, weeks, 

and months to come. 

Thank you very much. The hearing is adjourned. 

[Whereupon, at 12:20 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

VA RESOURCES REQUIREMENT ACCESS

Question 1. What will be the impact on veterans if VA does not receive the funding that is being requested? 

Response. Pub. L. 113–146, the Veterans Access, Choice and Accountability Act 

(VACAA), provided $10 billion for the new Veterans Choice program and $5 billion 

to improve access at VA health care facilities; however, VACAA also directs VA to 

accomplish several tasks that will incur costs but were not funded by the Act, which 

will have the impact of further decreasing VA funds available to provide health care 

to Veterans. These provisions include: 

Sec. 201. Independent assessment of the health care delivery systems and 

management processes. 

Sec. 202. Commission on Care. 

Sec. 203. Technology task force on review of scheduling system and software. 

Sec. 303. Clinic management training for employees at medical facilities of 

the Department of Veterans Affairs. 

Sec. 402. Provision of counseling and treatment for sexual trauma by the VA 

to members of the Armed Forces. 

Sec. 403. Reports on military sexual trauma. 

Sec. 501. Extension of pilot program on assisted living services for veterans 

with Traumatic Brain Injury. 

In addition, VA requested funds for increased costs above the budget request for 

Caregivers stipends and new Hepatitis C treatments. VA also requested a $368 million increase above the FY 2015 Advance Appropriation level for Veterans Health 

Care programs, but neither H.R. 4486 nor Senate Report 113–174 have provided the 

requested increase. 

Question 2. What barriers does VA face when hiring additional health care professionals, especially primary care doctors—given our nationwide shortage of primary 

care doctors? What is VA doing to address such barriers? 

Response. The barriers VA faces in hiring healthcare professionals include both 

systematic and local issues. On a macro scale, shortages specific to role (e.g. primary 

care, psychiatry) reflect national staffing challenges. There are also geographic considerations, in particular in rural and other underserved areas. To be successful VA 

must provide competitive salaries and benefits along with an environment that is 

conducive to a productive and rewarding work experience including work-life 

balance. 

VA employs an aggressive, multifaceted strategy to recruit and hire physicians, 

Executive and clinical leaders at 150 medical centers assess physician staffing 

needs. Physician shortages or deficits at specific locations are addressed by increased marketing and recruitment efforts on a case-by-case basis. Marketing is also 

53 

targeted to academic affiliates, professional health care associations, the Department of Defense (DOD), Health and Human Services (HHS) and Office of Personnel 

Management (OPM). 

VA’s support of additional training positions and partnership with academic affiliates (who manage these residency positions), will help to increase the workforce in 

areas of high demand and limited capacity. Further, VA is in the early exploratory 

stage of examining novel programs and partnerships to expand training capacity, 

including the schools of Osteopathic Medicine and the Family Practice programs, as 

well as through the Federal Teaching Center model with Health Resources and 

Services Administration (HRSA). 

Veterans Health Administration’s (VHA) National Recruitment Program (NRP) 

provides an in-house team of skilled professional recruiters employing private sector 

best practices to the agency’s most critical clinical and executive positions. The NRP 

has increased its targeted recruitment efforts for mission critical clinical vacancies 

that directly impact and, once filled, will improve access to care. These specialties 

include primary care, mental health, and critical medical subspecialties. 

The national recruiters are attending conferences to showcase clinical practice opportunities to potential candidates. These include American College of Physicians; 

American Psychiatric Association and American Psychological Association. The team 

will also attend additional conferences through the end of 2014, targeting specialties 

such as Anesthesia, Gastroenterology, Family Medicine, Emergency Medicine, and 

Pharmacy. 

VHA, in partnership with the Office of Academic Affiliations (OAA), pioneered the 

agency’s first-ever recruitment outreach program targeting health professions trainees. The Take a Closer Look Initiative provides VHA with a standardized outreach 

strategy to recruit health professions trainees from VHA affiliate programs for employment upon completion of training. Residents and fellows receive attractive marketing throughout their programs with information on careers at VHA, as well as 

guidance on contacting and facilitating employment with a National Recruiter. 

In addition to actively recruiting physicians, increasing and further incorporating 

nurse practitioners and physician assistants with specialized training and experience in primary care into care teams will increase Veterans access to care. Additionally, VA continues to recruit for a variety of administrative, technical and professional occupations to ensure the right mix of staff are available to provide safe, 

quality care to Veterans. 

The national recruiters, all of whom are Veterans, work directly with Veterans 

Integrated Service Network (VISN) Directors, Medical Center Directors, and clinical 

leadership in the development of comprehensive, client-centered recruitment strategies that address both current and future critical needs. Since its founding in 

April 2009, VHA’s NRP efforts resulted in filling 1,286 mission-critical vacant positions, as of 8/21/14, which increased access to care in rural communities and contributed to Title 38 Veteran hiring goals. In fiscal year (FY) 2014, as of 8/21/14, the 

recruiters have placed 482 health care providers: 

• 91.49 percent are physicians; • 30.91 percent are primary care physicians; • 26.55 percent will go to rural/highly rural facilities; and • 16.18 percent are Veterans 

Sixteen of these Veteran hires will fill clinical and executive leadership roles at 

VA hospitals. 

By filling long-standing vacancies, VHA’s NRP is able to eliminate several multimillion dollar contracts for temporary provider staff. In one case, the team staffed 

a full anesthesiology department in the Northern California Health Care System, 

and in another, a full surgical team at the Texas VA Medical Center, translating 

into improved patient care and cost savings to VHA. 

MENTAL HEALTH

Question 3. Would any of the funding VA is requesting be targeted toward VA’s 

capacity to treat veterans who need mental health treatment? 

Response. Yes, there is funding available through the FY 2015 budget request and 

the Veterans Access, Choice, and Accountability Act to expand mental health provider capacity. The additional staffing under consideration for mental health (MH) 

would help to achieve the proposed overall staffing ratio of 7.72 MH providers per 

1,000 MH patients. 

CONSTRUCTION

Question 4. What are the infrastructure needs envisioned by the additional $6 billion and how would they impact VA’s capacity to provide care to veterans? 

54 

Response. VA is in the process of developing a spend plan for the $5 billion provided in Section 801 of the Veterans Choice Act and will submit it to the Committees as soon as it is finalized. 

As specified in the law, these funds will be used to increase the access of veterans 

to care and to improve the physical infrastructure of the Department. This mixture 

of investments will help ensure VA is increasing its capacity to meet the current 

and projected future demand for services. 

Question 5. What is the specific importance of leasing to VA’s ability to deliver 

medical care? 

Response. Leasing is an essential vehicle that allows VA to provide care to Veterans at the right place at the right time. Leasing allows flexibility in that VA can 

reassess local Veterans’ needs as they exist at the end of the lease term. As the 

needs and demographics of Veterans change and develop over time, VA is able to 

adapt and respond in a more agile manner than if VA owned the facilities. Additionally, VA can vacate aging facilities at the end of the lease term. 

Question 6. Why does VA need its own leasing authority for medical facilities? 

Response. VA continues to work to respond to this question and will follow up 

with the Committee as soon as possible. 

DATA QUALITY

Question 7. What steps has VA taken to address criticisms to trustworthiness of 

data produced by the Department in order to ensure Congress and the public can 

have faith in information provided by VA? 

Response. VA has taken several first-steps to ensure data integrity and transparency, and restore the trust of Veterans, of our elected representatives, and all 

Americans: 

• Suspended all VHA senior executive performance awards for FY 2014. 

• Removed the 14-day access measure from all individual employee performance 

plans to eliminate motives for inappropriate scheduling practices or behaviors. In 

the course of completing this task, over 13,000 performance plans were amended. 

• Updating the antiquated appointment scheduling system—in the short-term, 

enhancing existing systems. Working toward a comprehensive, state-of-the-art, 

‘‘commercial, off-the-shelf’’ scheduling system. Expanding digital technology to freeup more people to care for Veterans. Adding more clinic hours in facilities. 

• Contracting with an outside organization to conduct a comprehensive, independent audit of scheduling practices across the entire VHA system, beginning early 

fiscal year 2015. 

• Every medical center and VISN Director are now conducting monthly, in-person 

inspections of all their clinics, including interacting with scheduling staff to assess 

scheduling practices and identify obstacles to timely care for Veterans. So far, over 

2,450 of these visits have been conducted. 

• Taken action on all of the IG’s recommendations in the May 2014 Interim Report on Phoenix and responded to OIG’s recommendations in the final report with 

action plans to be implemented during FY 2015. 

• VA has set a goal to improve forecasting to better align available resources with 

identified demands. 

• Building a more robust, continuous system for measuring patient experiences, 

to provide real-time, site-specific information on patient satisfaction. 

• Improving communications between the field and the central office, between 

employees and leadership, and between VA and Veterans Service Organizations and 

stakeholders. 

ADDRESSING CULTURE

Question 8. Outline the actions VA has taken to ensure employees who take the 

courageous step of coming forward to expose wrongdoing, waste, fraud or abuse are 

not intimidated, punished, or face retaliated against for such action? 

Response. VA recognizes the dedication and courage shown by employees who report violations of law, wrongdoing, waste, fraud, and abuse. VA is committed to protecting whistleblowers from retaliation. VA is working collaboratively with the U.S. 

Office of Special Counsel (OSC) to review allegations of retaliation, and VA will 

make a whistleblower whole where there has been a finding of retaliation. This may 

include, but is not limited to, placing the whistleblower back into his or her position, 

or assigning the whistleblower to a new supervisor or position. In addition, VA will, 

as appropriate, take disciplinary action against employees who have committed substantiated acts of retaliation. 

55 

On July 11, 2014, VA registered for the OSC Section 2302(c) Certification Program. This Program will allow VA to meet its statutory obligation to inform its employees about the rights and remedies available to them under the Whistleblower 

Protection Act, the Whistleblower Protection Enhancement Act, and related civil 

service laws. 

On October 7, 2014, VA received that certification from the OSC. This is an acknowledgement of the seriousness, commitment, and resources the VA is directing 

toward fundamental change in VA’s systems and culture. 

Under the OSC certification process, VA: 

1. placed informational posters regarding prohibited personnel practices (PPP), 

whistleblowing, and whistleblower retaliation in a public setting at VA facilities and 

VA personnel and equal employment opportunity offices; 

2. provided and will continue to provide new hires with written materials on PPP, 

whistleblowing, and whistleblower retaliation; 

3. developed a Web site on PPP and whistleblower rights and protections; and 

4. developed, in cooperation with the OSC, supervisory training on PPP and whistleblower rights and protections. VA executives, managers, and supervisors must 

complete this training on a biennial basis. 

One of the requirements of the Program is that all supervisors in the agency complete training on whistleblower rights and protections and prohibited personnel 

practices. To that extent, VA has worked closely with the OSC to develop specialized 

training for VA executives, managers, and supervisors on whistleblower rights and 

protections and prohibited personnel practices. VA executives, managers, and supervisors were required to complete this training by September 30, 2014, and biennially 

thereafter. 

To reinforce the above, VA leadership sent a message to all VA employees regarding the importance of whistleblower protection, emphasizing that managers and supervisors bear a special responsibility for enforcing whistleblower protection laws. 

VA Leadership meets with employees at VA facilities across the country to reemphasize that message. 

VA’s Office of Diversity and Inclusion (ODI) is also conducting on-site and virtual 

training for facility leadership on workplace inclusion, prevention of workplace 

harassment, and whistleblower protections. ODI also recently issued communications on whistleblower rights and protections through its Diversity@Work Newsletter and Diversity News Broadcast, accessible on ODI’s Webpage, http:// 

www.diversity.va.gov. 

As part of VA’s commitment to whistleblower rights and protections, VA has established a whistleblower Webpage, http://www.diversity.va.gov/whistleblower.aspx, 

accessible from VA’s internet home page, http://www.va.gov. VA’s whistleblower 

Webpage outlines employee and supervisor rights and responsibilities, including 

avenues of redress for complaints, informational posters and materials, and whistleblower training resources. 

Additionally, VA has established the Office of Accountability Review (OAR) to ensure leadership accountability for improprieties related to patient scheduling and access to care, whistleblower retaliation and related matters that impact public trust 

in VA. As of September 26, VA has announced the proposed removal of four senior 

executives following investigations by the OAR and the VA Office of Inspector 

General. 

VA will continue to take additional steps in creating a cultural shift within the 

organization and ensure its employees have a safe channel for disclosing whistleblower information. 

Question 9. Following the release of Acting Secretary Gibson’s June 13, 2014, letter to staff regarding whistleblower protections, has there been a distinct increase 

in employees who have raised concerns or suggestions with individuals in leadership 

positions across the system? 

Response. Given that whistleblower disclosures may be made to any employee in 

VA or to OSC, we are unable to determine whether there was an increase in the 

number of employees who raised concerns or suggestions following Deputy Secretary 

Gibson’s message to all employees on June 13, 2014, regarding the importance of 

whistleblower rights and protections. We continue to encourage employees to disclose wrongdoing, violations of law, fraud, waste, or abuse. 

Question 10. How doe VA intend to create an accountable, safe, and transparent 

department focused on caring for veterans? 

Response. VA is conducting multiple simultaneous investigations on patient 

scheduling issues, questions of record manipulation, appointment delays, patient 

deaths, and whistleblower retaliation. Based on the findings of those investigations, 

VA will take corrective and/or disciplinary action. To help regain Veterans’ trust, 

56 

Congress’ trust, the trust of the American people, and the trust of our employees, 

when we do hold employees accountable we are going to transparently share information as appropriate and while respecting an employee’s privacy rights. For cases 

involving senior executives, the Veterans Access, Choice, and Accountability Act of 

2014 allows us to take expedited action when VA has determined that a senior manager has committed misconduct or has performed poorly. VA’s newly established Office of Accountability Review (OAR) is monitoring the progress of all ongoing OSC 

and Office of Inspector General (OIG) investigations, and as they are completed, will 

help VA leadership determine appropriate accountability measures. 

As discussed in response to question eight, VA has mandated online training for 

all VA executives, managers and supervisors on whistleblower rights and protections and prohibited personnel practices. This training, along with existing mandatory training on equal employment opportunity, diversity and inclusion, and prevention of workplace harassment, conflict management training for supervisors, and 

mandatory Workplace Harassment/No FEAR training helps to create an atmosphere 

that welcomes accountability, safety, and transparency. 

As Secretary McDonald described in a message to all employees sent on August 28, 2014, sustainable accountability in a high performing customer service organization is more complex than just firing employees. It includes a productive discussion of accountability, ensuring all employees, from top to bottom, understand 

how their daily work supports VA’s mission, values, and strategic goals. VA has 

strong, institutional values—mission-critical ideals that must profoundly influence 

our day-to-day behavior and performance: Integrity, Commitment, Advocacy, Respect, and Excellence. On his first day in office, Secretary McDonald asked all VA 

employees to join him in reaffirming their commitment to these core values. 

Question 11. Further, what steps has VA taken to ensure problems, investigations, and recommendations are elevated to the appropriate level of leadership for 

thorough evaluation and immediate corrective action? 

Response. Employees are encouraged to disclose wrongdoing, violations of law, 

fraud, waste, or abuse. If the information being disclosed pertains to a possible or 

actual criminal violation, employees must report the information to VA’s OIG. 

In VA’s training for executives, managers, and supervisors on whistleblower 

rights and protections and prohibited personnel practices, VA reemphasizes the importance of investigating disclosures of wrongdoing, violations of law, fraud, waste 

or abuse. VA also emphasizes that all executives, managers, and supervisors who 

receive these disclosures should notify a senior executive (an employee in the Senior 

Executive Service (SES) or a Title 38 SES-equivalent employee) supervisor about 

the disclosure. 

PERSONNEL ACTIONS

Question 12. How many personnel actions were issued under Acting Secretary 

Gibson of Veteran’s Affairs Department? 

Response. The term ‘‘personnel actions’’ within the VA describes a variety of actions. These actions include, but are not limited to, reassignments, conversions in 

career status, realignments, and transfers. Between the time period of May 30, 

2014, and July 29, 2014, when Deputy Secretary Gibson served as VA’s Acting Secretary, a total of 104,009 personnel actions were issued. Of those 104,009 actions, 

1,062 were adverse personnel actions. 

Question 13. If firing does not send a clear message regarding accountability regarding the care and management of veterans, how does VA intend to hold individuals accountable for wrong doing? 

Response. Secretary McDonald has demonstrated his commitment to serving Veterans by directing focus on VA’s core values: Integrity, Commitment, Advocacy, Respect, and Excellence. VA will continue to use all tools available to correct misconduct and improve performance in accordance with applicable laws, rules, and 

regulations. 

HOLDING SENIOR LEADERS ACCOUNTABLE

Question 14. VA announced new administrative procedures would be triggered 

when concerns are identified during an audit. This is a bit vague and the Committee in its oversight capacity would like to understand these procedures in detail. 

Please describe in detail the triggers that are used to employ these new administrative procedures? 

Response. The Department’s OAR has initiated a series of leadership interviews 

designed to elicit testimony regarding the actions VHA facility leaders took, and are 

continuing to take, to ensure that scheduling and wait list protocols are being followed throughout their facilities. If those interviews unearth senior leader misVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00060 Fmt 6633 Sfmt 6621 Z:\ACTIVE\071614.TXT PAULIN
57 

conduct or serious failure of oversight, disciplinary procedures may be triggered. If 

the interviews demonstrate that a facility’s leaders exercised appropriate oversight 

with respect to scheduling and wait lists, the audit process will be closed out with 

respect to that facility. 

Question 15. Who is involved in activating these so-called ‘‘triggers’’ and what is 

the line of communication from audit staff to work center? 

Response. VHA leaders are working collaboratively with the Department’s OAR— 

an interdisciplinary team of attorneys, employee relations specialists, and other subject matter experts—to identify facilities requiring review and to carry out interviews and any necessary disciplinary actions. 

Question 16. Have these new ‘‘triggering procedures’’ been rolled out and how 

have the procedures been utilized to hold leaders and managers accountable to date? 

Response. Leaders of approximately eight VHA facilities have been interviewed, 

with several dozen additional interviews in the works. The team will likely interview leaders at all VHA facilities when the VA OIG completes its ongoing investigations into scheduling and wait list-related misconduct. 

Question 17. What are some of the ways you are refocusing your leaders and managers on the mission of veteran’s health and well-being? 

Response. Veteran’s health and well-being has always been a focus for the vast 

majority of VA’s leaders and managers. In any cases where this is found not to have 

been true, appropriate fact-findings and/or administrative investigations are taking 

place and for any substantiated findings, disciplinary measures will be taken. 

Additionally, Secretary McDonald recently sent out a mandate for all of VA to reaffirm commitment to mission and core values. The Secretary directed that by August 22, 2014, all Under Secretaries and Assistant Secretaries confirm that they and 

their employees have reaffirmed their commitment to the ICARE core values. 

NON-VA CARE

Question 18. In the written testimony submitted to the Committee it was indicated that between May 15 and June 30, VA had made over 430,000 referrals for 

veterans to receive care in the private sector. Is VA tracking the average wait time 

for these veterans to receive care? If not, what are the challenges preventing VA 

from doing this? 

Response. VA does not have specific data on the timeliness of the 430,000 referrals. However, VA has recently developed a management report that will assist in 

the reporting of non-VA care appointment timeliness. The field will be expected to 

adhere to specific referral procedures in order for VA to accurately track wait times. 

The reliability of the tracking will be dependent on the procedural input from the 

field. All sites were provided training on the procedures during the national rollout of the Non-VA Coordination model. The challenge remains to ensure that the 

facilities are properly following the procedures. 

Since January 2014, VA has tracked appointment timeliness for Patient Centered 

Community Care referrals using a combination of VA data and contract data. The 

following average appointment metrics are reported: 

Consult request to Authorization Created .................................. 16.2 

Authorization sent to Contractor to Authorization Accepted ..... 5.6 

Accepted Authorization to Appointment Scheduled ................... 3.3 

Days to Scheduled Appointment ................................................ 12.5 

Nationally, the average days from Consult to Scheduled Appointment is 37.6 days. 

SCHEDULING PRACTICES

Question 19. In VA’s efforts to better understand issues surrounding scheduling, 

it has directed an independent external audit of VHA’s scheduling practices. Can 

you please provide further detail regarding VA’s expectations of this audit and any 

details of the project’s timeline? 

Response. The Joint Commission is VA’s accreditation vendor and provides accreditation services for all VHA medical facilities, Community Based Clinics and Consolidated Mail Outpatient Pharmacies. VHA has requested that The Joint Commission (TJC) provide special focused reviews of internal VHA scheduling and other 

processes that could cause delays in care. Specifically, TJC will review the standards for regulatory compliance that align with how VHA schedules appointments, 

and if the scheduling is timely, accurate, and results in the prevention of delays in 

care for Veterans. Additional reviews may also be conducted if TJC becomes aware 

58 

of newly provided services at facilities or for other reasons for which TJC believes 

that the safety and quality of patient care is vulnerable. 

TJC does not perform audits, but instead examines standards and reviews the 

connected processes. The Joint Commission will perform reviews at all VHA facilities. The reviews began on September 18, 2014 and will continue through FY 2015 

until all visits are completed. 

BEST PRACTICES

Question 20. Acting Secretary Gibson noted in his written testimony that VHA is 

looking to develop a process to share best practices from high performing facilities 

in order to offer suggestions those facilities that require improvement. Please provide additional detail regarding this effort. In particular, what high performing facilities have you identified. 

Response. A VHA Steering Group has begun the process of determining how to 

measure the performance of facilities to find those that achieve excellent performance in their particular environment. This may allow for example, a small facility 

in a highly rural area to be paired with a like-facility with better performance. Specific facilities in each domain have not yet been identified by the Steering Group. 

Question 21. How do you intend to share these best practices across the VHA system; and 3) what is the project’s timeline? 

Response. VA has a variety of models in which best practices have been spread 

across the larger health system. The VA Health Services Research and Development’s (HSR&D) Quality Enhancement Research Initiative (QUERI) program’s mission is to implement best practices into routine care. HSR&D/QUERI also identifies 

best practices through the Evidence Synthesis Program (ESP) Centers, including a 

recent rapid review of VHA wait times. A strategic goal of the QUERI program is 

to also identify which systems-level models work best, especially in high-performing 

facilities, to spread clinical best practices across different settings. A key program 

(Blended Facilitation) has been adopted by VHA national program offices to enhance 

the uptake of PTSD and related treatments. QUERI has applied innovative models 

to promote the uptake of primary care-mental health integration, e-health, 

anticoagulation treatment, and population management strategies especially for vulnerable Veteran populations, and is currently developing a Lean evaluation center 

in collaboration with the QSV Veterans Engineering Resource Center to promote 

best practices across a variety of facilities. HSRD is also leading a series of studies 

focused on best practices in disclosing adverse events to Veterans in a way that 

lessens Veterans’ anxiety and distress and increases their confidence and trust in 

VA. 

HSR&D also shares lessons learned from research through various dissemination 

efforts such as its Cyberseminars program. For example, recent sessions included: 

‘‘Telemental Health in VA: Opportunities for Improving Access to Cognitive Behavioral Therapy for Pain’’ and ‘‘Using Lessons for VA to Improve Primary Care for 

Women With Mental Health and Trauma Histories.’’ 

The National Center for Patient Safety (NCPS) uses ‘‘Lesson Learned’’ as well as 

Patient Safety Alerts to improve system-wide performance. VA also uses a bundle 

approach to improve performance on certain common hospital acquired conditions. 

Bundles are developed to make it easy for common and standard approaches to be 

used to combat hospital infections. These bundles are paired with measurement of 

performance and feedback on that performance to drive down infection rates. Subject matter experts in infectious diseases, critical care, and others also provide consultation to facilities. To further enhance updates NCPS uses Breakthrough Series 

to encourage facilities to enhance uptake of best practices. Using these techniques, 

VA has seen dramatic decreases in rates of catheter-associated urinary tract infection, ventilator associated pneumonia, methicillin-resistant staphylococcus aureus 

(MRSA) infections, and other hospital-acquired conditions. It is anticipated that 

these and other models will be used to share best practices between facilities. 

A Steering Group has been chartered and we anticipate a more detailed strategy 

will be developed to better assess facility performance, determine areas requiring attention within some facilities, create an action plan for improvement, and then 

matching facilities to enhance and sustain improvements. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BURR TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 22. According to a study published in the Annals of Family Medicine, 

the average non-VA primary care provider has an average panel size of 2,300 patients compared to VA’s current target of 1,200 patients per primary care provider. 

59 

A. What steps has VA taken to evaluate the appropriateness and effectiveness of 

the primary care panel size? 

Response. The Department of Veterans Affairs (VA) has taken several steps to 

evaluate the appropriateness of primary care panel size: 

• Comparison with external agencies and review of relevant medical literature 

using capitated models (Department of Defense (DOD), Kaiser Permanente, etc.) 

show comparable panel sizes; • Evaluation of the range of VA panel sizes to ensure that outcomes, such as Ambulatory Care Sensitive Conditions admissions and Emergency Department visits do 

not deteriorate as panel sizes reach the top decile for VA; and • An evaluation of primary care team burn-out and stress as a function of rising 

panel size is currently underway. 

B. In July 2004, VA issued a directive on primary care panel size, which expired 

on May 31, 2008; has VA updated this guidance? 

Response. The Guidance on Primary Care Panel Size Directive was replaced by 

the Primary Care Management Module Handbook, published on April 21, 2009. This 

is currently undergoing revision and is expected to be published in FY 2015. The 

guidance regarding panel size is currently unchanged from the earlier Directive. 

Question 23. In a recent House Committee on Veterans’ Affairs hearing, Dr. 

Lynch stated that, on average, VA primary care physicians see 10 patients each day 

compared to non-VA primary care physicians who see an average of 22 patients each 

day. He further stated that the number of patients seen daily by VA primary care 

physicians may range from 6–22 patients. 

A. Why do VA primary care physicians see roughly half the amount of patients 

per day as those outside VA? 

Response. The number of patients that VA physicians see per day varies from 

clinic to clinic and from facility to facility depending on the physician’s specialty, 

the age and complexity of the patients they treat, and factors such as the number 

of available examination rooms and clinic support staff. VA patients tend to be elderly (mean age 63) with complex comorbidities compared to many health care organizations in the private sector and private practices. It is important to note that not 

all clinical encounters are equal—more complex patients require more time. This 

universally-recognized variation in the complexity of clinical encounters is accounted 

for by the use of ‘‘relative value units’’ (RVUs) that consider the time and intensity 

of the service delivered by the provider during a given encounter. Within Veterans 

Health Administration (VHA), we calculate and monitor the RVU-based productivity 

of our providers. 

The largest component of VHA’s physician workforce is the Internal Medicine specialty (largely primary care), representing over 5,000 full-time equivalent employees 

or approximately 25 percent of our total physician workforce. Internal medicine physicians tend to be assigned older Veterans and those with multiple medical problems 

in their patient panels. The average number of appointments a typical internal medicine specialist sees ranges from 7 to 22 patients per day across all VHA sites, with 

the overall average being about 10 patients per day. A survey conducted by the nonprofit group Physicians Foundation and reported in the Washington Post indicates 

that 39.8 percent of U.S. doctors see between 11 and 20 patients per day. 

In addition, the re-organization of primary care into Patient Aligned Care Teams 

(PACT) featuring more comprehensive and coordinated health care requires more 

face-to-face time with the provider at each visit. With the advent of PACT, primary 

care teams were encouraged to offer different venues of care to meet the preferences, convenience, and specific health care needs of Veterans. A greater reliance 

on health care via telephone, group visits, and secure messaging is encouraged, allowing a reduction in face-to-face clinic visits with a commensurate increase in virtual patient encounters. 

B. What steps has VA taken to evaluate the number of patient appointment slots 

to ensure that VA is maximizing their resources? 

Response. VistA Scheduling, the software tool currently used to schedule appointments with providers, is not adequate to maximize resources because of the design 

of the nearly 30 year old software. A report called the Clinic Utilization Statistical 

Summary is available to each site, but can be very difficult to understand and interpret. To improve the situation, VA has produced a report nationally called the Access Index. The Access Index, available for every VA Clinic Profile, allows users to 

measure and understand the relationship between patient appointments and clinic 

slots. This report measures both the utilization of the schedule (how much of the 

available schedule was booked) and utilization of slots (how many available slots 

were used) for that individual profile. It also allows clinicians to understand the relationship between appointment length and slot length, which can be different. In 

60 

addition, VA clinicians commonly have multiple profiles, (for example Mental 

Health providers have an average of 7 profiles), which makes overall assessment of 

evaluation the maximization of resources more challenging. To resolve this situation, VA is pursuing acquisition of a modern commercial off-the-shelf package that 

will enable better resource management. 

Question 24. Mr. Secretary, in your testimony, you state that, in facilities identified during the Nationwide Access Audit as having problems, VA will begin administrative procedures to determine the appropriate personnel actions needed. 

A. What personnel actions has VA taken either at the facility, VISN, or Central 

Office? 

Response. We are in the midst of a nationwide accountability audit, in follow— 

up to the access audit, to determine which supervisors, managers and employees 

may have intentionally directed or carried out inappropriate scheduling practices. 

Nine scheduling-related personnel actions have been proposed to date and we expect 

others may be necessary as our accountability investigations continue. 

B. Has anybody directly related to the improper scheduling practices been fired? 

Response. All proposed disciplinary actions are still in progress. Some of the proposals do involve termination of employment. 

Question 25. On June 18, 2014, Secretary Gibson, you announced that VA medical 

facilities Directors would conduct monthly in-person reviews of scheduling practices. 

While this is an important step to ensuring that correcting inappropriate scheduling 

practices remains a top priority, I am concerned that the ‘‘corrosive culture’’ and 

whistleblower retaliation will make it unlikely that VA employees will accurately 

portray additional barriers to access. 

A. Secretary Gibson, do you share my concerns, and if so, how does the organization overcome these issues? 

Response. VA recognizes the dedication and courage shown by employees who report violations of law, wrongdoing, waste, fraud, and abuse. VA is committed to protecting whistleblowers from retaliation. VA is working closely with the U.S. Office 

of Special Counsel (OSC) to investigate allegations of retaliation, and VA will take 

corrective action where there has been a finding of retaliation. This may include, 

but is not limited to, placing the whistleblower back into his or her position, or assigning the whistleblower to a new supervisor or position. In addition, when substantiated, VA will, as appropriate, take disciplinary action against employees who 

have committed acts of retaliation. 

On July 11, 2014, VA registered for the OSC Section 2302(c) Certification Program. This Program will allow VA to meet its statutory obligation to inform its employees about the rights and remedies available to them under the Whistleblower 

Protection Act, the Whistleblower Protection Enhancement Act, and related civil 

service laws. 

On October 7, 2014, VA received that certification from the OSC. This is an acknowledgement of the seriousness, commitment, and resources the VA is directing 

toward fundamental change in VA’s systems and culture. 

Under the OSC certification process, VA: 

1. placed informational posters regarding prohibited personnel practices (PPP), 

whistleblowing, and whistleblower retaliation in a public setting at VA facilities and 

VA personnel and equal employment opportunity offices; 

2. provided and will continue to provide new hires with written materials on PPP, 

whistleblowing, and whistleblower retaliation; 

3. developed a Web site on PPP and whistleblower rights and protections; and 

4. developed, in cooperation with the OSC, supervisory training on PPP and whistleblower rights and protections. VA executives, managers, and supervisors must 

complete this training on a biennial basis. 

One of the requirements of the Program is that all supervisors in the agency complete training on whistleblower rights and protections and prohibited personnel 

practices. To that extent, VA has worked closely with the OSC to develop specialized 

training for VA executives, managers, and supervisors on whistleblower rights and 

protections and prohibited personnel practices. VA executives, managers, and supervisors were required to complete this training by September 30, 2014, and biennially 

thereafter. 

To reinforce the above, VA leadership sent a message to all VA employees regarding the importance of whistleblower protection emphasizing that managers and supervisors bear a special responsibility for enforcing whistleblower protection laws, 

and meets with employees at VA facilities across the country to reemphasize that 

message. 

VA’s Office of Diversity and Inclusion (ODI) is also conducting on-site and virtual 

training for facility leadership on workplace inclusion, prevention of workplace harVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6621 Z:\ACTIVE\071614.TXT PAULIN
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assment, and whistleblower protections. ODI also recently issued communications 

on whistleblower rights and protections through its Diversity@Work Newsletter and 

Diversity News Broadcast, accessible on ODI’s Webpage, http:// 

www.diversity.va.gov. 

As part of VA’s commitment to whistleblower rights and protections, VA has established a whistleblower Webpage, http://www.diversity.va.gov/whistleblower.aspx, 

accessible from VA’s internet home page, http://www.va.gov. VA’s whistleblower 

Webpage outlines employee and supervisor rights and responsibilities, including 

avenues of redress for complaints, informational posters and materials, and whistleblower training resources. 

Additionally, VA has established the Office of Accountability Review (OAR) to ensure leadership accountability for improprieties related to patient scheduling and access to care, whistleblower retaliation and related matters that impact public trust 

in VA. Since September 26, VA has announced the proposed removal of four senior 

executives following investigations by the OAR and the VA Office of Inspector General. 

Other actions include a memo to all employees from Secretary McDonald reaffirming the importance of VA’s Core Values (Integrity, Commitment, Advocacy, Respect, 

and Excellence or I CARE). 

VA will continue to take additional steps in creating a cultural shift within the 

organization and ensure its employees have a safe channel for disclosing whistleblower information. 

Question 26. On June 23, 2014, the Office of Special Counsel sent a letter to the 

President regarding the ‘‘Continued Deficiencies at Department of Veterans Affairs’ 

Facilities.’’ This letter confirms the well-known cultural problems within the Department and VA’s lack of responsiveness to problems that have been identified by independent investigative agencies. Secretary Gibson, you took immediate steps after receiving this letter, calling for a review of the Office of Medical Inspector and referring all hotline cases to the Office of Inspector General. 

A. Has the comprehensive review of the Office of Medical Inspector been completed? Please provide the Committee with the results of this internal review. 

Response. In response to the OSC’s June 23, 2014, letter to the President that included criticisms of the Office of the Medical Inspector (OMI), the Acting Secretary 

of Veterans Affairs directed an immediate review and subsequent restructuring of 

OMI to better serve Veterans. He announced that this restructuring would create 

a strong internal audit function to ensure that health care quality and patient safety remain a primary and constant focus. On July 10, 2014, an Interim Director of 

OMI was appointed from outside the office to spearhead the restructuring effort. 

The Acting Secretary determined a clear need to revise the policies, procedures, and 

personnel structure by which OMI operates, and has directed a restructuring of the 

organization. 

VA reviewed and is in the process of restructuring OMI to better serve Veterans. 

This restructuring creates a strong internal audit function to include risk assessment capabilities to ensure that health care quality and patient safety remain a primary and constant focus. 

B. Would you please provide the Committee with a timeline for a path forward 

with respect to the restructuring of the Office of Medical Inspector? 

Response. Since July 2014, OMI has made significant progress in restructuring 

the policies and procedures by which it operates. OMI’s status as an independent, 

objective advisor to the Under Secretary for Health (USH) was reaffirmed in a 

memorandum signed by the USH in September 2014. After a two-month hiatus on 

accepting new cases, OMI resumed conducting OSC whistleblower investigations in 

September with a renewed focus on both health care quality and accountability. 

OMI’s investigators have likewise adopted a revised standard for judging whether 

substantiated whistleblower allegations represent a threat to public health and 

safety. 

OMI is working closely with VA’s new Office of Accountability Review (OAR) as 

well as the Office of General Counsel before, during, and after its investigative site 

visits to VA medical facilities. Because of these closer working relationships and increased leadership oversight within both VHA and VA, a shared understanding has 

developed that VA’s responses to OSC referrals represent the work of the entire 

Agency, not just OMI. In addition, OMI has established a more collaborative working relationship with OSC. More frequent communication allows OMI to clarify 

whistleblower allegations, encourage whistleblower cooperation (where necessary) 

with investigations, and share preliminary findings with OSC weeks before OSC receives VA’s official written report. 

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Among other procedural changes, OMI provides a ‘‘Notice of Witness Obligations 

and Protections’’ to each witness to inform them of their responsibilities and rights, 

including protection from reprisal. In the area of personnel restructuring, each team 

of OMI investigators is now augmented by a human resources (HR) expert identified 

by OAR. This H.R. expert becomes an integral team member, in most cases traveling with other investigators to each site, where they are able to address instances 

of potential individual wrongdoing and advise the lead investigator on personnel 

matters, including disciplinary procedures. OMI is also hiring three additional senior, experienced Title 38, Nurse V program managers to expand its ability to manage the growing number of case investigations. 

In addition, OMI conducted benchmarking activities in recent weeks with several 

external organizations within both the Federal Government and the private sector. 

This benchmarking has served to inform VA about internal audit procedures and 

standards used elsewhere in the health care industry, and provided new ideas and 

helpful reference materials. As a first step toward developing the desired internal 

audit function, VHA is realigning the Office of Compliance and Business Integrity 

(CBI), which performs financial audit, compliance, and business oversight activities, 

with OMI. By working together, these two offices can leverage CBI’s auditing capability and OMI’s clinical expertise to create the synergy needed to audit both business and clinical processes. 

Further restructuring will continue in the coming months. VA would be happy to 

provide periodic updates. 

C. How does the Department plan to ensure that all oversight offices, including 

the Office of Special Counsel and VA’s Inspector General, are cooperating with VA’s 

internal offices and working collaboratively to address systemic issues and potential 

patient harm? 

Response. The mandate to review OMI’s current environment served as a catalyst 

for a broader organizational assessment of VHA’s capacity for maintaining effective 

oversight. In conjunction with OIG, VHA has implemented multiple processes that 

facilitate open, collaborative, and regular communications about systemic issues and 

potential patient harm. VHA and OIG use both informal and formal methods of 

communication: phone calls are common, frequent emails, and structured entrance/ 

exit conferences and briefings. 

VHA program office leadership meets monthly with Assistant Inspectors General 

(AIG) for Audit and Evaluation, Health Care Inspections, and Criminal Investigations. The purpose of the monthly meeting is to candidly exchange information 

about concerns by either party regarding upcoming or ongoing audits or inspections, 

hotline allegations of care deficiencies, early notification on significant findings from 

active reviews, VHA internal information about health care issues, and process improvements. 

OMI also meets monthly with the AIG for Health Care Inspections to review cases 

and health care issues both groups are addressing to better inform future investigations. The two organizations also share information about planned inspections in an 

effort to avoid duplication and overlap and to benefit from any investigative activity 

that has already occurred. 

In addition, OMI meets regularly with OSC to review the status of whistleblower 

investigations, and to discuss schedules for reports and other deliverables. These 

meetings should go a long way toward improving communication between OSC and 

VA on investigative findings, ensuring complaints are thoroughly examined and that 

whistleblower’s receive the protections they are entitled to under the law. 

The VA has also established an accountability review office, located within the Office of the Secretary and independent of VHA, to ensure that appropriate leadership 

accountability actions are taken when facility leaders are implicated in findings by 

OIG, OMI, or other investigative bodies. The accountability review office functions 

collaboratively with OIG, OSC and OMI to improve Departmental leaders’ visibility 

over issues raised by various oversight entities. 

This improved cooperation will help overcome some of the organization’s current 

challenges in providing effective health care oversight, and should support efforts 

to restore Veterans’ and the public’s trust. 

Question 27. At the hearing, Acting Secretary Gibson indicated that VA processes 

a quarter million non-VA care referrals per month and each referral includes, on 

average, seven appointments. For fiscal year 2013 and fiscal year 2014 to date, 

please provide a breakdown of the referrals by specialty and the average number 

of appointments per unique veteran by specialty. 

Response. Attached in the Excel spreadsheet are authorizations per Category of 

Care (COC), as of 8–22–14, for Fee Basis Claims Systems authorizations by COC 

and noted is the arithmetic mean and median for each category. 

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RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 28. What is your response to those who say the VA’s workforce shortages 

are a myth, and that the real problem is VA medical personnel who are not working 

hard or fast enough? Why is it unproductive to point to the number of patients seen 

in a day or year by doctors in the private sector, and demand the VA meet those 

same numbers? Would establishing such benchmarks help veterans? 

Response. Veterans Health Administration (VHA) has a physician workforce of 

more than 18,000 full-time equivalent employees representing over 30 sub-specialties. The largest proportion of VHA’s physician workforce is composed of Internal 

Medicine (largely primary care) and Mental Health (psychiatrists), representing 

nearly half of the physician workforce. The majority of VHA’s physicians are salaried, with approximately 10 percent of the physician workforce working in a VA facility on a fee-basis or under another contractual type arrangement. Primary Care 

(PC), the largest component of the Department of Veterans Affairs (VA) physician 

workforce (34 percent), has been employing a panel model for standardizing productivity and staffing in PC since 2004. Mental Health, the second largest component 

of VA’s physician workforce (14 percent) has developed a productivity model that 

was implemented in June 2013. As of July 2014, 91 percent of all specialties have 

productivity and staffing standards in place and the remaining specialties will be 

completed by September 30, 2014. 

It is unproductive to point to the number of patients seen by doctors in the private 

sector and demand the VA meet those same numbers because some private sector 

doctors tend to be financially rewarded for the number of patients they see in a day. 

However, not all patients need face-to-face visits with a physician in order to meet 

their needs. By contrast, VA doctors are encouraged to have flexible schedules to 

meet urgent needs. As well, since 2010, VA primary care workforce has embraced 

the patient centered medical home model that uses a diversified approach to providing patient care. Patient Aligned Care Teams utilize multiple diverse interdisciplinary team members to provide care to each patient. This allows the team to 

efficiently customize patient care to meet the individual and unique needs of our 

Veterans. Although some Veterans require frequent face-to-face visits with their 

provider, many benefit more from telephone interactions, secure messaging, or care 

from other team members including nurses, behavioral therapists, clinical pharmacists, and social workers. Following PACT implementation, providers often see a 

decrease in scheduled face-to-face visits with their patients, but patients will have 

an increased number of contacts (face-to-face and non-face-to-face) with their entire 

provider team. Providers are able to use this time to manage their panel of patients 

by processing clinical reminders, managing clinical computer alerts, performing telephone and virtual visits and interacting with their primary care team members. 

Providers are actually encouraged to keep 10–20 percent of their daily visit slots unscheduled to allow flexibility to manage urgent needs for their patients, with a goal 

toward reducing reliance on urgent care and emergency department utilization. 

Therefore, approximating provider workload by monitoring number of face-to-face 

visits alone ignores the complexity of managing all of the ‘‘ways in’’ that are visible 

to a patient: face-to-face, telephone, secure messaging, team member visits, etc. The 

overall team effort adds value to our Veterans’ health and well-being. 

Question 29. I understand that the VA just enacted a hiring freeze for the VHA 

Central Office and VISN offices in order to put more emphasis on increasing personnel at medical facilities. Can you elaborate on this decision—why was it made 

and what are the early results? Has the VA seen any gains in personnel? Moving 

forward, are the VHA Central Office and VISN offices improperly staffed? 

Response. Per the attached June 9, 2014, press release, bullet #3 cites the specific 

language then-Acting Secretary Gibson used to announce and explain the hiring 

freeze. The hiring freeze enables Human Resources staff to focus on hiring for mission critical positions which directly support Veterans’ access and care. The Department is assessing the organization and staffing of VHA Central Office and VISN 

HQs. The hiring freeze ensures we retain our focus on operational hiring in the 

field, while the evaluation of a more streamlined headquarters management structure continues. 

71 

FOR IMMEDIATE RELEASE 

June 9, 2014 

VA Releases Data on Quality, Access to Veterans Healthcare 

1Acting Secretary Gibson Provides Transparency, Announces 

Further Actions on Timely Healthcare Access 

WASHINGTON—Today, the Department of Veterans Affairs (VA) released the results from its Nationwide Access Audit, along with facility level patient access data, 

medical center quality and efficiency data, and mental health provider survey data, 

for all Veterans health facilities. 

Full details made public at VA.gov follow Acting Secretary of Veterans Affairs 

Sloan Gibson’s commitment last week in Phoenix, Arizona and San Antonio, Texas 

to provide timely access to quality healthcare Veterans have earned and deserved. 

‘‘It is our duty and our privilege to provide Veterans the care they have earned 

through their service and sacrifice,’’ said Acting Secretary Gibson. ‘‘As the President 

has said, as Secretary Shinseki said, and as I stated plainly last week, we must 

work together to fix the unacceptable, systemic problems in accessing VA 

healthcare. 

‘‘Today, we’re providing the details to offer transparency into the scale of our challenges, and of our system itself. I’ll repeat—this data shows the extent of the systemic problems we face, problems that demand immediate actions. As of today, VA 

has contacted 50,000 Veterans across the country to get them off of wait lists and 

into clinics. Veterans deserve to have full faith in their VA, and they will keep hearing from us until all our Veterans receive the care they’ve earned.’’ 

Acting Secretary Gibson announced a series of additional actions in response to 

today’s audit findings and data, including: 

• Establishing New Patient Satisfaction Measurement Program 

Acting Secretary Gibson has directed VHA to immediately begin developing a new 

patient satisfaction measurement program to provide real-time, robust, locationby-location information on patient satisfaction, to include satisfaction data of 

those Veterans attempting to access VA healthcare for the first time. This program will be developed with input from Veterans Service Organizations, outside 

health care organizations, and other entities. This will ensure VA collects an additional set of data—directly from the Veteran’s perspective—to understand how VA 

is doing throughout the system. 

• Holding Senior Leaders Accountable 

Where audited sites identify concerns within the parent facility or its affiliated 

clinics, VA will trigger administrative procedures to ascertain the appropriate follow-on personnel actions for specific individuals. 

• Ordering an Immediate VHA Central Office and VISN Office Hiring 

Freeze 

Acting Secretary Gibson has ordered an immediate hiring freeze at the Veterans 

Health Administration (VHA) central office in Washington D.C. and the 21 VHA 

Veterans Integrated Service Network (VISN) regional offices, except for critical 

positions to be approved by the Secretary on a case-by-case basis. This action will 

begin to remove bureaucratic obstacles and establish responsive, forward leaning 

leadership. 

• Removing 14-Day Scheduling Goal 

VA is eliminating the 14-day scheduling goal from employee performance contracts. This action will eliminate incentives to engage in inappropriate scheduling 

practices or behaviors. 

• Increasing Transparency by Posting Data Twice-Monthly 

At the direction of the Acting Secretary, VHA will post regular updates to the access data released today at the middle and end of each month at VA.gov. Twicemonthly data updates will enhance transparency and provide the most immediate 

information to Veterans and the public on Veterans access to quality healthcare. 


VANews.eps
72 

• Initiating an Independent, External Audit of Scheduling Practices 

Acting Secretary Gibson has also directed that an independent, external audit of 

system-wide VHA scheduling practices be performed. 

• Sending Additional Frontline Team to Address Phoenix 

Following his trip to Phoenix VA Medical Center last week, Acting Secretary Gibson directed a VHA frontline team to travel to Phoenix to immediately address 

scheduling, access, and resource requirements needed to provide Veterans the 

timely, quality healthcare they deserve. 

• Utilizing High Performing Facilities to Help Those That Need Improvement 

VA will formalize a process in which high performing facilities provide direct assistance and share best practices with facilities that require improvement on particular medical center quality and efficiency, also known as SAIL, performance 

measures. 

• Applying Immediate Access Reforms Announced in Phoenix to Most Challenged VA Facilities 

Last week, Acting Secretary Gibson announced a series of measures to address 

healthcare access problems in Phoenix. Today, Acting Secretary Gibson announced he’ll apply the same reforms to facilities with the most access problems 

from the results of the audit, including: 

• Hiring Additional Clinical and Patient Support Staff 

VA will deploy teams of dedicated human resource employees to accelerate the 

hiring of additional, needed staff. 

• Employing New Staffing Measures 

VA’s first goal is to get Veterans off wait lists and into clinics. VA is using temporary staffing measures, along with clinical and administrative support, to ensure these Veterans receive the care they have earned through their service. 

• Deploying Mobile Medical Units 

VA will send mobile medical units to facilities to immediately provide services 

to patients and Veterans awaiting care. 

• Providing More Care by Modifying Local Contract Operations 

VA will modify local contract operations to be able to offer more communitybased care to Veterans waiting to be seen by a doctor. 

• Removing Senior Leadership Where Appropriate 

Where appropriate, VA will initiate the process of removing senior leaders. Acting Secretary Gibson is committed to using all authority at VA’s disposal to enforce accountability among senior leaders. 

• Suspending Performance Awards 

VA has suspended all VHA senior executive performance awards for FY 2014. 

• Future Travel 

Over the course of the next several weeks, Acting Secretary Gibson will travel to 

a series of VA facilities across the country. He will hear directly from Veterans 

and employees about obstacles to providing timely, quality care and how VA can 

immediately address them. 

National audit and patient access data available at www.va.gov/health/accessaudit.asp. 

Medical center quality and efficiency (SAIL) and mental health data available at 

http://www.hospitalcompare.va.gov/. 

# # # 

Question 30. Is there a national standard for how long patients should wait to get 

primary care or mental health care? What is that standard? How frequently are 

those standards met? To what extent does the VA hold itself to those standards? 

Response. There is no U.S. national standard within primary care in regard to 

wait times. At VA, patient needs often can be met via non-face-to-face communication or by visits with members of the Patient Aligned Care Team (Primary Care 

team), as well as Primary Care Provider appointments. The goal is to meet the patient’s need in the most timely and clinically appropriate way possible. 

Though there is not one U.S. national standard for mental health access, VA has 

attempted to measure mental health access based on Veteran preference and need 

73 

for the initial appointment and provider/Veteran agreed upon next visit date for follow-up visits. 

VA’s long-term goal for mental health oversight and metrics is the development 

of a finite number of composite measures that can help to ‘‘signal’’ when an organization is at risk of departing from a stated patient care or access goal, with recommended actions to address a given signal. However, short-term, VA is monitoring 

the number of new Veteran appointments seen in mental health, the number of Veterans departing inpatient mental treatment (including residential care) who are 

seen in outpatient care after discharge from such care, and aggressive monitoring 

of the Electronic Wait List as an indicator for delays in care. 

Individual health care systems create their own goals and have a variety of methods to measure progress toward their goals. Merritt Hawkins, a physician staffing 

firm, polled five types of offices across the country about several types of non-emergency care wait times for new patient appointments. They found patients waited an 

average of 29-days nationally to see a dermatologist for a skin exam, 66-days to 

have a physical in Boston and 32-days for a heart evaluation by a cardiologist in 

Washington. The New York Times recently published an article on the issue: The 

Health Care Waiting Game: Long Waits for Doctors’ Appointments Have Become 

the Norm (5 July, Elisabeth Rosenthal, New York, NY) 

Because of recent experience with manipulation of wait-time measures at certain 

sites of care, VA is exploring ways to ensure validity and reliability in its access 

standards, including how to appropriately measure timely access to care, and is 

working to report patient ratings of access to care. See question 42 below. 

Question 31. We are all well aware that the VA’s scheduling system is outdated, 

far too easily manipulated and inadequate for both VA employees and veterans. I 

recently chaired a hearing of my Federal workforce subcommittee at which Stephen 

Warren testified that the VA is now moving forward quickly to solicit a new system. 

What is the latest update in obtaining the new system? When would such a system 

be operational and deployed? 

Response. On August 25, 2014, VA announced its plan to issue a Request for Proposal (RFP) for a new Medical Appointment Scheduling System, which will replace 

the legacy scheduling system. The new system will improve access to care for Veterans by providing medical schedulers with cutting-edge, management-based scheduling software. A draft RFP was made public on September 17, 2014, and eligible 

vendors have a window to provide feedback. A final RFP is expected to be released 

by the end of October and vendors will have 30 days to respond from the day of 

issuance. Even as the VA issues an RFP to replace the existing system, efforts are 

underway to enhance the current scheduling system. Some of the enhancements include: 

• VA recently awarded a contract to improve the existing scheduling interface, 

providing schedulers a calendar view of resources instead of the current text-based, 

multiple-screen view. This update is scheduled to begin roll out beginning in January 2015; 

• VA is also developing mobile applications to allow Veterans to directly request 

certain types of primary care and mental health appointments (scheduled to begin 

deployment December 2014). Another application under development will give VA 

schedulers an easier-to-use interface to schedule medical appointments (scheduled 

to begin deployment December 2014); and 

• VA is also rolling out new clinical video tele-Health capabilities in October 2014 

to further enhance access to care. 

As part of the current RFP preparation process, VA is working with Veterans 

Service Organizations (VSO) to incorporate the groups’ feedback on requirements 

important to Veterans focusing on user experience and business process documentation. Additionally, the VA’s acquisition process will comply with recently established 

legislative requirements related to the Department’s scheduling software. 

Question 32. To what extent does the VA currently offer evening and weekend appointments? Does the VA currently have sufficient staffing to expand this option to 

more veterans? 

Response. Primary Care—VHA Directive 2013–001, Extended Hours Access for 

Veterans Requiring Primary Care Including Women’s Health and Mental Health 

Services at Department of Veterans Affairs Medical Centers and Selected Community 

Based Outpatient Clinics, explains in detail extended hour requirements for Primary 

Care and Mental Health Clinics. Weekly, extended hours for Primary Care Clinics 

must be available no less than one weekday and one weekend day per facility; these 

clinics must also cover the full range of general mental health services as defined 

in the Directive. Very large Community Based Outpatient Clinics are required to 

74 

have extended hours at least one day per week. Extended-hour clinics are defined 

as anytime outside of 8:00am–4:30pm Monday through Friday. 

In FY 2013, VA primary care providers (PCP) conducted 119,573 in-person encounters during extended hours (23,253 week-end and 96,320 week-day). In FY 

2014, VA PCPs conducted 195,039 in-person encounters during extended hours 

(67,167 weekend and 127,872 weekday). 

Mental Health—VA is committed to providing mental health services to Veterans 

in a manner that may mitigate time of appointment as a barrier to such care. In 

FY 2013, VA delivered 121,096 in-person mental health encounters during extended 

hours on weekdays and 21,651 encounters during extended hours on weekends. The 

corresponding numbers for FY 2014 to date are 115,707 and 34,644. 

Question 33. Last month, the VA announced plans to reorganize the Office of the 

Medical Inspector (OMI). Can you elaborate on the proposed changes? What is the 

expected completion of this reorganization? What led to the proposed changes? 

Response. Please refer to the response to questions 26A and 26B. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 34. The twice-monthly data updates will enhance transparency and provide the immediate information to Veterans and the public on Veterans access to 

VA health care. According to the 3 July version Alaska has some of the shortest 

New Patient wait times in America. In fact our new patient average for Mental 

Health counseling is the 2nd fastest in the Nation. I believe this is a testament to 

the partnerships that our VA has established with Indian Health Services. What is 

the VA’s plan to expand the Tribal Agreements? 

Response. Based on the geographical and rural status of Alaska and because of 

the limited Department of Veterans Affairs (VA) presence in Alaska, VA’s reimbursement agreements with Alaska Tribal Health Programs (THP) cover reimbursement for direct care services provided to eligible Alaska Native American Indian 

(AN/AI) Veterans as well as non-AN/AI Veterans. This along with the number of 

Veterans in Alaska in comparison to areas with a higher Veteran population may 

have indeed contributed to the shorter wait times for new patients. Currently, VA’s 

national reimbursement agreement with the Indian Health Service (IHS) and reimbursement agreements with THP in the continental United States cover only eligible AN/AI Veterans. For Native Veterans, VA is expanding the number of agreements with tribal health care facilities. There are currently 59 signed agreements 

with another 63 in progress, as of August 6, 2014. In accordance with section 

102(c)(2) of Public Law 113–146, the Veterans Access, Choice, and Accountability 

Act of 2014, VA and IHS will assess the feasibility and advisability of expanding 

VA’s agreements with IHS and THP (outside of Alaska) to cover Non-Native 

Veterans. 

Question 35. VA has suspended all VHA senior executive performance awards for 

fiscal year 2014 and increased accountability for senior leaders. Do you expect to 

bring back these awards in 2015? If not, what is the plan to attract and retain superior executive leadership in the future? 

Response. The Secretary is the final deciding official for senior executive performance ratings and awards. At this time, it is too early to determine the process for 

fiscal year 2015. However, VA’s Senior Executive Service performance appraisal system is certified by the U.S. Office of Personnel Management, which allows VA to 

be competitive with other Federal agencies that are certified regarding individual 

pay and aggregate total compensation limits. In addition, VA still has the ability 

to offer incentives, such as retention incentives when competing for top talent. 

Question 36. As you know in order for non-VA providers to provide care and services to veterans they need to have the right credentials, how will the VA work with 

non-VA providers to facilitate the delivery of telemedicine services across state 

lines? 

Response. In 2006, the Office of General Counsel provided an opinion on Federal 

Supremacy and State medical licensing issues in Telemedicine contracts. In this 

opinion it states that, ‘‘VA can determine that contractors who are licensed in ‘a’ 

State are qualified to provide VA with teleradiology services in any State. Such contractors do not need to be licensed in the State(s) where the services are performed, 

including the State(s) they enter electronically using telemedicine.’’ VHA Handbook 

1100.19, Credentialing and Privileging was modified accordingly to state: 

(a) Contracts for telemedicine and/or teleconsultation services need to require that 

these services be performed by appropriately-licensed individuals. Unless otherwise 

75 

required by the specific contract or Federal law (such as the Federal Controlled Substances Act), contract healthcare professionals must meet the same licensure requirements imposed on VA employees in the same profession whether they are on 

VA (Federal) property or not when providing telemedicine or teleconsultation 

services. 

(b) Some states do not allow telemedicine and/or teleconsultation across state 

lines, unless the provider is licensed in the state where the patient is physically located. In these states, the clinical indemnity coverage of contract practitioners may 

be void, even if they are credentialed and privileged by VA. Prior to the commencement of services by the contract practitioners providing telemedicine and/or teleconsultation or remotely monitoring physiology data from Veteran patients, the State 

regulatory agency in the state in which the practitioner is physically located as well 

as the state where the patient is physically located, must be consulted. When dealing with Federal entities, additional licenses that authorize the provision of telemedicine and/or teleconsultation services in the relevant states may not be required. 

The opinion of the Regional Counsel needs to be sought in these matters. 

The burden is on the contractor to address any issues that may be identified by 

the State regulatory agency in the state where the contractor is located as well as 

the State where the Veteran patient is located as well as the contractor’s medical 

malpractice carrier. VA accepts any appropriately licensed health care provider. 

Question 37. In the Veterans Access to Care thorough Choice, Accountability, and 

Transparency Act included is increased care to vets by non-VA providers, what policies are you implementing to increase sharing of electronic medical records between 

these providers and the VA? 

Response. The Veterans Health Administration (VHA) has established a Virtual 

Lifetime Electronic Record (VLER) Program for electronic health information exchange (HIE) in accordance with national standards and specifications as described 

by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology. Through VLER HIE, VHA now has the 

capability to exchange Veteran health data with private sector hospitals and clinics. 

VLER provides secure and seamless access between Electronic Health Records in 

structured, standardized formats using national specifications. This Exchange is accomplished through several push and pull programmatic mechanisms, known as Direct and Exchange. Sharing of these records ensures that enrolled Veterans receive 

coordinated care between their VA clinicians and Non-VA health care providers. 

There are many other health information sharing platforms that may be used by 

the HIE community in information sharing. VA is in the process of developing a 

VHA Directive that will provide guidance to VA health care facilities considering 

participating in local community HIE organizations. This same Directive will give 

guidance about using community HIE portals to view non-VA health information for 

Veterans. 

Section 101(l)(2) of the Veterans Access, Choice, and Accountability Act provides 

that to the extent possible, medical records submitted by non-Department providers 

shall be submitted electronically. Furthermore, subsection 101(n) of the act requires 

that the Secretary prescribe interim final regulations on the implementation of subsection 101 of the Act; the sharing of electronic medical records will be considered 

in the drafting of such regulations. 

Question 38. Given the Veterans Administration’s need to increase access to high 

quality health care, how would implementation of the VHA Nursing handbook, and 

recognition of the Full Practice Authority of APRNs working in the VHA, help increase capacity and improve access for Veterans? 

Response. The Office of Nursing Services began the development of a VHA nursing handbook in 2009 to establish policy for the process of care delivery and the elements of practice for nursing. All VA program offices provided input in 2012 utilizing the internal concurrence process. Since that time, the VHA Under Secretary 

for Health has conducted meetings with several internal and external stakeholders 

including a variety of professional organizations, as well as Veterans Service Organizations. The proposed change is being driven by the efficacious use of resources 

and to decrease variability in care provided by Advanced Practice Registered Nurses 

(APRN) throughout the VA system. 

The 2010 Institute of Medicine (IOM) landmark report, ‘‘The Future of Nursing: 

Leading Change, Advancing Health,’’ recommended removal of scope-of-practice barriers to allow APRNs to practice to the full extent of their education, training and 

certification. This evidenced-based recommendation by the IOM prompted VHA to 

propose Full Practice Authority (FPA) for APRNs. Thus, VHA’s proposed Nursing 

Handbook is consistent with the IOM recommendation to remove barriers including 

76 

the variation in APRN practice that exists across VHA as a result of disparate state 

regulations. 

The VHA’s proposed policy is consistent with the National Council of State Boards 

of Nursing Consensus Model and includes all APRN roles. Model APRN regulation 

is aimed at public protection by ensuring uniformity across all jurisdictions. Uniformity of national standards and regulation not only allows for the mobility of 

nurses, it also serves the public by increasing access to care. Within the nursing 

handbook, VHA is proposing the authorization of FPA for APRNs, without regard 

to their individual State Practice Acts, except for the dispensing, prescribing and administration of controlled substances. This proposed change to nursing policy would 

standardize APRN practice throughout the VA system. As an integrated Federal 

health care system, the proposed policy parallels current policy in the Department 

of Defense (DOD). Implementation of FPA in VHA would enable Servicemen and 

women transitioning from DOD to VA, to receive the same level of care from APRNs 

in both systems. 

A significant number of states have approved full practice authority for APRNs, 

with many VA medical centers successfully utilizing APRNs to the full extent of 

their education and training. The proposed nursing policy would not authorize 

APRNs to replace or act as physicians; the proposed nursing policy would authorize 

FPA within the field of nursing. Implementation of FPA for APRNs would increase 

patient access by alleviating the effects of national health care provider shortages 

on VA staffing levels, as well as, enabling VA to provide additional health care services in medically underserved areas. 

The VA released an audit in early June 2014 showing that more than 57,000 Veterans have had to wait at least 3-months for initial appointments. There has been 

a large influx of new enrollees in the VA Health Care System and VA statistics 

demonstrate a consistent upward trend in enrollment numbers since 2000. Over the 

past 3 years, primary care appointments have increased by 50 percent, yet the primary care physician staff has increased by 

9 percent. Many nurse practitioners are working in these clinics, but are not able 

to function to the full extent of their education and training, due to barriers created 

by disparate state regulations. 

Implementation of FPA would allow APRNs to function at the top of their education, training and certification, resulting in increased access to VA primary care 

services in states where scope of practice barriers currently limit an APRN’s ability 

to practice. VHA would be able to utilize APRN providers to improve patient access 

for Veterans in need of timely Primary Care services and to decrease waiting time 

for new patient appointments. FPA may also result in cost savings to VA by decreasing the need to outsource care to the community. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 39. Given the Veterans Administration’s need to increase access to high 

quality health care, how would implementation of the VHA Nursing handbook, and 

recognition of the Full Practice Authority of Advanced Practice RNs working in the 

VHA help increase capacity and improve access for Veterans? 

Response. Please see response to Question 38 above. 

Question 40. Given the need to hire more clinicians and in the spirit of exploring 

all options, have you considered reaching out to former employees who recently retired or those who left the VA in the last year or two to see if they would be able 

to help assist to increase the capacity at the VA? Because they already know the 

system they could become fully productive faster than someone not familiar with the 

VA. 

Response. As staffing needs vary across the Veterans Health Administration 

(VHA) system, facilities are encouraged to pursue the hiring of critical staff utilizing 

whatever means that would yield the most success (considering local labor markets 

and hiring trends). This includes hiring re-employed annuitants (retired Federal employees) and hiring former staff to perform work on a fee basis (per procedure). 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN BOOZMAN TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 41. Acting Secretary Gibson, in your prepared testimony you speak to 

removing the 14-day scheduling goal from VA policy. Do you anticipate another numeric goal being put in its place? If so, any thoughts on what it will be; did current 

77 

VA health schedulers have any ideas for a better target? I know you have met with 

private sector health providers; did these private providers have any thoughts on 

scheduling metrics or suggestions for a new system? 

Response. The Department of Veterans Affairs (VA) is building a more robust, 

continuous system for measuring access and patient satisfaction, to provide realtime, robust, site-specific information on patient satisfaction. VA will augment our 

existing Survey of Health Experiences of Patients (SHEP) survey with new questions and larger sample size in the coming year, to capture more Veteran experience 

data using telephone, social media, and on-line means. Our effort includes close collaboration with the Veterans Service Organizations (VSO), with whom we have already met to begin planning our efforts. VA is also contracting for an independent 

assessment of the ‘‘current state’’ of clinic management infrastructure in addition 

to establishing a benchmark for access levels from the body of evidence and from 

other healthcare organizations. 

The 14-day access measure has been removed from all individual employee performance plans to eliminate any motive for inappropriate scheduling practices or behaviors. In the course of completing this task, over 13,000 performance plans were 

amended—from then-Acting Secretary Gibson’s prepared remarks before the Veterans of Foreign Wars Annual Convention July 22, 2014. VHA Schedulers have 

many comments on ways to improve the current process for scheduling including entering required time-stamp information, including Desired Date (DD). These ideas 

are in the process of being consolidated in a memo that will clarify existing policy 

and practice. Private sector practices tend to use capacity measures (such as the 

time to the third open slot) to measure access. VA has limited capability to use capacity measures because of legacy VistA scheduling software limitations. However, 

the Choice Act requires VA measure individual patient waiting times rather than 

capacity measures. VA has therefore proposed using the Veterans Preferred Date 

(formerly called the Desired Date) to meet the intent of the law. In order to improve 

the reliability of this measure, VHA anticipates adopting many elements of the new 

procedures suggested by schedulers, defining the clinic management role better, and 

standardizing the training of the clinic manager, including schedulers. While the 

waiting time goals have been removed from performance standards, the timeliness 

information will be need to comply with elements of the Choice Act. VA is exploring 

ways to ensure validity and reliability in its access standards, including how to appropriately measure timely access to care. 

Question 42. Has the new patient satisfaction measurement program been put in 

place? Who will oversee that program? Will there be outreach to veterans to ensure 

they know their input is appreciated and crucial to future success of the system? 

Response. The Department of Veterans Affairs (VA) is building a more robust, 

continuous system for measuring access and patient satisfaction, to provide realtime, robust, site-specific information on patient satisfaction. VA will augment our 

existing Survey of Health Experiences of Patients (SHEP) survey with new questions and larger sample size in the coming year, to capture more Veteran experience 

data using telephone, social media, and on-line means. Our effort includes close collaboration with the Veterans Service Organizations (VSO), with whom we have already met to begin planning our efforts. VA is also contracting for an independent 

assessment of the ‘‘current state’’ of clinic management infrastructure in addition 

to establishing a benchmark for access levels from the body of evidence and from 

other healthcare organizations. 

The 14-day access measure has been removed from all individual employee performance plans to eliminate any motive for inappropriate scheduling practices or behaviors. In the course of completing this task, over 13,000 performance plans were 

amended—from then-Acting Secretary Gibson’s prepared remarks before the Veterans of Foreign Wars Annual Convention July 22, 2014. VHA Schedulers have 

many comments on ways to improve the current process for scheduling including entering required time-stamp information, including Desired Date (DD). These ideas 

are in the process of being consolidated in a memo that will clarify existing policy 

and practice. Private sector practices tend to use capacity measures (such as the 

time to the third open slot) to measure access. VA has limited capability to use capacity measures because of legacy VistA scheduling software limitations. However, 

the Choice Act requires VA measure individual patient waiting times rather than 

capacity measures. VA has therefore proposed using the Veterans Preferred Date 

(formerly called the Desired Date) to meet the intent of the law. In order to improve 

the reliability of this measure, VHA anticipates adopting many elements of the new 

procedures suggested by schedulers, defining the clinic management role better, and 

standardizing the training of the clinic manager, including schedulers. While the 

waiting time goals have been removed from performance standards, the timeliness 

information will be need to comply with elements of the Choice Act. VA is exploring 

78 

ways to ensure validity and reliability in its access standards, including how to appropriately measure timely access to care. 

Question 43. I certainly appreciate the approach of looking at well performing 

medical centers and taking those best practices and using them at those places that 

need help and improvement to provide timely, quality care to our veterans. Are you 

able to say which VAMCs are the high performing facilities you will be looking at 

and some examples of the best practices you will try to spread from these places? 

Response. VHA has formed a Steering Group to begin the process of determining 

how to measure the performance of facilities to find those that achieve excellent performance in their particular environment. This may allow for example, a small facility in a highly rural area to be paired with a like facility with better performance. 

Specific facilities in each domain have not yet been identified, nor which specific 

areas of vulnerability will need to be targeted. Further, best practices should be informed by the medical or business literature which may require additional research 

to ensure the validity of some practices. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DEAN HELLER TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 44. It is my understanding the VA has not yet authorized construction 

for a new Community Based Outpatient Clinic (CBOC) in Pahrump, Nevada. The 

Director of the VA Southern Nevada Healthcare System, Isabel Duff, has indicated 

this proposal is awaiting approval by VA Central Office. To date, a timeline or any 

indication for approving this project has not been released. I respectfully request the 

VA provide a timeline for approving this clinic’s construction so that the facility can 

break ground before Fall 2014. 

Response. The lease package for the Pahrump, Nevada Community Based Outpatient Clinic was approved by the Under Secretary for Health on August 8, 2014, 

and subsequently by the Secretary on August 22, 2014. A copy of the signed approval memorandum was provided to the Veterans Integrated Services Network 

Capital Assets Manager on August 22, 2014. The Department of Veterans Affairs 

(VA) began the acquisition process, to include working with the General Services 

Administration (GSA), for this lease on August 22, 2014. VA anticipates a lease 

award for this site by the end of the calendar year. 

Question 45. I respectfully request a timeline for expected completion of the second phase of the VA’s face-to-face audits. 

Response. The second phase of VA’s face-to-face access audit concluded on June 4, 

2014. 

Question 46. During the hearing, you informed me that you would be visiting 

Reno, NV, in August 2014, and assured me that you would visit the Reno VA Regional Office during the trip. I respectfully ask for the dates of this trip and a complete list of the VA facilities in Nevada that you will visit. 

Response. On Tuesday, August 19, 2014, Secretary McDonald conducted site visits 

to the Reno Nevada VA Regional Office and the Reno Nevada VA Medical Center. 

(79) 

A P P E N D I X 

REPORT SUBMITTED BY HON. MARK BEGICH DATED MAY 2003 FROM THE PRESIDENT’S

TASK FORCE TO IMPROVE HEALTH CARE DELIVERY FOR OUR NATION’S VETERANS


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1 Elisabeth Rosenthal, ‘‘The Health Care Waiting Game,’’ New York Times (July 6, 2014). 

2 Id. 

3Kenneth W. Kizer and Ashish K. Jha, ‘‘Restoring Trust in VA Health Care,’’ NEJM (June 5, 

2014). 

PREPARED STATEMENT BY WOUNDED WARRIOR PROJECT

Chairman Sanders, Ranking Member Burr, and Members of the 

Committee: Recent scandals marked by widespread inability among 

VA medical facilities to provide initial treatment promptly, by 

cover-ups of problems in health care scheduling and delivery, and 

by recriminations against VA employee ‘‘whistleblowers,’’ underscore the importance of this Committee’s examining the state of VA 

health care. 

These are grave problems that must not be dismissed. Problems 

of care-delivery in this system, however, are not insoluble. What is 

more challenging are practices that suggest that instead of a culture of caring for veterans, too many facilities have seemed caught 

up in a culture of cover-up. For too long, VA leaders over-emphasized a narrative of Department successes and relied heavily on 

performance ‘‘data’’ to measure those successes. Perverse incentives 

led some to falsify or skew data to meet required metrics. Yet even 

as this complex health care system is described as infected by a 

‘‘toxic culture,’’ we learn of clinicians at VA facilities who have long 

been working overtime and on weekends, voluntarily, to help the 

veterans under their care. This duality underscores that VA operates a complex system, one that—while marred by scandal—employs many very dedicated, compassionate health care 

professionals. 

Many of the veterans we serve rely on that system for some or 

all of their care. We owe it to them to improve VA health care, not 

to dismantle the system or impose sweeping untested solutions. In 

that regard, with VA’s problems in providing veterans an initial appointment within a then-required 14-day rule, it should be noted 

that lack of timeliness in providing care is not unique to VA. As 

reported earlier this month by the New York Times, ‘‘there is 

emerging evidence that lengthy waits to get a doctor’s appointment 

have become the norm in many parts of American medicine, particularly among general doctors, but also for specialists.’’ 1 While 

describing VA as reeling from revelations of long wait times, the 

Times reported that VA is one of the only health care systems in 

the Nation that openly tracks waiting times and has standards for 

what they should be.2

Wounded Warrior Project has not been hesitant over the years 

to critique VA timeliness of care, the effectiveness of certain VA 

services, its adherence to law and its own policies, and the consistency of its practices. That criticism and expectation has been directed to the high obligation the Department owes to those wounded, ill and injured in service—obligations reflected in laws the Department is charged to administer. 

We commend to the Committee’s attention a recent perspective 

co-authored by former VA Under Secretary of Health Ken Kizer, 

‘‘Restoring Trust in VA Health Care.’’ 3 The authors ask rhetorically, how ‘‘[a]fter the VA had gained a hard-won reputation for 

providing superior quality care 15 years ago, * * * did cracks apVerDate Mar 15 2010 13:20 Apr 13, 2015 Jkt 000000 PO 00000 Frm 00109 Fmt 6601 Sfmt 6601 Z:\ACTIVE\071614.TXT PAULIN
106 

4 Id. 

5 Id. 

pear in its delivery of safe, effective, patient-centered care?’’ They 

offer three main causes: 

‘‘ * * * an unfocused performance-measurement program, 

increasingly centralized control of care delivery and associated increased bureaucracy, and increasing organizational 

insularity.’’ 4

While each is a critical flaw, an important starting point for this 

Committee would be to press VA to revisit its performance measures. As Kizer writes, the use of ‘‘hundreds of [performance] measures with varying degrees of clinical salience * * * not only encourages gaming but also precludes focusing on, or even knowing, 

what’s truly important.’’ Kizer’s prescription in terms of first steps 

is sound: 

‘‘First, after ensuring that all veterans on wait lists are 

screened and triaged for care, the VA should refocus its 

performance-management system on fewer measures that 

directly address what is most important to veteran patients and clinicians—especially outcome measures.’’ 5

This would represent a good initial step toward restoring trust. 

We urge the Committee to continue its oversight in that effort. 

Æ